St Croix Hospice

“It is required that each patient’s individualized written plan of care reflects patient and family goals 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. 2 of 19 (11%) clinical records reviewed revealed the agency did not ensure that patients’ plans of care were individualized and accurately reflected identified problems, planned interventions, and measurable goals derived from assessment data. CLINICAL RECORD 13: The patient elected the hospice benefit on 03/23/2026 with the terminal diagnosis of anoxic brain damage with comorbidities of cardiac arrest; epilepsy without status epilepticus; quadriplegia; chronic pain; wedge compression fractures of T11–T12 vertebrae; spinal stenosis; depressive disorder; anxiety disorder; insomnia; osteoarthritis; and diverticulitis. At the Registered Nurse (RN) Admission visit on 03/23/2026, the patient was assessed with pain rated 6/10 (goal 0), described as intermittent daily cramping and stabbing back pain impacting enjoyment of activities, concentration, emotions, and sleep/rest. Dyspnea was rated 2/10 (goal 0) with increased secretions. The patient was alert and oriented to self, place, and situation, with new-onset aphasia, occasionally able to respond with one-word replies. A poor cough reflex and difficulty clearing secretions were noted. Following a pre-admission swallow study, a pureed diet with nectar-thickened liquids was recommended due to dysphagia and aspiration risk. During the Interdisciplinary Group (IDG) Meeting on 04/02/2026, the patient was identified as at risk for aspiration, evidenced by coughing during eating and medication administration. Aphasia onset was also documented. On 04/03/2026, nursing documentation identified constipation, with the last bowel movement reported as more than five days prior. The Facility Nurse (FSN) was instructed on as-needed (PRN) use of a Dulcolax suppository. On 04/07/2026, the last bowel movement was documented as 04/05/2026, and the physician was contacted; an order for daily lactulose was obtained. At the IDG Meeting on 04/16/2026, documentation reflected changes in pain management due to prior ineffectiveness: Oxycodone and Morphine (5 mg every 4 hours PRN) were discontinued, and a Fentanyl 50 mcg/hour (hr) patch was initiated. Education was reportedly provided to facility staff regarding pain management, infection control, safety precautions, skin breakdown prevention, and medication adherence. The visit note documented that the current medication and treatment plan were effective; however, there was no clear supporting evidence of reassessment data validating effectiveness at that time. On 04/30/2026, IDG documentation stated the pain regimen was effectively controlling pain and that the patient was medically managed, with continued staff education documented. There was limited objective data to support sustained effectiveness, patient response, or measurable outcomes. The active medication list included multiple agents addressing behavioral health, seizures, pain, muscle spasms, constipation, and insomnia, including Fentanyl 50 mcg/hr, Lorazepam (both scheduled and PRN), Depakote, Vimpat, Onfi, Baclofen, Senna, Lactulose, and others. Despite complex symptom burden and polypharmacy, documentation did not consistently demonstrate ongoing evaluation of medication effectiveness, side effects, or interdisciplinary coordination specific to symptom management outcomes. The initial plan of care included safety measures such as emergency planning, fall precautions, oxygen precautions, seizure precautions, standard precautions, and adherence to a pureed diet. However, across the certification period (03/23/2026 – 06/20/2026), documentation demonstrates gaps in individualized reassessment, insufficient evidence of goal evaluation, and limited objective documentation of changes in clinical status or treatment effectiveness. Care plan goals and interventions included management of altered neurological status, pain/comfort, and home safety. Goals reflected patient/caregiver understanding of recognizing changes in level of consciousness, pain management, and safety hazards, with instructions to notify hospice of significant changes. Interventions included education on recognizing decreased levels of consciousness, pain control measures, evaluation of intervention effectiveness, assessment of functional status related to safety risks, and reinforcement of fall precautions. However, documentation lacked evidence of caregiver competency validation or measurable outcomes tied to these goals. CLINICAL RECORD 18: The patient, who resided at home, elected the hospice benefit on 03/27/2026 with a terminal diagnosis of unspecified severe protein-calorie malnutrition with comorbid conditions including COPD, chronic fatigue syndrome, adjustment disorder with mixed anxiety and depression, insomnia, weakness, and shortness of breath (SOB). During a visit by the RN on 01/19/2026, the patient’s respiratory rate (RR) was 20, labored, and shallow. The nurse documented the patient’s clinical state in part through the visit narrative, “Patient and wife state that patient is going through 1 inhaler every 2-3 days...Patient found to be hypoxic at 79-81% on room air. Patient placed on 3 liters per minute (LPM) oxygen via nasal cannula, and pulse ox increased to 92%. Patient encouraged to take nebulizer treatment as well, which seems to have helped with his difficulty breathing... barrel chest noted to be more pronounced this visit...Discussed respiratory distress treatment and need to increase nebulizer treatments to 4 a day to help cut down on the amount of inhaler usage and to keep patient on O2 at all times now...” At the IDG Meeting dated 01/22/2026, the nurse noted that the patient had been exhibiting an increase/exacerbation of his respiratory system, with breath sounds diminished at the bases, and expiratory wheezing in the patient’s upper lobes. Occasional conversational dyspnea was noted, as well as predominant dyspnea on exertion, which was more pronounced. The nurse documented that the patient utilizes an inhaler, oxygen, nebulizer treatments, Morphine, and Ativan directed toward dyspnea symptoms. It was noted that the patient was using 3-4 respiratory inhalers per month. Patient has been overutilizing the PRN Albuterol inhaler and is oxygen-dependent to control his Shortness of Breath. The patient’s oxygen saturation fluctuates on room air. At times it is less than 88%.... Care plan goals and interventions included assessing the patient’s cardiopulmonary system with the goal of exhibiting a reduction and/or relief of any cardiopulmonary symptoms. A review of the patient’s plan of care for the benefit period from 03/27/2026 to 04/16/2026 revealed that the agency did not ensure that an individualized, measurable goal for care was included in the plan of care to assess progress toward the goals and the efficacy of the current treatment plan. A joint clinical record review and interview were conducted on 05/08/2026 with the Manager of Clinical Services (Personnel Record 3) and the Regional Director of Clinical Operations (Personnel Record 2). During this review, it was confirmed that patients’ plans of care did not incorporate planned interventions or goals that reflected the identified assessment findings. Both leaders acknowledged that the plans of care did not align with clinical assessments, resulting in incomplete and non-individualized care planning.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals and includes measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. 6 of 19 (32%) clinical records reviewed revealed that the agency did not ensure that the identified goals for the patients’ care and treatment were individualized and measurable. CLINICAL RECORD 1: The patient, residing in a group home, elected hospice on 04/04/2023 with a terminal diagnosis of cerebral atherosclerosis, comorbid vascular dementia, and anxiety disorder. On 03/10/2026, the Registered Nurse (RN) documented the patient’s anxiety at 5/10 (goal 0), with caregiver report of increasing anxiety not relieved by Xanax. The physician was contacted, and Xanax was increased. At the 03/11/2026 Interdisciplinary Group (IDG) Meeting, the nurse reported worsening anxiety requiring this dosage increase, and “anxiety management education” was noted; however, there was no documented evaluation of effectiveness or follow-up plan. Anxiety was not addressed at the 03/25/2026 IDG Meeting. On 03/25/2026, the Nurse Practitioner documented during her Face-to-Face visit, continued increased anxiety necessitating the prior Xanax adjustment, indicating persistent symptoms. By 04/08/2026, IDG documented the patient was minimally responsive, with additional clinical decline; anxiety was noted as “managed,” despite recent escalation in medication. The medication regimen included Xanax (increased from 0.5 mg BID PRN on 01/26/2026 to 1 mg on 03/10/2026), Seroquel 100 mg at bedtime, and Depakote 250 mg BID for behaviors. A review of plans of care for 02/15/2026–04/15/2026 and 04/16/2026–06/14/2026 revealed “altered neurological status” as an identified problem on 04/04/2023. No measurable, patient-centered symptom goals related to polypharmacy targeting anxiety and agitation management were identified to evaluate treatment. CLINICAL RECORD 7: The patient, residing in an assisted living facility, elected hospice on 01/13/2026 with a terminal diagnosis of malignant neoplasm of the bladder and comorbidity of altered mental status. On 04/13/2026, the RN documented increased restlessness, worsening insomnia, and delusions that others attempted to poison the patient. The Nurse Practitioner increased the Seroquel from 25 mg to 50 mg nightly. On 04/20/2026, the RN documented escalating confusion and paranoia, with the patient repeatedly expressing fear that multiple doctors were administering medications. On 04/22/2026, Seroquel was discontinued, and Haldol 2 mg/mL, 0.5 mL twice daily, was initiated for behavioral symptoms, indicating continued decline and ineffective prior treatment. At the 04/22/2026 Interdisciplinary IDG Meeting, worsening delusions and insomnia were discussed, and group home staff education was provided on fall precautions, medication administration, and redirection. On 04/23/2026, the RN documented persistent and worsening delusions, with the patient stating that “green Indian people” were trying to medicate him and refusing meals due to fear of hidden medications. A review of the plans of care for 01/13/2026–04/12/2026 and 04/13/2026–07/11/2026 identified only a generalized problem of altered neurological status. Goals were limited to caregiver knowledge of recognizing changes in mentation and when to notify hospice. Interventions were limited to education on recognizing changes in the level of consciousness. There were no patient-specific, measurable goals addressing restlessness, agitation, insomnia, paranoia, or delusional behaviors, nor any measurement goal for a reduction in frequency or severity of delusions, improved sleep duration, or decreased agitation to evaluate the effectiveness of treatment. CLINICAL RECORD 12: During the admission visit by the RN on 03/23/2026, the patient exhibited disabling dyspnea at rest that was poorly responsive to bronchodilators. His oxygen saturation reading was 89% on 5 liters per minute (LPM) of oxygen via nasal cannula (NC). On 03/31/2026, a physician’s order was documented for Xanax 0.5mg three times daily as needed for anxiety. An IDG Meeting was held on 04/08/2026, and the nurse noted the addition of Xanax to the patient’s medications to help with anxiety. It was also noted that education was provided on fall precautions, pain and anxiety management, but there no details of what specifically was discussed were documented. On 04/22/2026, during the IDG Meeting, the nurse noted some medication changes, including Gabapentin, which was started for worsening neuropathy. It was noted that education was provided on dyspnea “management” and oxygen titration. Goals noted and reviewed were for the patient to be free from pain and dyspnea. The patient was documented to be on 6 LPM oxygen via NC and ambulatory only short distances with fatigue and cough. He was noted to drink 8-9 beers daily and to take THC (tetrahydrocannabinol) gummies in addition to his prescribed medications. A review of the patient’s plans of care for the benefit periods dated 05/03/2026 to 07/01/2026 and 03/23/2026 to 05/02/2026 included goals that the patient would understand the medication schedule and medications affecting mentation, pain to be managed at an “acceptable” level to the patient, the patient would exhibit a reduction/relief of cardiopulmonary symptoms, and that the patient/caregiver would be able to demonstrate/verbalize an understanding of how to correct safety hazards in the home, and the proper safety measures related to fall prevention and and understanding of applicable safety measures. The goals were not measurable or patient-specific. CLINICAL RECORD 13: The patient elected the hospice benefit on 03/23/2026 with a terminal diagnosis of anoxic brain damage with comorbidities of cardiac arrest; epilepsy without status epilepticus; quadriplegia; chronic pain; wedge compression fractures of T11–T12 vertebrae; spinal stenosis; depressive disorder; anxiety disorder; insomnia; osteoarthritis; diverticulitis At the RN admission visit on 03/23/2026, the patient was assessed with pain rated 6/10 (goal 0), described as intermittent daily cramping and stabbing back pain impacting enjoyment of activities, concentration, emotions, and sleep/rest. Dyspnea was rated 2/10 (goal 0) with increased secretions. The patient was alert and oriented to self, place, and situation, with new-onset aphasia, occasionally able to respond with one-word replies. A poor cough reflex and difficulty clearing secretions were noted. Following a pre-admission swallow study, a pureed diet with nectar-thickened liquids was recommended due to dysphagia and aspiration risk. During the IDG Meeting on 04/02/2026, the patient was identified as at risk for aspiration, evidenced by coughing during eating and medication administration. Aphasia onset was also documented. On 04/03/2026, nursing documentation identified constipation, with the last bowel movement reported as more than five days prior. The Facility Nurse (FSN) was instructed on as-needed (PRN) use of a Dulcolax suppository. On 04/07/2026, the last bowel movement was documented as 04/05/2026, and the physician was contacted; an order for daily lactulose was obtained. At the IDG Meeting on 04/16/2026, documentation reflected changes in pain management due to prior ineffectiveness: Oxycodone and Morphine (5 mg every 4 hours PRN [as needed]) were discontinued, and a Fentanyl 50 mcg/hour (hr) patch was initiated. Education was reportedly provided to facility staff regarding pain management, infection control, safety precautions, skin breakdown prevention, and medication adherence. The visit note indicated that the current medication and treatment plan were effective; however, there was no clear supporting evidence of reassessment data validating effectiveness at that time. On 04/30/2026, IDG documentation stated the pain regimen was effectively controlling pain and that the patient was medically managed, with continued staff education documented. There was limited objective data to support sustained effectiveness, patient response, or measurable outcomes. The active medication list included multiple agents addressing behavioral health, seizures, pain, muscle spasms, constipation, and insomnia, including Fentanyl 50 mcg/hr, Lorazepam (both scheduled and PRN), Depakote, Vimpat, Onfi, Baclofen, Senna, Lactulose, and others. Despite complex symptom burden and polypharmacy, documentation did not consistently demonstrate ongoing evaluation of medication effectiveness, side effects, or interdisciplinary coordination specific to symptom management outcomes. The initial plan of care included safety measures such as emergency planning, fall precautions, oxygen precautions, seizure precautions, standard precautions, and adherence to a pureed diet. However, across the certification period (03/23/2026 – 06/20/2026), documentation demonstrates gaps in individualized reassessment, insufficient evidence of goal evaluation, and limited objective support for changes in clinical status or treatment effectiveness. Care plan goals and interventions included management of altered neurological status, pain/comfort, and home safety. Goals reflected patient/caregiver understanding of recognizing changes in level of consciousness, pain management, and safety hazards, with instructions to notify hospice of significant changes. Interventions included education on recognizing decreased levels of consciousness, pain control measures, evaluation of intervention effectiveness, assessment of functional status related to safety risks, and reinforcement of fall precautions. However, documentation lacked consistent evidence of caregiver competency validation or measurable outcomes tied to these goals. CLINICAL RECORD 14: The patient, residing at home, elected hospice on 08/29/2024 with a terminal diagnosis of Alzheimer’s disease. At the 02/11/2026 IDG Meeting, the patient was documented as pocketing food, requiring thickened liquids, and experiencing difficulty swallowing. The patient also required a Hoyer lift for transfers. While the IDG noted “goals set and reviewed,” the only goal identified was for the patient to remain free of wounds. Medication adjustments included conversion of Senna to liquid form and addition of MiraLAX for constipation. At the 03/25/2026 Face-to-Face Encounter visit, the Nurse Practitioner documented further decline, with the patient consuming only 25–50% of meals, requiring one-to-one feeding, exhibiting increased dysphagia, and continuing to pocket food. The physician’s certification for the benefit period dated 04/21/2026–06/19/2026 further noted worsening dysphagia, prolonged meal times exceeding one hour, frequent sleeping during meals, need for thickened liquids, and ongoing food pocketing. At the 04/08/2026 IDG, the patient was described as “medically managed,” with the IDG goals limited to remaining free from falls. The nurse simultaneously documented minimal fluid intake, worsening dysphagia, and repeated somnolence during meals. A review of the plans of care dated 02/20/2026–04/20/2026 and 04/21/2026–06/19/2026 revealed that aside from the notation of thickened liquids, there was no patient-specific measurable goals to address safe swallowing, nutritional intake, or aspiration risk. CLINICAL RECORD 18: The patient, who resided at home, elected the hospice benefit on 03/27/2026 with a terminal diagnosis of unspecified severe protein-calorie malnutrition with comorbid conditions including COPD (chronic obstructive pulmonary disease), chronic fatigue syndrome, adjustment disorder with mixed anxiety and depression, insomnia, weakness, and shortness of breath (SOB). During a visit by the RN on 01/19/2026, the patient’s respiratory rate (RR) was 20, labored, and shallow. The nurse documented the patient’s clinical state in part through the visit narrative, “Patient and wife state that patient is going through 1 inhaler every 2-3 days...Patient found to be hypoxic at 79-81% on room air. Patient placed on 3 liters per minute (LPM) oxygen via nasal cannula, and pulse ox increased to 92%. Patient encouraged to take nebulizer treatment as well, which seems to have helped with his difficulty breathing... barrel chest noted to be more pronounced this visit...Discussed respiratory distress treatment and need to increase nebulizer treatments to 4 a day to help cut down on the amount of inhaler usage and to keep patient on O2 at all times now....” At the IDG Meeting dated 01/22/2026, the nurse noted that the patient had been exhibiting an increase/exacerbation of his respiratory system, with breath sounds diminished at the bases, and expiratory wheezing in the patient’s upper lobes. Occasional conversational dyspnea was noted, as well as predominant dyspnea on exertion, which was more pronounced. The nurse documented that the patient utilizes an inhaler, oxygen, nebulizer treatments, Morphine, and Ativan directed toward dyspnea symptoms. It was noted that the patient was using 3-4 respiratory inhalers per month. Patient has been overutilizing the PRN Albuterol inhaler and is oxygen-dependent to control his SOB. The patient’s oxygen saturation fluctuates on room air, and at times it is less than 88%. Care plan goals and interventions included assessing the patient’s cardiopulmonary system with the goal of exhibiting a reduction and/or relief of any cardiopulmonary symptoms. A review of the patient’s plan of care for the benefit period dated 03/27/2026 to 04/16/2026 revealed that the agency did not ensure that an individualized, measurable goal for care was included in the plan of care to assess progress toward the goals and the efficacy of the current treatment plan. A joint clinical record review and interview were conducted on 05/08/2026 with the Manager of Clinical Services (Personnel Record 3) and the Regional Director of Clinical Operations (Personnel Record 2). During this review, it was confirmed that patient goals documented in the plans of care were not consistently measurable. Both leaders acknowledged that the goals lacked specific, quantifiable criteria necessary to evaluate patient progress and outcomes, resulting in care planning that did not support effective monitoring or clinical decision-making.”

“It is required that hospice aides be 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 an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. 2 of 18 (11%) clinical records reviewed with Hospice Aide services revealed that the agency did not ensure that the Registered Nurse (RN) provided clear, complete instructions to the Hospice Aide (HA) in order to provide quality, safe care. CLINICAL RECORD 3: A review of the patient’s initial plan of care (POC) for the benefit period dated 04/04/2026 to 07/02/2026 included orders for the HA to visit the patient weekly. The HA POC dated 04/23/2026, active at the time of record review, included the following interventions to be performed at every visit: bed bath, hair care, skin care, catheter care, perineal care, shaving, and oral care. During the RN visit on 04/23/2026, the nurse documented the patient exhibited symptoms of congestive heart failure at rest, was oxygen dependent, and had an oxygen saturation reading of 97% on 5 liters per minute (LPM) of oxygen via nasal cannula (NC). Again, on 04/30/2026, the nurse documented that the patient was on 5 LPM of oxygen. The RN did not provide instructions to the HA regarding the care of the patient on continuous oxygen, including when and for how long the oxygen could be removed for care. CLINICAL RECORD 14: The hospice benefit was elected on 08/29/2024. The patient’s POC for the benefit period dated 04/21/2026 to 06/19/2026 included orders for the HA to visit the patient, effective 04/21/2026, three times a week for one week, five times a week for 7 weeks, and 4 times a week for one week. The HA POC dated 02/11/2026, and active at the time of record review, included the following interventions to be provided at each visit: bed bath, skin care, shaving, oral care, nail care, incontinence care (patient unable to use toilet, incontinent of bowel and bladder, check and change patient in bed with the assist of 1 person, uses medium tabbed briefs or pullups at spouse’s discretion and disposable wipes). During the RN visit on 04/27/2026, a 14Fr Foley catheter was placed. A physician’s order was documented to insert a 14FR Foley catheter with a 10 mL balloon and to change the catheter as needed. The HA POC was not updated to include instructions to the HA for catheter care. HA visits were documented on 04/29/2026, 05/01/2026, 05/02/2026, and 05/03/2026. During a joint clinical record review and interviews with the Manager of Clinical Services (Personnel Record 3) and the Regional Director of Clinical Operations (Personnel Record 2) on 05/05/2026 and 05/08/2026 the findings were confirmed that the HA POCs did not include full, complete instructions to the HA in order to care for the patients with continuous oxygen and a Foley catheter.”

“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. During review of the Volunteer Program documentation and interviews with the Director of Care Services (Corporate – Personnel Record 5) and the Volunteer Program Manager on 05/07/2026, it was determined that the average percentage of total patient care hours for all paid hospice employees and contract staff was 0.81% in 2024, 0.92% in 2025, and 0.55% year-to-date in 2026, indicating a sustained and significant variance from the 5% regulatory expectations. Due to the ongoing inability to meet the 5% threshold, a Performance Improvement Project (PIP) was initiated and remained active at the time of the site visit. Leadership transitions were noted, with the Volunteer Program Manager beginning employment in October 2025 and the Director of Care Services assuming oversight of the volunteer program approximately one month prior to the survey. The program is supported through local, regional, and corporate oversight structures. The organization has implemented multiple recruitment and engagement strategies, including using online platforms such as VolunteerMatch/Idealist, outreach to community colleges and universities, and distributing recruitment materials at community locations, including libraries, senior centers, and churches. Incentive-based recruitment initiatives are in place, offering credits through the corporate recognition program for volunteer and employee referrals. Administrative and operational support includes a HIPAA-compliant volunteer management system designed to facilitate hour tracking, communication, and engagement. The system allows for real-time updates, recognition through role-based and service-based “badges,” and automated reminders for birthdays and anniversaries to promote volunteer retention. Additional recognition efforts include incentives such as state fair tickets, company apparel, and corporate store credits. At the time of the interview, volunteer recruitment activity had recently made progress, with one new volunteer activated for the parent site on the day of the site visit and one additional individual in the onboarding process for the ADS (Alternate Delivery site). Despite these efforts, measurable outcomes have not yet achieved the required 5% volunteer contribution. During review of the Volunteer Program documentation and interviews with the Director of Care Services (Corporate – Personnel Record 5) and the Volunteer Program Manager on 05/07/2026, it was determined that the average percentage of total patient care hours for all paid hospice employees and contract staff was 0.81% in 2024, 0.92% in 2025, and 0.55% year-to-date in 2026, indicating a sustained and significant variance from the 5% regulatory expectations. Due to the ongoing inability to meet the 5% threshold, a Performance Improvement Project (PIP) was initiated and remained active at the time of the site visit. Leadership transitions were noted, with the Volunteer Program Manager beginning employment in October 2025 and the Director of Care Services assuming oversight of the volunteer program approximately one month prior to the survey. The program is supported through local, regional, and corporate oversight structures. The organization has implemented multiple recruitment and engagement strategies, including using online platforms such as VolunteerMatch/Idealist, outreach to community colleges and universities, and distributing recruitment materials at community locations, including libraries, senior centers, and churches. Incentive-based recruitment initiatives are in place, offering credits through the corporate recognition program for volunteer and employee referrals. Administrative and operational support includes a HIPAA-compliant volunteer management system designed to facilitate hour tracking, communication, and engagement. The system allows for real-time updates, recognition through role-based and service-based “badges,” and automated reminders for birthdays and anniversaries to promote volunteer retention. Additional recognition efforts include incentives such as state fair tickets, company apparel, and corporate store credits. At the time of the interview, volunteer recruitment activity had recently made progress, with one new volunteer activated for the parent site on the day of the visit and one additional individual in the onboarding process for the ADS site. Despite these efforts, measurable outcomes have not yet attained the required 5% volunteer contribution.”