Every finding on record at St Croix Hospice, LLC

Based on a home observation visit, staff interview, clinical record reviews and agency policy review, the hospice failed to ensure the Plans of Care (POC) for 5 of 6 sampled patients included all physician orders and all medical equipment and supplies necessary to meet identified patient needs (Patients #1, #2, #3, #4 and #6).   Failure to include all physician orders and all medical equipment and supplies the patient used on the POC placed patients at risk of unanticipated decline or injury and of needs not met.    Findings include: --- 4. Patient #1 had a hospice admission date of 12/5/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 12/5/25 to 3/4/26, identified the patient had a diagnosis of Alzheimer's disease and used the following medical equipment and supplies: cleanser foam, no rinse, adult briefs, medium exam gloves, lip balm, mouthwash, barrier ointment, shampoo cap, oral swabs and body cleanser.    b. During a home observation visit on 12/29/25 at 1:15 PM with Staff C, RN, the surveyor observed the patient to be sitting in a wheelchair with a wheelchair cushion and then observed staff to transfer the patient from the wheelchair to the bed utilizing a gait belt.  The surveyor also observed a bedside table, toilet safety frame and shower chair in the patient's room/bathroom.  Staff C stated the patient has utilized the medical supplies and equipment since admission.    The hospice failed to include all medical supplies and equipment utilized by the patient on the plan of care including wheelchair, wheelchair cushion, gait belt, bedside table, toilet safety frame and shower chair.    5. Patient #6 had a hospice admission date of 9/25/25, a death date of 12/1/25 and received hospice services while residing in an assisted living facility.  Clinical record review revealed:   a. The POC, dated 9/25/25 to 12/23/25, identified the patient had diagnoses of other specified disorders of the brain, altered mental status and dementia and identified the patient used the following medical supplies and equipment: foam cleanser, fit right protective underwear, lip balm, body cleanser, oral swabs and scented wipes.    b. The skilled nurse visit note, dated 11/24/25, completed by Staff C, RN identified the patient utilizes a gel/foam mattress.    c. The IDG meeting notes, dated 11/26/25, failed to identify the gel/foam mattress utilized by the patient.    The hospice failed to include all medical supplies and equipment utilized by the patient on the plan of care, including gel/foam mattress.    The above findings were reviewed with the Administrator and Clinical Manager.   According to the hospice policy, titled The Plan of Care, dated December 2018, the plan of care will contain, but will not be limited to the following: durable medical equipment and medical supplies necessary to meet patient needs, drugs and treatments, and physician (or other authorized licensed independent practitioner) orders. 1.Patient #2 had a hospice admission date of 11/14/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 11/14/25 to 2/11/26, identified the patient had a diagnosis of cerebral atherosclerosis and included an order for oxygen therapy. The physician order written as follows: oxygen gas for inhalation, 1 to 5 liter for anxiety/shortness of breath, via nasal cannula/face mask, tracheostomy for continuous, at bedtime or as needed for anxiety or shortness of breath. The hospice failed to ensure the order was specific to the patient's individual needs. b. The interdisciplinary group (IDG) meeting notes, dated 11/25/25, failed to identify patient specific orders for oxygen utilized by the patient.   The hospice failed to include patient specific orders for oxygen utilized by the patient. 2. Patient #3 had a hospice admission date of 12/12/25 and received hospice services while residing in a private residence.  Clinical record review revealed:  a. The POC, dated 12/12/25 to 3/11/26, identified the patient had a diagnosis of lung cancer and included the following medical equipment and supplies: foam cleanser, no rinse, nail clipper, hydraguard, adult briefs, extra protective underwear, exam glove, remedy lotion, mouthwash, moisturizing oral gel, body cleansing cloth, shampoo cap, skin cream, silicone barrier cream with zinc oxide, total body cleanser, oral dentips, under pad, washbasin and aloe touch wipes. b. The skilled nurse note, dated 12/13/25, included documentation Staff F, Registered Nurse (RN) supplied a medication planner and set up the patient's medications. c. The IDG meeting note, dated 12/23/25, failed to identify a medication planner as medical equipment and supplies utilized by the patient.   The hospice failed to include all medical equipment and supplies utilized by the patient. 3. Patient #4 had a hospice admission date of 12/6/25 and received hospice services while residing in a private residence.  Clinical record review revealed:  a. The POC, dated 12/6/25 to 3/5/26, identified the patient had a diagnosis of acute on chronic heart disease and included orders for skilled nurse services, medications and treatments. The POC included identification of medical equipment and supplies used by the patient including an oxygen concentrator, oxygen tubing and oxymask size 7. The POC failed to include physician orders for the specific use of oxygen for the patient. b. The skilled nurse visit note at start of care, dated 12/6/25, documented the patient used oxygen from 2 to 4 liters per minute. c. The IDG meeting notes, dated 12/9/25 and 12/23/25, failed to identify physician orders for oxygen therapy utilized by the patient.   The hospice failed to include all physician orders including oxygen therapy utilized by the patient.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene This standard was not met, as evidenced by observation, document review, and interview. Agency policy #7-009 "Hand Hygiene" (reviewed 02/14/2024), read in part, "1. Wet hands and apply the soap and rub hands together vigorously; avoid use of hot water because repeated exposure to hot water may increase risk of dermatitis. 2. Wash hands for at least 20 seconds covering all surfaces of the hands and fingers. 3. Rinse with warm water and dry the hands with a disposable towel from the fingers toward the forearm. 4. Use a dry disposable towel to turn off faucet." In 1 of 4 (25%) home visits observed, the agency did not ensure that hand hygiene was performed correctly when indicated. Home Visit 2/Clinical Record 2: The patient elected hospice care on 09/12/2024. During the home visit with the Licensed Practical Nurse (LPN) [Personnel Record 7] on 09/24/2024, the LPN turned the faucet on, washed their hands with dish soap, rinsed their hands, turned the faucet off with their right hand, and used a paper towel to dry their hands. The LPN did not use a dry disposable towel to turn off the faucet per the agency policy. In an interview on 09/24/2024, the Manager of Accreditation confirmed that the LPN did not use a disposable towel to turn off the faucet after washing their hands per the policy.

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. In 2 of 18 (11%) clinical records reviewed of patients that received Licensed Practical Nurse (LPN) visits, the agency did not ensure that a Registered Nurse (RN) provided supervision of the LPN nursing services per agency policy. Agency policy #1-031 "Responsibilities/Supervision of Clinical Services" (reviewed 02/14/2024), read in part, "A monthly patient visit will be completed by a registered nurse to supervised licensed practical/vocational nursing services." Clinical Record 11: The patient elected hospice care on 04/05/2024. The plan of care dated 07/04/2024 through 10/01/2024 ordered skilled nursing twice (2) weekly beginning 07/04/2024. A Licensed Practical Nursing (LPN) supervisory visit was completed on 07/22/2024. LPN visits were completed 07/25/2024, 08/02/2024, 08/30/2024, 09/13/2024, 09/17/2024, and 09/19/2024. A clinical record review revealed no evidence that the LPN supervisory visit was completed monthly in August per agency policy. Clinical Record 15: The patient elected hospice care on 10/08/2023. The plan of care dated 01/06/2024 through 04/04/2024 ordered skilled nursing twice (2) weekly beginning 01/07/2024. LPN visits were completed on 01/10/2024, 01/12/2024, 01/30/2024, 02/08/2024, 02/23/2024, and 03/14/2024. A LPN supervisory visit was completed on 03/20/2024. A clinical record review revealed no evidence that the LPN supervisory visit was completed monthly in February per agency policy. In a joint record review and interview on 09/25/2024, the Manager of Accreditation confirmed that monthly LPN supervisory visits were not completed per agency policy.

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 ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. 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" (reviewed 02/14/2024), read in part, "Hospice aide supervisory visits will be conducted on-site at least every two (2) weeks by a hospice registered nurse." In 6 of 17 (35%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that a Registered Nurse (RN) made 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 HA. Clinical Record 5: The patient elected hospice care on 06/02/2024. The recertification plan of care effective 08/01/2024 through 09/29/2024 ordered HA services twice (2) weekly beginning 08/01/2024 and five (5) times a week beginning 08/05/2024. The HA provided visits from 08/01/2024 through 08/27/2024 as ordered. The HA supervisory visit was completed on 08/27/2024, with 26 days outstanding. A clinical record review revealed no evidence that HA supervisory visits were completed every 14 days per agency policy. Clinical Record 7: The patient elected hospice care on 05/09/2024. The recertification plan of care effective 07/27/2024 through 09/24/2024 ordered HA services twice (2) weekly beginning 07/28/2024. The HA visits were provided beginning 07/30/2024 as ordered. A clinical record review revealed no evidence that HA supervisory visits were completed every 14 days per agency policy through the date of the record review on 09/24/2024, with 56 days outstanding. Clinical Record 10: The patient elected hospice care on 07/11/2023. The recertification plan of care update effective 09/03/2024 through 11/01/2024 ordered HA services twice (2) weekly beginning 09/03/2024. The HA visits were provided beginning 09/05/2024 as ordered. A clinical record review revealed no evidence that HA supervisory visits were completed every 14 days per agency policy through the date of the record review on 09/24/2024, with 19 days outstanding. Clinical Record 11: The patient elected hospice care on 04/05/2024. The recertification plan of care update effective 07/04/2024 through 10/01/2024 ordered HA services twice (2) weekly beginning 07/04/2024. The HA visits were provided beginning 07/05/2024 as ordered. The HA supervisory visit was completed on 07/22/2024, with 17 days outstanding. A clinical record review revealed no evidence that HA supervisory visits were completed every 14 days per agency policy. Clinical Record 12: The patient elected hospice care on 05/01/2024. The recertification plan of care update effective 07/30/2024 through 10/27/2024 ordered HA services twice (2) weekly beginning 07/30/2024. The HA visits were provided beginning 07/30/2024 as ordered. The HA supervisory visit was completed on 08/19/2024, with 20 days outstanding. A clinical record review revealed no evidence that HA supervisory visits were completed every 14 days per agency policy. Clinical Record 13: The patient elected hospice care on 08/01/2023. The recertification plan of care update effective 07/26/2024 through 09/23/2024 ordered HA services twice (2) weekly beginning 07/28/2024. The HA visits were provided beginning 07/30/2024 as ordered. The HA supervisory visits were completed on 08/17/2024 and 09/16/2024, with 18 and 30 days outstanding, respectively. A clinical record review revealed no evidence that HA supervisory visits were completed every 14 days per agency policy. In a joint record review and interview on 09/25/2024, the Manager of Accreditation confirmed that HA supervisory visits were not completed every 14 days per agency policy for clinical records 5, 7, 10, 11, 12, and 13.

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 contains 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” Effective Date: December 2018 read in part “Orders will be obtained from a licensed physician (or other authorized independent practitioner) for care and services to be provided to hospice patients.” In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the clinical record contained the patient’s physician’s orders. Clinical Record 1: The patient elected hospice care on 03/27/2024 and resided in a facility. The facility called the hospice after hours on 09/21/2024 to report a change in condition. An “On-Call Triage Note” dated 09/21/2024 documented, “PT has a skin tear to left hand that she placed steri strips on.” A clinical record review revealed no evidence of a physician order for the wound care provided by the facility. In a joint record review and interview on 09/24/2024, the Manager of Accreditation confirmed that the clinical record lacked evidence that the record included physician orders for the wound care provided by the facility.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure the interdisciplinary group (IDG) prepare a written plan of care for each patient. The updates to the plan of care failed to include the drug regimen review for 7 of 7 sampled patients (Patients #1, #2, #3, #4, #5, #6 and #7). The hospice reported a current census of 77 patients at the time of survey. The survey identified the deficient practice occurred in both the Council Bluffs parent and Denison branch offices. Failure to ensure the interdisciplinary group (IDG) members involved in the assessment of patient needs identified actual or potential issues when preparing a written plan of care for each patient. Findings include: According to the hospice policy, titled Medication Monitoring, dated 2/22/21, ongoing patient medication monitoring will use a collaborative approach between the clinicians, physicians, pharmacists, patients and families/caregivers. The interdisciplinary group will confer with an individual (drug management consultant) with education and training in drug management who is an employee of or under contract with the hospice to ensure that drugs and biologicals meet each patient's needs. The hospice Registered Nurse will assess the effect of medications on the patient. The assessment will identify drug interactions, duplicative drug therapy and noncompliance with drug therapy. During an interview on 12/7/21 at 1:30 PM, the Administrator stated the DRR laboratory monitoring is very rare and the hospice focuses on palliative care. She further stated the Medical Director reviews medications at each IDG and makes recommendations if needed. 1. Patient #1 had a hospice admission date of 11/19/21 and received services while residing in a private home setting. The clinical record review revealed the following: a. The Plan of Care (POC), dated 11/19/21 to 2/16/22, included physician orders for medications and treatments and IDG orders for skilled nursing, chaplain, massage therapy, music therapy, home health aide and social work services. b. The Interdisciplinary Group (IDG) meeting notes, dated 11/24 and 12/1/21, lacked review of the medications. c. The Client Medication Report, dated 11/19/21, documented client medications review for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and and non compliance with drug therapy failed to identify drug therapy currently associated with laboratory monitoring. The hospice failed to discuss the patients medications the patient required with the physician and IDG members. 2. Patient #2 had a hospice admission date of 10/06/21 and received services while residing in a private home residence. The clinical record review revealed the following: a. The Plan of Care, dated 10/06/21 to 01/03/21 included physician orders for medications and treatments and IDG orders for skilled nursing, chaplain, massage therapy, home health aide and social work services. b. The IDG meeting notes, dated 10/13, 10/20, 11/03, 11/17 and 12/01, lacked a review of the medications. c. The Client Medication Report, dated 10/20/21, documented client medications review for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non compliance with drug therapy failed to identify drug therapy currently associated with laboratory monitoring. The hospice failed to discuss the patients medications the patient required with the physician and IDG members. 3. Patient #4 had a hospice admission date of 09/07/21 and a discharge date of 09/09/21 and received services while residing in a private home residence. The clinical record review revealed the following: a. The Plan of Care, dated 09/07/21 to 12/05/21 included physician orders for medications and treatments and IDG orders for skilled nursing, chaplain, home health aide and social work services. b. The IDG meeting notes, dated 09/08/21, lacked a review of the medications. c. The Client Medication Report, dated 09/07/21, documented client medications review for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non compliance with drug therapy failed to identify drug therapy currently associated with laboratory monitoring. The hospice failed to discuss the patients medications the patient required with the physician and IDG members. 4. Patient #6 had a hospice admission date of 10/18/18 and a discharge date of 11/24/21 and received services while residing in a nursing facility. The clinical record review revealed the following: a. The POCs, dated 10/18/18 to 01/15/19 and 10/02/21 to 11/24/21, included physician orders for medications and treatments and IDG orders for skilled nursing, chaplain, massage therapy, home health aide and social work services. b. The Interdisciplinary Group (IDG) meeting notes, dated 10/24/18, 9/29/21, 10/13, 10/27, 11/10, 11/24 and 12/1/21, lacked review of the DRR. c. The Client Medication Report, dated 10/18/18, documented client medications review for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and and non compliance with drug therapy failed to identify drug therapy currently associated with laboratory monitoring. The hospice failed to discuss the patients medications the patient required with the physician and IDG members. 5. Patient #3 had a hospice admission date of 11/22/21, received hospice services while residing in a private home setting. Review of the clinical record revealed the following: a. The POC, dated 11/22/21 to 2/19/22, included physician orders for medications and treatments and IDG orders for skilled nursing, chaplain and social work services. b. The IDG meeting notes, dated 12/1/21, lacked review of the DRR. c. The Client Medication Report, dated 11/23/21, documented client medication review for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects and failed to identify drug therapy currently associated with laboratory monitoring. The hospice failed to discuss the patients medications the patient required with the physician and IDG members. 6. Patient #5 had a hospice admission date of 7/2/21 and discharge date of 11/30/21, and received hospice services while residing in a private home setting. Review of the clinical record revealed the following: a. The POC's, dated 7/2/21 to 9/29/21 and 9/30/21 to 12/28/21, included physician orders for medications and treatments and IDG orders for skilled nursing, hospice aide, music therapy, massage therapy, chaplain and social work services. b. The Interdisciplinary Group (IDG) meeting notes, dated 7/7/21, 10/13, 10/27, 11/10 and 11/24/21, lacked review of the DRR. c. The Client Medication Report, dated 10/22/21, documented client medication review for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects and failed to identify drug therapy currently associated with laboratory monitoring. The hospice failed to discuss the patients medications the patient required with the physician and IDG members. 7. Patient #7 had a hospice admission date of 6/5/20 and discharge date of 9/2/21, and received hospice services while residing in a private home setting. Review of the clinical record revealed the following: a. The POC, dated 7/30/21 to 9/27/21, included physician orders for medications and treatments and IDG orders for skilled nursing, hospice aide, chaplain and social work services. b. The IDG meeting notes, dated 7/7, 7/21, 8/4, 8/18 and 9/1/21, lacked review of the DRR. c. The Client Medication Report, dated 7/7/21, documented client medication review for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects and failed to identify drug therapy currently associated with laboratory monitoring. The hospice failed to discuss the patients medications the patient required with the physician and IDG members. The Hospice Administrator and Clinical Manager received the above findings. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice Interdisciplinary Group failed to establish patient-specific and measurable outcomes as goals to reach from the implementation of interventions on the Plan of Care in order to manage to the patient condition regarding wound measurements for 1 of 1 sampled patients with a wound (Patients #5). The hospice reported a current census of 77 patients at the time of survey. Failure by the hospice Interdisciplinary Group (IDG) registered nurses establish measurable and patient-specific outcome goals in relation to wounds increased the risk hospice personnel would not recognize unmet patient needs and/or satisfactory palliation of the patient's symptoms. Findings include: According to hospice policy, titled Interdisciplinary Group Meeting, dated 3/25/21, the IDG meeting plan of care update report will be used for update of the patient and family/caregiver and the attending physician. It will note changes, response to treatment and progress toward targeted outcomes, which may include: an increase or decrease in symptoms or acuity of nutritional status, pain management and condition of skin/presence, status of pressure ulcers. During an interview on 6/29/21 at 1:30 PM, the Administrator stated the hospice does not measure a patients wound unless the condition worsened and are treated palliative. The hospice identified they had no wound policy available. 1. Patient #5 had a hospice admission date of 7/2/21 and discharge date of 11/30/21, and received hospice services while residing in a private home residence. Review of the clinical record revealed the following: a. The IDG meeting notes, 7/7/21, included IDG orders for skilled nursing services 2 times per week. b. The skilled nurse visit notes, dated 8/10/21, included documentation the patient had developed a stage 2 wound on the buttocks. The document failed to include wound measurements. d. The skilled nurse visit note, dated 10/4, 10/7, 10/12, 10/15, 10/22, 10/26, 10/29, 10/26, 10/29, 11/2, 11/4, 11/10, 11/12, 11/16, 11/18 and 11/23/21, included documentation the patient had a wound on the buttock but failed to include wound measurements. The Plan of Care, dated 9/30/21 to 12/28/21, identified goals of a Plan of Care will be established that meets the patient needs. The goals failed to identify measurable outcomes related to the goals for wound management. The Hospice Administrator and Clinical Manager received the above findings for Patient #5. Hospice staff provided no further information prior to the end of the survey.