St Croix Hospice

“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; other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: 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, observation, and interview. In 3 of 19 (16%) clinical records reviewed and home visits observed, the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient’s current medications. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 04/24/2025 with a diagnosis of Alzheimer’s disease. The patient resided in a skilled nursing facility (SNF). During the home visit with the Hospice Aide (HA)[Personnel Record 7] on 09/09/2025, the hospice medication profile (printed on 09/08/2025) was compared with the SNF medication list (printed on 09/09/2025). The following medication(s) were documented on the hospice medication profile and not documented on the SNF medication list: lorazepam 0.5 mg, one (1) tablet every 4 hours as needed (ordered 04/29/2025). The following medication(s) were listed on the SNF list and not present on the hospice list: Mucinex 600 mg, one (1) tablet every 12 hours as needed (ordered 08/15/2025); vitamin D 1000 mg, one (1) tablet daily (ordered 10/09/2024); cholecalciferol 50 mcg, one (1) tablet daily (ordered 05/31/2024). The last nursing visit was the previous week. Clinical Record 2/Home Visit 2: The patient elected the hospice benefit on 07/17/2025 with a diagnosis of Parkinson’s disease. The patient resided in an assisted living facility (ALF). During the home visit with the Registered Nurse (RN) [Personnel Record 4] on 09/09/2025, the hospice medication profile (printed on 09/08/2025) was compared with the ALF medication bottles. The hospice medication profile documented “morphine 0.25 ml every 2 hours as needed (ordered 07/22/2025) and the ALF medication bottle label documented morphine 0.25 ml every 3 hours as needed (ordered 07/25/2025). During an interview, the RN stated, “That’s strange, we don’t even order it every 3 hours.” The last nursing visit was the previous week. Clinical Record 4/Home Visit 4: The patient elected the hospice benefit on 03/17/2025 with a diagnosis of Huntington’s disease. The patient resided in a skilled nursing facility (SNF). During the home visit with the Music Therapist (MT) [Personnel Record 9] on 09/09/2025, the hospice medication profile (printed on 09/08/2025) was compared with the SNF medication list (printed on 09/09/2025). The following medication(s) were documented on the hospice medication profile and not documented on the SNF medication list: “Ingrezza 40 mg, one (1) capsule daily (ordered 04/09/2025); lorazepam 0.25 ml every 4 hours as needed (ordered 03/18/2025); multivitamin, one (1) tablet daily (ordered 03/18/2025); pantoprazole 40 mg, one (1) tablet (ordered 03/18/2025); and polysaccharide 150 mg daily (ordered 03/18/2025).” The following medications were documented on the SNF medication list and not on the hospice medication profile: “trazadone 50 mg, one (1) tablet at bedtime (ordered 05/22/2025), benztropine 1 mg, take one (1) twice daily (ordered 07/02/2025); bisacodyl 5 mg, one (1) tablet daily (ordered 05/16/2025). The last nursing visit was the previous week. During an interview and joint clinical record review on 09/11/2025, the Regional Director of Clinical Operations and Statewide Clinical Director confirmed the findings and stated that the medications should be reconciled during weekly nursing visits.”

“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, observation, and interview. In 2 of 19 (11%) clinical records reviewed and home visits observed, the agency did not ensure that the patient’s plan of care included the patient’s current medications. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 04/24/2025 with a diagnosis of Alzheimer’s disease. The patient resided in a skilled nursing facility (SNF). During the home visit with the Hospice Aide (HA)[Personnel Record 7] on 09/09/2025, the following medication(s) were listed on the SNF list and not included in the patient’s plan of care: Mucinex 600 mg, one (1) tablet every 12 hours as needed (ordered 08/15/2025); vitamin D 1000 mg, one (1) tablet daily (ordered 10/09/2024); cholecalciferol 50 mcg, one (1) tablet daily (ordered 05/31/2024). The last nursing visit was the previous week. Clinical Record 4/Home Visit 4: The patient elected the hospice benefit on 03/17/2025 with a diagnosis of Huntington’s disease. The patient resided in a skilled nursing facility (SNF). During the home visit with the Music Therapist (MT) [Personnel Record 9] on 09/09/2025, the following medications were documented on the SNF medication list and not included in the patient’s plan of care: “trazadone 50 mg, one (1) tablet at bedtime (ordered 05/22/2025), benztropine 1 mg, take one (1) twice daily (ordered 07/02/2025); and bisacodyl 5 mg, one (1) tablet daily (ordered 05/16/2025). The last nursing visit was the previous week. During an interview and joint clinical record review on 09/11/2025, the Regional Director of Clinical Operations and Statewide Clinical Director confirmed the findings and stated that the medications should be reconciled during weekly nursing visits.”

“It is required that 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 3 of 18 (17%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the HA received written patient instructions to meet the patient’s needs.. CLINICAL RECORD 4: The patient elected hospice care on 03/17/2025 with a diagnosis of Huntington’s disease. The patient resided in a skilled nursing facility (SNF). The HA care plan dated 03/24/2025 assigned the HA the relevant tasks: “assist to bedside commode, assist to toilet, assist with bedpan, assist with feeding, bathing (bed), bathing (partial sponge bath), bathing (shower), dressing, hair care, nail care, oral care, perineal care, provide incontinence care, shampoo, skin care, transfer assist, turn and position in bed, change linens, oxygen safety, provide vigil, report pain to nurse, report skin changes to nurse, RN to orient aide to care plan, safety.” All tasks were to be completed on every visit. The plan of care ordered HA services twice weekly. The HA care plan did not provide the HA with specific instructions regarding the type of bath to be performed. CLINICAL RECORD 16: The patient elected hospice care on 05/01/2025 with a diagnosis of protein-calorie malnutrition. The patient resided in a SNF. The HA care plan dated 05/01/2025, and revised on 05/02/2025 assigned the HA the relevant tasks: “assist to toilet, turn and position in bed, assist with feeding, shampoo, hair care, skin care-full body lotion, perineal care, oral care, nail care, dressing, bathing (shower), provide incontinence care, transfer assist, change linens, report pain to nurse, report skin changes to nurse-in addition to reporting to RN case manager, ensure that caregiver is updated and it is logged on both communication record and electronic medical record, RN to orient aide to care plan, oxygen safety, provide vigil.” All tasks were to be completed on every visit. The plan of care ordered HA services twice weekly. A physicians order dated 06/03/2025 ordered: “medial right foot wound covered with Opti foam.” A physicians order dated 07/31/2025 ordered: “right dorsal foot wound covered with bordered gauze.” The HA care plan did not notify the HA of the wounds, nor provide specific instructions to notify the RN if the wound dressing became soiled, dislodged, or wet during care. CLINICAL RECORD 19: The patient elected hospice care on 02/28/2025 with a diagnosis of acute on chronic combined systolic and diastolic heart failure. The patient resided at home. The HA care plan dated 02/28/2025, revised 03/01/2025 and 05/01/2025 assigned the HA the relevant tasks: “assist to bedside commode, assist to toilet, assist with bedpan, assist with feeding, bathing (bed) with details assist of 1 to perform bed bath, half bath, sponge bath or shower, bathing (partial sponge bath), bathing (shower), bathing (tub bath), dressing, hair care, nail care, oral care, perineal care, shampoo, shaving, skin care, transfer patient, change linens, oxygen safety, report pain to nurse, report skin changes to nurse, safety.” The 03/01/2025 revision added: “provide incontinence care, provide vigil, RN to orient aide to care plan-upon admission and with all changes.” The 05/01/2025 revision unchecked the boxes for “assist to toilet, assist to bedside commode” but left the typed details as if they were still assigned tasks, and removed bathing (partial sponge bath), bathing (shower), bathing (tub bath). The revision on 05/01/2025 included the assigned tasks: bed bath, half bath, sponge bath, and shower. All tasks were to be completed on every visit. Aide frequency was twice weekly. The aide care plan did not provide the aide with specific instructions for the bath type to be performed. During an interview and joint clinical record review on 09/10/2025, the Regional Director of Clinical Operations and Statewide Clinical Director confirmed the finding and stated, “There should only be one bath type to choose from or specific days on which to give a certain bath.””

“It is required that a hospice aide provides services: included in the plan of care. This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 18 (11%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the HA provided services included in the plan of care. HOME VISIT 1/CLINICAL RECORD 1:The patient elected hospice care on 04/24/2025 with a diagnosis of Alzheimer’s disease. The patient resided in a skilled nursing facility (SNF). The HA care plan dated 04/29/2025 assigned the HA the relevant tasks: “turn and position in bed, assist with feeding, skin care, oral care, dressing, bathing (shower), provide incontinence care, transfer assist, report pain to nurse, report skin changes to nurse, nurse to orient aide to care plan, provide vigil.” All tasks were to be completed on every visit. The plan of care ordered HA services twice weekly. During a home visit with the Hospice Aide [Personnel Record 7] on 09/09/2025, the HA shampooed the patient’s hair, which was not included in the HA care plan. A clinical record review revealed that the HA visit notes dated 05/12/2025 and 06/05/2025 documented: “Shower N (no). Bed bath given” and “Shower N. Bed bath given,” respectively. The HA visit note dated 07/31/2025 documented: “transfer/assist NA (not applicable).” CLINICAL RECORD 12: The patient elected hospice care on 05/25/2025 with a diagnosis of chronic obstructive pulmonary disease (COPD). The patient resided in a SNF. The HA care plan dated 06/27/2025 assigned the HA the relevant tasks: “assist to toilet, bathing (tub bath), dressing, oral care, perineal care, shampoo, shaving, skin care, transfer assist, oxygen safety, provide vigil, report skin changes to nurse, report pain to nurse, Registered Nurse (RN) to orient aide to plan of care, safety.” All tasks were to be completed on every visit. The plan of care ordered HA services twice weekly. The HA visit note dated 07/14/2025 documented that a shower was provided: “Bathing (tub bath). Shower preferred. Facility tub not in working order.” During an interview and a joint clinical record review on 09/10/2025, the Regional Director of Clinical Operations and Statewide Clinical Director confirmed the findings. They agreed that the HA should have had the “nurse adjust the plan of care before changing the bath types.””

“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 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. A joint review of the agency’s volunteer program on 09/10/2025 with the Regional Clinical Officer and Manager of Volunteers revealed that the volunteer percentage for the last twelve (12) months (September 2024 to August 2025) averaged 1.1%. The Volunteer Manager advised that they “Were continuing to add to the volunteer team, trying to get each volunteer to add at least 2 hours to keep up with the census growth.” A review of the volunteer program was conducted with the Regional Clinical Officer and Manager of Volunteers on 09/10/2025, during which time the volunteer percentage for the last twelve (12) months (September 2024 to August 2025) averaged to 1.1%. The Volunteer Manager advised they “were continuing to add to volunteer team, trying to get each volunteer to add at least 2 hours to keep up with the census growth.””