Every finding on record at St Croix Hospice LLC

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, 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. In 4 of 15 (27%) clinical records reviewed for patients that received hospice aide services revealed the hospice did not ensure that the Registered Nurse completed and documented an on-site supervisory visit to assess the quality of care and services provided by the hospice aide no less frequently than every 14 days. DOCUMENT 3: Agency Policy, Hospice Aide Supervisory Visits Policy No. 1-037, stated in part, "A registered nurse must 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 hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs." CLINICAL RECORD 3: The patient elected the hospice benefit on 04/08/2024 and resided in a skilled nursing facility (SNF). A review of the clinical record revealed the patient was receiving hospice aide visits between 04/10/2024-07/09/2024. There was no documented evidence of supervisory visits by the registered nurse between 04/10/2024-07/09/2024. CLINICAL RECORD 8: The patient elected the hospice benefit on 07/05/2024 and resided in a skilled nursing facility (SNF). A review of the clinical record revealed the patient was receiving hospice aide visits between 08/08/2024-09/24/2024. There was no documented evidence of supervisory visits by the registered nurse between 08/08/2024-09/24/2024. CLINICAL RECORD 9: The patient elected the hospice benefit on 05/24/2024 and resided at home. A review of the clinical record revealed the patient was receiving hospice aide visits between 06/03/2024-07/23/2024. There was no documented evidence of supervisory visits by the registered nurse between 06/03/2024-07/23/2024. CLINICAL RECORD 12: The patient elected the hospice benefit on 04/30/2024 and resided in a skilled nursing facility (SNF). A review of the clinical record revealed the patient was receiving hospice aide visits between 05/01/2024-06/26/2024. There was no documented evidence of supervisory visits by the registered nurse between 05/01/2024-06/26/2024. During a joint record review and interview on 01/09/2025, the Manager of Accreditation agreed that there was no documented evidence of hospice aide supervisory visits during the times identified. The Manager of Accreditation stated, "The nurses thought they were supposed to check no to supervision if the hospice aide was not present. We discovered in September of 2024 they weren't documenting the supervision, so education was provided on documenting it when they do aide supervision."

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 revealed the hospice Volunteer Requirement Report did not ensure that hospice volunteers provided 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. DOCUMENT 2: A review of the Hospice Volunteer Requirement Report revealed 0.79% cost savings for the year of 2024. During an interview on 01/09/2025, the Regional Volunteer Coordinator agreed that the hospice did not meet the 5% volunteer cost savings in 2024. Additionally, during an interview on 01/09/2025, the Regional Volunteer Coordinator stated, "We know we didn't meet the requirement in 2024, we are onboarding three new volunteers now and are working on increasing the volunteer hours."