St Croix Hospice Waukesha

“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; [and] 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; [and] 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 measures 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. In 4 of 23 (17%) clinical records reviewed and home visits observed, the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient’s current medications. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 10/29/2022 with a diagnosis of cerebral atherosclerosis. The patient resided in a skilled nursing facility (SNF). During a home visit with the Hospice Aide (HA) [Personnel Record 9] on 06/24/2025, the hospice medication profile (printed on 06/23/2025) and the SNF medication profile (printed on 06/24/2025) were reviewed. The following medications were documented on the hospice medication profile and were not documented on the SNF medication profile: lorazepam 0.5mg, take one (1) tablet daily (ordered 08/01/2023); and venlafaxine 37.5 mg, take one (1) tablet daily (ordered 03/20/2024). The following discrepancy was noted: the hospice medication profile documented “acetaminophen 500 mg tablets, take two (2) tablets at bedtime and in the morning” (ordered 02/09/2022); the SNF medication profile documented “acetaminophen 500 mg, take 2 tablets three times daily.” Clinical Record 2/Home Visit 2: The patient elected the hospice benefit on 05/27/2025 with a diagnosis of malignant neoplasm of the male breast. The patient resided in a skilled nursing facility (SNF). During the home visit with the Registered Nurse [Personnel Record 6] on 06/24/2025, the hospice medication profile (printed on 06/23/2025) and the SNF medication profile (printed on 06/24/2025) were reviewed. The following medications were documented on the SNF medication profile and were not documented on the hospice medication profile: Ensure Plus, take one (1) can twice daily (ordered 05/28/2025); Dakin’s wound solution, apply as needed for wound care (ordered 05/29/2025); Fleet’s enema, insert one (1) daily as needed (ordered 05/27/2025); Lactobacillus, give one (1) capsule daily (ordered 05/27/2025); and tizanidine 2 mg, give one (1) tablet every 8 hours as needed (ordered 05/27/2025). Clinical Record 4/Home Visit 4: The patient elected the hospice benefit on 10/06/2023 with a diagnosis of atherosclerotic heart disease. The patient resided in an assisted living facility (ALF). During the home visit with the Hospice Aide (HA) [Personnel Record 10] on 06/25/2025, the hospice medication profile (printed on 06/23/2025) and the ALF medication profile (printed on 06/25/2025) were reviewed. The following medications were documented on the hospice medication profile and were not documented on the ALF medication profile: diphenhydramine 25 mg, take one (1) tablet at bedtime (ordered 02/29/2024); lidocaine patch, apply at bedtime (ordered 12/31/2024); nystatin cream, apply two (2) times daily (ordered 02/18/2025); and Senna S, take one (1) tablet at bedtime (ordered 01/27/2025). The following medications were documented on the ALF profile and not documented on the hospice medication profile: atorvastatin 40 mg, one (1) tablet at bedtime (ordered 03/08/2024); ferrous sulfate 325 mg, one (1) tablet at bedtime (ordered 03/08/2024); acetaminophen 325, take two (2) tablets every 4 hours as needed (ordered 03/08/2024); and acetaminophen PM 500-25 mg, take one (1) tablet at bedtime (ordered 02/29/2024). Clinical Record 6/Home Visit 6: The patient elected the hospice benefit on 04/23/2025 with a diagnosis of chronic heart failure. The patient resided in an assisted living facility (ALF). During the home visit with the Spiritual Counselor [Personnel Record 8] on 06/26/2025, the hospice medication profile (printed on 06/23/2025) and the ALF medication profile (printed on 06/26/2025) were reviewed. The following medications were documented on the hospice medication profile and were not documented on the ALF medication profile: guaifenesin 400 mg tablet, one (1) tablet every 4 hours as needed (ordered 04/23/2035); ketoconazole 2% shampoo, apply weekly as needed (ordered 04/23/2025); Lamisil 1% spray, apply daily as needed (ordered 04/23/2025); lidocaine cream, apply every 6 hours as needed (ordered 04/23/2025); erythromycin eye ointment, apply 2 times daily (ordered 04/23/2025). During a joint clinical record review and interview on 06/25/2025, the Manager of Accreditation agreed that the “medications had not been reconciled.” DHS_131.20(3)(f) DHS_131.33(3)(e)”

“It is required that each patient’s individualized written plan of care: reflects patient and family goals; identifies planned interventions based on problems identified in the initial and updated comprehensive assessments; [and] includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient This standard was not met as evidenced by clinical record review, observations, and interview. In 1 of 23 (4%) clinical records reviewed, the agency did not ensure that the patient’s plan of care (POC) included drugs and treatments necessary to meet the needs of the patient. Clinical Record 2/Home Visit 2: The patient elected the hospice benefit on 05/27/2025 with a diagnosis of malignant neoplasm of the male breast. The patient resided in a skilled nursing facility (SNF). During the home visit with the Registered Nurse [Personnel Record 6] on 06/24/2025, the following medications were documented on the SNF medication profile: Ensure Plus, take one (1) can twice daily (ordered 05/28/2025); Dakin’s wound solution, apply as needed for wound care (ordered 05/29/2025); Fleet’s enema, insert one (1) daily as needed (ordered 05/27/2025); Lactobacillus, give one (1) capsule daily (ordered 05/27/2025); and tizanidine 2 mg, give one (1) tablet every 8 hours as needed (ordered 05/27/2025). The POC dated 05/27/2025 did not document Ensure Plus, Dakin’s wound solution, Fleet’s enema, Lactobacillus, and tizanidine. During a joint clinical record review and interview on 06/27/2025, the Manager of Accreditation confirmed that the medications were not added to the patient’s plan of care. DHS_131.21(3)(b)4”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan: as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. In 1 of 23 (4%) clinical records reviewed, the agency did not ensure that the patient’s plan of care was updated as frequently as the patient’s condition required. Clinical Record 18: The patient elected hospice care on 03/11/2025 with a diagnosis of squamous cell carcinoma of the skin of the scalp and neck. The plan of care (POC) dated 03/11/2025 documented: “Problem: Pain/Altered comfort. Need for an assessment of the effectiveness of pain control. Evaluated effectiveness of pain control. Pain is currently at a level acceptable to the patient. Need for skilled teaching regarding pain/altered comfort. Instructed to notify hospice of any significant change in pain intensity. Instructed regarding pain control measures. Pt/CG understands need to report pain. Will demonstrate understanding of pain management issues.” An as-needed skilled nursing visit note dated 04/13/2025 documented “increased pain and increased weakness. New pain medications were ordered.” A Foley catheter was placed on 04/22/2025 during the SN’s ‘as-needed’ visit. Between 05/30/2025 and 06/06/2025, the patient was documented as ‘transitioning,’ and SN visits were increased to daily for ‘transitioning and symptom control.” The pain POC was not revised, the catheter was not added to the POC, and during the time the patient was transitioning, no revisions were made to the POC. The POC did not include documentation of updates since the patient’s start of care. During a joint clinical record review and interview on 06/27/2025, the Manager of Accreditation agreed and stated that “the nurses needed to update the plan of care with these changes.” DHS_131.21(3)(c)”

“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 and interview. In 6 of 21 (29%) clinical records reviewed in which Hospice Aide services were accepted, the agency did not ensure that the Hospice Aide (HA) received written patient care instructions from the Registered Nurse to meet the patient’s needs. Clinical Record 2: The patient elected hospice care on 05/27/2025 with a diagnosis of malignant neoplasm of the central portion of the male breast. The patient resided in a skilled nursing facility (SNF). The plan of care ordered HA services twice weekly. The HA care plan(s) dated 05/27/2025 and updated 05/28/2025 assigned the HA the relevant tasks: “bed bath, dressing, incontinence care-wipe front to back, apply clean brief, apply thin layer of barrier cream, skin care, report skin changes to nurse.” All tasks were to be completed on every visit. A physician’s order dated 05/28/2025 ordered: “cleanse sacral wound with Dakin’s and pack wound with softened gauze. Coccyx/left buttocks apply Medihoney and Optifoam. Wound on left hip covered with Optifoam.” The HA care plan did not notify the HA of the wounds, nor provide specific instructions to notify the RN if the wound dressings became soiled, dislodged, or wet. Clinical Record 7: The patient elected hospice care on 11/21/2024 with a diagnosis of primary pulmonary hypertension. The patient resided in an assisted living facility (ALF). HA services were ordered twice weekly. The HA care plan(s) dated 11/21/2024, updated 11/22/2024, and 04/28/2025 assigned the HA the relevant tasks: “dressing-patient requires assistance with lower body dressing, peri care, skin care-apply lotion to all four extremities, report skin changes to nurse.” All tasks were to be completed on every visit. A physician’s order dated 05/20/2025 ordered: “Cover both legs with antifungal ointment with petroleum jelly and spread from foot to knee. Vaseline mesh over wound, abdominal pad, and compression sleeve from base of toes to knees.” The HA care plan did not notify the HA of the wounds, nor provide specific instructions to notify the RN if the wound dressings became soiled, dislodged, or wet. Clinical Record 13: The patient elected hospice care on 03/11/2025 with a diagnosis of other nonspecific abnormal findings of the lung. The patient resided in an assisted living facility (ALF). HA services were ordered twice weekly. The HA care plan(s) dated 3/11/2025 and updated 03/17/2025 assigned the HA the relevant tasks: “assist to toilet, bathing-shower, dressing, skin care-apply lotion to upper and lower body, report skin changes to nurse.” All tasks were to be completed on every visit. The initial skilled nursing (SN) assessment dated 03/11/2025 documented “buttock wound covered with foam dressing-surgical incision/fistula.” The HA care plan did not notify the HA of the wounds, nor provide specific instructions to notify the RN if the wound dressing became soiled, dislodged, or wet. Clinical Record 16: The patient elected hospice care on 04/05/2023 with a diagnosis of other chronic osteomyelitis. The patient resided in a SNF. HA services were ordered twice weekly. The HA care plan(s) dated 04/05/2023 and last updated 05/12/2025 assigned the HA the relevant tasks: “bed bath and shower, peri care, incontinence care, catheter care, report skin changes to nurse.” All tasks were to be completed every visit except the shower and bath, which were once weekly. The SN assessment dated 04/04/2023 documented “Stage III on hip, covered with Mepilex.” The wound was present as of the date of the clinical record review, 06/25/2025. The HA care plan did not notify the HA of the wound, nor provide specific instructions to notify the RN if the wound dressing became soiled, dislodged, or wet. Clinical Record 17: The patient elected hospice care on 04/07/2025 with a diagnosis of cerebral atherosclerosis. The patient resided in an ALF. HA services were ordered twice weekly. The HA care plan(s) dated 04/07/2025, and updated 04/08/2025, assigned the HA the relevant tasks: “Assist to toilet, bathing-shower, dressing, hair care, oral care, peri care, incontinence care, shampoo, report skin changes, and ensure caregiver is updated and that it is logged.” All tasks were to be completed on every visit. The SN visit note dated 04/11/2025 documented “leg wound-pat dry with gauze, cover with Optifoam.” The SN visit note dated 04/24/2025 documented: “Steristrips to forehead.” The HA care plan did not notify the HA of the wounds, nor provide specific instructions to notify the RN if the wound dressing became soiled, dislodged, or wet. Clinical Record 19: The patient elected hospice care on 02/09/2024 with a diagnosis of Alzheimer’s disease. The patient resided in a SNF. HA services were ordered twice weekly. The HA care plan(s) dated 02/09/2024 and updated 02/12/2024, assigned the HA the relevant tasks: “ostomy care every visit, assist of 1, rest of order depends on type of system used,” and shower-first visit of week, dressing, hair care, oral care, incontinence care, shampoo, skin care, transfer assist. All tasks were to be completed on every visit except the shower. The initial SN assessment, dated 02/09/2024, documented that the patient had an ostomy and was on Depakote and Keppra for seizures. The plan of care dated 02/09/2024 documented the patient’s seizures and the intervention to “instruct on seizure precautions, signs and symptoms of seizures.” The HA care plan did not provide clear instructions regarding the assigned task: “ostomy care every visit. Assist of 1. Rest of order depends on type of system used,” and did not notify the HA of the seizure precautions, nor provide specific instructions for the care of the ostomy. During a joint clinical record review and interview on 06/25/2025, the Manager of Accreditation confirmed the wounds had not been listed on the HA care plans and the ostomy order “was unclear and not specific.” DHS_131.26(2)(a)”

“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 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 conducted with the Manager of Volunteer Services, Manager of Accreditation, and Regional Volunteer Coordinator on 06/26/2025 revealed the volunteer percentage for the past year (May 2024 to May 2025) was below five percent (5%) of the total patient care hours of all paid hospice employees and contract staff and calculated at 0.27% for the parent, 0.06% for ADS 1, 0.20% for ADS 2, and 0.29% for ADS 3. 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, Manager of Accreditation, and Regional Volunteer Coordinator on 06/26/2025, and the volunteer percentage for the past year (May 2024 to May 2025) in either an administrative or patient care role, was calculated at 0.27% for the parent, 0.06% for ADS 1, 0.20% for ADS 2, and 0.29% for ADS 3.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #2-002 “Verification of Physician Orders” (dated 11/2018) stated in relevant part: “Orders will be obtained from a licensed physician for care and services to be provided to hospice patients... Orders will be documented in the EMR (electronic medical record), dated and signed by the professional receiving the order.” In 2 of 23 (9%) clinical records reviewed, the agency did not ensure that the patient’s clinical record contained a physician’s order for care and services provided. Clinical Record 18: The patient elected hospice care on 03/11/2025 with a diagnosis of squamous cell carcinoma of the skin of the scalp and neck. A clinical record review on 06/26/2025 revealed that a Foley catheter was placed on 04/22/2025 during the skilled nurse’s ‘as-needed’ visit. During the clinical record review, there was no evidence of a physician order in the electronic medical record (EMR) to authorize the catheter. Clinical Record 20: The patient elected hospice care on 03/13/2025 with a diagnosis of atherosclerotic cardiovascular disease (ACVSD). The patient resided in an assisted living facility (ALF). The HA care plan(s) dated 03/13/2025 and updated 03/14/2025 ordered HA visits twice weekly. The HA stopped making visits after three (3) visits as the patient was “refusing most tasks.” The Registered Nurse was aware of the refusals as they were writing “not applicable” to the HA supervisory visits. There was no physician order documented to discontinue the aide services. During a joint clinical record review and interview on 06/26/2025, the Manager of Accreditation advised, “Our expectation is that the order goes into the EMR (electronic medical record). DHS_131.33(3)(j)”