St Croix Hospice La Crosse

“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, 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. 1 of 19 (5%) clinical records reviewed revealed the agency did not ensure a medication reconciliation was completed and that medications were updated to the medication profile. HOME VISIT 3/CLINICAL RECORD 8: The patient’s date of election was 11/14/2025. The patient resided in a Skilled Nursing Facility. The hospice Medication Profile, printed on 07/06/2026, listed Atorvastatin 20 mg tablet, one tablet orally at bedtime, started 11/17/2025, and Farxiga 10 mg tablet, one tablet orally daily, started 11/17/2025. During the observed home visit on 07/07/2026 with the Chaplain (Personnel Record 7), the hospice medication profile was compared to the facility’s medication list. The facility’s medication list did not include Atorvastatin and Farxiga. The facility’s registered nurse reported that the Atorvastatin was discontinued on 01/06/2026 and Farxiga was discontinued on 04/21/2026. The record lacked evidence that medication reconciliation occurred when new medications were added or when changes were made to existing medications. During a joint record review and interview on 07/07/2026, the Regional Director of Clinical Operations/Administrator confirmed that there was no documented evidence that medications were reconciled when new medications were added or when changes were made to existing medications. DHS_131.33(3)(e) Content. A patient’s clinical record shall contain all of the following: A current medications list.”

“It is required that a hospice aide provide services that are included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 15 (13%) clinical records reviewed of patients receiving hospice aide services revealed the agency did not ensure that the hospice aides provided services included in the plans of care. CLINICAL RECORD 7: Election of the hospice benefit was 01/13/2026. The hospice aide plan of care dated 01/14/2026 included assignment of the following tasks: “bathing (shower) first visit of week, assist of one with EZ stand to transfer to shower bench; dressing first of the week, assist of one with dressing; hair first of the week, assist of one with hair care; oral care first of the week, assist of one with oral hygiene; perineal care first of the week, assist of one with pericare; provide incontinence care first visit, assist of one for incontinent care; shampoo first visit of week, assist of one with shampoo; skin care first visit of week, assist of one with skin care/lotion; transfer assist every visit, assist of one with EZ stand; offer fluids every visit, pt (patient) can independently eat/drink/feed self thin liquids/regular textures; socialization last visit of week, orient to self only; provide vigil every visit at EOL [end of life] provide vigil for pt/cg (caregiver) at EOL; report pain to nurse every visit, report uncontrolled pain to RNCM (registered nurse case manager); RN to orient aide to care plan upon admission and with all changes to POC (plan of care); and safety every visit, report safety concerns to RNCM.” The hospice aide visit documentation for 05/01/2026, 05/12/2026, 05/19/2026, and 05/26/2026 documented the aide completed the shampoo, hair care, skin care, perineal care, oral care, dressing, bathing (shower), provided incontinence care, transfer assist, offered fluids, socialization, safety, and RN to orient aide to care plan. The plan of care assigned socialization for the last visit of the week The hospice aide visit documentation for 05/05/2026, 05/15/2026, and 05/23/2026 documented the aide completed the shampoo, hair care, skin care, perineal care, oral care, dressing, bathing (shower), provided incontinence care, transfer assist, offered fluids, socialization, safety, and RN to orient aide to care plan. The plan of care assigned shampoo, hair care, skin care, perineal care, oral care, bathing (shower), and provide incontinence care for the first visit of the week. CLINICAL RECORD 11: The patient elected the hospice benefit on 03/17/2026. The hospice aide plan of care dated 03/18/2026 assigned the following tasks: “bathing (shower) first visit of week, assist of one with dressing, pt becomes short of breath; dressing first visit of week, assist of one with dressing, pt becomes short of breath; hair care first visit of week (and) last visit of week, assist of one to ensure hair is neatly combed each visit; nail care last visit of week, assist of 1 to clean and file nails; oral care first visit of week, set up of one to brush teeth with toothbrush and toothpaste; provide incontinence care first visit of week (and) last visit of week, pt has stress urinary incontinence and wears liners, she is independent in the task but needs reminders; shampoo first visit of week, assist of one to shampoo hair weekly with shower; skin care first visit of week (and) last visit of week, assist of one to apply lotion to dry skin; transfer assist first visit of week, independent with walker; socialization last visit of week, pt is alert and oriented but forgetful, enjoys talking about her heritage and past with (country); provide vigil every visit provide supportive presence at end of life; report pain to nurse every visit, record finding on communication note and inform both facility staff and RNCM of finding; report skin changes to nurse every visit, record finding in communication note and inform both facility staff and RNCM of finding; RN to orient aide to care plan upon admission with changes to POC; and safety every visit, ensure pt is wearing pendant around neck.” The hospice aide visit notes dated 03/27/2026, 04/03/2026, and 04/10/2026 documented shampoo, oral care, dressing, bathing (shower) - bed bath, and transfer assist. The plan of care assigned shampoo, oral care, dressing, bathing (shower), and transfer assist for the first visit of the week. The hospice aide visit notes dated 03/31/2026 and 04/07/2026 documented nail care and socialization. The plan of care assigned nail care and socialization for the end of the week. The hospice aide visit notes dated 03/27/2026, 03/31/2026, 04/03/2026, 04/07/2026, and 04/10/2026 documented that a sponge or bed bath was given. Sponge bath and bed bath were not assigned on the hospice aide plan of care. During a joint clinical record review and interview on 07/09/2026, the Regional Director of Clinical Operations/Administrator confirmed that the hospice aides did not provide services included in the plans of care. During a joint clinical record review and interview on 07/09/2026, the Manager of Clinical Services confirmed that the hospice aides did not provide services included in the plans of care. DHS_131.26(2)(b) “Plan of care. The nurse aide shall provide care in accordance with the patient’s plan of care.”

“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. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. 4 of 15 (27%) clinical records with hospice aide services reviewed revealed that the agency did not ensure the hospice aides notified the registered nurses of the changes in the patients’ plans of care. CLINICAL RECORD 1: The patient elected the hospice benefit on 02/16/2026. The Hospice Aide Care Plan dated 02/17/2026 assigned the following tasks: “bathing (partial sponge bath) - assist of 1: assistance needed for footcare; soak/cleanse feet ensuring between toes and creases are gently cleansed and dried thoroughly. Then apply lotion and tubigrip/compression stockings. Patient is diabetic on blood thinners; provide incontinence care - assist of 1: gently cleanse perineal area from front to back with wipes after urination/bowel movement; skin care - assist of 1: apply lotion to clean/dry skin; transfer assist - assist of 1: front-wheeled walker for transfers recommended; change linens -dependent: change linens weekly and/or if soiled; empty trash - dependent: empty garbage in bedroom, bathroom, and kitchen if needed; offer fluids - assist of 1: cueing and reminders for hydration; socialization - assist of 1: pt enjoys going for walks outside. If it is safe terrain using front wheeled walker; provide vigil - assist of 1: provide supportive presence at end of life; report pain to nurse - HHA (hospice aide)to report any concerns to caregiver and RNCM (registered nurse case manager); report skin changes to nurse - report any skin changes to nurse and spouse; RN to orient aide to care plan upon admission and with all changes to POC (plan of care); safety - encourage safety with ADL’s (activities of daily living); redirect poor body mechanics; encourage good lighting, clear pathways, proper footwear, good hygiene habits, report safety concerns to husband and nurse.” The hospice aide visit note dated 03/18/2026 documented “bathing (partial sponge bath) completed: N (no)”, Note: Self; skin care completed: N, Note: self; incontinence care completed: N, Note: self; transfer assist completed: N, Note: self; empty trash completed: N, Note: husband; and change linens completed: N, Note: husband.” The hospice aide visit note dated 05/06/2026 documented “bathing (partial sponge bath) completed: N, Note: Self; skin care completed: N, Note: self; incontinence care completed: N, Note: self; transfer assist completed: N, Note: self transfers; empty trash completed: N, Note: self; and change linens completed: N, Note: self.” The hospice aide visit note dated 05/20/2026 documented “bathing (partial sponge bath) completed: N, Note: Self; skin care completed: N, Note: self; incontinence care completed: N, Note: self; and empty trash completed: N, Note: husband.” The hospice aide visit note dated 06/17/2026 documented “bathing (partial sponge bath) completed: N, Note: Self; skin care completed: N, Note: self; incontinence care completed: N, Note: self; empty trash completed: N, Note: spouse; and change linens completed: N, Note: spouse.” The documentation of the aforementioned visit notes was absent notifying the registered nurse of changes to the plan of care. CLINICAL RECORD 2: The patient elected the hospice benefit on 03/30/2026. The Hospice Aide Care Plan dated 04/01/2026 assigned the following tasks: “bathing (shower) - assistance of 1 with showering utilizing warm water and mild soap; oral care - assistance of 1 with brushing teeth utilizing toothpaste and toothbrush; provide incontinence care - assist of 1 with incontinence care; shampoo - assistance of 1 with shampooing brushing and styling; skin care - assist of 1 with lotioning skin; transfer assist - contact RN for transfer order; provide vigil - provide vigil at EOL(end of life); report pain to nurse - report pain to RNCM and your family is updated and chart in HCHB (electronic medical record - HomeCare HomeBase); report skin changes to nurse - report skin changes to RNCM and your family is updated and charted in HCHB; RN to orient aide to care plan upon admission and with any changes to POC; and safety - ensure items are within reach and notify family prior to leaving.” The hospice aide visit note dated 04/01/2026 documented “Shampoo Completed: N, Note: social; skin care Completed: N, Note: social; oral care Completed: N, Note: self; bathing (shower) Completed: N, Note: self; provide incontinence care Completed: N, Note: social; and transfer assist Completed: N, Note: self.” The hospice aide visit note dated 04/07/2026 documented “Shampoo Completed: N, Note: social; skin care Completed: N, Note: social; oral care Completed: N, Note: social; bathing (shower) Completed: N, Note: social; provide incontinence care Completed: N, Note: social; and transfer assist Completed: N, Note: self.” The documentation lacked notification to the registered nurse of changes to the plan of care. CLINICAL RECORD 7: The hospice aide plan of care dated 01/14/2026 revealed bathing (shower) first visit of week assist of one with EZ stand to transfer to shower bench; dressing first of the week assist of one with dressing; hair first of the week assist of one with hair care; oral care first of the week assist of one with oral hygiene; perineal care first of the week assist of one with pericare; provide incontinence care first visit assist of one for incontinent care; shampoo first visit of week assist of one with shampoo; skin care first visit of week assist of one with skin care/lotion; transfer assist every visit assist of 1 with EZ stand; offer fluids every visit pt can independently eat/drink/feed self thin liquids regualar textures; socialization last visit of week orient to self only; provide vigil every visit at EOL [end of life] provide vigil for pt/cg at EOL; report pain to nurse every visit report uncontrolled pain to RNCM; RN to orient aide to care plan upon admission and with all changes to POC; and safety every visit every visit report safety concerns to RNCM. The hospice aide visit documentation for 05/01/2026, 05/12/2026, 05/19/2026, and 05/26/2026 revealed the aide completed the shampoo, hair care, skin care, perineal care, oral care, dressing, bathing (shower), provide incontinence care, transfer assist, offer fluids, socialization, safety, and RN to orient aide to care plan. The plan of care indicated socialization for the last visit of the week. The hospice aide visit documentation for 05/05/2026, 05/15/2026, and 05/23/2026 revealed the aide completed the shampoo, hair care, skin care, perineal care, oral care, dressing, bathing (shower), provide incontinence care, transfer assist, offer fluids, socialization, safety, and RN to orient aide to care plan. The plan of care indicated shampoo, hair care, skin care, perineal care, oral care, bathing (shower), and provide incontinence care for the first visit of the week. The documentation of the aforementioned visit notes was absent notification to the registered nurse of changes to the plan of care. CLINICAL RECORD 11: The patient elected the hospice benefit on 03/17/2026. The hospice aide plan of care dated 03/18/2026 assigned the following tasks: “bathing (shower) first visit of week, assist of one with dressing, pt becomes short of breath; dressing first visit of week, assist of one with dressing, pt becomes short of breath; hair care first visit of week (and) last visit of week, assist of one to ensure hair is neatly combed each visit; nail care last visit of week, assist of 1 to clean and file nails; oral care first visit of week, set up of 1 to brush teeth with toothbrush and toothpaste; provide incontinence care first visit of week (and) last visit of week, pt has stress urinary incontinence and wears liners, she is independent in the task but needs reminders; shampoo first visit of week, assist of 1 to shampoo hair weekly with shower; skin care first visit of week (and last visit of week, assist of one to apply lotion to dry skin; transfer assist first visit of week, independent with walker; socialization last visit of week, pt is alert and oriented but forgetful, enjoys talking about her heritage and past with (country); provide vigil every visit provide supportive presence at end of life; report pain to nurse every visit, record finding on communication note and inform both facility staff and RNCM of finding; report skin changes to nurse every visit, record finding in communication note and inform both facility staff and RNCM of finding; RN to orient aide to care plan upon admission with changes to POC; and safety every visit, ensure pt is wearing pendant around neck.” The hospice aide visit notes dated 03/27/2026, 04/03/2026, and 04/10/2026 documented the completed tasks of shampoo, oral care, dressing, bathing (shower) - bed bath, and transfer assist. The plan of care assigned shampoo, oral care, dressing, bathing (shower), and transfer assist for the first visit of the week. The hospice aide visit notes dated 03/31/2026 and 04/07/2026 documented nail care and socialization were completed. The plan of care assigned nail care and socialization for the end of the week. The hospice aide visit notes dated 03/27/2026, 03/31/2026, 04/03/2026, 04/07/2026, and 04/10/2026 documented that a sponge or bed bath was given. Sponge bath and bed bath were not assigned tasks on the hospice aide plan of care. The documentation of the aforementioned visit notes was absent notification to the registered nurse of changes to the plan of care. During a joint clinical record review and interview on 07/09/2026, the Regional Director of Clinical Operations/Administrator confirmed that the hospice aide documentation lacked notification to the registered nurses of the changes in the plans of care. During a joint clinical record review and interview on 07/09/2026, the Manager of Clinical Services confirmed that the hospice aide documentation lacked notification to the registered nurses of the changes in plans of care. DHS_131.26(2)(b)(7) Plan of care. The nurse aide shall provide care in accordance with the patient’s plan of care. Nurse aide services consist of, but are not be limited to all of the following: Reporting changes in the patient’s condition and needs.”

“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. The hospice documents the cost savings achieved through volunteers. This standard was not met as evidenced by document review and interview. Upon review of the volunteer program, the documentation showed direct-care staff hours (15,986.13) and volunteer hours (134.07), resulting in a percentage of 0.84% for the period from August 2025 through June 2026. Due to the acquisition of this location by another organization, the agency did not have documentation of hours prior to this time, despite efforts to acquire them. The agency had a Volunteer Cost Savings PIP (Performance Improvement Project) that was initiated on 01/01/2025, which stated in part, “Some (state) branches are not at or above 5% cost savings... Root Cause Analysis: 04/2020-12/31/2023, PHE (Public Health Emergency)-1135 Volunteer Services Waiver in place, and the Waiver lifted on 1/2024.” The Tasks Related to the desirable outcome listed RVCs (Regional Volunteer Coordinators) to re-evaluate and enhance the recruitment strategy; enhance the recruitment network within the community; and engage with current volunteers to maximize volunteer activity, which were started on 01/15/2025. During a conversation, it was discovered that the agency has music and massage therapists who are hospice-paid employees, resulting in more direct-care staff hours. The agency did not ensure that the hospice volunteer hours were, at a minimum, equal to five percent (5%) of the total patient care hours. During a joint review of the volunteer program records and an interview on 07/09/2026, the Regional Director of Clinical Operations/Administrator confirmed that the agency did not meet the requirement 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. During a joint review of the volunteer program records and an interview on 07/09/2026, the Regional Volunteer Coordinator confirmed that the agency did not meet the requirement 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 despite the efforts to increase volunteers and/or volunteer documented hours. Upon review of the volunteer program, the documentation showed direct-care staff hours (15,986.13) and volunteer hours (134.07), resulting in a percentage of 0.84% for the period from August 2025 through June 2026. Due to the acquisition, the agency did not have documentation of hours prior to this time, despite efforts to acquire them. The agency had a Volunteer Cost Savings PIP (Performance Improvement Project) that was initiated on 01/01/2025, stated in part, “Some (state) branches are not at or above 5% cost savings... Root Cause Analysis: 04/2020-12/31/2023, PHE-1135 Volunteer Services Waiver in place, and the Waiver lifted on 1/2024.” The Tasks Related to the desirable outcome listed RVCs (Regional Volunteer Coordinators) to re-evaluate and enhance the recruitment strategy; enhance the recruitment network within the community; and engage with current volunteers to maximize volunteer activity, which were started on 01/15/2025. During a conversation, it was discovered that the agency has music and massage therapists who are hospice-paid employees, resulting in more direct-care staff hours. The agency did not ensure that the”

“Observed in Record Review. In 7 of 14 patient records reviewed, Confirmed by the Case Review Quality Manager. The organization had not developed an individual plan of care based on problems identified in the initial comprehensive and updated assessments or patient and family goals. Example: During review of HOSv#3, HOSrr#1 the plan of care had not documented a patient goal based on a problem identified in the patient comprehensive but had documented a staff goal Aide Supervision and the goal had documented that the aide supervision to be every 14 days. HOSv1 Had documented that the patient and caregiver would demonstrate an understanding of bowel regime by the end of the certification.. HOSrr#1 had documented that the patient and caregiver would understand Hospice philosophy by the end of the certification period.”

“Observed in Record Review. In 9 of 14 patient records reviewed, Confirmed by the Administrator. Multiple PRN medications with a similar indication had been ordered and had not specified which to administer first. Example: During review of HOS rr#6 medication orders had documented Lorazepam 0.5mg prn for nausea, Haldol 2mg prn for nausea and Zofran 1tab prn for nausea, Morphine 100mg prn for pain, Tylenol 500mg prn for pain, and hydrocodone 1 tab q6hours prn for pain. HOSrr#4 had medication orders documented for Tylenol 500mg prn for pain, morphine 100mg prn for pain and oxycodone 5mg prn for pain.”

“Observed in Document Review. During review of the patient/caregiver booklet ---Mayo Clinic Hospice Caregiver’s Guide--provided in the home, the hospice pharmacy surveyor noted that the instructions provided for destruction of unused controlled patches such as Fentanyl. Buprenorphine, and me1thylphenidate did not match the organization’s Hospice policy for Medication Disposal of Controlled Medications in the patient’s home Hospice Procedure. The guide indicated the unused patch should be cut in half and the contents then placed into kitty litter or coffee grounds before placing in the household trash and the policy outlined removing the adhesive cover from the unused patch and then folding in half and putting the sticky sides together before putting the unused patch in a neutralizing substance such as kitty litter or coffee grounds. The Food and Drug Administration (FDA) currently recommends folding the patch in half before destruction as outlined in the organization’s policy, but not as currently instructed in the patient/caregiver booklet. This issue was validated with the quality nurse and the nurse manager at the time of the survey.”