Kansas City Palliative Home Care

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the home health provider failed to ensure the plan of care (POC) was individualized and included all patient-specific nutritional requirements, interventions, and treatments, and failed to sufficiently address the patient’s specific functional status and care needs in four of five full records reviewed (Records/Patients #1, #2, #3, and #4). This deficient practice has the potential to affect all the patients on service with the provider. Findings included: Review of the provider’s policy titled, “Care Planning Process,” last reviewed 06/26/2024, showed, in part: - The POC includes but is not limited to: * Needs and goals expressed or identified by the patient/caregiver and developed with the guidance of the interdisciplinary team * Scope and frequency of services, medical equipment, supplies, medications and treatments needed to meet the patient/caregiver needs; and * Doctor’s Orders demonstrating new, changed or discontinued orders. Review of the provider’s policy titled, “Palliative Home Care Plan of Care,” dated 11/01/2019, showed, in part: - The POC shall be completed in full to include: * Type, frequency and duration of all visits/services * Specific procedures in modalities for therapy services * Functional limitations and precautions * Activities permitted or restrictions * Specific dietary or nutritional requirements or restrictions * Medications, treatments and procedures * Any safety measures to protect against injury * Instructions to patient caregiver as applicable - Orders for therapy services shall include the specific procedures and modalities to be used in the amount, frequency, and duration; and - The patient, therapist, and other agency personnel shall participate in developing the plan of care. RECORD/PATIENT #1: Review of the clinical record showed that the patient was admitted for home health services on 02/03/2025 with a primary diagnosis of hypomyelination (lack of brain myelin, the protective sheath on nerve cells, affecting brain and spinal cord function)- hypogonadotropic hypogonadism (delayed puberty)- hypodontia (fewer teeth than normal) syndrome (4H syndrome). This rare genetic neurological disorder that affects the nervous system leading to symptoms like poor balance, stiff limbs, learning disabilities, delayed teeth eruption, and vision/speech issues. Other pertinent diagnoses included; bilateral optic atrophy (a vision-impairing condition where both optic nerves, the nerve cables connecting eyes to the brain, degenerate, causing vision loss, blurred vision, poor color vision, and sometimes involuntary eye movements, often appearing as a pale or white optic disc on examination, resulting from nerve fiber loss due to genetic, inflammatory, traumatic, or other systemic diseases), dystonia (a neurological movement disorder causing uncontrollable, involuntary muscle contractions that lead to repetitive, twisting movements or abnormal postures), other disorders of psychological development (conditions originating in childhood that affect brain development, impacting learning, communication, social skills, and behavior), and hypoxemia (low levels of oxygen in the blood). The patient resided at home with his/her parents. Review of the POC dated 11/30/2025 to 01/28/2026, showed generalized interventions but failed to identify patient-specific nutritional interventions, aspiration precautions, fall precautions, measurable goals, therapy exercises and coordination with outside therapy providers. Clinical documentation showed the patient was nonverbal, required maximum assist with activities of daily living (ADLs), had balance impairments, swallowing difficulties with aspiration risk, and nutritional concerns. These documented findings were not accurately reflected in the plan of care. Observation on 01/28/2026 beginning at 12:30 PM, with Registered Nurse (RN) B, showed: - The patient was nonverbal; - The patient wore a diaper for bowel and bladder incontinence; - RN B recommended options to assist in potty training; - The patient was able to crawl but did not walk; - The patient was able to sit in a seated position but would fall over after a short period of time; - The patient became tired throughout the visit and started falling over more frequently; - The patient’s caregiver placed a soft helmet on the patient due to increased impaired balance; - RN B informed the caregiver that he/she had never seen the patient wear a helmet before and the caregiver informed RN B that he/she applied the helmet when the patient would fall over more frequently); - The caregiver reported that the patient had a decrease in appetite; - The caregiver reported that the patient drank fluids from a bottle but was getting choked on the fluids more often; - RN B suggested trying to give the patient fluids in a sippy cup instead of a bottle; - The caregiver reported that the bottle worked best but he/she would try a sippy cup; - The caregiver reported that the patient continued to receive therapy in the home and the plan was for the patient to return to the outpatient rehabilitation facility after influenza (flu) season was over; and - The patient required total assistance, had complex nutritional and functional needs, and received care that was not sufficiently addressed in the plan of care. During an interview on 01/29/2026, beginning at 1:55 PM, the director of quality and regulatory compliance (RN A) stated that: - The patient did not have an apnea monitor so it shouldn’t have been listed for DME on the POC; - The patient does not have oxygen or use a nebulizer; - Sick versus well respiratory plan is listed on the POC because the patient takes cetirizine for relief of allergies and congestion; and - The documentation in the clinical record regarding a speech device was in reference to a communication board that the family had recently started trying to use. RECORD/PATIENT #2: Review of the clinical record showed that the patient was admitted for home health services on 02/03/2025 with a primary diagnosis of Sanfilippo mucopolysaccharidoses, a rare inherited lysosomal storage disorder that primarily affects the brain, causing progressive neurological degeneration. Additional diagnosis included thrombocytopenia (a medical condition characterized by a below-normal number of platelets in the blood, which impairs the blood’s ability to clot and stop bleeding), defects in post-translational modification of lysosome enzymes (genetic metabolic disorders where enzymes are synthesized but failed to be properly modified, leading to mis-trafficking to the extracellular space instead of the lysosome), dysphasia- oropharyngeal phase (a swallowing disorder characterized by difficulty initiating a swallow and moving food from the mouth to the throat, often resulting in coughing, choking, or nasal regurgitation), epilepsy (a neurological disorder characterized by recurrent seizures) unspecified (the cause or type is not specified) intractable (doesn’t respond well to standard treatments) without status epilepticus (doesn’t involve prolonged seizures), mixed receptive-expressive language disorder (a neuro developmental condition that affects a child’s ability to both understand and produce language), obstructive sleep apnea (a disorder where breathing repeatedly stops and starts during sleep because throat muscles relax and block the airway), functional quadriplegia (the complete or severe inability to move all four limbs due to extreme frailty or a disabling condition), and encounter for attention to gastrostomy (refers to medical visits for the care, management, or adjustment of a gastrostomy, which is a feeding tube into the stomach). The patient resided at home with his/her parents. Review of the POC dated 01/14/2026 to 03/14/2026, failed to include patient-specific feeding interventions, aspiration precautions, seizure precautions, visit frequencies for the SN and home health aide (HHA), and measurable goals, despite documentation of gastrostomy tube use, dysphasia, epilepsy, and total-assist functional needs. Observation on 01/28/2026 beginning at 12:30 PM, with RN C, showed: - The patient had just returned home from school (the POC failed to identify the patient’s school attendance, schedule, and details for coordination of care with the school staff); - The patient was nonverbal; - The HHA was present during the visit to provide a sponge bath; - The patient required two-person/total assistance; - The patient was transferred to an exam table inside of the living room area for the sponge bath and assessment; - The patient was unable to be left on the table unattended due to risk of rolling off the table; - The patient wore a diaper for bowel and bladder incontinence; - The patient’s family reported that school staff had called earlier in the day due to the patient crying from possible discomfort; - RN C asked if the school staff tried to “vent” the patient due to possible abdominal discomfort (relieve pressure build-up from the g-tube); - The patient’s family applied a syringe to the g-tube to relieve the air/gas build-up that could have potentially caused the discomfort at school; - The patient did not cry during the observation visit; - There was a mattress on the floor in the living room for the patient; - The patient required 24-hour around the clock care; - The patient’s family denied any questions or concerns during the visit; and - RN C informed the patient’s family to contact the provider if patient had discomfort that was unrelieved. During an interview on 01/29/2026, beginning at 1:55 PM, the director of quality and regulatory compliance (RN A) stated that: - The patient was attending school during the day and unable to have visits until returning home from school; - This was the last year for the patient to attend school due to turning 21 this summer; - The POC had SN to educate on “suctioning” because the family had suction equipment in the home but did not use it; - The POC did not include specific suctioning orders or interventions because the family did not use it; - The Ensure nutritional supplement was administered by the family whenever the family felt like the patient’s nutritional needs were not met throughout the day; - The anti-seizure medication was the patient’s seizure precaution interventions; - The POC did not include additional seizure precautions because the seizures were currently managed with the medication; - The SN and HHA visit frequencies did not pull over to the plan of care for some reason but were one time a week visits for both disciplines; - The plan of care failed to include g-tube maintenance/care orders and should have; and - Education needed to be provided to staff regarding the POC needing to include g-tube interventions and orders. RECORD/PATIENT #3: Review of the clinical record showed that the patient was admitted for home health services on 12/31/2025 with a primary diagnosis of hypoplastic left heart syndrome (HLHS) - a severe congenital heart defect where the left side of the heart is underdeveloped, preventing it from pumping blood to the body properly), end stage renal disease (ESRD – the kidneys can’t filter waste) on peritoneal dialysis (home-based treatment for kidney failure that uses the abdomen’s lining (peritoneum) to filter blood, removing waste and excess fluid via a catheter), hypoxemia (abnormally low level of oxygen in the blood), global developmental delay (GDD - children under age of five who lag behind in two or more developmental areas – motor skills, speech/language, cognitive, and social/emotional-significantly missing milestones), and Charcot-Marie-Tooth (CMT – group of inherited, progressive genetic disorders that cause damage to peripheral nerves, primarily affecting the feet, legs, and hands). The patient resided at home with his/her parents. Review of the POC dated 12/31/2025 to 02/28/2026, showed generalized interventions but failed to identify patient-specific aspiration precautions, oxygen settings, apnea monitor settings, measurable goals, therapy exercises and coordination with outside therapy providers, type of dialysis and dialysis provider. Clinical documentation showed the patient required assist with ADLs, swallowing difficulties with aspiration risk, peritoneal dialysis, use and nutritional concerns. These documented findings were not accurately reflected in the plan of care. Observation on 01/29/2026 beginning at 08:45 AM, with Registered Nurse (RN) D, showed: - The paid caregiver fully dressed the patient; - The patient had speech delay; - The patient wore a diaper for bowel incontinence; - The patient was able to crawl but did not walk; - The patient’s caregiver connected the gastrostomy feeding tube to the patient and started the feeding; - RN D asked the mother questions about the apnea monitor and settings and the mother stated they do O2 spot checks, and the patient wears the monitor during sleep at night with the alarms set to wake her if numbers go out of settings; - The mother stated the patient gets dialysis every night for twelve hours; - The patient gets therapy one day a week from an outside company; - The mother stated the patient had a swallow study completed on 01/28/2026 and he failed the test. She said his vocal cords are closing slow and he needs to be on a nectar diet; and - The patient required total assistance, had complex nutritional and functional needs, and received care that was not sufficiently addressed in the plan of care. During an interview on 01/29/2026, beginning at 1:55 PM, the director of quality and regulatory compliance (RN A) stated that there were no aspiration precaution interventions, O2 settings, apnea monitor settings, dialysis orders, or physician listed caring for the dialysis on the plan of care, and it should be. RECORD/PATIENT #4: Review of the clinical record showed that the patient was admitted for home health services on 10/16/2025 with a primary diagnosis of spastic quadriplegic cerebral palsy (a severe, non-progressive neurological disorder caused by brain damage, resulting in high muscle tone (stiffness) in all four limbs, the torso, and the face), neuromuscular scoliosis (side-to-side spine curvature), epilepsy (chronic neurological condition marked by recurring seizures, caused by abnormal electrical activity in the brain, leading to symptoms like convulsions, staring spells, confusion, or altered sensations). The patient resided at home with his/her parents. Review of the POC dated 12/15/2025 to 02/12/2026, showed generalized interventions but failed to identify patient-specific aspiration precautions and seizure precautions. Clinical documentation showed the patient required maximum assist with ADLs, aspiration risk, and seizure precautions. These documented findings were not accurately reflected in the plan of care. The patient required total assistance, had complex nutritional and functional needs, and received care that was not sufficiently addressed in the plan of care. During an interview on 01/29/2026, beginning at 1:55 PM, the director of quality and regulatory compliance (RN A) stated that there were no aspiration precaution interventions, and no seizure precaution interventions on the plan of care, and it should be.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure services were provided in accordance with the plan of care (POC) in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients on service with the provider. Findings included: Review of the provider’s policy titled, “Physician’s Orders,” dated 07/25/2011, showed, in part: - Purpose: To ensure an accurate and complete planning care and accurately verify medication, durable medical equipment (DME) or treatment orders for billing and other purposes; and - Care and services will be provided in accordance with physician’s orders. RECORD/PATIENT #1: Review of the clinical record showed that the patient was admitted for home health services on 02/03/2025 with a primary diagnosis of hypomyelination (lack of brain myelin, the protective sheath on nerve cells, affecting brain and spinal cord function)- hypogonadotropic hypogonadism (delayed puberty)- hypodontia (fewer teeth than normal) syndrome, 4H syndrome (Rare genetic neurological disorder that affects the nervous system leading to symptoms like poor balance, stiff limbs, learning disabilities, delayed teeth eruption, and vision/speech issues). Other pertinent diagnoses included; bilateral optic atrophy (a vision-impairing condition where both optic nerves, the nerve cables connecting eyes to the brain, degenerate, causing vision loss, blurred vision, poor color vision, and sometimes involuntary eye movements, often appearing as a pale or white optic disc on examination, resulting from nerve fiber loss due to genetic, inflammatory, traumatic, or other systemic diseases), dystonia (a neurological movement disorder causing uncontrollable, involuntary muscle contractions that lead to repetitive, twisting movements or abnormal postures), other disorders of psychological development (conditions originating in childhood that affect brain development, impacting learning, communication, social skills, and behavior), and hypoxemia (low levels of oxygen in the blood). The patient resided at home with his/her parents. Review of the POC dated, 11/30/2025 to 01/28/2026, showed in part, the professional nurse was to a perform comprehensive nursing assessment every (q) visit and items to include: nutrition/hydration, skin, bowel/urinary elimination, respiratory status, neurological status, and weights. Review of the clinical record documentation showed that the patient’s last weight assessment was on 10/28/2025 (three months prior) at 1:58 PM and the weight recorded was 27 pounds. The clinical record failed to show documentation of the patient’s weight being assessed at each visit as outlined in the POC. During an interview on 01/29/2026, beginning at 1:55 PM, the director of quality and regulatory compliance (RN A) stated that: - The plan of care showed weights every visit but the nurse reported that he/she was only obtaining weights monthly; and - The last documented weight was three months prior on 10/28/2025.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to provide a discharge summary to the primary care physician after discharge within five business days of the patient’s discharge in two of three discharge records reviewed (Records/Patients #5 and #7). This deficient practice has the potential to adversely affect the post discharge care of all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Palliative Home Care Plan of Care,” dated 11/01/2019, showed, in part, a completed discharge summary will be sent to the primary care practitioner or other health care professional who is responsible for providing care and services to the patient after discharge from the home health agency within five (5) business days of the patients discharge. RECORD/PATIENT #5: Review of the clinical record showed that the patient was admitted for home health services on 06/09/2025 with a primary diagnosis of Ehlers-Darlos syndrome (EDS), a group of inherited connective tissue disorders. Connective tissue, largely made-up of collagen, provides strength and support to skin, joints, blood vessels, and organs. In EDS, Collagen is faulty or made in abnormal amounts, making tissues too stretchy and fragile. The patient resided at home with family. Review of the discharge record, dated 08/12/2025, showed: - The discharge date was 08/07/2025; - The discharge summary was completed on 08/12/2025; and - The discharge summary was faxed to the primary care provider on 08/13/2025, six (6) days after the discharge date. During an interview on 01/29/2026, beginning at 1:55 PM, the director of quality and regulatory compliance (RN A) stated that: - The discharge summary should have been submitted to the primary care provider within 5 days; - He/she acknowledged that discharge documentation and submissions were completed late; and - Discharge documentation and submission education needed to be provided to staff. RECORD/PATIENT #5: Review of the clinical record showed that the patient was admitted for home health services on 08/21/2025 with a primary diagnosis of intracranial injury with loss of consciousness status unknown (brain injury occurred but whether the patient lost consciousness, or for how long, is undocumented). Review of the discharge record, dated 11/17/2025, showed: - The discharge date was 10/19/2025; - The discharge summary was completed on 11/17/2025; and - The discharge summary was faxed to the primary care provider on 11/26/2025 (thirty-eight days after the discharge date).”