Kh Prime Hospice Care

“Observed in Tracer Activities. During review of the organization’s contracted services, the organization failed to provide for its planned scope and level of care, treatment, or services. For example, during the contract review, it was noted that the organization did not have a contract or arrangement for physical therapy (PT), occupational therapy (OT), and speech language pathology (SLP) services. Upon further review, there was no evidence of direct employees that the organization maintained to provide PT, OT, and SLP services. Furthermore, the administrator shared that these services were not provided or applicable to the patients served by the organization. This was reviewed, discussed, and validated with the administrator.”

“Observed in Tracer Activities. There was no evidence that the governing body and leadership had consistently implemented policies and procedures to support the patient care, treatment, and services as evidenced by condition level deficiencies at §418.54, §418.102, §418.116, §418.72, §418.104, §418.100, §418.58, §418.78, and §418.52. This was reviewed, discussed, and validated with the administrator. Observed in Leadership Session. During Leadership session it was noted the Governing Body had not ensured an Administrator was appointed for the day-to-day operations of the hospice. For example: review of the only Governing Body minutes from 2023 and the prior owners revealed an Administrator that was no longer with the organization. The new owner/Administrator was unable to provide documentation the current Governing Body had appointed an Administrator. This was reviewed, discussed, and validated with the Administrator/owner. Observed in Leadership Session. During Leadership it was noted the organization’s new owners did not have an annual operating budget for the past year nor did they have a governing body to oversee and approve a budget. This was discussed, reviewed, and validated with the Administrator.”

“Observed in Record Review. In 2 of 14 patient records reviewed, During RRNHV# 9 and RRNHV# 6’s patient records review it was noted the organization had not maintained complete patient records. For example: during RRNHV# 9’s patient record review it was noted the Election of Benefit (EOB) and Patient Consent forms were not present in the electronic medical record (EMR) or the paper medical record. The Administrator shared the documents had been scanned from home and not upload with the original documents at home and not in the RRNHV# 9’s medical records at the time of the surveyor review of the record. Review of RRNHV# 6’s EMR revealed no documentation of an EOB or Patient Consent form. The Administrator stated the original documents were on a different computer at home. This was reviewed, discussed, and validated with the Administrator. Observed in Record Review. In 1 of 14 patient records reviewed, During RRNHV# 9’s patient record review it was noted the organization had not ensured it maintained complete and accurate patient records. For example: review of RRNHV# 9’s start of care RN comprehensive assessment revealed documentation that an additional assessment was completed two days in the future of the RN signature date. Further review of RRNHV# 9’s patient record revealed a SN visit note dated two days after the start of care with documentation that the SN visit note was signed by the DPCS for the clinician that completed the assessment. Audit trails was requested and not provided. This was reviewed, discussed, and validated with the Administrator. Observed in Record Review. In 1 of 14 patient records reviewed, During RRNHV# 8’s patient record review it was noted the organization did not ensure staff followed the organization policy Entries into the Clinical Record No.5-006.2, that included hospice personnel providing direct patient care and supervisory functions have authority to make entries into the clinical record. For example: review of RRNHV# 8’s patient record revealed a discharge summary signed by HR# 5/Community Liason with no direct patient care responsibilities. This was reviewed, discussed, and validated with the Administrator.”

“Observed in HR File Review. In 3 out of 9 personnel records reviewed, the organization failed to ensure that emergency management education had been provided to their staff. For example, in review of HR#1, the medical director had no evidence of emergency management training upon hire in 2024 or annual training in 2025. In review of HR#7, the Director of Patient Care Services (DPCS) did not have annual training for 2025. In review of HR#9, the alternate medical director did not have annual training for 2023, 2024, and 2025. This was reviewed, discussed, and validated with the administrator.”

“Observed in Patient Home. In 1 of 1 home visits conducted, it was noted the organization did not maintain confidential patient records in accordance with privacy and security standards of the Health Insurance Portability and Accountability Act (HIPAA). For example: during RRHV# 1’s home observation RRNHV# 9’s medical record binder with RRNHV# 9’s name on the outside of the medical record binder and hospital admission records located in the binder was found on the coffee table in the living room of RRHV# 1’s home. The Administrator shared he brought RRNHV# 9’s medical record binder to RRHV# 1’s home approximately one hour prior to the surveyors home observation and thought it was the patient folder for RRHV# 1.”

“Observed in Record Review. In 14 out of 14 records reviewed, the organization failed to maintain complete and accurate patient records. For example, in all records reviewed, an oxygen safety assessment had completed, however, none of the patients had orders for oxygen and no documentation that indicated oxygen was in use. Upon further review, all assessments included detailed education that was provided to the patients regarding the specific equipment in their home setting such as, Instructed patient to keep their oxygen tanks away from gas stoves, Provided demonstration on safe oxygen storage in an upright position, Patient performed correct return demonstration of oxygen use, and Patient/representative verbalized correct procedure for utilizing emergency oxygen tank. This was reviewed, discussed, and validated with the administrator.”

“Observed in Record Review. In 2 of 14 patient records reviewed, During RRNHV# 8 and RRNHV# 6’s patient record review it was noted the organization did not ensure the plan of care included interventions to manage pain and symptoms. For example: review of RRNHV# 8’s RN comprehensive assessment revealed RRNHV# 8 had difficulty swallowing and was on a mechanical soft diet. However, review of RRNHV# 8’s plan of care and updates to the plan of care revealed no intervention for mechanical soft diet. Review of RRNHV# 6’s RN comprehensive assessment revealed RRNHV# 6 had difficulty swallowing and was on a puree diet and thickened liquids. However, review of RRNHV# 6’s plan of care and updated plan of care revealed no interventions for a puree diet or thickened liquids. Further review of RRNHV# 6’s patient record revealed RRNHV# 6 had a pressure ulcer to the coccyx and it was being cleaned with normal saline and a duoderm was being applied by the nurse during visits and by the family daily. However, review of RRNHV# 6’s plan of care revealed no interventions for wound care. This was reviewed, discussed, and validated with the Administrator.”

“Observed in Record Review. In 1 out of 14 records reviewed, the organization failed to provide for its planned scope and level of care, treatment, or services. For example, in the record review for RRNHV#1, the Medical Social Worker (MSW) noted in their initial psychosocial assessment that the patient reported 10/10 pain during the visit. Upon further review, the MSW noted that they would report the change in condition to the hospice, however, there was no evidence that the hospice IDG or physician was notified. There were no documented communication notes indicating that the MSW reported the change in condition, and the next visit from a hospice team member occurred three days later by a skilled nurse. This was discussed, reviewed, and validated by the administrator.”

“Observed in Leadership Session. During the leadership and data system tracer, the organization failed to act when it did not achieve or sustain planned improvements. Because the organization did not have evidence of any performance improvement activities for 2025, there was no evidence that it acted when planned improvements were not achieved or sustained. This was reviewed, discussed, and validated with the administrator. Observed in Leadership Session. During the leadership and data system tracer, the organization failed to act on improvement priorities. For example, the organization did not identify any improvement priorities for 2025. Because they did not identify any improvement priorities, they could not act on them. This was reviewed, discussed, and validated with the administrator. Observed in Leadership Session. During the leadership and data system tracer, the organization failed to evaluate actions to confirm that they resulted in improvements. For example, the organization had no evidence that they completed any performance improvement activities for 2025, and could not demonstrate any evaluation of their actions to confirm they resulted in improvement. This was reviewed, discussed, and validated with the administrator.”

“Observed in HR File Review. In 3 out of 9 personnel records reviewed, the organization failed to ensure that bloodborne pathogen education had been provided to their staff. For example, in review of HR#1, the medical director had no evidence of bloodborne pathogen training upon hire in 2024 or annual training in 2025. In review of HR#7, the Director of Patient Care Services (DPCS) did not have annual training for 2025. In review of HR#9, the alternate medical director did not have annual training for 2023, 2024, and 2025. This was reviewed, discussed, and validated with the administrator.”

“Observed in HR File Review. In 1 of 9 HR files reviewed, During HR# 8’s HR file review it was noted the organization did not ensured competence was assessed as part of the orientation. For example: review of HR#8/MSW’s HR file revealed no evidence of an initial competence evaluation. This was reviewed, discussed, and validated with the HR Administrative Assistant and Administrator. Observed in HR File Review. In 1 out of 9 personnel records reviewed, the organization failed to ensure that staff competence is initially assessed. For example, in the review of HR#2, there was no evidence that the organization completed initial competencies for the Licensed Vocational Nurse (LVN). The LVN had been employed for approximately one month, however, no competencies had been performed. Furthermore, the LVN was observed during RRHV#1 working independently without supervision. This was reviewed, discussed, and validated with the administrator.”

“Observed in Record Review. In 1 of 15 patient records reviewed, During RRNHV# 8’s patient record review it was noted the organization did not ensure the initial Certification of Terminal Illness (CTI) included medical management of the patient’s conditions unrelated to the terminal condition. For example: review of the initial revealed a copy and pasted LCD Guideline from the start of care RN comprehensive assessment that included possible signs and symptoms the patient was not experiencing such as a. Aspiration pneumonia in the past 12 months?, d. Decubitis ulcer stage 3 or 4 in the past 12 months?, and f. Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin less than (<) 2.5 gm/dl?. This was reviewed, discussed, and validated with the Administrator.”

“Observed in Patient Home. In 1 out of 1 home visits conducted, the organization failed to ensure that the patient record contains information that reflects the patient’s care, treatment, or services. For example, during the home visit conducted for RRHV#1, the nurse was observed performing a medication reconciliation. During the reconciliation, the following medications were included on the medication profile, but not present in the home; Timolol Malate 0.5% ophthalmic solution. Upon further discussion, the daughter shared that those medications were discontinued three months prior to the patient’s admission to hospice. Furthermore, during the reconciliation, the following medications were present in the home, but not included on the medication profile; Refresh Eye Drops, Vicks Nasal Saline Spray, and Omeprazole 40 mg DR capsules. This was reviewed, discussed, and validated with the administrator.”

“Observed in Record Review. In 2 out of 14 records reviewed, the organization failed to ensure that entries in the patient record are authenticated. For example, in the record review for RRNHV#5, the consent forms and hospice election date were left blank. Upon further review of the documents, the patient, representative, and organization’s witness had left no identifying date of when the document was signed and when the hospice election was to take effect. In the record review for RRNHV#2, the signed hospice election form had an election date that was dated two (2) days after the RN comprehensive assessment and start of care date had been completed. This was reviewed, discussed, and validated with the administrator.”

“Observed in Record Review. In 4 out of 14 records reviewed, the organization failed to ensure that the patient’s attending physician received a copy of the hospice discharge summary. For example, in record review of RRNHV#2, the patient was hospitalized and there was no evidence that the receiving facility had received a copy of the discharge summary. In record review of RRDC#1 and RRNHV#4, the patients had transferred to another hospice, however, there was no evidence that the discharge summary was sent to the receiving provider. In record review of RRDC#2, the patient refused further services, however, there was no evidence that the discharge summary had been sent to the patient’s attending physician. This was reviewed, discussed, and validated with the administrator.”