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; [and] 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 measurements 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 1 of 5 (20%) 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 3/HOME VISIT 1: The patient elected hospice care on 07/31/2025. The patient resided in a skilled nursing facility (SNF). During the home visit with the Hospice Aide (HA)[Personnel Record 10] on 09/03/2025, the hospice medication profile (printed 09/03/2025) and the SNF medication list were reviewed. The SNF medication list documented: Bacitracin external ointment 500 units/gm, apply to right upper back topically prn [as needed] for prevention dated 04/28/2025, acetaminophen rectal suppository 650 mg, give one suppository rectally every 6 hours prn mild pain/fever dated 07/31/2025, and guaifenesin er [extended release] tablet 12 hour 600 mg, give one tablet every 12 hours prn cough dated 01/04/2023. The Bacitracin, acetaminophen suppository, and guaifenesin were not on the agency medication profile. The most recent comprehensive assessment was dated 09/02/2025. During a joint record review and interview on 09/03/2025, the Regional Director of Clinical/Interim Administrator/Interim Director of Nursing confirmed that there was no documented evidence that the medications were reconciled at the time of each comprehensive assessment and updated to the drug profile.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene. This standard was not met as evidenced by document review, interview, and observation. Agency policy #7-009 “Hand Hygiene” (12/2018) stated in part, “Hand decontamination using an alcohol-based hand rub should be performed.... Before having direct contact with patient... After contact with a patient’s intact skin (when taking a pulse, blood pressure, or lifting a patient)...After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient...After removing gloves.” In 1 of 3 (33%) home visits observed, the agency did not ensure that hand hygiene was performed when indicated per agency policy. HOME VISIT 2/CLINICAL RECORD 2: During the home visit with the Registered Nurse (RN) [Personnel Record 5] on 09/04/2025, the RN took the patient in the geri chair to the patient’s room, obtained a chair from the hallway for the RN’s use. The RN touched the patient and the patient’s equipment during the interaction. The RN did not decontaminate their hands before touching the patient or the patient’s equipment. During a joint document review and interview on 09/04/2025, the Regional Director of Clinical/ Interim Administrator/Interim Director of Nursing confirmed that the RN did not follow the hand hygiene policy during the visit.”

“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 2 of 5 (40%) clinical records reviewed of patients receiving Hospice Aide (HA) services, the agency did not ensure that the HA received written patient care instructions to meet the patient’s needs. CLINICAL RECORD 2: The patient elected hospice care on 07/25/2025 with a primary diagnosis of cerebral atherosclerosis and secondary diagnoses which included vascular dementia. The patient resided in a skilled nursing facility (SNF). The HA care plan dated 07/27/2025 assigned the HA the tasks, “Bathing (Bed) every visit assist of 1 to perform bed bath” and “Bathing (shower) every visit assist of 1 to perform shower and apply shampoo, then rinse and pat dry.” The care plan did not provide clear instructions to the HA regarding the type of bath to be performed at the visit. CLINICAL RECORD 5: The patient elected hospice care on 08/05/2025 with a primary hospice diagnosis of end-stage renal disease and secondary diagnoses, which included Alzheimer’s disease with late onset. The patient resided in an assisted living facility (ALF). The HA care plan dated 08/06/2025 assigned the HA the tasks, “Bathing (Bed) every visit assist of to perform bed bath and apply lotion throughout (the) body”, “Bathing (Partial Sponge Bath) every visit assist of to perform sponge bath apply lotion throughout (the) body”, and “Bathing (shower) every visit assist of to perform shower and apply shampoo then rinse and pat dry, brush or comb hair after shower.” The care plan did not provide clear instructions to the HA regarding the type of bath to be performed at the visit. During a joint clinical review and interview on 09/05/2025, the Regional Director of Clinical/Interim Administrator/Interim Director of Nursing confirmed that the instructions on the HA care plan were not specific regarding which bath to perform.”