St Croix Hospice

“It is required that each patient’s individualized written plan of care: reflects patient and family goals; [and] identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure the plan of care (POC) reflected patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 2: The patient elected hospice care on 01/10/2025 with a diagnosis of Parkinson’s disease with dyskinesia, without mention of fluctuations. The initial nursing assessment dated 01/10/2025, the narrative documented, “The patient eats bites of mechanical soft diet with honey thickened liquids....He has significant dysphagia and requires feeding”. The interdisciplinary group (IDG) POC dated 01/10/2025 did not document a goal(s) and an intervention(s) for dysphagia. Clinical Record 5: The patient elected hospice care on 08/21/2023 with a diagnosis of chronic diastolic congestive heart failure. The initial “Massage Therapy Hospice Add-On Evaluation” dated 08/28/2023, ordered one (1) time weekly for massage. This document provided evidence of massage goals and interventions. The IDG POC dated 08/28/2023 documented the problem: “Massage therapy evaluation for hospice patient.” The IDG POC dated 08/28/2023 did not document goal(s) and intervention(s) for massage therapy. The Corporate Manager of Accreditation and the Manager of Clinical Services stated during an interview and a joint record review on 04/11/2025, that the Massage Therapist was documenting goals and interventions within the visit note, but the goals and interventions were not flowing over to the IDG POC like the other disciplines. They stated, “It appears there might be a ‘Click’ that was missed.” The Administrator, Manager of Accreditation, and Manager of Clinical Services confirmed during an interview on 04/11/2025 that the IDG POC did not reflect patient and family goals and interventions based on problems identified in the comprehensive assessments.”

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the plan of care (POC) included all treatments to meet the patient’s needs. Clinical Record 4: The patient elected hospice care on 06/23/2023 with a diagnosis of Ischemic cardiomyopathy. The skilled nursing (SN) assessment dated 12/20/2024 documented that the SN received wound care orders from the physician: “Hospice nurse to cleanse with wound wash, pat dry with gauze, apply small amount of medihoney, and cover with dressing once weekly. Family to perform wound care once weekly or as needed if soiled or dislodged.” The IDG POC dated 12/20/2024 documented the patient goal “Need for wound care - Hospice.” The IDG POC documented the interventions, “Provided wound care per physician orders...Instructed in performing wound care.” A clinical record review revealed no evidence of the IDG POC documenting interventions for the specific wound care to be provided by the SN, and the specific wound care to be taught to the patient’s caregivers. The Administrator, Manager of Accreditation, and Manager of Clinical Services stated in an interview on 04/11/2025 that the IDG POC did not include all interventions with specifics.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.. This standard was not met as evidenced by document review and interview. The agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The review of the “Volunteer Hours Compared to Direct Patient Care Employee Hours Report” revealed the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. A review of the agency’s 2024 “Volunteer Hours Compared to Direct Patient Care Employee Hours Report” revealed that the volunteer percentage of hours worked for the year 2024 was 1.48%. There was evidence of a performance improvement plan (PIP) initiated in January 2025. However, the agency has not reached the 5% usage since the implementation of the PIP. The percentage of volunteer hours for January 2025 = 0.4%; February 2025 = 0.2%; and March 2025 = 0.1%. The Regional Volunteer Coordinator stated in an interview on 04/11/2025 that three (3) new volunteers are onboarding at the agency. During an interview on 04/11/2025, the Administrator, Manager of Accreditation, and Manager of clinical services confirmed that volunteers had not provided at least five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The review of the “Volunteer Hours Compared to Direct Patient Care Employee Hours Report” revealed the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.”