DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
261648 A. BUILDING __________
B. WING ______________ 		07/13/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
ST CROIX HOSPICE 811 WESTCHESTER AVENUE, HARRISONVILLE, MO, 64701
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0625      
29559 Based on policy review, record review, and interviews, St Croix hospice failed to ensure that written patient care instructions from the registered nurse for the hospice aide were appropriate and accurate in one of the two records reviewed for aide services. (Record/Patient #2). Findings included: Review of the agency policy titled "Hospice Aide Services", last revised in 2018 states in part that " hospice aide assignments, plan of care, and interventions will be documented and included in the patient's clinical record". Review of the agency policy titled "The plan of Care", last revised in 2018 states in part that the written plan of care will have safety measures. "Any change in the patient's condition must result in a change to the plan of care". RECORD/PATIENT #2: Review of admission documentation showed the patient was admitted to hospice service on 01/06/21 for end stage cardiopulmonary disease. Review of the hospice nurse visit notes dated 06/17/21, 06/21/21, 06/28/21, and 07/01/21 showed that the patient was using oxygen at 2 liters per minute (LPM), per nasal cannula. Review of the 06/11/21 nurse visit note showed that the patient had a fall at the assisted living facility (ALF) where he/she resided. The nurse documented that pain medication was provided for shoulder pain. Review of the hospice nurse visit note from 06/25/21 showed the patient had moderate daily back pain. During an interview on 07/08/21 at 11:13 AM with the patient's primary registered nurse, responsible for the aide written instructions, he/she stated the following: - He/she was the case manager of Patient #2; and -When asked if dressing the patient would cause any pain for the patient, he/she stated that the patient "had shoulder and back pain after (the patient) fell a couple weeks ago". The patient had trouble with range of motion. During an interview with the assisted living facility care staff, where the patient resided, on 07/07/21 at 4:49 PM, he/she stated the following: - The patient has pain in his/her shoulder when putting on a shirt if lifting his/her arm too high or too quickly; - After the hospice aide changed the patient's shirt on 07/03/21, the patient showed facial grimacing afterward; and - After nail care by the hospice aide on 07/03/21 the patient appeared short of breath and (the patient) had his/her oxygen off. An interview with the hospice aide on 07/08/21 at 12:13 PM, showed that he/she stated the following: - He/she provided care on 07/03/21 to Patient #2, and this was the first time he/she cared for the patient; - He/she was unaware of the patient's fall and possible shoulder / range of motion or pain issues from dressing; and - Was unaware that the patient used oxygen. Review of the hospice aide written instructions from the patient's RN case manager showed no mention of the patient's oxygen use, or when the patient should wear oxygen during the provision of hygiene care. The instructions failed to include precautions that the patient may experience back or shoulder pain during dressing due to fall that occurred on 06/11/21. During an interview with the hospice administrator on 07/08/21 at 2:55 PM, he/she stated that he/she expected special patient care precautions be included in the aide written care instructions.