Every finding on record at St. Croix Hospice, LLC

It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: medical supplies and appliances necessary to meet the needs of the patient. 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 included all necessary medical supplies and appliances to meet the patient's needs. CLINICAL RECORD 14: The patient elected the hospice benefit on 01/14/2025. The plans of care dated 01/14/2025 through 01/26/2025, 01/27/2025 through 04/26/2025, and 04/27/2025 through 06/25/2025 ordered "Oxygen via nasal cannula at 2 liters for dyspnea." The plans of care did not include documentation of the patient's oxygen concentrator and oxygen supplies. During a joint record review on 07/17/2025, the Statewide Clinical Director confirmed that the patient's oxygen concentrator and oxygen supplies were not listed on the patient's plan of care until 06/26/2025.

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" (dated 12/01/2018 and reviewed 02/14/2024) stated in part, "A monthly patient visit will be completed by a registered nurse to supervise licensed practical/vocational nursing services." In 4 of 17 (24%) clinical records reviewed of patients who received Licensed Practical Nursing services, the agency did not ensure that Licensed Practical Nurse (LPN) supervisory visits were completed by a Registered Nurse at least monthly, as per agency policy. CLINICAL RECORD 1: The patient elected the hospice benefit on 02/11/2025. The plans of care dated 02/11/2025 through 05/11/2025 and 05/12/2025 through 08/09/2025 ordered "SN 1x per week." A clinical record review revealed LPN visit notes dated 02/18/2025, 03/04/2025, 03/19/2025, 04/02/2025, and 05/14/2025. The first LPN supervisory visit was dated 05/21/2025, with 92 days outstanding. CLINICAL RECORD 4: The patient elected the hospice benefit on 08/26/2022. The plans of care dated 08/21/2023 through 10/19/2023, 10/20/2023 through 12/18/2023, 12/19/2023 through 02/16/2024, and 02/17/2024 through 04/16/2024 ordered "SN 1x per week." A clinical record review revealed LPN visit notes dated 10/11/2023, 11/08/2023, 11/22/2023, 12/06/2023, 12/20/2023, 01/03/2024, 01/24/2024, 02/07/2024, 02/28/2024, and 03/13/2024. The first Licensed Practical Nurse supervisory visit was dated 04/15/2024, 186 days outstanding. CLINICAL RECORD 7: The patient elected the hospice benefit on 05/16/2025. The plan of care dated 05/16/2025 through 08/13/2025 ordered "SN 2x per week." A clinical record review revealed LPN visit notes dated 05/23/2025. No LPN supervisory visits were documented by the Registered Nurse (RN). CLINICAL RECORD 17: The patient elected the hospice benefit on 03/09/2025. The plans of care dated 03/09/2025 through 06/06/2025 and 06/07/2025 through 09/04/2025 ordered "SN 2x per week." A clinical record review revealed LPN visit notes dated 03/25/2025, 03/27/2025, 03/31/2025, 04/21/2025, 06/05/2025, 06/12/2025, and 07/15/2025. No LPN supervisory visits were documented by the RN. During joint record reviews and interviews on 07/15/2025, 07/16/2025, and 07/17/2025, the Statewide Clinical Director confirmed that licensed practical nurse supervisory visits were completed less frequently than monthly, stating, "We discovered during audits last week that some of our Registered Nurses were not completing LPN supervisory visits. Education was completed with the nurses involved."

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 6 of 18 (33%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that Hospice Aides were supervised by a Registered Nurse at least every 14 days. CLINICAL RECORD 2: The patient elected the hospice benefit on 08/20/2024 with a diagnosis of malignant neoplasm of the lung. The patient resided at home. The plans of care dated 08/20/2024 through 11/17/2024, 11/18/2024 through 02/15/2025, 02/16/2025 through 04/16/2025, and 04/17/2025 through 06/14/2025 ordered "HA 2x per week." The first HA visit note was dated 08/23/2024. HA visits were provided as ordered. A clinical record review revealed that the RN documented HA supervisory visits on 09/06/2024 and 10/29/2024 (with 53 days outstanding), 03/28/2025 (with 150 days outstanding), 04/22/2025 (25 days outstanding), 04/25/2025, and 06/06/2025 (with 42 days outstanding). CLINICAL RECORD 4: The patient elected the hospice benefit on 08/26/2022 with a diagnosis of congestive heart failure (CHF). The patient resided at home. The plans of care dated 06/22/2023 through 08/20/2023, 08/21/2023 through 10/19/2023, 10/20/2023 through 12/18/2023, 12/19/2023 through 02/16/2024 and 02/17/2024 through 04/16/2024 ordered "HA 3x per week." The first Hospice Aide visit was dated 11/25/2022. HA visits were provided as ordered. A clinical record review revealed that the RN documented HA supervisory visits on 02/09/2023 and 04/15/2024 (the COVID-19 Public Health Emergency (PHE) waiver ended on 05/11/2023), with 340 days outstanding between the end of the waiver and the next documented HA supervisory visit. CLINICAL RECORD 7: The patient elected the hospice benefit on 05/16/2025 with a diagnosis of cirrhosis of the liver. The patient resided in an assisted living facility (ALF). The plan of care dated 05/16/2025 through 08/13/2025 ordered "HA 2x per week." The first Hospice Aide visit note was dated 05/19/2025. HA visits were provided as ordered. A clinical record review revealed that the RN documented a HA supervisory visit on 06/06/2025, with 18 days outstanding. CLINICAL RECORD 8: The patient elected the hospice benefit on 05/15/2025 with a diagnosis of Parkinson's Disease. The patient resided in a skilled nursing facility (SNF). The plan of care dated 05/15/2025 through 08/12/2025 ordered "HA 2x per week." The first Hospice Aide visit note was dated 05/20/2025. HA visits were provided as ordered. A clinical record review revealed that the RN documented HA supervisory visits on 06/02/2025 and 06/23/2025, with 21 days outstanding. CLINICAL RECORD 10: The patient elected the hospice benefit on 05/08/2025 with a diagnosis of cerebral infarction. The patient resided in a SNF. The plan of care dated 05/08/2025 through 08/05/2025 ordered "HA 2x per week." The first Hospice Aide visit note was dated 05/09/2025. HA visits were provided as ordered. A clinical record review revealed that the RN documented HA supervisory visits on 05/12/2025 and 06/05/2025 (with 24 days outstanding) and 06/23/2025 (with 18 days outstanding). CLINICAL RECORD 11: The patient elected the hospice benefit on 06/17/2025 with a diagnosis of malignant neoplasm of the brain. The plan of care dated 06/17/2025 through 08/15/2025 ordered "HA 3x per week." The first Hospice Aide visit note was dated 06/18/2025. HA visits were provided as ordered. The first HA supervisory visit was dated 07/14/2025, with 26 days outstanding. During joint record reviews and interviews on 07/15/2025 and 07/16/2025, the Statewide Clinical Director confirmed the above findings, stating, "We discovered after doing audits last week that some of our Registered Nurses were not documenting aide supervisory visits. Education was provided to the nurses involved last week."

Based on interview and document review, the agency failed to thoroughly investigate all allegations of drug diversion and take action to prevent further potential violations for 3 of 17 patients (P1, P2, P3) reviewed for alleged violation of drug diversion. --- During interview on 12/13/22, at 10:35 a.m. consulting pharmacist (CP)-B indicated large amounts of high dose oxycodone had been filled for hospice patients with the agency. CP-A had worked on 10/22/22, and received prescription orders for high dose oxycodone for three patients of the agency. Registered nurse (RN)-A picked up the prescriptions for all three of the hospice patients. The hospice agency was called, and clinical manager (CM)-A was notified of the pharmacy concerns related to the medication oxycodone. The pharmacy required nurses to sign when they picked up medications, so the medication sign out sheets for oxycodone were pulled up for the month of October and RN-A had picked up all the oxycodone prescriptions for the agency's hospice patients. When interviewed on 12/14/22, at 9:45 a.m. CP-A stated he called the agency on 10/24/22, and discussed his concerns with CM-A. CM-A was notified P1, P2 and P3 had oxycodone 20 milligrams (mg) filled on 10/22/22, and the medications had been picked up by RN-A. CM-A was asked if the agency could verify these patients required the high doses and verify the quantities of oxycodone ordered. CM-A stated she would look into it. After the call to CM-A, CP-A continued to see RN-A pick up medications for hospice patients of the agency. On 11/25/22, the pharmacy received prescriptions for a new hospice patient, P1, that included very high doses of oxycodone as well as fentanyl tablets. P1's past history of prescriptions were reviewed and there was no indication of medication use to warrant the amount of pain medication ordered. RN-A verified the prescriptions were correct. P1's past history of prescriptions was also reviewed. P1 received medications from CP-A's pharmacy as well as from the hospice's mail order pharmacy that the agency typically used. Receiving medications from both of the pharmacies was unusual and the prescribing physician (MD)-C was notified. During interview on 12/13/22, at 1:30 p.m. MD-C indicated she was first made aware of concerns with the hospice patients' medications on 11/25/22, when CP-A called. The usual practice for the agency was hospice nurses initiated the order or refill request in the RX application. MD-C would then sign it and route to the pharmacy indicated on the request. MD-C reviewed medications closely on admission and recertification's but not necessarily on recurring orders. On 12/13/22, at 4:30 p.m. the investigation documentation was requested from the agency. The investigation process was reviewed and failed to include patient or family interview for assessment of pain symptoms and response to treatment. CM-A was notified RN-A had picked up hospice patient's medication on 10/22/22, at the local pharmacy; however, RN-A was not scheduled to work on 10/22/22. RN-A ordered hospice medications from the local pharmacy and not the hospice mail in pharmacy as per usual procedure. RN-A's failure to follow the agency policy of ordering medications through the agency pharmacy and acting on behalf of the agency when she was not scheduled to work was not investigated. During a group interview with attorney (ATT)-D, chief compliance officer (CCO)-E, director of human resources (HR)-F, and vice president of clinical services (VP)-G on 12/14/22, at 10:45 a.m. ATT-D stated they had been working around the clock to identify potential patients that may have been affected by RN-A's potential drug diversion. Twenty-three patients had been identified with pain medications ordered but not listed on their medication administration records (MAR). He did not think any patients had been directly contacted nor did he feel it was necessary to contact the patients involved. CCO-E was reviewing the patient charts and had not identified harm had occurred. They were still investigating if CM-A had been notified of medication concerns on 10/24/22, and what had been done at that time. During a group interview on 12/15/22, at 9:30 a.m. with CM-A, CCO-E, HR-F and VP-G, CM-A indicated she had received a telephone call on 10/24/22, from CP-A regarding P2 and P3's oxycodone use. She did not recall mention of P1. CP-A was concerned with the increased use of oxycodone with the two patients and asked if the patients could be evaluated for a long acting pain medication instead. RN-A was notified of the pharmacist's concerns and asked to evaluate P2 and P3 for a long acting pain medication. RN-A reported later in the day, she had evaluated the patients and they had fentanyl patches initiated. CM-A checked the patients MAR's and verified they had been prescribed long acting fentanyl patches. CM-A was not aware RN-A was picking up medications at the pharmacy. CP-A's pharmacy was only used by the agency for urgent prescriptions that were needed, otherwise the agency used a different mail order pharmacy for their patients' medications. CM-A stated she never asked RN-A why the medications were being ordered at the local pharmacy and not the agency's usual pharmacy. She was not made aware of other issues with medications until 11/28/22, when she received an email from the regional director of clinical operations (RDCO)-H to investigate a complaint related to potential drug diversion by RN-A. CM-A received a list of patients with suspected drug diversion and reviewed the patient charts. RN-A was interviewed on 11/28/22 and placed on administrative leave. The agency did not call the thirteen patients to inquire about their medication and symptoms of pain. The progress notes were reviewed in the patient records with no indication of untreated pain. CM-A verified RN-A had documented the progress notes reviewed and their accuracy could not be determined. The patients had other prescriptions on hand to treat pain symptoms. If an increase in pain had been noted, nurses would have utilized the prescription medications in the home to treat the patient's pain. Unresolved pain symptoms would have been reported to the primary physician promptly for further treatment. The agency's undated policy Assessment of Possible Abuse/Neglect indicated the clinical director would review the documentation of the abuse for completeness and objectivity and follow-up investigation, conduct further review if necessary and document additional information. The organization would maintain a list of private and public community agencies that provided or arranged for assessment of suspected or alleged abuse/neglect victims.

Based on interview and document review, the agency failed to report alleged incidents of possible mistreatment to the designated state agency within 5 working days for 3 of 13 patients (P1, P2, and P3) who had an allegation of drug diversion by a hospice employee. This had the potential to affect all 66 current patients receiving hospice services from this branch. --- When interviewed on 12/14/22, at 9:45 a.m. CP-A stated he called the hospice agency on 10/24/22, and notified clinical manager (CM)-A that P1, P2 and P3 had oxycodone 20 milligrams (mg) filled on 10/22/22, and the medications had been picked up by RN-A. CM-A was notified of the quantities of the medication that had been picked up and asked if the agency could verify these patients required the high doses and quantities of oxycodone ordered. CM-A stated she would look in to it. After the phone call, CP-B continued to see RN-A pick up medications for hospice patients of the agency. On 11/25/22, the pharmacy received prescriptions for a new hospice patient, P1, that included very high doses of oxycodone as well as fentanyl tablets. P1's past history of prescriptions was reviewed and there was no indication of medication use to warrant the amount of pain medication ordered. RN-A verified the prescriptions were correct. P1's past history of prescriptions was also reviewed. P1 received medications from CP-B's pharmacy as well as from the hospice's mail order pharmacy that the agency typically used. Receiving medications from both of the pharmacies was unusual and the prescribing physician (MD)-A was notified. During interview with MD-C on 12/13/22, at 1:30 p.m. MD-C indicated she was first made aware of concerns with the hospice patients' medications on 11/25/22, when CP-B called. She notified the regional director of clinical operations (RDCO) the evening of 11/25/22, to request they investigate the matter. When interviewed on 12/14/22, at 11:40 a.m. the vice president of clinical services (VP)-G stated filing a vulnerable adult (VA) report would have been the chief compliance officer's (CCO) task. CCO-E stated the agency had not filed VA reports to the state agency because there had been no harm to the patients. The allegation of drug diversion was investigated by the agency and the hospice employee was terminated. The agency notified the hospice medical director and the board of nursing and felt no more needed to be done. There was no evidence the medications were ever in patient homes and the misappropriation of medication was against the agency and the pharmacy and not the patients. The agency determined the police needed to be called and the matter did not require a VA report to the state agency. During a group interview with attorney (ATT)-D, chief compliance officer (CCO)-E, director of human resources (HR)-F, and vice president of clinical services (VP)-G on 12/14/22, at 10:45 a.m. ATT-D stated they had been working around the clock to identify potential patients that may have been affected by RN-A's potential drug diversion. Twenty-three patients had been identified with pain medications ordered but not listed on their medication administration records (MAR). During a group interview on 12/15/22, at 9:30 a.m. with CM-A, CCO-E, HR-F and VP-G, CM-A indicated she received an email from the regional director of clinical operations (RDCO)-H on 11/28/22, to investigate a complaint related to potential drug diversion by RN-A. CM-A received a list of patients with suspected drug diversion and reviewed the patient charts. RN-A was interviewed on 11/28/22 and placed on administrative leave. CM-A had not filed a VA report with the state agency and thought RDCO had filed one. The agency's undated policy Assessment of Possible Abuse/Neglect indicated the agency would report all suspected cases of abuse, neglect, or exploitation in compliance with appropriate state statutes to appropriate protection organizations. The clinician would submit a verbal report of the suspected abuse/neglect to the proper authorities in accordance with state law and complete a suspected abuse and/or neglect investigation report within 24 hours of the incident.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by a review of clinical records, interviews and observations. In 2 of 13 (15%) clinical records reviewed, the agency did not ensure that the plan of care specified all the care and services necessary to meet the patient's needs related to safety and fall precautions. Clinical Record 11: Election of Benefit 6/17/22: (Terminal Diagnosis: Neuroleptic Induced Parkinsonism) RN Admission note stated, "At risk for falls," based on the initial fall risk assessment. Interdisciplinary team (IDT) meeting held on 8/3/2022, the RN documented "One fall since last IDG" and "Safety and pain management goals reviewed." The plan of care effective for the benefit period 6/17/2022 to 9/4/2022 did not include any safety or fall related problems, goals, or interventions. During the home visit observation on 9/19/2022, the facility nurse reported that the patient had an unwitnessed fall on 9/17/22 and had "scraped both knees." It was further said that the fall mattress was in place, and the patient was wearing gripper socks. Plan of Care, effective for benefit period 9/15/2022 to present, did not contain any problems, goals, or interventions related to safety or falls. The use of the fall mat and gripper socks was not present. In an interview with the Administrator (Staff 1) on 9/19/22, it was confirmed that the care plan did not have the safety problem opened and thus did not contain specific goals or interventions, including the fall mattress and gripper socks which had been implemented for fall prevention. The Administrator also acknowledged that although the IDT note referenced the safety goals being reviewed, the agency could not provide documentation as to what those were. Clinical Record 7: Election of Benefit 12/13/21: (Terminal Diagnosis: Congestive Heart Failure) Admission Diagnosis list included "R29.6 Repeated Falls." RN recertification comprehensive assessment, completed on 7/12/22, documented the patient had "a prior history of falls within the last three (3) months" and, based on risk assessment, was "at risk for falls." Care plan effective from admission (12/13/21) to current, including subsequent IDG updates, did not include problems, goals, or interventions related to safety or fall prevention. In an interview conducted on 9/21/22, the Administrator (Staff 1) reported that "fall precautions" was listed on the admission plan of care but agreed that based on the patient's recent fall history, this should have been an active problem in the care plan with goals and specific interventions listed.

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 interview. 1 of 13 (8%) clinical records reviewed, the agency did not ensure the hospice aide care plan provided specific instructions for assigned tasks. Clinical Record 10: Comprehensive Admission assessment (9/14/22) RN documented, "Right arm in a sling, Pt (patient) has large incision with sutures in place. Gauze dressing over this and then ACE bandage. Family/CG (caregiver) not to touch X (times) for three weeks. Pt is non weight bearing to RUE (right upper extremity)." Hospice aide care plan, effective as of 9/14/22, listed "bathing (bed) first and last visit of the week, assist X (times) one to wash the upper and lower body and wash hair, full body lotion on bathing days" and "Provide incontinence care...assist X 1 to provide incontinence care in bed. Pt is able to transfer to commode with assist X 2 on good days." Aide care plan does not define "good days" and does not alert aide that patient is non-weight bearing on the right arm or that dressing was not to be touched. In an interview with the Administrator (Staff 1) on 9/21/22, it was confirmed that the aide care plan did not provide the aide with specific instructions regarding the right arm wound dressing or mobility restrictions and that "good days" should have been defined.

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 a review of clinical records and interview. 1 of 13 (8%) clinical records reviewed, the agency did not ensure that a physician order was present for all medications the patient was taking. Clinical Record 5: Recertification comprehensive assessment, completed on 6/29/22, the RN documented "Melatonin use as needed." Drug profile, effective from admission (3/31/2021) to current, does not contain any active or discontinued orders for Melatonin. In an interview with the Administrator (Staff 1) on 9/21/22, it was confirmed that per the RN documentation, Melatonin was being taken by the patient, and the agency could not locate a physician order.