St. Croix Hospice

“It is required that each patient’s individualized written plan of care reflects the patient and family goals and 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. In 6 of 14 (43%) clinical records reviewed, the agency did not ensure the patient’s individualized plan of care reflected the patient and family goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments related to massage therapy. CLINICAL RECORD 2: The patient elected hospice care on 05/07/2025. A physician order was obtained on 05/05/2026 for a Massage Therapy Evaluation. The massage therapist evaluation dated 05/11/2026 documented, “What medical indications were addressed at this session: reduce anxiety, reduce restlessness, reduce muscle tension/affect contractures, reduce pain.” The Hospice Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of Care Update Report for IDG dated 05/21/2026 and 06/04/2026 did not include documentation of patient and family goals or planned interventions for the massage therapy. CLINICAL RECORD 3: The patient elected hospice care on 03/18/2026. A physician order was obtained on 05/12/2026 for a Massage Therapy Evaluation. The massage therapist evaluation dated 05/20/2026 documented, “What medical indications were addressed at this session: Increase comfort/relaxation.” The Hospice IDG Comprehensive Assessment and Plan of Care Update Report for IDG dated 05/21/2026 and 06/04/2026 did not include documentation of patient and family goals or planned interventions for the massage therapy. CLINICAL RECORD 6: The patient elected hospice care on 01/13/2026. A physician order was obtained on 05/14/2026 for a Massage Therapy Evaluation. The massage therapist evaluation dated 05/20/2026 documented, “What medical indications were addressed at this session: reduce anxiety, reduce agitation, reduce muscle tension/affect contractures, reduce pain, increase comfort/relaxation.” The Hospice IDG Comprehensive Assessment and Plan of Care Update Report for IDG dated 05/21/2026 and 06/04/2026 did not include documentation of patient and family goals or planned interventions for the massage therapy. CLINICAL RECORD 7: The patient elected hospice care on 04/14/2026. A physician order was obtained on 04/23/2026 for a Massage Therapy Evaluation. The massage therapist evaluation dated 05/01/2026 documented, “What medical indications were addressed at this session: reduce muscle tension/affect contractures, reduce pain, reduce edema/increase circulation, increase comfort/relaxation.” The Hospice IDG Comprehensive Assessment and Plan of Care Update Report for IDG dated 05/07/2026, 05/21/2026, and 06/04/2026 did not include documentation of patient and family goals or planned interventions for the massage therapy. CLINICAL RECORD 8: The patient elected hospice care on 04/02/2026. A physician order was obtained on 04/20/2026 for a Massage Therapy Evaluation. The massage therapist evaluation dated 04/27/2026 documented, “What medical indications were addressed at this session: reduce anxiety, reduce agitation, reduce restlessness, reduce muscle tension/affect contractures, improve skin condition, increase comfort/relaxation.” The Hospice IDG Comprehensive Assessment and Plan of Care Update Report for IDG dated 05/07/2026, 05/21/2026, and 06/04/2026 did not include documentation of patient and family goals or planned interventions for the massage therapy. CLINICAL RECORD 11: The patient elected hospice care on 03/24/2026. A physician order was obtained on 04/20/2026 for a Massage Therapy Evaluation. The massage therapist evaluation dated 04/29/2026 documented, “What medical indications were addressed at this session: reduce anxiety, reduce muscle tension/affect contractures, reduce pain, improve skin condition, increase comfort/relaxation.” The Hospice IDG Comprehensive Assessment and Plan of Care Update Report for IDG dated 05/07/2026, 05/21/2026, and 06/04/2026 did not include documentation of patient and family goals or planned interventions for the massage therapy.. During a joint record review and interview on 06/16/2026, the Administrator/Regional Director of Operations (Personnel Record 7) confirmed the findings and stated in part, “These will be updated today.””

“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 equal to five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. A joint review of the “Volunteer Hours “ report dated 01/01/2025 through 12/31/2025 with the Administrator and the Volunteer Coordinator on 06/15/2026 revealed that volunteers provided 3.23% of day-to-day administrative and/or direct patient care services for 2025. The Volunteer Coordinator confirmed that volunteer utilization was below the required 5% for 01/01/2025 through 12/31/2025. During an interview on 06/15/2026, the Administrator (Personnel Record 7) confirmed that volunteer utilization was below 5% for 12/31/2025 through 03/31/2026, and stated, “We have one volunteer; if we are unable to match a patient with our volunteer, our Volunteer Coordinator visits those patients.””