St Paul Hospice Services
A hospice in Kaukauna, Wisconsin 54130
316 E Fourteenth St, Kaukauna, Wisconsin 54130. (920) 766-6180.
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The short answer
Record last released by CMS on Oct 23, 2026.
- 2 deficiencies cited in the last three years
- Not rated family caregiver rating
- 9of 10 CMS’s Hospice Care Index
Each figure’s source sits beside it, in its section below.
What these words mean2
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
2 deficiencies cited in the last three years
The middle of the 14 hospices serving ZIP code 54130 had 5.
The last inspection on record was on Jun 16, 2026: a recertification inspection by the state.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
When those deficiencies happened
2 deficiencies in 1 month of the last 36. Last cited Jun 2026. Most serious: Standard-level. The last 3 years, to Oct 27, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Nov | Dec | ||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Jun 16, 2026: recertification inspection by the state2 deficiencies
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Supervision of hospice aides (42 CFR 418.76(h)(1)(i))
The inspectors’ words, 144 words
“Based on record review and interview , the agency failed to ensure supervisory visits of hospice aides were completed and documented at least every 14 days in 8 of 13 patient records reviewed (Patient #1 -#6 , #8 and #9.) Findings include: Review of agency policy and procedures revealed no policy or procedure related to supervision of hospice aides and documentation of supervisory visits. Review of Patient #1 -#6, #8 and #9 medical records revealed no documented evidence that registered nurse supervisory visits of hospice aides had been completed since the start of care. During an interview on 06/16/2026 at 9:45 a.m., Registered Nurse B stated, “I try to do my supervisory visits every month.” During an interview on 06/16/2026 at 12:33 p.m., Administrator A stated, “I have no way of knowing if these have been done; there is no where to document this.””
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Written agreement (42 CFR 418.112(c)(6))
The inspectors’ words, 133 words
“Based on record review and interview, the agency failed to ensure the patient plan of care (POC) delineated hospice and facility services for patients residing in assisted living facilities (ALF) and skilled nursing facilities (SNF) in a total of 8 of 13 patient records reviewed ( Patient #1-#6 , #8 and #9.) Findings include: Review of agency policy and procedures revealed no policy or procedure related to delineation of services for patients residing in facilites. Review of Patient #1-#6, #8 and #9 medical records revealed the patients resided in an ALF or SNF. The patients’ POC’s failed to identify or delineate the services and responsibilities of the hospice and the facility. During an interview on 06/16/2026 at 12:33 PM Administrator A stated “We don’t tell the facility what they need to be doing.””
The one inspection in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Jun 16, 2026 | Recertification inspection by the state | 2 deficiencies cited |
Is it certified?
- Medicare-certified hospice since Oct 21, 2008.
- Ownership: non-profit.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency or CMS’s most serious finding: the place’s failure to meet a rule caused, or was likely to cause, serious injury, harm, impairment or death to someone in its care. Source: CMS; 42 CFR 489.3. on record in the last three years.
CMS, Hospice General Information. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Has anything been proven against it?
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- 0 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Who does the caring?
- From Medicare claims (Jan 1, 2023 to Dec 31, 2024): 18 nurse care minutes per routine home care day, 13.5% of skilled nursing minutes at weekends and a visit near death for 94.6% of patients who died.
- Where its patients were cared for (Jan 1, 2024 to Dec 31, 2024): 17% at home, 38% in assisted living, 45% in a skilled nursing facility.
CMS, Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | This provider |
|---|---|
| Nurse care minutes per routine home care day | 18.0 min |
| Skilled nursing minutes at weekends | 13.5% |
| Visits near death | 94.6% of patients who died |
Who owns it?
- Franciscan Sisters of Christian Charity Sponsored Ministries Inc. runs it.
- 16 owners or officers are people: Joellen Kohlmann (corporate director); Paula Vandehey (corporate director); Sondra Norder (corporate officer); Sondra Norder (runs it (operational or managerial control)); Lauren E Schneekloth (managing employee (under contract)); Trevor M Frank (corporate director); Pat Hietpas (corporate director); Kelli Clussman (corporate director); Nicole A Brady (corporate director); Charleen Acker (corporate director); Clay Eiting (corporate director); Amber Schroeder (corporate officer); Amber Schroeder (managing employee (on the payroll)); Corinne Miller (managing employee (on the payroll)); Corinne Miller (runs it (operational or managerial control)); Michael Gage (corporate director).
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospice All Owners and Hospice Enrollments. Released Sep 29, 2026. Updated quarterly.
What do families say?
- CMS gives no family caregiver survey rating: “The number of cases is too small to report Star Ratings.”
- In CMS’s survey of family caregivers (Oct 1, 2023 to Sep 30, 2025): 91% rated it 9 or 10 out of 10, and 93% would definitely recommend it.
- CMS’s Hospice Care Index: 9 of 10 (Jan 1, 2023 to Dec 31, 2024).
- 96.88% of patients were assessed on all seven of CMS’s measures at the start of care (Oct 1, 2024 to Sep 30, 2025); 54.8% had visits from a nurse or social worker on at least 2 of their last 3 days (Jan 1, 2023 to Dec 31, 2024).
CMS, CAHPS Hospice Survey and Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Family caregiver survey ratingCMS star rating from its survey of patients’ family caregivers, 1 to 5 | Not rated |
| Hospice Care IndexCMS’s Hospice Care Index, 0 to 10 (higher is better): a point for each of ten measures from Medicare claims on which the hospice meets CMS’s threshold | 9 of 10 |
How does it compare nearby?
- Of the 14 hospices CMS’s data show serving patients in ZIP code 54130, where this hospice’s office is, the middle number of deficiencies cited in the last three years was 5; this one had 2.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
| Place | Deficiencies, 3 years |
|---|---|
| St Paul Hospice Services This hospice | 2 |
| Unity Hospice | 7 |
| Thedacare at Home | 4 |
| Compassus Neenah | 5 |
| Aurora at Home | 3 |
| Heartland Hospice Green Bay | 16 |
| Amedisys Hospice of Green Bay | 6 |
| Sharon S Richardson Community Hospice | 12 |
| Preceptor Hospice | 5 |
| Compassus Green Bay | 5 |
| St Croix Hospice Waukesha | 6 |
| Moments Hospice of Appleton | 0 |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- CMS ended its Special Focus Program for hospices with serious problems on Feb 14, 2025, so no hospice is marked as one.
- Hospice quality measures have a gap from October 2025: CMS replaced its patient assessment then, and public results from the new one (HOPE) are expected around November 2027.
Sources
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Centers for Medicare & Medicaid Services, Hospice General Information (yc9t-dgbk).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Provider Data (252m-zfp9).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, CAHPS Hospice Survey (gxki-hrr8).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR hospice inspection reports (Hospice Survey Reports - Oct 2021 through Sep 2026.xlsx).
Released Oct 23, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice All Owners (e983965e-1603-4cb8-82b5-c40090e380d1).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Enrollments (25704213-e833-4b8b-9dbc-58dd17149209).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice ZIP Data (95rg-2usp).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Oct 27, 2026.
From the hospice
The public record above comes first. Anything the hospice adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospice will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospice”, and paying will never change a finding, a rating or the order of results.