St Croix Hospice Eau Claire

“It is required that each patient’s individualized written plan of care reflects the patient and family goals and 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 and interview. In 4 of 27 (15%) clinical records reviewed, the agency did not ensure that the patient’s plan of care reflected the patient’s and family’s goals and identified planned interventions based on problems identified in the initial and comprehensive assessments. CLINICAL RECORD 1: The patient elected hospice care on 02/02/2026 with a diagnosis of Alzheimer’s disease. On 03/30/2026, the physician ordered massage therapy, four visits per month. “Our goal would be to reduce anxiety bring comfort relaxation pain reduction.” The massage therapy evaluation visit documented “What medical indications were addressed at this session: reduce anxiety, reduce agitation, reduce restlessness, reduce muscle tension/affect contractures, reduce pain, improve skin condition, increase comfort/relaxation. Indicate modalities used: Swedish massage, compressions.” The Hospice IDG Comprehensive Assessment and Plan of Care Update Reports dated 04/02/2026, 04/16/2026, 04/30/2026, and the recertification plan of care effective 05/03/2026 through 07/31/2026 did not document planned interventions based on problems identified in the massage therapy evaluation visit. CLINICAL RECORD 12: The patient elected hospice care on 06/29/2026 with a diagnosis of malignant neoplasm of lower lobe, right bronchus or lung. On 07/02/2026, the physician ordered massage therapy, four visits per month for three months. The massage therapy evaluation visit documented “What medical indications were addressed at this session: reduce anxiety, reduce agitation, reduce restlessness, reduce muscle tension/affect contractures, reduce pain, increase comfort/relaxation. Indicate modalities used: Swedish massage, compressions, trigger point, and lymphatic drainage.” The Hospice IDG Comprehensive Assessment and Plan of Care Update Reports dated 07/14/2026 and 07/28/2026 did not document patient and family goals and planned interventions based on problems identified in the massage therapy evaluation visit. CLINICAL RECORD 15: The patient elected hospice care 05/22/2026 with a diagnosis of acute respiratory failure with hypoxia. On 05/25/2026, the physician ordered “Hospice RN to insert 16F Foley with 30ml balloon for urinary retention and comfort. May irrigate with 60 mL NS for patency.” The Hospice IDG Comprehensive Assessment and Plan of Care Update Reports beginning 06/04/2026 did not document patient and family goals for the Foley catheter. On 06/16/2026, the physician ordered, “ Start oxygen 2-4 liters per minute (LPM) via (NC) nasal cannula as needed for comfort.” The Hospice IDG Comprehensive Assessment and Plan of Care Update Reports beginning 06/18/2026 did not document patient and family goals for the oxygen. CLINICAL RECORD 20: The patient elected hospice care on 05/06/2026 with a diagnosis of atherosclerotic heart disease. On 06/23/2026, the physician ordered massage therapy monthly for one month and then four visits per month for one month. The massage therapy evaluation visit dated 06/23/2026 documented “What medical indications were addressed at this session: reduce anxiety, reduce agitation, reduce restlessness, reduce muscle tension/affect contractures, reduce pain, improve skin condition, increase comfort/relaxation. Indicate modalities used: Swedish massage, compressions.” The Hospice IDG Comprehensive Assessment and Plan of Care Update Reports dated 07/07/2026 and 07/21/2026 did not document patient and family goals and planned interventions based on problems identified in the massage therapy evaluation visit. On 06/05/2026, the physician ordered, “Cleanse wound area with sterile normal saline or wound cleanser and clean gauze. Cover with barrier cream twice daily and as needed. Registered Nurse Case Manager (RNCM) to assess weekly.” The Hospice IDG Comprehensive Assessment and Plan of Care Update Reports beginning 06/09/2026 did not document patient and family goals for the wound care being provided. During the joint record review and interview on 07/30/2026, the Administrator/Regional Director of Operations (Personnel Record 7) confirmed that the plan of care for clinical record 1 did not document planned interventions for massage therapy, clinical record 12 did not document patient and family goals and interventions for massage therapy, clinical record 20 did not document patient and family goals and planned interventions for massage therapy or patient and family goals for foley catheter and oxygen, and clinical record 20 did not document patient and family goals and planned interventions for massage therapy and patient and family goals for the wound care being provided. DHS_131.21(1)General requirements. A written plan of care shall be established and maintained for each patient admitted to the hospice program and the patient’s family. The hospice plan of care is a document that describes both the palliative and supportive care to be provided by the hospice to the patient and the patient’s family, as well as the manner by which the hospice will provide that care. The care provided to the patient and the patient’s family shall be in accordance with the plan of care.”

“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. Agency policy #1-031 “Responsibilities/Supervision of Clinical Services” (revision date 12/2018) stated in part, “A monthly patient visit will be completed by a registered nurse to supervise licensed/ vocational nursing services.” In 1 of 4 (25%) clinical records reviewed of patients who received Licensed Practical Nurse (LPN) visits, the agency did not ensure that a Registered Nurse (RN) provided supervision of the LPN services as per agency policy. CLINICAL RECORD 4: The patient elected hospice services on 10/28/2025 with a diagnosis of atherosclerotic heart disease. The hospice certification and plan of care for benefit period 10/28/2025 through 01/25/2026 ordered Skilled Nursing (SN) three times a week for one week and then twice weekly for twelve (12) weeks. A SN visit was provided by the Licensed Practical Nurse (LPN) on 11/24/2025. A review of the clinical record on 07/30/2026 revealed no documentation of LPN supervision through the date of review. In a joint record review and interview on 07/30/2026, the Administrator/Regional Director of Operations (Personnel Record 7) confirmed that LPN supervisory visits were not completed per agency policy.”

“It is required that a hospice aide provide services: included in the plan of care. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 6 (17%) home visits observed and clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure the Hospice Aide provided services that were included in the plan of care. HOME VISIT 5/CLINICAL RECORD 5: The patient elected hospice care on 03/27/2026 with a diagnosis of atherosclerotic heart disease. During the home visit with the Hospice Aide [Personnel Record 5] on 07/29/2026, the HA was observed providing a sponge bath for the patient. During the visit, the HA applied A & D barrier cream to the patient’s buttocks and applied TED hose (anti-embolism stockings) to the patient’s bilateral lower extremities. The Hospice Aide care plan did not assign the tasks of applying barrier cream or applying TED hose. During the joint record review and interview on 07/29/2026, the Administrator/Regional Director of Operations (Personnel Record 7) confirmed that the services provided (application of barrier cream and TED hose) were not included in the Hospice Aide care plan. DHS_131.26(2)(b)Plan of care. The nurse aide shall provide care in accordance with the patient’s plan of care.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s needs. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #1-031 “Responsibilities/Supervision of Clinical Services” (revision date 12/2018) read in part, “Hospice aide supervisory visits will be conducted on site at least every 14 days by a hospice registered nurse.” In 1 of 26 (4%) clinical records reviewed for patients receiving Hospice Aide (HA) services, the agency did not ensure Hospice Aide supervisory visits were completed by a Registered Nurse (RN) at least every 14 days. CLINICAL RECORD 21: The patient elected hospice services on 12/30/2025 with a diagnosis of Alzheimer’s disease. The plan of care dated 12/30/2025 through 03/29/2026 ordered HA services twice (2) times weekly beginning 01/04/2026. The HA visits were provided as ordered, beginning 01/06/2026. The HA supervisory visit was completed on 01/22/2026, 16 days outstanding. In a joint record review and interview on 07/30/2026, the Administrator/Regional Director of Operations (Personnel Record 7) confirmed that HA supervisory visits were not completed every 14 days. DHS_131.26(2)(c)1 A registered nurse shall make an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the nurse aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. The nurse aide does not have to be present during this visit.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles and noted in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 5 of 6 (83%) clinical records reviewed of patients who received volunteer services, the agency did not ensure the services provided by volunteers were noted in the plan of care. CLINICAL RECORD 2: The patient elected hospice care on 10/14/2025 with a hospice diagnosis of atherosclerotic heart disease. A physician order was obtained on 05/08/2026 for monthly volunteer services. A physician order was obtained to increase to twice a month 5/21/2026, and then weekly on 06/02/2026. Volunteer visits were provided as ordered beginning 05/18/2026. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 05/12/2026 documented in part, “Volunteer Services Providing Companionship Visits 2x-4x within every 30 days.” The patient’s individualized written plan of care for benefit period 04/12/2026 through 06/10/2026, and patient’s Hospice IDG Comprehensive Assessment and Plan of Care Update Report for IDG dates 05/12/2026, 05/26/2026, 06/08/2026, 06/23/1016, 07/07/2026, and 07/21/2026 did not document patient and family goals or planned interventions for the volunteer services being provided. CLINICAL RECORD 8: The patient elected hospice care on 01/08/2026 with a hospice diagnosis of cerebral atherosclerosis. A physician order was obtained on 02/02/2026 for volunteer services two to four times every thirty (30) days for volunteer introduction. Volunteer visits were provided as ordered beginning 02/02/2026. The Hospice IDG Comprehensive Assessment and Plan of Care Update Reports completed every two weeks beginning 02/12/2026, and the patient’s individualized written recertification plans of care dated 04/08/2026 through 07/06/2026 and 07/07/2026 through 09/04/2026/12/2026 did not document patient and family goals or planned interventions for the volunteer services being provided. CLINICAL RECORD 9: The patient elected hospice care on 02/04/2026 with a hospice diagnosis of cerebral atherosclerosis. A physician order was obtained on 02/26/2026 for volunteer services two to four times within thirty (30) days. Volunteer visits were provided as ordered beginning 02/26/2026. The Hospice IDG Comprehensive Assessment and Plan of Care Update Reports completed every two weeks beginning 03/04/2026, and the patient’s individualized written recertification plan of care dated 05/05/2026 through 08/02/2026 did not document patient and family goals or planned interventions for the volunteer services being provided. CLINICAL RECORD 14: The patient elected hospice care on 01/20/2026 with a hospice diagnosis of unspecified severe protein calorie malnutrition. A physician order was obtained on 03/18/2026 for volunteer services two to four times within thirty (30) days. Volunteer visits were provided as ordered beginning 03/24/2026. The Hospice IDG Comprehensive Assessment and Plan of Care Update Reports completed every two weeks beginning 03/26/2026, and the patient’s individualized written recertification plans of care dated 04/20/2026 through 07/18/2026, and 07/19/2026 through 09/16/2026 did not document patient and family goals or planned interventions for the volunteer services being provided. CLINICAL RECORD 20: The patient elected hospice care on 05/06/2026 with a hospice diagnosis of Atherosclerotic heart disease. A physician order was obtained on 06/30/2026 for monthly volunteer services. Volunteer visits were provided as ordered beginning 07/06/2026. The Hospice IDG Comprehensive Assessment and Plan of Care Update Reports completed on 07/07/2026 and 07/21/2026 did not document patient and family goals or planned interventions for the volunteer services being provided. During the joint record review and interview on 07/30/2026, the Administrator/Regional Director of Operations (Personnel Record 7) confirmed that volunteer services were not noted in the plan of care for clinical records 2, 8, 9, 14, and 20.”

“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 hospice agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. During an interview and a joint review of the agency’s “Volunteer Cost Saving Report” on 07/27/2026, the Administrator/Regional Director of Clinical Operations (Personnel Record 7) confirmed that volunteer utilization was below 5% for 01/01/2025 through 12/31/2025 (0.90%), and 01/01/2024 through 12/31/2024 (0.98%). For the current year to date, volunteer utilization was 01/01/2026 through 06/30/2026 (1.01%), During an interview on 07/30/2026, the Volunteer Coordinator (Personnel Record 12) confirmed the findings and stated in part, “We are focusing on recruitment. We currently have twenty (20) volunteers and are connecting with the student population to recruit volunteers.” The hospice agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.”

“It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IID representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 8 (12%) clinical records reviewed of patients who resided or received respite services in a skilled facility, the agency did not ensure the hospice plan of care identified the care and services needed and specified which provider was responsible for performing the functions agreed upon and included in the plan of care. CLINICAL RECORD 6: The patient elected hospice care on 12/08/2025 with a diagnosis of atherosclerotic heart disease. The patient resided in a skilled nursing facility (SNF). The patient had a wound and used oxygen. A review of the clinical record revealed that the hospice plan of care did not identify the care and services needed and did not specify which provider would be responsible for performing the functions agreed upon and included in the plan of care. The Administrator/Regional Director of Operations (Personnel Record 7) confirmed in an interview and joint record review on 07/30/2026 that the clinical records did not identify the care and services needed or specify which provider was responsible.”

“It is required that the written Patient Bill of Rights includes the right to: choose his or her attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure that all patient rights were followed as the attending physician was not informed of changes in condition. Clinical Record 1: The patient chose his attending physician to follow him for care. As patient encountered changes in condition, there was no documentation that the attending physician was informed of the changes. The Skilled Nursing notes in the skilled facility record documented hypoglycemic and hyperglycemic episodes, medication discrepancies, physician ordered blood draws for INR orders not obtained, bleeding that was difficult to stop after falls, and reporting of falls and injuries. The Hospice Medical Director had provided physician orders for care. There was no documentation that the attending physician had declined to manage the patient’s care. Hospice Care was delivered from 12/17/2022 until 02/02/2023, when the patient died. Interview with the Director of Clinical Services, and the Regional Director of Clinical Services stated that this record had been reviewed before 10/10/2023.”

“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 1 of 5 (20%) clinical records reviewed of patients receiving hospice aide services, the agency did not ensure the hospice aide received specific written patient care instructions for care delivery. Clinical Record 1: The patient elected hospice care on 12/21/2022. The skilled nursing visit note dated 01/03/2023 documented that the facility only used a Hoyer lift to transfer patient. Additionally, the patient had a Foley catheter. The care and maintenance of the Foley catheter and the use of a Hoyer Lift for transfers were not included in the hospice aide care plan. The Regional Clinical Specialist agreed that the hospice aide care plan was not complete and that this record had been reviewed prior to 10/10/2023.”

“It is required that the Interdisciplinary Group (IDG) member ensures that the IDG communicates with the SNF/NF or ICF/IDF medical director, the patient’s attending physician, and other physicians participating in the patient’s/resident’s care to coordinate the hospice care with the medical care provided by other physicians. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records for patient’s residing in skilled nursing facilities reviewed, the agency did not ensure that the attending physician was promptly notified of changes in condition by the IDG membership. Clinical Record 1: Patient was receiving hospice services in a skilled nursing facility. In reviewing the skilled nursing facility clinical record, on 12/26/2023, Insulin was not administrated timely or using the physician ordered dose, on 12/29/2023, an INR blood test was ordered but not obtained, the anticoagulant medication was discontinued by the anticoagulant clinic on 01/31/2023, several falls were documented, however, no specific detail about injury. The Hospice IDG notes and IDG members documentation at the initiation of care on 12/21/2023 and every two weeks thereafter did not document any coordination of care with the Attending Physician about changes in condition while patient was residing in the skilled nursing facility. Interview with the Regional Director of Clinical Service confirmed this record was had been previously reviewed by clinical leadership prior to 10/10/2023 and the agency ended the contract with this facility.”