Every finding on record at St Croix Hospice LLC

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. 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 comprehensive assessment included an initial bereavement risk assessment. Clinical Record 14: The patient was readmitted and elected hospice benefit on 9/15/2023. A review of the clinical record revealed an initial bereavement assessment for the previous admission dated 11/26/2021. There was no evidence of an initial bereavement assessment for the current election of hospice care on 9/15/2023. During an interview and a joint review of the record on 10/26/23, the agency's Director of Accreditation confirmed that the bereavement coordinator reviewed the record there was not an initial bereavement risk assessment completed for the 9/15/2023 admission.

It is required that each patient’s individualized written plan of care 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 3 of 23 (13%) clinical records reviewed, the agency did not ensure that the plan of care (POC) identified interventions based on problems identified in the comprehensive assessments. Clinical Record 5: The patient elected hospice care on 5/20/22. The face-to-face visit completed on 5/1/2023 documented, "diagnosis Alzheimer's disease and dysphagia...she is on a pureed diet with thickened liquids. She does cough, and drinks are running out of her mouth." The face-to-face visit completed by the nurse practitioner on 8/30/23, for the current benefit period 9/12/23 through 11/10/23, documented that the patient continued on a pureed diet with thickened liquids. The plans of care, effective 3/16/23 through current, did not identify any problems, goals, or interventions related to the patient's dysphagia or dietary modifications. During an interview on 10/27/23, the Director of Accreditation stated that when the diet was changed to pureed with thickened liquids, the plan of care was not updated. Clinical Record 7: The patient elected hospice care on 9/12/23. The certificate of terminal illness signed on 9/13/23 documented, "admitted to hospice services on 9/12/23 with end-stage Alzheimer's disease with mixed vascular dementia and behaviors. She was just hospitalized for control of her behaviors." The initial comprehensive assessment completed by the nurse on 9/12/23 documented, "Does anxiety significantly affect the patient? YES." The patient's drug profile included documentation of the medications: Risperdal 0.5mg daily, Risperdal 1mg daily, Trazodone 50mg at bedtime, and Lorazepam 0.5mg twice daily, all with an effective date of 9/12/23. The Lorazepam 0.5mg was increased to every 4 hours on 9/21/23. On 10/16/23, the Lorazepam was changed to the liquid form with dosing every 6 hours. The plan of care, effective 9/12/23 through current, did not identify goals, problems, or interventions related to the patient's anxiety or behaviors. During an interview on 10/27/23, the Director of Accreditation confirmed the patient's plan of care did not address the patient's anxiety. Clinical Record 10: The patient elected hospice care on 8/13/23. On 8/14/23, the physician ordered "indwelling foley catheter insertion and change monthly." The comprehensive assessment completed by the Registered Nurse (RN) on 8/23/23 documented that the patient had an indwelling catheter. The comprehensive assessment completed by the RN on 10/23/23 documented that the patient continued to have the indwelling catheter in place. The plan of care, effective 8/13/23 through current, did not identify problems, goals, or interventions for an indwelling catheter. During an interview on 10/26/23, the Director of Accreditation confirmed the patient's plan of care did not address the patient's indwelling catheter.

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, interview, and observation. In 1 of 20 (5%) clinical records reviewed of patients that received hospice aide services, the agency did not ensure the hospice aide care plan included specific written patient care instructions. Clinical Record 5: The patient elected the hospice benefit on 5/20/22 with the terminal diagnosis of Alzheimer's disease. On 10/16/23, the Registered Nurse (RN) documented that the "legs are crossed over each other and difficult to reposition. Patient does have foam heal protector boot applied." During the home visit on 10/25/23, the patient wore a foam boot on the left foot. The RN [Personnel Record 13] reported that the patient had a foot drop. The hospice aide care plan, effective 8/15/23 through current, assigned the hospice aide the tasks of bathing and dressing every visit. The hospice aide care plan did not include documentation of instructions for the hospice aide regarding removing or applying the foam boot during personal care. During an interview on 10/26/23, the agency's Director of Accreditation confirmed that the hospice aide care plan did not provide instructions to the hospice aide regarding the foam boot.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. This standard was not met as evidenced by clinical record review and interview. In 1 of 20 (5%) clinical records reviewed of patients that received hospice aide services, the agency did not ensure the hospice aide reported changes in the patient's plan of care to the Registered Nurse (RN). Clinical Record 6: The patient elected the hospice benefit on 3/9/23 with a terminal diagnosis of Alzheimer's disease. The hospice aide care plan effective 9/5/23 through current assigned the hospice aide the task: bed bath every visit. The hospice aide care plan ordered hospice aide services three times a week. On 10/10/23 the hospice aide documented the bed bath was not completed, "will do on next visit." On 10/20/23 the hospice aide documented the bed bath was not given, "given bath by staff." The clinical record did not include documentation that the RN was informed by the hospice aide that the hospice aide care plan was not followed. The hospice aide care plan did not indicate that the patient nor facility staff/caregiver could make decisions regarding personal care to be provided. During an interview and a joint record review on 10/26/23, the Director of Accreditation confirmed that the RN was not informed of these deviations to the hospice aide care plan.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. 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 and interview. In 1 of 23 (4%) clinical records reviewed, the agency did not ensure the clinical record contained physician orders for all current medications and treatments. Clinical Record 15: The patient elected hospice care on 8/24/22 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). On 8/24/22, the physician ordered "oxygen at 2 liters continuously." On 9/12/23, the Registered Nurse (RN) documented, "patient has O2 (oxygen) on at 3 liters per minute." On 10/24/23, the RN documented that the patient remained on oxygen at 3 liters per minute continuously. A review of the clinical record revealed no evidence of a physician order for the oxygen to be increased to 3 liters per minute. During an interview on 10/26/23, the Director of Accreditation confirmed there were no physician orders for the increase in oxygen. No additional information was provided prior to the exit conference on 10/27/23.

Based on hospice clinical record review, hospice policy review, patient representative interview and hospice staff interview, the hospice failed to ensure the the documentation and correct identification, in a prominent part of the patient's record, any advance directives executed by the patient or patient's representative for 5 of 6 sampled patients (Patients #1, #2, #3, #4 and #5). Failure to ensure the hospice documented and correctly identified any executed advance directives in a prominent part of the record placed patients at risk for their advance directives not being correctly carried out. Findings include: --- According to the undated hospice policy titled Bill of Rights, each patient will be an active, informed participant in his/her plan of care. To ensure this process, the patient will be empowered with certain rights and responsibilities as described. A patient, who has not been judged to lack legal capacity, may designate someone (surrogate decision maker), to act as his/her representative. This representative, on behalf of the patient, may exercise any of the rights provided by the policies and procedures established by the organization. 1. Patient #1 had a hospice admission date of 3/22/23 and received routine hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The signed consent, dated 3/22/23, included the patient wished to be a do not resuscitate (DNR). The consent identified the patient had a designated (POA). b. The plan of care (POC) dated, 3/22/23 to 6/19/23, identified the patient had wishes for DNR status but failed to include information that the patient had a POA. The clinical record lacked a copy of any of the advance directives enacted by the patient or patient's representative. 2. Patient #2 had a hospice admission date of 6/14/23 and received routine hospice services while residing in a private home residence. Review of the clinical record revealed the following: a. The signed consent, dated 6/14/23, included the patient wished to be a do not resuscitate (DNR). The consent identified the patient had a designated (POA). b. The Iowa Physician Orders for Scope of Treatment (IPOST), dated 6/14/23, included the patient wished to be a do not resuscitate (DNR). The consent identified the patient had a designated (POA). c. The plan of care (POC) dated, 6/14/23 to 9/11/23, identified the patient had wishes for DNR status but failed to include information that the patient had a POA. The clinical record lacked a copy of any of the advance directives enacted by the patient or patient's representative. 3. Patient #3 had a hospice admission date of 5/28/23 and received routine hospice services while residing in a private home residence. Review of the clinical record revealed the following: a. The signed consent, dated 5/28/23, included in the patient wished to be a full code, attempt resuscitation. The consent identified the patient had a designated (POA). b. The Iowa Physician Orders for Scope of Treatment (IPOST), dated 5/28/23, included the patient wished to be a full code. The consent identified the patient had a designated (POA). c. The plan of care (POC) dated, 5/28/23 to 8/25/23, identified the patient had an IPOST but failed to include accurate information on code status or information that the patient had a POA. The POC stated do not resuscitate. The clinical record lacked a copy of any of the advance directives enacted by the patient or patient's representative. 4. Patient #4 had a hospice admission date of 5/28/23 and received routine hospice services while residing in a private home residence. Review of the clinical record revealed the following: a. The signed consent, dated 4/17/23, included in the patient wished to be a full code, attempt resuscitation. The consent identified the patient had a designated (POA). b. The Iowa Physician Orders for Scope of Treatment (IPOST), dated 4/17/23, included the patient wished to be a full code. The consent identified the patient had a designated (POA). c. The plan of care (POC) dated, 4/17/23 to 7/15/23, identified the patient had an IPOST but failed to include information on code status or information that the patient had a POA. The clinical record lacked a copy of any of the advance directives enacted by the patient or patient's representative. 5. Patient #5 had a hospice admission date of 4/25/23 and received routine hospice services while residing in a private home residence. Review of the clinical record revealed the following: a. The signed consent, dated 4/25/23, included in the patient wished to be a DNR. The consent identified the patient had a designated POA. b. The Iowa Physician Orders for Scope of Treatment (IPOST), dated 4/25/23, included the patient wished to be a DNR. The consent identified the patient had a designated POA. c. The plan of care (POC) dated, 4/25/23 to 7/23/23, identified the patient had an IPOST and wished to be a DNR but failed to include information on code status or information that the patient had a POA. d. The coordination note, dated 4/26/23, revealed the nurse attempted to call the patient's family (not the POA) to identify the new order but no answer. The document failed to include notification of the patient's identified POA. During an interview on 6/22/23 at 9:18 AM, the patient's POA identified he/she was the POA and had concerns the nurse failed to always give him/her updates on the nurses visit and the patient's status. During an interview on 6/20/23 at 9:50 AM, Staff D, Registered Nurse (RN) identified the POA and stated she did provide updates to the patient's POA, but did also provide updates to the patient's family members and not to the patient's POA. The clinical record lacked a copy of any of the advance directives enacted by the patient or patient's representative. The above information was reviewed with Administrator. No additional information provided prior to the end of the survey.