St. Croix Hospice

“Based on policy and procedure review and staff interview, the hospice failed to have a written policy and procedure to ensure processes were in place for the agency’s on-call services which had the potential to affect all agency patients who may require after-hour services. The census was 345. Findings are: A. Review of agency policy and procedures revealed the agency did not have a policy and procedure in place specific to the processes the agency was to follow for on-call services. B. During an interview on 3/17/26 at 1:30 PM, the Regional Director of Clinical Operations confirmed the agency did not have a policy specific to on-call services to ensure processes were in place to meet the needs of the agency patients for on-call services.”

“Based on record review, policy and procedure review, and staff interview, the hospice failed to follow their policy and procedure to provide a verbal report to the receiving organization and to document the communication in the clinical record for 1 of 2 (Patient 7) patients who had a transfer to another provider. The total sample size was 8. The total census was 345. Findings are: A. Review of the agency policy and procedure titled Transfer Information, Policy N. 1-022, last reviewed 2/4/25, revealed:1. The hospice Registered Nurse (RN) or Manager of Clinical Services (MCS) was to provide a verbal report to the receiving organization with a preliminary report on the patient. 2. The communication was to be documented in the clinical record. B. Review of Patient 7’s clinical record revealed:1. A Coordination Notes Report revealed the hospice was notified on 2/23/26 at approximately 2:30 PM by the patient’s caregiver of the desire to transfer the patient to another hospice provider.2. A Coordination Notes Report, with a late entry date of 2/24/26, revealed the patient discharged/transferred effective 2/23/26.3. There was no documentation of a verbal report provided by St. Croix staff to the receiving hospice, date and time the verbal report was made to the receiving hospice, who at the receiving hospice received St. Croix’s verbal report, and what preliminary information was included in the verbal report provided by St. Croix staff to the receiving hospice. C. During an interview on 3/19/26 at 10:40 AM, the Regional Manager of Clinical Operations confirmed there was no documentation that the hospice RN or MCS provided a verbal report to the receiving organization with a preliminary report on the patient.”

“It is required that each patient’s individualized written plan of care: 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, interview and observation. In 4 of 27 (15%) clinical records reviewed, the agency did not ensure the written plans of care included interventions specific to meet the patient needs identified in the comprehensive assessments. Clinical Record 1: Election of benefit 3/2/23 with a diagnosis of senile degeneration of the brain. During the home visit observation on 1/8/24, the patient was observed with fall mattresses on the floor and a scoop mattress on the bed. Initial comprehensive assessment documented a fall risk score 9, indicating “at risk for falling.” The comprehensive recertification assessment, dated 12/4/23, stated, “patient has had four falls at the very end of last benefit period/beginning of this benefit period. Interventions in place for falls prevention: fall mat on both sides of the bed, bed in lowest positions, use of good body mechanics, wearing well-fitting non-skid shoes, use of wheeled walker and wheelchair, handrails, good lighting, and night-lights and review the use of assistive devices with every visit. New fall mats at the bedside.” The plan of care (effective from 3/2/23 through the date of this review) did not include any problems or goals related to safety or fall precautions, nor were any of the interventions listed within the nursing visit note included. The Administrator (personnel record 1) reviewed the clinical record and reported during the interview on 1/9/24 that the plan of care did not include the safety goal or specific interventions and said, “They should have been on there.” Clinical Record 12: Election of benefit 8/31/23 with end-stage renal disease (ESRD) diagnosis. The initial comprehensive assessment (8/31/23) documented the patient was receiving hemodialysis three times a week (Monday, Wednesday, and Friday) via a central line in the right chest area. The plan of care, effective from 8/31/23 to the present, did not include any problems, goals, or interventions related to dialysis nor the type of access that the patient had in place for dialysis treatments. During an interview with the Administrator on 1/12/24, it was reported that the record was reviewed, and the plan of care did not include any specific interventions related to the dialysis or the dialysis catheter (central line). Clinical Record 14: Election of benefit 8/22/23 with a diagnosis of Huntington’s disease. The comprehensive recertification assessment note, dated 10/31/23, documented a comorbidity of dysphagia. The narrative note stated, “diet/intake 75-100% mechanical soft with pureed meat, nectar thick liquids though she does utilize pleasure diet and requests non-altered foods, she continues to choke on meals.” The physician certification of terminal illness narrative, dated 11/7/23, documented “increased swallowing difficulty with choking and aspiration.” The plan of care effective for the benefit period 11/20/23 to 2/17/23 listed “pleasure diet” but did not include any problems, goals, or interventions related to dysphagia or aspiration precautions. On 1/12/24, the Administrator was interviewed and confirmed that the plan of care only listed the pleasure diet. The Administrator agreed that it should have included more specific dietary modifications and should have listed aspiration precautions. Clinical Record 20: Election of benefit 6/21/23 with a diagnosis of Parkinson’s disease. The comprehensive assessment, dated 11/20/23, documented a fall risk score of 8 “at risk for falls.” The interdisciplinary team (IDT) note, dated 12/6/23, wrote, “falls with a new onset of hallucinations and agitated towards staff.” On 12/6/23 a Physical Therapy (PT) evaluation was ordered due to falls. The record did not contain evidence the patient had fallen but was at risk. The plan of care, effective from the 11/20/23 assessment to the current one, did not include any problems, goals, or interventions related to safety or fall precautions. On 1/12/24, the Administrator reported the record had been reviewed and said the patient had been placed in the “fall program,” which included the PT evaluation. Still, the plan of care was not updated to include the safety problem or fall precautions/interventions.”

“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. In 1 of 4 (25%) clinical records reviewed, in which Licensed Practical Nurse (LPN) supervision was required, it revealed that the agency did not ensure the LPN supervisory visits were conducted in adherence with the agency policy. Document 1: Agency policy titled, “No. 1-031 Responsibilities/Supervision of Clinical Services” (last reviewed 3/3/23) documented in the relevant part, “A monthly patient visit will be completed by a registered nurse to supervise licensed practical/vocational nursing services.” Clinical Record 26: The patient elected the hospice benefit on 3/12/23 and continued until the patient’s death on 6/6/23. On 4/12/23 and 4/20/23, an LPN completed and signed the nursing visits. The first documented LPN supervisory visit occurred on 5/29/23. Personnel Record 1: During an interview with the Administrator on 1/12/24, it was confirmed that the record did not contain any additional documentation that an LPN supervisory visit was made within the 30-day timeframe.”

“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, interview and observation. In 3 of 22 (14%) records reviewed, in which aide services were accepted, revealed the agency did not ensure the hospice aide plans of care included specific instructions for the aide to follow, thus leaving the aide to make decisions outside their scope of practice. Clinical Record 1: The patient elected the hospice benefit on 3/2/23 with a diagnosis of senile degeneration of the brain. During the home visit observation on 1/8/24, the patient wore bilateral pressure-relieving boots. The hospice aide care plan, effective from 8/11/23 to the present, instructed the aide to perform a bed bath but did not specify if the aide should remove the pressure-relieving boots during care. Clinical Record 8: The patient elected the hospice benefit on 11/16/23 with a diagnosis of senile degeneration of the brain. The hospice aide care plan, effective 12/6/23 to current, ordered aide visits two times per week and listed the following relevant tasks: “bathing (bed) every visit assist of 1, full body bathing, patient unable to assist” and “bathing (shower) every visit assist of 1 for transfers into shower; assist 1 for bathing, patient able to assist with upper body needs, needs full assist with back and lower body washing, clean shower room/shower chair per family preference.” The care plan did not include further clarification on when the aide would perform a bed bath versus a shower. Clinical Record 12: The patient elected the hospice benefit on 8/31/23 with a diagnosis of end-stage renal disease. The clinical record documentation revealed the patient was receiving hemodialysis three times a week and had a central line to the right chest covered with a transparent dressing. The hospice aide care plan, effective 9/1/23, listed the relevant tasks of bathing (bed), dressing, and skin care every visit. The aide care plan did not alert the aide that a central line was present or include any special instructions regarding the central line. During an interview on 1/11/24, the Administrator reported reviewing these aide care plans and confirmed the aide plans did not contain specific instructions for the pressure relieving boots, bathing, or central line notification but stated, “They have been updated now.””

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a Registered Nurse as the changes relate to the plan of care and any quality assessment and improvement activities. This standard was not met as evidenced by clinical record review and interview. In 1 of 22 (5%) clinical records reviewed, in which aide services were accepted, revealed the agency did not ensure the hospice aides reported changes in the patient’s plan of care needs to the RN. Clinical Record 18: The patient elected the hospice benefit on 2/13/23 with a diagnosis of chronic obstructive pulmonary disease (COPD). The plan of care for the benefit period 12/10/23 to 2/7/24 included hospice aide visits ordered two times per week. On 12/14/23, the hospice aide documented, “(Patient) called me and said she was tired and didn’t want me to come.” On 1/2/24, the hospice aide documented, “(Patient) called and stated she just wanted to wait till Thursday as her caregiver was coming today.” On 1/9/24, the hospice aide documented, “(Patient) Called, and she said wait till Thursday.” There was no documentation that the hospice aide reported the changes to the Registered Nurse. During an interview on 1/11/24, the Administrator reviewed the clinical record and confirmed that there was no additional documentation that the RN was notified of any missed visits. The Administrator further reported that within the electronic medical record (EMR), if the hospice aide had selected “missed visit,” it would automatically alert the RN that the aide visit was not made, but the aide did not select the “correct reason” thus there was not an alert sent via the EMR.”