St Croix Hospice Baraboo

“It is required that 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. 4 of 18 (22%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the registered nurse(s) provided specific written instructions for the hospice aide(s). CLINICAL RECORD 4: The patient elected the hospice benefit on 02/07/2025. The HA care plan was updated 07/09/2025 to include the following: “Assist to toilet, oral care, dressing-first visit of week and as needed, prepare snack, offer snack, bathing (bed)-first visit of week, provide incontinence care, shampoo-last visit of week, skin care, transfer assist, change linens-last visit of week, socialization-last visit of week, provide vigil, report pain to nurse, report skin changes to nurse, nurse to orient aide to care plan, safety precautions.” All tasks were to be completed every visit unless specified. The HA visit frequency was two times weekly. The hospice aide care plan was updated on 11/18/2025 to include the following: “Assist to toilet, oral care, provide incontinence care, skin care, transfer assist, change linens-last visit of week, bathing (shower)-first visit of week, offer fluids, prepare snack, socialization-last visit of week, provide vigil, report pain to nurse, report skin changes to nurse, nurse to orient aide to care plan, safety precautions.” All tasks were to be completed every visit unless specified. The HA visit frequency was two times weekly. A nursing visit dated 11/01/2025 noted the patient to have “bilateral kerlix wrapped legs for edema.” The HA care plan did not provide the aide with notification of the dressings or with specific instructions for the legs during assigned tasks. CLINICAL RECORD 6: The patient elected the hospice benefit on 08/15/2025. The HA care plan dated 08/15/2025 assigned the following relevant tasks: “Bathing (shower)-assist of two for transfers first visit of every week, dressing, nail care-clean and file only-last visit of the week, oral care-toothettes, incontinence care, skin care-full body lotion, transfer assist-hoyer lift, turn and position in bed, change linens-first visit of the week, report pain to nurse, report skin changes to nurse, nurse to orient aide to care plan, safety precautions. All tasks were to be completed every visit unless otherwise specified. The HA visit frequency was twice weekly. The initial nursing admission note dated 08/16/2025 noted the patient had a “J/G tube. and the medication list documented six (6) medications for seizures (Amantadine, Baclofen, Diazepam, Lacosamide, Levetiracetam, Zonisamide). The HA care plan did not provide the aide with notification of the patient’s feeding tube nor seizure precautions. CLINICAL RECORD 11: The patient elected the hospice benefit on 06/07/2025. The HA care plan dated 07/09/2025 assigned the following relevant tasks: “Bathing (Shower) first visit of week and Bathing (Tub Bath) first visit of week, Bathing (Bed) last visit of week. The care plan was updated on 08/22/2025 however the assigned tasks remained the same with an HA visit frequency of twice weekly. The HA care plan did not provide the aide with a specific bath type for the first visit of the week; what was assigned was both a shower and tub bath for that first visit of the week. CLINICAL RECORD 12: The patient elected the hospice benefit on 08/19/2025. The HA care plan dated 08/20/2025 assigned the following relevant tasks: “Oral care, incontinence care, shampoo, skin care-apply lotion after shower, transfer assist, turn and position in bed, provide vigil, report pain to nurse, report skin changes to nurse, nurse to orient aide to care plan, safety precautions.” The HA care plan was updated on 09/04/2025 to add “use Hoyer lift for transfers.” The HA care plan was updated 09/07/2025 to add “Bathing-shower.” All tasks were to be completed every visit with the exception of the shower which was weekly. The HA visit frequency was twice weekly. A physician’s order dated 08/22/2025 documented the following: “Clean area with wound cleanser, pat dry with gauze, apply calcium alginate to wound bed, cover with sacral Optiview dressing. Clean area with wound cleanser, pat dry with gauze, apply Xerofoam, cover with gauze, Kerlix and posey sleeve.” A physician’s order dated 08/26/2025 documented the following: “Posterior medial vertebrae wound: Clean area with wound cleanser, pat dry with gauze, apply calcium alginate to wound bed, cover with sacral Optiview dressing. Left forearm wound: Clean area with wound cleanser, pat dry with gauze, apply Xerofoam, cover with gauze, Kerlix and posey sleeve.” A physician’s order dated 10/14/2025 documented the following: “Stage III pressure ulcer to medial spine.......cover with foam bordered dressing.” A physician’s order dated 10/18/2025 documented the following: “Wound to right second toe: Cover with gauze to keep dry. Lamb’s wool between toes on bilateral feet.” The HA care plans did not notify the aide(s) of the wounds nor provide specific instructions for the aide to notify the nurse if the dressing(s) became soiled, dislodged or wet. CLINICAL RECORD 14: The patient elected the hospice benefit on 07/21/2025. The HA care plan dated 07/30/2025 assigned the following relevant tasks: “Bathing- shower, dressing, oral care, incontinence care, skin care, report pain to nurses, report skin changes to nurses, nurse to orient aide to care plan, provide vigil, safety.” All tasks were to be completed every visit. The HA visit frequency was twice weekly. A nursing visit note dated 08/03/2025 documented a “Pleurex drain was placed.” The HA care plan did not notify the aide(s) of the drain nor provide specific instructions for the drain during assigned tasks. A joint clinical record review and interview was conducted with the Statewide Clinical Director on 12/04/2025 during which it was agreed the HA care plans should have included instructions ‘for the seizures, wounds, only 1 bath type and any drains or tubes.””

“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. Document review of the volunteer program revealed the agency did not ensure hospice volunteers provided 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. Review of the hospice volunteer program revealed the volunteer percentage for October 2024 through November 2025 equaled 0.64% and included administrative and patient care services. During a joint document review and interview with the Manager of Volunteer Services and Regional Volunteer Coordinator on 12/03/2025, the volunteer percentage of 0.64% was confirmed. Document review of the volunteer program revealed the agency did not ensure hospice volunteers provided 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. An interview and document review was conducted with the Manager of Volunteer Services and Regional Volunteer Coordinator on 12/03/2025, and the volunteer percentage for the past year (October 2024 to November 2025) in either an administrative or patient care role equaled 0.64%.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, interview and personnel record review. 2 of 11 (18%) personnel records reviewed revealed the agency did not ensure that the skills and competencies of all individuals providing care, including volunteers, were assessed. The agency policy GF 101 7.9, titled “Employee Records” dated January 2024, stated in relevant parts: “The MCS (Manager of Clinical Services) is responsible for completing initial and annual skills checklists for RN, aides, chaplains, social workers, music therapists, massage therapists. They will retain a copy at the branch office...After completion, the MSC will email a copy of the completed document to...” PERSONNEL RECORD 3: A personnel record review was conducted on 12/03/2025, which revealed that there were no documented annual skills checklists in 2023 for this Clinical Manager/Registered Nurse, hired on 05/24/2021. PERSONNEL RECORD 8: A personnel record review was conducted on 12/03/2025, which revealed that there were no documented annual skills checklists in 2023 for this Music Therapist, hired on 10/16/2013. The personnel record review and interview were conducted on 12/03/2025 with the Human Resources Manager (HRM) who was unable to locate the skills competency assessments for 2023 for the above employees (Personnel records 3 and 8). The HRM stated that the checklists “had not been scanned to Human Resources” and would have the local office(s) check. A check at the local office was performed by the Statewide Clinical Director (SCD) on 12/03/2025 who stated: “They contacted the employees who believe the competencies had been completed but were unable to locate the forms.” The HRM and SCD stated, “These (checklists) should have been completed and sent to Human Resources by the previous manager.””

“Based on record review and interview, the Interdisciplinary Group (IDG) failed to review and revise the Plan of Care (POC) as the patient required in 10 of 10 patients (Patients #1-10) and failed to provide coordination of services for patients that reside in an Assisted Living Facility (ALF) / Skilled Nursing Facility (SNF) in 9 out of 10 patient records reviewed (Patients #1, #2, #4, #5, #6, #7, #8, #9, #10). Findings include: The agency’s IDG failed to maintain direction and coordination of care provided. See Tag L0554. The cumulative effect of this systemic problem resulted in the agency’s inability to ensure the provision of quality care.”

“Based on record review and interview, agency staff failed to ensure that the IDG (Interdisciplinary Group) maintained responsibility for directing and coordinating the care provided to 10 of 10 patient records reviewed (Patients #1-10) and failed to provide coordination of services for patients that reside in an Assisted Living Facility (ALF) / Skilled Nursing Facility (SNF) in 9 out of 10 patient records reviewed (Patients #1, #2, #4, #5, #6, #7, #8, #9, #10). Findings include: Review of policy “;Interdisciplinary Group Coordination of Care” No. 1-035 last revised 2/20/2024 revealed in part, “;4. [Hospice] personnel will communicate changes in a timely manner via telephone, one-to-one meetings, interdisciplinary group meetings, and home visits. Documentation of all communications will be included in the clinical record. Documentation will include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication.” Further review revealed, “;6. Written evidence of care coordination will be found in the plan of care and/or interdisciplinary team meeting forms in the patients clinical record and will involve the patients attending physician.” Review of Patient #1s medical record revealed Patient #1 was admitted to hospice service on 12/1/2023 with a primary diagnosis of coronary artery disease. Secondary diagnoses included dementia and atrial fibrillation. Patient #1 resided in a memory care unit in an ALF (Assisted Living Facility.) Patient #1 was ambulatory with an unsteady gait and transferred with the assist of one and a walker. Patient #1 had a history of frequent falls prior to hospice admission. Review of Patient #1s medical record revealed Patient #1s dementia progressed through February 2024 with episodes of aggression, agitation, increased confusion, and exit-seeking. Patient #1 also became less steady and more impulsive. In March 2024, Patient #1 experienced 5 falls; April 2024 8 falls; May 2024 4 falls; June 2024 1 fall; July 2024 5 falls; August 1 through August 13, 2024, 1 fall. Further review of Patient #1s medical record revealed there were no medication changes after 2/29/2024. Further review of Patient #1s record revealed no documentation within the IDG (Interdisciplinary Group) meeting reports of discussions within the IDG regarding the frequent falls and possible further intervention to assist in preventing them, throughout this time period. There was also no documentation in Patient #1s record of collaboration/discussions with facility staff regarding the frequent falls and possible intervention that may assist in decreasing them. There was no documentation of collaboration with Patient #1s PCP (Primary Care Provider) regarding the frequent falls. Review of Patient #2’s medical record revealed Patient #2 was admitted to hospice service on 6/22/2023 with a primary diagnosis of Alzheimer’s Disease. Patient #2 resided in a SNF (Skilled Nursing Facility). Further review revealed no documentation within the IDG meeting reports of discussions within the IDG of review of the care plans and what may need to be changed based on the patient’s current status and no documentation of discussion regarding collaboration with the SNF. Review of Patient #3’s medical record revealed Patient #3 was admitted to hospice service on 7/5/2024 with a primary diagnosis of congestive heart failure. Patient #3 resided in a private home. Further review revealed no documentation within the IDG meeting reports of discussions within the IDG of review of the care plans and what may need to be changed based on the patient’s current status. Review of Patient #4’s medical record revealed Patient #4 was admitted to hospice service on 9/20/2024 with a primary diagnosis of Alzheimer’s Disease. Patient #4 resided in an ALF (Assisted Living Facility) There was no documentation within the IDG meeting report of discussion regarding the formulation of an initial plan of care and no documentation of discussion regarding collaboration with the ALF. Review Of Patient #5’s medical record revealed Patient #5 was admitted to hospice service on 8/28/2024 with a primary diagnosis of heart disease. Patient #5 resided in an ALF. Further review revealed no documentation within the IDG meeting reports of discussions within the IDG of the review of the care plans and what may need to be changed based on the patient’s current status and no documentation of discussion regarding collaboration with the ALF. Review of Patient #6’s medical record revealed Patient #6 was admitted to hospice service on 5/15/2024 with a primary diagnosis of dementia. Patient #6 resided in an ALD. Further review of Patient #6’s record revealed 2 falls: one on 8/28/2024 and another on 9/7/2024. A Patient Safety Analysis was documented after both falls. Root causes for both falls was increasing weakness and confusion. There was no documentation within the IDG meeting reports of discussions within the IDG regarding the falls or what may need to be changed based on the patient’s current status and no documentation of discussion regarding collaboration with the ALF. Review of Patient #7’s medical record revealed Patient #7 was admitted to hospice service on 9/6/2024 with a primary diagnosis of sepsis (systemic infection). Patient #7 resided in an ALF. There was no documentation within the IDG meeting report regarding discussion of the formulation of an initial plan of care. There was no documentation of discussion regarding collaboration with the ALF. Review of Patient #8’s medical record revealed Patient #8 was admitted to hospice service on 9/24/2022 with a primary diagnosis of vascular dementia. Patient #8 resided in an ALF. There was no documentation within the IDG meeting reports of discussions within the IDG of the review of the care plans and what may need to be changed based on the patient’s current status and no documentation discussion regarding collaboration with the ALF. Review of Patient #9’s medical record revealed Patient #9 was admitted to hospice service on 7/31/2024 with a primary diagnosis of congestive heart failure. Patient #9 resided in SNF. There was no documentation within the IDG meeting reports of discussions within the IDG of the review of the care plans and what may need to be changed based on the patient’s current status and no documentation of discussion regarding collaboration with the SNF. Review of Patient #10’s medical record revealed Patient #10 was admitted to hospice service on 9/13/2024 with a primary diagnosis of Alzheimer’s Disease. Patient #10 resided in an ALF. There was no documentation within the IDG meeting reports of discussions within the IDG of the review of the care plan and what may need to be changed based on the patient’s current status and no documentation of discussion regarding collaboration with the SNF. During an interview with Regional Director B on 10/1/2024 at 11:20 a.m., Regional Director B was asked if the IDG meeting reports should indicate what was discussed in the IDG meeting, including collaboration with ALF/SNF. Regional Director B stated yes.”