Every finding on record at St. Croix Hospice LLC

It is required that medical social services are provided by a qualified social worker: based on a psychosocial assessment; according to the patient’s and family’s needs and acceptance of these services; per the plan of care; [and] under the direction of a physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed of patients who received medical social work (SW) services, the agency did not ensure that MSW services were provided per the patient's plan of care (POC). Clinical Record 4: The patient elected the hospice benefit on 08/18/2024 with a diagnosis of malignant neoplasm of the colon. The plan of care dated 11/16/2024 through 02/13/2025 ordered "SW 1x/month." A clinical record review revealed no documentation of a SW visit between 12/01/2024 and 12/31/2024. There was no documentation explaining why a SW visit was not completed between 12/01/2024 and 12/31/2024. During a joint record review on 04/28/2025, the Manager of Accreditation and the Regional Director of Clinical Operations confirmed the finding. The Regional Director of Clinical Operations stated, "There is no social work visit in December 2024, and no missed visit notes."

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 4 of 14 (29%) clinical records reviewed of patients who received Hospice Aide services, the agency did not ensure that the Hospice Aide (HA) received written patient care instructions to meet the patient's needs. Clinical Record 3: The patient elected the hospice benefit on 12/05/2024 with a diagnosis of Alzheimer's Disease. The patient resided in a skilled nursing facility (SNF). A physician's order dated 01/30/2025 included wound care with a dressing to the patient's coccyx. The plan of care dated 12/05/2024 through 03/04/2025 ordered "HA 2x/week." The HA care plan dated 02/13/2025 assigned the HA the relevant task of a "bed bath on the first visit of the week and a shower on the last visit of the week." The HA care plan did not document instructions related to the wound dressing on the coccyx, should it become wet or dislodged during the bed bath or shower. Clinical Record 5: The patient elected the hospice benefit on 01/07/2025 with a diagnosis of alcoholic hepatic failure. The patient resided at home. A physician's order dated 01/19/2025 included wound care with a dressing to the patient's bilateral feet. The plan of care dated 01/07/2025 through 04/06/2025 ordered "HA 3x/week." The HA care plan dated 01/07/2025 assigned the HA the relevant task of a "shower at every visit." The HA care plan did not document instructions related to the wound dressings on the patient's bilateral feet, should they become wet or dislodged during the shower. Clinical Record 14: The patient elected the hospice benefit on 08/01/2024 with a diagnosis of malignant neoplasm of the pancreas. The patient resided at home. A physician's order dated 08/01/2024 ordered "Oxygen via nasal cannula at 6 liters as needed for shortness of breath." The plan of care dated 08/01/2024 through 10/29/2024 ordered "HA 2x/week." The HA care plan dated 08/02/2024 did not document instructions related to using oxygen during personal care. Clinical Record 17: The patient elected the hospice benefit on 10/22/2024. A physician's order dated 11/26/2024 ordered wound care with a dressing to the patient's right heel. The plan of care dated 10/22/2024 through 12/11/2024 ordered "HA 2x/week." The HA care plan dated 11/16/2024 assigned the HA the relevant task of a "bed bath at every visit." The HA care plan did not document instructions related to the wound dressing on the patient's right heel, should it become wet or dislodged during the bed bath. During a joint record review on 04/30/2025, the Manager of Accreditation and the Regional Director of Clinical Operations confirmed that the HA care plans did not include wound dressing or oxygen instructions.

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 and interview. In 2 of 14 (14%) clinical records reviewed of patients who received Hospice Aide services, the agency did not ensure that the Hospice Aide was supervised by a Registered Nurse (RN) no less frequently than every 14 days. Clinical Record 13: The patient elected the hospice benefit on 10/09/2024 with a diagnosis of chronic obstructive pulmonary disease. The patient resided at home. The plans of care dated 10/09/2024 through 01/06/2025, 01/07/2025 through 04/05/2025, and 04/06/2025 through 06/03/2025 ordered "HA 1x/week starting week of 10/13/2024." The first HA visit was on 10/16/2024. The RN documented HA supervisory visits on 11/26/2024, with 41 days outstanding, 12/31/2024, 35 days outstanding, 02/07/2025, 38 days outstanding, and 04/15/2025, 67 days outstanding. Clinical Record 15: The patient elected the hospice benefit on 07/18/2024 with a diagnosis of Alzheimer's Disease. The patient resided in an assisted living facility (ALF). The plan of care dated 10/16/2024 through 12/16/2024 ordered "HA 2x/week." The first HA visit was on 10/16/2024. The RN documented HA supervisory visits on 10/29/2024 and 11/15/2024, 17 days outstanding. During a joint record review on 04/30/2025, the Manager of Accreditation and the Regional Director of Clinical Operations confirmed HA supervisory visits were completed less frequently than every 14 days.

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 day-to-day administrative or direct patient care services in an amount that equaled at least five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. A review of the agency's Volunteer Cost Savings Report for 2024 (01/01/2024 through 12/31/2024) revealed that the total percentage of hours worked by volunteers for the year 2024 was 0.30%. Documentation of a performance improvement plan (PIP) initiated in January 2025 to increase the percentage of volunteer hours to 5% was reviewed. The agency's Volunteer Cost Savings Report for 2025 revealed that the total percentage of hours worked by volunteers for the first quarter of 2025 was 0.69%. During an interview on 05/01/2025, the Regional Director of Clinical Operations confirmed the finding, stating, "We have not been able to provide 5% of our hours from volunteers for 2024 or the first quarter of 2025. We are currently onboarding four new volunteers." Review of the agency's volunteer cost savings report revealed that the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 13 (15%) records reviewed revealed that the agency did not ensure that the interdisciplinary comprehensive assessment was completed within five days after the election of the hospice benefit. Clinical Record 10: The hospice benefit election document was signed on 6/30/2022, and a physician order was written on 6/30/2022 for “MSW 1x/wkx1wk”. As of 7/19/2020, the clinical record reveals no MSW assessment or visit. Clinical Record 8: The hospice benefit election document was signed on 6/14/2022. RN assessment completed on 6/14/2022. MSW assessment was not completed until 6/22/22. Staff #13 Interview with Director of Accreditation confirms that there is no visit documented and no documentation of a reason for a missed visit. 2 of 13 (15%) records revealed that the agency did not ensure that the interdisciplinary comprehensive assessment was completed within 5 days after the election of the hospice benefit.

It is required that medical social services are provided based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services and per the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 13 (7%) clinical records reviewed revealed that the agency did not ensure that the medical social worker completed a psychosocial assessment and followed the plan of care. Clinical Record 10: Start of Care (SOC) dated 6/30/2022 revealed an order written on 6/30/2022 for “MSW 1x/wkx1wk”. As of 7/19/2020, the clinical record reveals no MSW assessment or visit. Staff #13 Interview with Director of Accreditation confirms that there is no visit documented and no documentation of a reason for a missed visit. 1 of 13 (7%) of the clinical records revealed that the agency did not ensure that medical social worker completed a psychosocial assessment and followed the plan of care.

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 a review of clinical records and interviews. 2 of 10 (20%) applicable records in which the patient received aide services revealed that the agency did not ensure that the aide care plan included specific instructions. Clinical Record 2: Physicians' orders on 9/13/2021 reveal orders for dressings on coccyx. Physician orders on 9/17/2021 include orders to remove sutures and staples. The aide care plan dated 9/13/2021 does not include any instruction to the aide regarding areas in which a dressing is applied or sutures and staples are present. Clinical Record 10: The aide care plan dated 6/30/2022 does not address the wound. RN assessment on 6/30/2022 indicates the patient has wounds on the left posterior heel and left medial calf. The aide care plan does not address wounds or how the aide is supposed to address those areas while providing bathing. Staff #13 Interview with Manager of Accreditations confirmed that aide care plan did not include specific instructions to aide related to wounds. 2 of 10 applicable records in which the patient received aide services revealed that the agency did not ensure that the aide care plan included specific instructions.

Based on review of hospice documents, policy review and interview, the hospice failed to ensure one of three patients reviewed (Patient 2) was provided telephone contact information for the hospice location and the state agency complaint hotline telephone number specific to the state in which the patient lived and receive hospice services which hindered the right to voice grievances in a timely manner regarding treatment or care that was (or failed to be) furnished by anyone who furnished services on behalf of the hospice. Failure to ensure patients receive correct contact information has the potential to limit the ability to exercise patients' rights to voice timely grievances and places all patients at risk for compromised preservation of individual patient rights. Findings Include: Review of Hospice policy titled, "Bill Of Rights, Policy No. 9-005, Revised December 2018," showed Review of an untitled hospice document dated 05/18/20, showed the Bill of Rights statement defined the right of the patient to voice grievances regarding treatment or care that is (or fails to be) furnished, or regarding the lack of respect for property by anyone who is furnishing services on behalf of the organization and must not be subjected to discrimination or reprisal for doing so. The statement defined the right of the patient to receive in writing, prior to the start of care, the telephone numbers for State Hotline and the CHAP Hotline, including hours of operation, and the purpose of the hotlines to receive complaints or questions about the organization. Patient 2 Review of Hospice Medical Record Coordination Notes Report dated 11/05/21 and completed by Staff A, RN Admission Nurse on admission, showed Patient 2 was 91 years old, admitted to Hospice with Acute Respiratory Failure, COVID-19 and Pneumonia on 11/05/21. Patient 2 resided in Kansas with her grandson. Review of documentation provided to Patient 2's grandson at admission on 11/05/21 by Staff A, RN, showed a Business Card from the hospice with hospice contact information for patients that included a Phone Number, Intake Fax and Address for a Hospice Branch located in Harrisonville, Missouri. Patient 2 was identified as having resided in the state of Kansas. The Hospice Admission Handbook provided to the patient on admission listed the phone numbers for local assistance at the Harrisonville, Mo. and Independence, Mo. locations. The patient's place of residence and hospice service provision was in the state of Kansas. During an interview on 12/14/21 at 10:26 AM, Staff D, Manager of Clinical Services (MCS), confirmed the hospice admission nurse provided Hospice Admission Handbook information from the Topeka Kansas office location, not the Missouri locations, although later review of the booklet provided to Patient 2's grandson showed the Missouri location information. During an interview on 12/13/21 at 2:23 PM, Patient 2's Grandson confirmed alleged grievances related to the provision of hospice services and supplies to the patient. The grandson confirmed he was delayed in reporting his grievances to the appropriate State Hotline in Kansas because the information provided to him on admission with the notice of rights and responsibilities was from the State of Missouri and not the state of Kansas, where the patient lived and received hospice services. The grandson provided the surveyor copies of documentation provided by the hospice on admission, with information to allege complaints to the state of Missouri. The hospice failed to ensure the timely exercise of grievances in keeping with patients' rights by providing inaccurate grievance contact information on admission.