Kindred Hospice

“Upon patient record review, 3 of 5 (Patients #2,#4,#5) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 2: The medication profile contains Creon frequency of every 15 minutes and conflicting instructions to take 15 minutes prior to meal. The medical record contained nursing documentation since 5/29/26 identifying intermittent use of oxygen. There was no evidence of oxygen on the medication profile. Patient 4: The medication profile contained duplicative listing of lorazepam with differing frequencies. Patient 5: The medication profile contained Naloxone with instructions to repeat administration if no response after 2-3 minutes. The instructions do not include a maximum number of doses allowed or instructions for handling if ineffective. The medical record contains nursing documentation 7/2/26 identifying the nurse obtained an order for Zofran to treat nausea. There was no evidence of Zofran on the medication profile.”

“Upon patient record review, 2 of 5 (Patients #2,#5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 2: The medical record contained nursing documentation identifying use of intermittent oxygen since 5/29/26. There was no evidence of an order for oxygen rate, frequency, and delivery method. The record also contained an order for Creon with frequency every 15 minutes and conflicting instructions to take 15 minutes prior to meal. Patient 5: The medical record contains nursing documentation 7/2/26 identifying the nurse obtained an order for Zofran to treat nausea. There was no evidence of a physician order in the record. The record also contained an order for Naloxone with instructions to repeat administration if no response after 2-3 minutes. The order does not contain instructions for maximum doses allowed or instructions for handling if ineffective.”

“Upon patient record review, 3 of 19 (Patient #1,3,8) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1: Active medication profile has Colace and MiraLAX listed as PRN for constipation. No evidence that instructions were included for which medication should be given first in the event of constipation Patient 3: The RN documentation indicated that the patient was using oxygen at 2LNC on 05/18 & 04/30 and 3LNC on 04/23 and 05/06/26. No evidence that an order was included on the active medication profile. Patient 8: The active medication profile has 2 orders for Tylenol, one tablet form and one suppository form. both written to be given for fever greater than 99.1. No evidence that instructions were given on when to use the tablet form and when to use the suppository form.”

“Upon patient record review, 1 of 19 (Patient #6) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 6: Aide documentation on 04/15/26 stated that the patient fell. Resulting in a bruise on her left eye and a wound on her left buttock. Aide documented that the nurse was notified of those findings. No evidence that the RN performed a follow-up assessment on the patients injury. The RN completed an assessment on 4/16/26 without mention of what was previously reported or that an investigation was completed at that time. No evidence that the RN addressed the patients fall until 04/23/26 when the ALF nurse notified the nurse of the fall. Aide documentation on 05/13/2026 indicated that the patient had 2 bed sores and was having trouble breathing while being cared for in the bed. No evidence that the RN performed a follow-up assessment on the patient’s injury. The RN completed an assessment on 05/14/26,without mention of what was previously reported or that an investigation was completed.”

“Upon client record review, 1 of 19 (Patient #14) did not have evidence that the hospice follows the individualized plan of care developed in in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient’s needs if any of them so desire. Patient 14: The medical record contained nursing documentation identifying patient fall 04/18/2026 resulting in skin tears to the bilateral upper arms. There was no evidence of physician notification regarding the fall in the medical record. The fall report did not indicate that the physician was notified.”

“Upon patient record review, 1 of 19 (Patient #10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 10: Active plan of care has outcomes and goals related to oxygen safety and the need for a safety plan to keep the patient safe/possibly needing adult protective services. No evidence that either of those problems were related to the patients needs during the time of service.”

“Upon patient record review, 3 of 19 (Patient #1,3,8) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1: The plan of care has orders for Colace and MiraLAX listed as PRN for constipation. No evidence that instructions were included on either order for which medication should be given first in the event of constipation. Patient 3: The RN documentation indicated that the patient was using oxygen at 2LNC on 05/18 & 04/30 and 3LNC on 04/23 and 05/06/26. No evidence that a physician order was received for oxygen at the time that the record was surveyed. Patient 8: The care plan has 2 orders for Tylenol, one tablet form and one suppository form. Both written to be given for fever greater than 99.1. No evidence that instructions were given on when to use the tablet form and when to use the suppository form.”

“Upon patient record review, 2 of 19 (Patient #2,4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 2: The medical record indicated that the patient uses a high back wheelchair for mobility. No evidence that a high back wheelchair was included on the current DME supply list. Patient 4: The medical record indicated that the staff uses a Hoyer lift with transfers. No evidence that a Hoyer lift was included on the current DME supply list.”

“Upon client record review, 2 of 19 (Patient #7,12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 7: The plan of care has orders for Massage Therapy to be completed once a week for 5 weeks starting March 1st, 2026. No evidence that the patient received a visit from the massage therapist during that time. Patient 12: On 4/29/2026 a physician order was placed for a volunteer evalution referral. No evidence that the evaluation had occurred at the time of survey.”

“Upon patient record review 3 of 19 (Patient #1,4,6) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 1: Aide POC has shaving and nail care to be completed at each visit. No evidence that those task were completed on the visits that occurred on May 4th, 5th, 6th, and 8th. Aide documented that per frequency those task did not need to be completed. Patient 4: Aide POC has frequency ordered as 2 times weekly. No evidence that the patient received 2 visits for the week of 03/02/26. No evidence that these visits were missed at the request of the patient/CG or that an order was received to decrease visits for the week. Patient 6: Aide POC has frequency ordered as 5 times weekly. No evidence that the patient received 5 visits for the weeks of 03/23/26, 04/06/26, and 04/13/26. No evidence that these visits were missed at the request of the patient/CG or that an order was received to decrease visits for the week.”