St Croix Hospice Lombard

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #2-004 “Medication Profile” (dated 12/01/2018) (reviewed 02/27/2025) stated in part, “Patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Upon admission to hospice, the admitting nurse will initiate a medication profile to document the current medication regimen. A drug regimen review will be performed at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication.” In 1 of 23 (4%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient’s current medications. Clinical Record 7: The patient elected the hospice benefit on 02/13/2025 with a diagnosis of chronic obstructive pulmonary disease (COPD). The patient resided in a skilled nursing facility (SNF). The skilled nursing (SN) visit note dated 02/14/2025 documented, “Patient stating he is having a hard time breathing. Oxygen saturation 96% on 4.5 liters of oxygen via nasal cannula.” The drug profile dated 02/14/2025 did not document oxygen. During joint record reviews on 05/14/2025 and 05/15/2025, the Manager of Accreditation and Regional Director of Clinical Operations confirmed that oxygen was not included in the patient’s drug profile.”

“It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #1-031 “Responsibilities/Supervision of Clinical Services” (dated 12/01/2018 and reviewed 02/14/2024) stated in part, “A monthly patient visit will be completed by a registered nurse to supervise licensed practical/vocational nursing services.” In 1 of 23 (4%) clinical records reviewed of patients that received skilled nursing services from a Licensed Practical Nurse (LPN), the agency did not ensure that the LPN provided nursing care under the supervision of a Registered Nurse (RN) per agency policy. Clinical Record 6: The patient elected the hospice benefit on 05/23/2023. The plan of care dated 05/23/2023 through 08/20/2023 ordered “SN 2x/week.” A clinical record review revealed LPN visits dated 05/24/2023, 05/20/2023, 06/06/2023, 06/12/2023, 06/20/2023, 06/22/2023, 06/30/2023, 07/03/2023, and 08/09/2023. The RN documented LPN supervisory visits on 05/26/2023 and 07/07/2023. No LPN supervisory visit was documented for June 2023. During a joint record review on 05/14/2025, the Manager of Accreditation and Regional Director of Clinical Operations confirmed that the LPN supervisory visits were completed less frequently than monthly.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 5 of 21 (24%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the hospice aide care plan included all written patient care instructions. Clinical Record 1: The patient elected the hospice benefit on 12/04/2024 with a diagnosis of cerebral atherosclerosis. The patient resided in an assisted living facility (ALF). On 12/28/2024, the physician ordered wound care with a dressing for a wound on the patient’s left hip. The plan of care dated 12/04/2024 through 03/03/2025 ordered “HA 2x/week.” The HA care plan dated 12/05/2024 assigned the HA the relevant task: “Bed bath every visit.” The HA care plan did not document instructions for the HA related to the wound dressing on the patient’s left hip, should it become wet or dislodged during the bed bath. Clinical Record 6: The patient elected the hospice benefit on 05/23/2023 with a diagnosis of congestive heart failure. The patient resided in a SNF. On 11/02/2024, the physician ordered wound care with a dressing for a wound on the patient’s right leg. The plan of care dated 09/14/2024 through 11/12/2024 ordered “HA 2x/week.” The HA care plan dated 10/10/2024 assigned the HA the relevant task: “Bed bath every visit.” The HA care plan did not document instructions for the HA related to the wound dressing on the patient’s right leg, should it become wet or dislodged during the bed bath. Clinical Record 19: The patient elected the hospice benefit on 08/06/2024 with a diagnosis of cerebral atherosclerosis. The patient resided at home. On 09/17/2024, the physician ordered wound care with a dressing for a wound on the patient’s sacrum. The plan of care dated 08/06/2024 through 11/03/2024 ordered “HA 2x/week.” The HA care plan dated 09/24/2024 assigned the HA the relevant task: “Bed bath every visit.” The HA care plan did not document instructions for the HA related to the wound dressing on the patient’s sacrum, should it become wet or dislodged during the bed bath. Clinical Record 22: The patient elected the hospice benefit on 10/17/2024 with a diagnosis of cerebral infarction. The patient resided at an assisted living facility (ALF). On 11/11/2024, the physician ordered wound care with a dressing for a wound on the patient’s left leg. The plan of care dated 10/17/2024 through 01/01/2025 ordered “HA 5x/week.” The HA care plan dated 10/26/2024 assigned the HA the relevant task: “Bed bath every visit.” The HA care plan did not document instructions for the HA related to the wound dressing on the patient’s left leg, should it become wet or dislodged during the bed bath. Clinical Record 23: The patient elected the hospice benefit on 10/30/2024 with a diagnosis of congestive heart failure. The patient resided at home. On 11/04/2024, the physician ordered wound care with a dressing for a wound on the patient’s coccyx. The plan of care dated 10/30/2024 through 12/26/2024 ordered “HA 2x/week.” The HA care plan dated 10/31/2024 assigned the HA the relevant task: “Bed bath every visit.” The HA care plan did not document instructions for the HA related to the wound dressing on the patient’s coccyx, should it become wet or dislodged during the bed bath. During joint record reviews on 05/14/2025 and 05/15/2025, the Manager of Accreditation and Regional Director of Clinical Operations confirmed that wound dressing instructions were not included in the Hospice Aide care plan.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide; and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 6 of 21 (29%) clinical records reviewed of patients who received Hospice Aide services, the agency did not ensure that Hospice Aide (HA) supervisory visits were completed by a Registered Nurse (RN) no less frequently than every 14 days. Clinical Record 1: The patient elected the hospice benefit on 12/04/2024 with a diagnosis of cerebral atherosclerosis. The patient resided in an assisted living facility (ALF). The plans of care dated 12/04/2024 through 03/03/2025 and 03/04/2025 through 06/01/2025 ordered “HA 2x/week starting week of 12/08/2024.” The first HA visit was dated 12/10/2024. Hospice Aide supervisory visits were documented as completed on 01/27/2025, with 48 days outstanding, and 04/15/2025, with 78 days outstanding. Clinical Record 4: The patient elected the hospice benefit on 06/07/2024 with a diagnosis of cerebral infarction. The patient resided in a skilled nursing facility (SNF). The plans of care dated 06/07/2024 through 09/04/2024, 09/05/2024 through 12/03/2024, 12/04/2024 through 02/01/2025, 02/02/2025 through 04/02/2025, and 04/03/2025 through 06/01/2025 ordered “HA 2x/week.” The first HA visit was dated 06/10/2024, with a documented HA supervisory visit completed on 07/03/2024, 23 days outstanding. Hospice Aide supervisory visits were dated 09/04/2024, with the next HA supervisory visit dated 10/08/2024, 34 days outstanding; 11/01/2024, with the next HA supervisory visit dated 11/27/2024, 26 days outstanding; 02/12/2025, with the next HA supervisory visits dated 02/28/2025, 16 days outstanding; 03/19/2025, 19 days outstanding; and 04/09/2025, 21 days outstanding. Clinical Record 6: The patient elected the hospice benefit on 05/23/2023 with a diagnosis of congestive heart failure. The patient resided in a SNF. The plans of care dated 08/21/2023 through 11/18/2023, 11/19/2023 through 01/17/2024, 01/18/2024 through 03/17/2024, 03/18/2024 through 05/16/2024, 05/17/2024 through 07/15/2024, 07/16/2024 through 09/13/2024, 09/14/2024 through 11/12/2024, 11/13/2024 through 01/11/2025, 01/12/2025 through 03/12/2025, and 03/13/2025 through 05/11/2025 ordered “HA 2x/week.” The first HA visit was dated 08/21/2023. HA supervisory visits were documented as completed on 08/22/2023, with the next HA supervisory visits dated 10/09/2023, 48 days outstanding; 01/24/2024, 107 days outstanding. HA supervisory visits were documented as completed on 04/08/2024, with the next supervisory visit dated 08/28/2024, 142 days outstanding; 11/01/2024, 64 days outstanding; 11/22/2024, 21 days outstanding; 03/08/2025, 106 days outstanding; and 04/17/2025, 40 days outstanding. Clinical Record 12: The patient elected the hospice benefit on 01/08/2025 with a diagnosis of Alzheimer’s Disease. The patient resided in a SNF. The plan of care dated 03/09/2025 through 05/07/2025 ordered “HA 2x/week.” The first HA visit was dated 03/13/2025. Hospice Aide supervisory visits were documented as completed on 04/10/2025 and 04/29/2025, with 19 days outstanding. Clinical Record 14: The patient elected the hospice benefit on 11/19/2024 with a diagnosis of malignant neoplasm of the esophagus. The patient resided at home. The plans of care dated 11/19/2024 through 02/16/2025 and 02/17/2025 through 05/17/2025 ordered “HA 2x/week.” The first HA visit was dated 11/22/2024. A clinical record review revealed no documented HA supervisory visits. Clinical Record 19: The patient elected the hospice benefit on 08/06/2024 with a diagnosis of cerebral atherosclerosis. The patient resided at home. The plan of care dated 08/06/2024 through 11/03/2024 ordered “HA 2x/week.” The first HA visit was dated 08/08/2024. A HA supervisory visit was documented as completed on 09/24/2024, with 47 days outstanding. During joint record reviews on 05/14/2025 and 05/15/2025, the Manager of Accreditation and the Regional Director of Clinical confirmed that Hospice Aide supervisory visits were completed less frequently than every 14 days. They stated that these supervisory visits were missed by one RN, who was identified and provided with reeducation during the site visit.”

“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 hospice volunteers provided day-to-day administrative or direct patient care services in an amount that equaled at least five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. A review of the agency’s “Volunteer Cost Savings Report” for 2024 (01/01/2024 through 12/31/2024) revealed that the total percentage of hours worked by volunteers for the year 2024 was 1.10%. Documentation of a performance improvement plan (PIP) initiated in January 2025 to increase the percentage of volunteer hours to 5% was reviewed. The agency’s Volunteer Cost Savings Report for 2025 revealed that the total percentage of hours worked by volunteers for 01/01/2025-04/30/2025 was 1.0%. During an interview on 05/14/2025, the Regional Director of Clinical Operations confirmed the finding, stating, “We have not been able to service 5% of our hours from volunteers since the waiver was lifted in 2024. We have eight volunteers that we are currently onboarding.” The agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services in an amount that equaled at least five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician’s orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 23 (9%) clinical records reviewed, the agency did not ensure that the patient’s clinical record included all physicians’ orders. Clinical Record 7: The patient elected the hospice benefit on 02/13/2025 with a diagnosis of chronic obstructive pulmonary disease (COPD). The patient resided in a skilled nursing facility (SNF). The skilled nursing (SN) visit note dated 02/14/2025 documented, “Patient stating he is having a hard time breathing. Oxygen saturation 96% on 4.5 liters of oxygen via nasal cannula.” The clinical record did not include a physician’s order for oxygen. Clinical Record 15: The patient elected the hospice benefit on 04/25/2025 with a diagnosis of intrahepatic bile duct carcinoma. The SN visit note dated 05/05/2025 documented, “Dressing to biliary drain changed. Drain flushed with 10ml of normal saline.” The clinical record did not include a physician’s order for dressing changes to the biliary drain site and normal saline flushes of the biliary drain. During joint record reviews on 05/14/2025 and 05/15/2025, the Manager of Accreditation and Regional Director of Clinical Operations confirmed that the clinical records did not include physicians’ orders for oxygen, biliary drain dressing changes, or biliary drain normal saline flushes.”