St. Croix Hospice

“Based on policy review, record review, and interview, the hospice provider failed to ensure the plan of care included interventions necessary for the palliation and management of a patient’s scalp lesions in, one out of three sampled patients (Record/Patient #1). This deficient practice has the potential to affect all hospice patients requiring ongoing interventions to be incorporated into and coordinated through the hospice plan of care. Findings included:Review of the provider’s policy titled “The Plan of Care,” last reviewed 01/08/2025, showed in part:- The plan of care (POC) will identify the patient’s needs and services to meet those needs;- The POC will be reviewed and revised as frequently as deemed necessary;- Any change in the patient’s condition must result in a change in the POC;- The written POC will contain pain and symptom management interventions;- The POC will include information from the updated comprehensive assessment; and- Care provided to the patient will be in accordance to the POC. RECORD/PATIENT #1:The patient had multiple scalp lesions for which hospice interventions had previously been ordered. Review of the hospice physician order dated 02/24/2026 directed facility staff to monitor for worsening scalp lesions, cleanse with soap and water, pat dry with gauze, leave open to air, and directed hospice nursing staff to assess weekly. The order was effective through 05/04/2026.Review of the clinical record failed to identify a subsequent physician order addressing ongoing management of the scalp lesions after expiration of the 02/24/2026 order. Review of the hospice interdisciplinary group (IDG) comprehensive assessment and plan of care update report effective 05/04/2026 through 08/01/2026 and IDG documentation dated 05/27/2026 failed to identify patient-specific scalp lesion interventions, wound care instructions, monitoring parameters, or physician-directed treatment orders despite clinical documentation continuing to reference scalp lesions following expiration of the physician’s order on 05/04/2026.Review of hospice documentation failed to demonstrate how scalp lesion care was to be provided, monitored, or coordinated after 05/04/2026. The hospice was unable to provide evidence that ongoing scalp lesion interventions were incorporated into the active plan of care or communicated to the assisted living facility following expiration of the physician order.During interview on 06/11/2026 at 11:42 AM, the assisted living facility representative stated that the facility had not received ongoing wound care orders related to the scalp lesions and reported lesion care was not included on the facility treatment record. The facility further stated it did not maintain wound care supplies and relied upon hospice direction regarding patient-specific wound care interventions. During interview on 06/15/2026 at 2:15 PM, the nurse practitioner/case manager stated that the patient had multiple scalp lesions and acknowledged the prior order was based upon dermatology recommendations. During interview on 06/15/2026 at 3:35 PM, the hospice administrator stated that the provider was unable to locate documentation, demonstrating a physician order, plan of care update, or transmission of scalp lesion care instructions to the facility following expiration of the order on 05/04/2026.These findings demonstrate the hospice failed to ensure the plan of care included services necessary for the palliation and management of the patient’s scalp lesions and failed to ensure those interventions were incorporated into the ongoing interdisciplinary plan of care.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure:- The plan of care reflected patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments (L0545);- The interdisciplinary group reviewed, revised, and documented the individualized plan as frequently as the patient’s condition required (L0552); and- Ensure that the interdisciplinary group-maintained responsibility for directing, coordinating, and supervising the care and services provided (L0554).The cumulative effect of these deficient practices resulted in the hospice’s failure to ensure the interdisciplinary group developed, updated, and coordinated an individualized plan of care that addressed significant changes in the patient condition.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure advance directive requirements were followed by not involving both legally designated joint powers of attorney (POAs) in health care decision making following a significant change in condition, in one of three patients reviewed (Patient/Record #1). This deficient practice has the potential to affect all the patients served by the provider. Findings included:Review of the provider’s titled document “Missouri Patient Rights and Responsibilities,” showed, in part:- Required that patients and/or their legally authorized representatives to be provided accurate, understandable information to support informed decision making, including participation in care decisions and notification of significant changes in condition;- Advanced directives were to be honored in accordance with state law and that designated representatives be involved in decision-making when the patient is unable to exercise their rights; and- The patients or representatives have the right to accept or refuse care only after being fully informed of available options and consequences.Review of the provider’s titled policy, “Advance Directives” revised December 2018 showed in part:- The policy required that patients and/or their legally authorized representatives be informed of their right to make medical decisions, including the right to accept or refuse care, and that valid advance directives, including Durable Powers of Attorney (POA) and do not resuscitate (DNR)/do not intubate (DNI) orders, be followed as required by law;- The policy required clinicians to identify, review, document, communicate advanced directive information, involve patient representatives when the patient lacks decision-making capacity, and ensure representatives participate in ongoing decision=making as the patient’s condition changes; and- The provided required accurate documentation of discussions and continued communication with the patient representatives regarding treatment decisions.RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice care on 04/15/2025 with a terminal diagnosis of hypertensive heart disease and died on 11/30/2025. The patient resided in a long-term care facility (LTCF).Review of the patient’s Durable Power of Attorney (DPOA) documentation, signed and notarized on 12/30/2024, showed the patient designated two agents required to act jointly in healthcare decision-making. The document did not authorize either agent to act independently.The advanced directive remained effective upon the patient’s incapacity and did not grant unilateral decision-making authority to a single agent. The patient’s Do Not Resuscitate (DNR) order did not indicate limitations on diagnostic evaluation or hospital transfer.Following the patient’s fall and significant change in condition on 11/24/2025, documentation did not demonstrate that both designated joint POAs were notified of the change in condition or involved in decision-making regarding hospital evaluation or transition or comfort-focused care.The clinical record reflected that comfort-focused measures were initiated; however, documentation did not demonstrate that the decision to forgo hospital evaluation was supported by documented, informed, and joint participation of both legally designated representatives, and the record failed to reflect corresponding updates to the plan of care reflecting that change in goals.During an interview on 01/20/2026 at 12:48 PM, the hospice registered nurse case manager (RNCM) stated that following the patient’s fall and decline on 11/24/2025, hospitalization was offered and the patient’s family elected to continue comfort-focused hospice care. During an interview on 01/22/2026 at 10:14 AM, an individual identified as one of the patient’s joint POAs stated that hospice staff informed him/her after the patient’s fall that the patient could not be sent to the hospital due to the patient’s DNR status. The POA stated that he/she agreed to comfort-focused care based on the information provided and did not understand that hospital evaluation could still be considered. A DNR order does not prohibit hospital evaluation or medical unless limitations are specified in the advanced directive. During an interview on 01/26/2026 at 10:40 AM, the patient’s other joint POA stated that hospice staff informed the family when services began that hospital evaluation was no longer an option and that they were to contact hospice instead of seeking outside medical care. The POA stated that he/she later learned hospitalization could have been considered and would have wanted the patient evaluated following the fall and change in condition.During an interview on 01/21/2026 beginning at 1:16 PM, the hospice administrator and registered nurse coordinator stated that staff contacted the first individual listed in the record and did not verify whether multiple POAs were required to act jointly. They stated the patient’s family elected comfort-focused care and staff contacted that individual because he/she was listed as the first contact. They acknowledged they were unaware the patient had designated joint POAs.”

“Based on policy review, record review, and interview the hospice provider failed to develop and maintain an individualized plan of care (POC) that addressed the patient’s assessed needs, problems, and significant changes in condition, in one of three patients reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. Findings included:Review of the provider’s titled policy, “The Plan of Care” reviewed 01/08/2025 showed in part the POC was to be individualized and include patient-specific problems, goals, and interventions based on ongoing assessment. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice care on 04/15/2025 with a terminal diagnosis of hypertensive heart disease (heart problems caused by long-term, uncontrolled pressure) and resided in a long-term care facility (LCTF). Record review showed the patient’s POC remained generic and failed to include individualized interventions for documented needs and changes in condition including: - On 05/25/2025 and 07/07/2025, the patient sustained falls, including a fall that was later confirmed to involve a fracture. The POC failed to include individualized fall-prevention interventions, and confirmed fracture, safety monitoring, or increased supervision measures following documented falls with injury;- On 08/09/2025, the LTCF reported the patient had recently completed treatment for a urinary tract infection (UTI) and was experiencing increased paranoia and anxiety. Subsequent documentation on 08/12/2025 reflected worsening psychosis and confusion. The POC failed to include infection-related monitoring, reassessment of contributing medical causes, or interventions addressing the impact of the UTI on the patient’s mental status;- On 11/18/2025, drooling and neurological changes were reported; and- On 11/24/2025 at 2:23 PM, the patient experienced a witnessed fall with loss of consciousness (LOC), followed by right-sided weakness, leaning to the right, loss of grip strength, decreased appetite, and inability to speak full sentences. The POC failed to include individualized neurological monitoring, swallowing precautions, increased safety interventions, or revised goals reflecting this significant decline. These findings show the POC was not individualized and did not reflect the patient’s changing clinical needs, worsening symptoms, and safety risks. During interview on 01/21/2026 at 2:08 PM, the registered nurse coordinated stated that the patient experienced worsening behaviors, falls, and neurological decline; however, the POC did not include individualized interventions to address these needs. During interview on 01/21/2026 at 2:08 PM, the administrator stated that there were no fall interventions in place prior to the fall on POC on 11/24/2025.”

“Based on policy review, record review, and interview, the hospice failed to ensure the interdisciplinary group (IDG) reviewed and revised the plan of care (POC) in response to significant changes in the patient’s condition, including documented falls, infection related mental status changes, behavioral decline and neurological deterioration, in one of three patients reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. Findings included:Review of the provider’s titled policy, “The Plan of Care” reviewed 01/08/2025, showed the IDG is responsibility for ongoing review and revision of the POC based on changes in the patient’s condition.RECORD/PATIENT #1:The patient was admitted to hospice on 04/15/2025 with a terminal diagnosis of hypertensive heart disease and resided in a long-term care facility (LTCF). The patient expired on 11/30/2025.Review of the clinical record showed repeated instances in which the patient experienced significant changes in condition, and the interdisciplinary group (IDG) failed to coordinate and implement revisions to the plan of care to address those changes, including:- On 07/07/2025, the patient sustained a fall later confirmed to involve a toe fracture. The IDG note dated 07/23/2025 documented no falls, despite clinical documentation confirming a fall with a toe fracture on 07/07/2025, and did not reflect revision of the POC to address fall risk, injury monitoring, or safety interventions;- On 08/09/2025, the LTCF reported the patient completed treatment for a urinary tract Infection (UTI) and was experiencing increased paranoia and anxiety;- On 08/12/2025, the hospice nurse documented worsening psychosis, anxiety, and confusion;- Review of the IDG note dated 08/18/2025 reflected ongoing hallucinations and paranoia; however, the POC was not revised to address infection-related monitoring, behavioral management changes, or reassessment of medication effectiveness;- Documentation on 10/03/2025, 10/07/2025, and 10/13/2025 showed anxiety and paranoia;- Review of the IDG note dated 10/15/2025 showed no symptom management changes and did not reflect revision of the POC to address behavioral or psychosocial needs;- On 11/18/2025, drooling and neurological changes were reported;- On 11/24/2025 at 2:23 PM, the patient experienced a witnessed fall with loss of consciousness followed by right sided weakness, leaning to the right, loss of grip strength, decreased appetite, and inability to speak in full sentences; and - The IDG note dated 11/26/2025 documented significant changes since the review but the documentation showed the patient’s current medications and treatments were effective and did not reflect revision of the POC to address increased care needs, neurological monitoring, swallowing risk, or safety interventions. During interview on 01/21/2026 at 2:08 PM, the administrator stated that:- If physician notification or care plan revision was not documented, it was not considered done; and- The POC was not updated following the patient’s significant decline.”

“Based on policy review, record review, and interview, the hospice failed to ensure the interdisciplinary group (IDG), including the hospice physician, maintained responsibility for directing, coordinating, and supervising care and services when significant changes in the patient’s condition occurred, in one of three patients reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. Findings included:Review of the provider’s titled policy, “Interdisciplinary Group Coordination of Care” reviewed 01/08/2025 showed in part:- The hospice interdisciplinary group (IDG) retains professional management responsibility for the provision of services and ensures services are furnished in a safe and effective manner;- The Case Manager is responsible for coordinating services with the interdisciplinary group from referral to discharge;- The type and scope of services provided by the IDG are based upon comprehensive and ongoing assessments and a comprehensive plan of care that defines patient and family/caregiver problems, goals, and interventions;- The Case Manager facilitates communication about changes in the patient’s status between IDG members and the patient’s attending physician;- Hospice personnel communicate changes in a timely manner, and documentation must include the date and time of the communication, individuals involved, information discussed, and the outcome;- Written evidence of care coordination is maintained in the plan of care and/or interdisciplinary team meeting documentation in the clinical record; and- The IDG develops, updates, and reviews the effectiveness of the plan of care at least every 15 days and communicates updates to the attending physician. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice care on 04/15/2025 with a terminal diagnosis of hypertensive heart disease (heart problems caused by long-term, uncontrolled pressure) and resided in a long-term care facility (LCTF). The patient expired on 11/30/2025. Review of the clinical record showed: - Falls with injury and fracture occurred on 05/25/2025 and 07/07/2025. Documentation did not demonstrate coordinated IDG communication with the physician or interdisciplinary revision of the plan of care (POC) following these events;- Escalating psychosis and behavioral changes throughout August and September 2025 lacked documentation that the IDG coordinated physician assessment or incorporated medical evaluation into care planning;- Neurological changes including drooling, weakness, and facial asymmetry reported 11/18/2025 through 11/21/2025 lacked evidence of coordinated physician notification, interdisciplinary reassessment, or updated medical direction reflected in the POC;- Review of IDG physician documentation showed the physician consistently documented review of standard checklist items (plan of care, medication profile, drug therapies, and diagnoses list) and agreement with the existing POC. The entries consisted of prepopulated checklist documentation and failed to reference or address the patient’s documented falls with injury, urinary tract infection with mental status changes, escalating psychosis, or subsequent neurological decline. There was no documentation of physician reassessment, new medical direction, or modification of the POC in response to these significant clinical events;- On 11/24/2025 at 2:23 PM, documentation showed the patient experienced a witness fall with loss of consciousness, followed by right-sided weakness, leaning to the right side, loss of grip strength, decreased appetite, and inability to speak full sentences; and- On 11/26/2025, the IDG note showed documented significant changes since the last review, and despite acknowledging these changes, the IDG documentation stated the patient’s current medications and treatments were effective and did not reflect revisions to the POC to address the patient’s increased care needs, neurological monitoring, or safety risks. Review of the IDG physician documentation for this period did not address this fall, the associated neurological changes, or the need for reassessment and did not reflect physician direction to modify the POC. During interview on 01/21/2026 at 2:08 PM, the registered nurse coordinated stated that the POC was not determined effective. During interview on 01/21/2026 at 2:08 PM, the administrator stated that:- If physician notification was not documented, it was not done;- There were no fall preventions in place prior to the fall on 11/24/2025;- If the POC was not updated it was not effective; and- The POC was not updated following the 11/24/2025 fall.”

“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” stated in part: “ A monthly patient visit will be completed by a registered nurse to supervise licensed practical/vocational nursing services.” In 5 of 10 (50%) clinical records reviewed of patients who received Licensed Practical Nurse services (LPN), the agency did not ensure that nursing care was provided under the supervision of a Registered Nurse per agency policy. CLINICAL RECORD 1: The patient elected the hospice benefit on 02/06/2025. A clinical record review on 07/23/2025 revealed no documented RN supervisory visit. The LPN documented visits on 02/27/2025, 03/07/2025, 03/13/2025, 03/19/2025, 03/25/2025, 04/01/2025, 04/22/2025, 05/05/2025, and 05/08/2025. CLINICAL RECORD 2: The patient elected the hospice benefit on 09/27/2024. A clinical record review on 07/23/2025 revealed no documented RN supervisory visit. The LPN documented visits on 04/01/2025, 04/15/2025, 04/22/2025, 05/05/2025, and 05/22/2025. CLINICAL RECORD 3: The patient elected the hospice benefit on 02/01/2022. A clinical record review on 07/23/2025 revealed no documented RN supervisory visit. The LPN documented visits on 05/29/2025 and 06/24/2025. CLINICAL RECORD 5: The patient elected the hospice benefit on 04/22/2025. A clinical record review on 07/23/2025 revealed no documented RN supervisory visit. The LPN documented visits on 04/23/2025, 05/05/2025, and 05/29/2025. CLINICAL RECORD 8: The patient elected the hospice benefit on 03/29/2025. A clinical record review on 07/23/2025 revealed no documented RN supervisory visit. The LPN documented visits on 03/31/2025, 04/11/2025, 04/21/2025, 05/08/2025, 06/06/2025, and 06/19/2025. During joint record reviews and interviews on 07/24/2025, the agency’s Accreditation Specialist confirmed the above findings, stating, “The supervisory visits are not documented in the chart.””

“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, document review, and interview. Agency policy #1-031 “Responsibilities/Supervision of Clinical Services” stated part: “Hospice aide supervisory visits will be conducted on site at least every 14 days by a hospice registered nurse.” In 8 of 17 (47%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not document a supervisory aide visit every 14 days. CLINICAL RECORD 1: The patient elected the hospice benefit on 02/06/2025. The plan of care dated 02/06/2025 through 05/06/2025 ordered “HA 2 x per week.” HA visits were provided as ordered. The RN documented HA supervisory visits on 03/12/2025 and 05/20/2025 (with 69 days outstanding), and 06/05/2025 (with 16 days outstanding). CLINICAL RECORD 2: The patient elected the hospice benefit on 09/27/2024. The plan of care dated 03/26/2025 through 07/23/2025 ordered “HA 2 x per week.” HA visits were provided as ordered. The RN documented HA supervisory visits on 03/13/2025, 05/20/2025 (with 68 days outstanding), and 06/05/2025 (with 17 days outstanding). CLINICAL RECORD 3: The patient elected the hospice benefit on 02/01/2022. The plan of care dated 05/16/2025 through 07/14/2025 ordered “HA 1 x per week.” HA visits were provided as ordered. The RN documented a HA supervisory visit on 06/13/2025 (which was 28 days after the start of HA services). A clinical record review on 07/23/2025 revealed that no further HA supervisory visits were documented in the clinical record. CLINICAL RECORD 4: The patient elected the hospice benefit on 04/15/2025. The plan of care dated 04/15/2025 through 06/13/2025 ordered “HA 1 x per week.” HA visits were provided as ordered. The RN documented a HA supervisory visit on 05/19/2025 (which was 28 days after the first HA visit). A clinical record review on 07/23/2025 revealed that no further HA supervisory visits were documented in the clinical record. CLINICAL RECORD 8: The patient elected the hospice benefit on 03/29/2025. The plans of care dated 03/29/2025 through 06/26/2025 and 06/27/2025 through 09/24/2025 ordered “HA 2 x per week.” HA visits were provided as ordered. The RN documented HA supervisory visits on 04/25/2025 (with 26 days outstanding), 05/14/2025 (with 19 days outstanding), 06/10/2025 (with 27 days outstanding), and 07/10/2025 (with 30 days outstanding). CLINICAL RECORD 18: The patient elected the hospice benefit on 05/23/2025. The plan of care dated 05/23/2025 through 08/20/2025 ordered “HA 2 x per week.” HA visits were provided as ordered. The RN documented HA supervisory visits on 06/10/2025 and 06/30/2025 (with 20 days outstanding). CLINICAL RECORD 19: The patient elected the hospice benefit on 01/30/2025. The plans of care dated 01/30/2025 through 04/29/2025 and 04/30/2025 through 07/28/2025 ordered “HA 1 x per week.” HA visits were provided as ordered. The RN documented a HA supervisory visit on 04/10/2025 (with 70 days outstanding). During joint record reviews and interviews on 07/24/2025, the agency’s Accreditation Specialist and Regional Clinical Director confirmed the above findings, stating “The supervisory visits are not documented in the chart.””

“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, 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 agency’s 2024 Hospice Volunteer Requirement Report revealed that the volunteer percentage of hours worked for January 2024 through May 2024 was 0.38%. The Administrator/Director of Nursing (DON) and the Alternate Administrator/Alternate DON confirmed the findings during an interview on 07/25/2025, stating, “They are getting more volunteers and the percentage is up to 0.5% in 2025.” The review of the Hospice Volunteer Requirement 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.”