Hospice of NE KS Multi-County

“Based on interview and policy review the Hospice failed to develop and implement policies and procedures to track the location of on-duty staff and sheltered patients in the agencys care during an emergency. Findings Include: On 11/29/23 between at 11:45 AM and 1:30 PM, the Administrator was interviewed about the Emergency Preparedness Program (EPP) and stated that the policies and procedures to track the location of on-duty staff and sheltered patients during an emergency were not in the EPP. Review of the EPP failed to show documents or forms to track the location of on-duty staff and sheltered patients in the agencys care during an emergency.”

“Based on interview and policy review the Hospice failed to develop and implement policies and procedures to describe its role in providing care at alternate care sites during an emergency. On 11/29/23 between at 11:45 AM and 1:30 PM, the Administrator was interviewed about the Emergency Preparedness Program (EPP) and stated that there were no policies and procedures to describe its role in providing care at alternate care sites during an emergency. Review of the EPP failed to show evidence of policies and procedures to describe its role in providing care at alternate care sites due to a Section 1135 Emergency Waiver during an emergency.”

“Based on document review, policy review and interview, the hospice failed to ensure information gathered from the initial bereavement assessment was incorporated into the plan of care for 10 (Patients 1,2, 3, 4, 5, 6, 7, 8, 9 and 10) of 10 active patients and 4 (Patients 11,12,13, and 14) 4 discharged patients reviewed. The hospices failure to incorporate initial bereavement findings into the care plan has the potential for ineffective family and caregiver coping. Findings Include: Review of hospice policy titled, “;Assessment-Initial and Comprehensive”, dated 2016, showed the comprehensive assessment will take into consideration the following factors: Bereavement: An initial bereavement assessment of the needs of the patients family and other individuals focusing on the social, spiritual and cultural factor that may impact their ability to cope with the patients death. Information gathered from the initial bereavement assessment will be incorporated into the plan of care. The policy showed the interdisciplinary team in consultation with the patients attending physician and patient/family, will prepare a written plan of care for each patient. The plan of care will specify patient and family-specific needs identified in the comprehensive assessment. Patient 1 A review of patient 1s “;Plan of Care Order” (Plan of Care), dated11/27/23 through 02/24/24 showed admission 11/27/23 to hospice with a primary diagnosis of Chronic Obstructive Pulmonary (lung) Disease and receipt of hospice services in the assisted living facility. Review of the comprehensive assessment showed, “;Bereavement” had been checked within the Spiritual Assessment, indicating bereavement needs had been assessed. There were no documented problems, interventions, nor outcomes incorporated into plan of care from the initial bereavement assessment. Patient 2 A review of patient 2s “;Plan of Care Order”, dated 11/10/23 through 02/07/24, showed admission 11/10/23 to hospice with a primary diagnosis of Alzheimers disease and receipt of hospice services in his home. Review of the comprehensive assessment showed, “;Bereavement” had been checked within the Spiritual Assessment, indicating bereavement needs had been assessed. There were no documented problems, interventions, nor outcomes incorporated into plan of care from the initial bereavement assessment. Patient 3 A review of patient 3s “;Plan of Care Order”, dated 11/24/23 through 01/22/24, showed admission 12/09/20 to hospice with a primary diagnosis of Cerebral Atherosclerosis (a disease that occurs when the arteries in the brain become hard, thick, and narrow) and receipt of hospice services in his home. Review of the comprehensive assessment showed, “;Bereavement” had been checked within the Spiritual Assessment, indicating bereavement needs had been assessed. There were no documented problems, interventions, nor outcomes incorporated into plan of care from the initial bereavement assessment. Patient 4 A review of patient 4s “;Plan of Care Order”, dated 10/15/23 through 12/13/23, showed admission 10/20/22 to hospice with a primary diagnosis of Atherosclerotic (hardening of the arteries) heart disease and receipt of hospice services in a long-term care facility. Review of the comprehensive assessment showed, “;Bereavement” had been checked within the Spiritual Assessment, indicating bereavement needs had been assessed. There were no documented problems, interventions, nor outcomes incorporated into plan of care from the initial bereavement assessment. Patient 5 A review of patient 5s “;Plan of Care Order”, dated 10/17/23 through 12/15/23, showed admission 04/20/23 to hospice with a primary diagnosis of Chronic Obstructive Pulmonary Disease and receipt of hospice services in a long-term care facility. Review of the comprehensive assessment showed, “;Bereavement” had been checked within the Spiritual Assessment, indicating bereavement needs had been assessed. There were no documented problems, interventions, nor outcomes incorporated into plan of care from the initial bereavement assessment. Patient 6 A review of patient 6s “;Plan of Care Order”, dated 11/17/23 through 02/14/24, showed admission 11/17/23 to hospice with a primary diagnosis of and Malignant Neoplasm of Cerebrum (brain tumor) and receipt of hospice services in her home. Review of the comprehensive assessment showed, “;Bereavement” had been checked within the Spiritual Assessment, indicating bereavement needs had been assessed. There were no documented problems, interventions, nor outcomes incorporated into plan of care from the initial bereavement assessment. Patient 7 A review of patient 7s “;Plan of Care Order”, dated 11/26/23 through 01/24/24, showed admission 02/04/22 to hospice with a primary diagnosis of Chronic Obstructive Pulmonary Disease and receipt of hospice services from the long-term care facility. Review of the comprehensive assessment showed, “;Bereavement” had been checked within the Spiritual Assessment, indicating bereavement needs had been assessed. There were no documented problems, interventions, nor outcomes incorporated into plan of care from the initial bereavement assessment. Patient 8 A review of patient 8s “;Plan of Care Order”, dated 11/07/23 through 02/24/24, showed admission 11/07/23 to hospice with a primary diagnosis of Chronic Obstructive Pulmonary Disease with (acute) Exacerbation and receipt of hospice services in the assisted living facility. Review of the comprehensive assessment showed, “;Bereavement” had been checked within the Spiritual Assessment, indicating bereavement needs had been assessed. There were no documented problems, interventions, nor outcomes incorporated into plan of care from the initial bereavement assessment. Patient 9 A review of patient 9s “;Plan of Care Order”, dated 11/07/23 through 02/04/24, showed admission 12/28/22 to hospice with a primary diagnosis of Chronic Obstructive Pulmonary Disease and receipt of hospice services in the long-term care facility. Review of the comprehensive assessment showed, “;Bereavement” had been checked within the Spiritual Assessment, indicating bereavement needs had been assessed. There were no documented problems, interventions, nor outcomes incorporated into plan of care from the initial bereavement assessment. Patient 10 A review of patient 10s “;Plan of Care Order”, dated 11/13/23 through 01/11/24, showed admission 09/19/22 to hospice with a primary diagnosis of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and receipt of hospice services in the long-term care facility. Review of the comprehensive assessment showed, “;Bereavement” had been checked within the Spiritual Assessment, indicating bereavement needs had been assessed. There were no documented problems, interventions, nor outcomes incorporated into plan of care from the initial bereavement assessment. Patient 11 A review of patient 11s “;Plan of Care Order”, dated 03/25/23 through 05/23/23, showed admission 11/23/22 to hospice with a primary diagnosis of Alzheimers disease and receipt of hospice services in the long-term care facility until discharge 01/20/23. Review of the comprehensive assessment showed, “;Bereavement” had been checked within the Spiritual Assessment, indicating bereavement needs had been assessed. There were no documented problems, interventions, nor outcomes incorporated into plan of care from the initial bereavement assessment. Patient 12 A review of patient 12s “;Plan of Care Order”, dated 04/19/23 through 06/17/23, showed admission 10/21/22 to hospice with a primary diagnosis of Other Frontotemporal Neurocognitive disorder (a group of disorders that occur when nerve cells in the frontal and temporal lobes of the brain are lost) and receipt of hospice services in the long-term care facility until discharge 06/15/23. Review of the comprehensive assessment showed, “;Bereavement” had been checked within the Spiritual Assessment, indicating bereavement needs had been assessed. There were no documented problems, interventions, nor outcomes incorporated into plan of care from the initial bereavement assessment. Patient 13 A review of patient 13s “;Plan of Care Order”, dated 10/24/22 through 11/08/24, showed admission 07/26/22 to hospice with a primary diagnosis of Alzheimers Disease and receipt of hospice services in the long-term care facility until discharge 11/08/22. Review of the comprehensive assessment showed, “;Bereavement” had been checked within the Spiritual Assessment, indicating bereavement needs had been assessed. There were no documented problems, interventions, nor outcomes incorporated into plan of care from the initial bereavement assessment. Patient 14 A review of patient 14s “;Plan of Care Order”, dated 11/10/23 through 02/07/241, showed admission 07/28/23 to hospice with a primary diagnosis of End Stage Heart Disease and receipt of hospice services in his home until discharge 07/29/23. Review of the comprehensive assessment showed, “;Bereavement” had been checked within the Spiritual Assessment, indicating bereavement needs had been assessed. There were no documented problems, interventions, nor outcomes incorporated into plan of care from the initial bereavement assessment. During an interview on 11/28/23 at 8:45 AM, Staff F, Bereavement Coordinator confirmed bereavement assessments were completed during the initial spiritual assessment and documented by checking the box marked “;Bereavement,” but concerns were not incorporated into the bereavement plan of care, until the time of the patients death. During an interview on11/28/23 at 8:50 AM, Staff A, Clinical Director confirmed the pre-bereavement risk assessment was to be completed by the Bereavement Coordinator during the initial spiritual assessment for patients and families and should be incorporated into the plan of care.”

“Based on document review, policy review and interview, the hospice failed to ensure written agreements for pharmacy services confirmed those services were made routinely available on a 24-hour basis, 7 days a week. The hospices failure to ensure required language in written agreements has the potential to affect availability of pharmacy services for all patients. Findings Include: Review of a hospice policy titled, “;Contractual Agreements”, dated 2016, showed written contracts and/or agreements govern the components of services; written contract/agreements shall specify the hospice retains professional responsibility for the services provided under arrangement. Review of a hospice Pharmacy Services agreement titled “;Pharmacy Services Agreement, effective January 1, 2011, showed the written agreement lacked language to support pharmacy services were made routinely available on a 24-hour basis, 7 days a week. Review of a hospice Pharmacy Services agreement titled “;Contract Pharmacy Services Agreement,” effective May 17, 2019, showed the written agreement lacked language to support pharmacy services were made routinely available on a 24-hour basis, 7 days a week. Review of a hospice Pharmacy Services agreement titled “;Contract Pharmacy Services Agreement,” effective May 17, 2019, updated 04/01/23, showed the written agreement lacked language to support pharmacy services were made routinely available on a 24-hour basis, 7 days a week. During an interview on 11/29/23 at 8:30 AM, Staff B, Administrator confirmed the Pharmacy agreements didnt contain all required language.”

“Based on document review, policy review and interview, the hospice failed to ensure written agreements for pharmacy services retained administrative and financial management and oversight of staff and services for all arranged services as required for patients. The failure of the hospice to ensure required language in written agreements has the potential to adversely affect all patients receiving pharmacy services from the hospice. Findings Include: Review of a hospice policy titled, “;Contractual Agreements”, dated 2016, showed written contract/agreements shall specify: Specific services to be provided, assurance by the contractor of the education, training and qualifications of personnel; the manner in which the contracted services are coordinated, supervised and evaluated by the hospice; the delineation of the role of the hospice and contractor in the admission process, patient family assessment/ and the interdisciplinary group conferences; the hospice retains professional responsibility for the services provided under arrangement and hospice retains responsibility for payment for services. Review of a hospice Pharmacy Services agreement titled “;Pharmacy Services Agreement, effective January 1, 2011 showed the agreement lacked language to support the hospice maintained administrative and financial management and oversight of staff and services for all arranged Pharmacy services as required for patients and that those services are required to be; authorized by the hospice; furnished in a safe and effective manner by qualified personnel; delivered in accordance with the patient’s plan of care and for Medicare purposes, the hospice is reimbursed for all covered services it provides, whether directly or under arrangement. Review of a hospice Pharmacy Services agreement titled “;Contract Pharmacy Services Agreement,” effective May 17, 2019 showed the agreement lacked language to support the hospice maintained administrative and financial management and oversight of staff and services for all arranged Pharmacy services as required for patients and that those services are required to be; authorized by the hospice; furnished in a safe and effective manner by qualified personnel; delivered in accordance with the patient’s plan of care and for Medicare purposes, the hospice is reimbursed for all covered services it provides, whether directly or under arrangement. Review of a hospice Pharmacy Services agreement titled “;Contract Pharmacy Services Agreement,” effective May 17, 2019, updated 04/01/23, showed the agreement lacked language to support the hospice maintained administrative and financial management and oversight of staff and services for all arranged Pharmacy services as required for patients and that those services are required to be; authorized by the hospice; furnished in a safe and effective manner by qualified personnel; delivered in accordance with the patient’s plan of care and for Medicare purposes, the hospice is reimbursed for all covered services it provides, whether directly or under arrangement. The hospice failed to follow policy and include in each of the “Contract Pharmacy Services Agreements” that the hospice retains professional responsibility for the services provided under arrangement; hospice retains responsibility for payment for services as well as specifying services provided, qualifications of staff, manner of supervision, evaluation and delineation of roles between the hospice and contractor in the admission process, assessments and interdisciplinary conferences for patients and families. During an interview on 11/29/23 at 8:30 AM, Staff B, Administrator confirmed the Pharmacy agreements did not contain all required language.”

“Based on document review, policy review and interview, the hospice failed to ensure clinical records contained correct orders for comfort medication at admission for 5 (Patients 2, 4, 5, 6 and 9) of 10 active patients reviewed and 2 (Patients 13 and 14) of 4 discharged patients reviewed. The hospices failure to ensure correct order information on admission has the potential to adversely affect all patients served by the hospice. Findings Include: Review of hospice policy titled, “;Contents of Clinical Record”, dated 2016, showed, “;The clinical record must contain correct, clinical information that is available to the patients attending physician and hospice staff.” The patients clinical records shall include physicians orders. Review of hospice policy titled, “;Clinical Record- Central Clinical Record”, dated 2016, showed the Hospice record shall be complete and documentation, shall be “;timely and accurate.” Patient 2 A review of patient 2s “;Plan of Care Order”, dated 11/10/23 through02/07/24, showed admission 11/10/23 to hospice with a primary diagnosis of Alzheimers disease and receipt of hospice services in his home. A review of patient 2s “;Physician Order”, templated into the electronic medical record (EMR) on admission, dated 11/10/23, showed “;Comfort Kit Standing Orders: Roxanol (a narcotic prescribed for pain/air hunger) (30 ML [milliliters])-20 mg/ml (milligrams/ml) – give 0.25 - 1 ml, SL (sublingual, under the tongue) every 2-3 hours as needed for pain/shortness of air. May administer up to 11 ml every hour as needed for increased pain, shortness of air.” This dosage of Roxanol was 11 times the intended dosage of 1 ml every hour, ordered on the Hospice Standing Orders form (paper form completed by RN on admission) and on the Plan of Care Order in the patients record. Patient 4 A review of patient 4s “;Plan of Care Order”, dated 10/15/23 through 12/13/23, showed admission 10/20/22 to hospice with a primary diagnosis of Atherosclerotic Heart Disease and receipt of hospice services in a long-term care facility. A review of patient 4s “;Physician Order”, templated into the EMR on admission, dated 10/20/22, showed “;Comfort Kit Standing Orders: Roxanol (a narcotic prescribed for pain/air hunger) (30 ML)-20 mg/ml– give 0.25 -1 ml, SL (sublingual, under the tongue) every 2-3 hours as needed for pain/shortness of air. May administer up to 11 ml every hour as needed for increased pain, shortness of air.” This dosage of Roxanol was 11 times the intended dosage of 1 ml every hour, ordered on the Hospice Standing Orders form (paper form completed by RN on admission) and on the Plan of Care order in the patients record. Patient 5 A review of patient 5s “;Plan of Care Order”, dated 10/17/23 through 12/15/23, showed admission 04/20/23 to hospice with a primary diagnosis of Chronic Obstructive Pulmonary Disease and receipt of hospice services in a long-term care facility. A review of patient 5s “;Physician Order”, templated into the EMR on admission, dated 04/20/23, showed “;Comfort Kit Standing Orders: Roxanol (a narcotic prescribed for pain/air hunger) (30 ML)-20 mg/ml– give 0.25 -1 ml, SL (sublingual, under the tongue) every 2-3 hours as needed for pain/shortness of air. May administer up to 11 ml every hour as needed for increased pain, shortness of air.” This dosage of Roxanol was 11 times the intended dosage of 1 ml every hour, ordered on the Hospice Standing Orders form (paper form completed by RN on admission) and on the Plan of Care order in the patients record. Patient 6 A review of patient 6s “;Plan of Care Order”, dated 11/17/23 through02/14/24, showed admission 11/17/23 to hospice with a primary diagnosis of and Malignant Neoplasm of Cerebrum and receipt of hospice services in her home. A review of patient 6s “;Physician Order”, templated into the EMR on admission, dated 11/17/23, showed “;Comfort Kit Standing Orders: Roxanol (a narcotic prescribed for pain/air hunger) (30 ML)-20 mg/ml– give 0.25 -1 ml, SL (sublingual, under the tongue) every 2-3 hours as needed for pain/shortness of air. May administer up to 11 ml every hour as needed for increased pain, shortness of air.” This dosage of Roxanol was 11 times the intended dosage of 1 ml every hour, ordered on the Hospice Standing Orders form (paper form completed by RN on admission) and on the Plan of Care order in the patients record. Patient 9 A review of patient 9s “;Plan of Care Order”, dated 11/07/23 through 02/04/24, showed admission 12/28/22 to hospice with a primary diagnosis of Chronic Obstructive Pulmonary Disease and receipt of hospice services in the long-term care facility. A review of patient 9s “;Physician Order”, templated into the EMR on admission, dated 12/28/22, showed “;Comfort Kit Standing Orders: Roxanol (a narcotic prescribed for pain/air hunger) (30 ML)-20 mg/ml– give 0.25 -1 ml, SL (sublingual, under the tongue) every 2-3 hours as needed for pain/shortness of air. May administer up to 11 ml every hour as needed for increased pain, shortness of air.” This dosage of Roxanol was 11 times the intended dosage of 1 ml every hour, ordered on the Hospice Standing Orders form (paper form completed by RN on admission) and on the Plan of Care order in the patients record. Patient 13 A review of patient 13s “;Plan of Care Order”, dated 10/24/22 through11/08/24, showed admission 07/26/22 to hospice with a primary diagnosis of Alzheimers Disease and receipt of hospice services in the long-term care facility until discharge 11/08/22. A review of patient 13s “;Physician Order”, templated into the EMR on admission, dated 07/26/22, showed “;Comfort Kit Standing Orders: Roxanol (a narcotic prescribed for pain/air hunger) (30 ML)-20 mg/ml– give 0.25 -1 ml, SL (sublingual, under the tongue) every 2-3 hours as needed for pain/shortness of air. May administer up to 11 ml every hour as needed for increased pain, shortness of air.” This dosage of Roxanol was 11 times the intended dosage of 1 ml every hour, ordered on the Hospice Standing Orders form (paper form completed by RN on admission) and on the Plan of Care order in the patients record. Patient 14 A review of patient 14s “;Plan of Care Order”, dated 11/10/23 through 02/07/24, showed admission 07/28/23 to hospice with a primary diagnosis of End Stage Heart Disease and received hospice services in his home until discharge 07/29/23. A review of patient 14s “;Physician Order”, templated into the EMR on admission, dated 07/28/23, showed “;Comfort Kit Standing Orders: Roxanol (a narcotic prescribed for pain/air hunger) (30 ML)-20 mg/ml– give 0.25 -1 ml, SL (sublingual, under the tongue) every 2-3 hours as needed for pain/shortness of air. May administer up to 11 ml every hour as needed for increased pain, shortness of air.” This dosage of Roxanol was 11 times the intended dosage of 1 ml every hour, ordered on the Hospice Standing Orders form (paper form completed by RN on admission) and on the Plan of Care order in the patients record. During an interview on 11/28/23 at 8:30 AM, Staff A, Clinical Director confirmed the hospice “;Physician Order” for Roxanol for identified patients did contain instruction to administer up to “;11 ml” every hour as needed for increased pain/shortness of air and that dosage was an incorrect, typographical error in the order template, within the electronic record. She confirmed standing orders (admission, paper form) for Roxanol administration were correct and that correct dosages made it onto the Plans of Care and Medication Profiles for all identified patients.”

“Based on document review, policy review and interview, the hospice failed to ensure criminal background checks were completed on all employees having patient contact or access to patient records for 1 (Staff D) of 1 employee files and 2 (Vol 1 and 2) of 2 volunteer files. The failure of the hospice to obtain criminal background checks has the potential to affect the safety of all patients receiving services from the hospice. Findings Include: Review of hospice policy titled, “;Criminal Background Checks”, dated 2016, showed hospice will obtain a criminal background check on all hospice employees who have direct patient contact or access to patient records. Review of personnel and volunteer files for Staff D, Volunteer 1 and Volunteer 2 showed a criminal background check had not been obtained and documented in the files. During an interview on 11/29/23 at 11:40 AM, Staff I, HR Manager, confirmed there was no background check obtained for Staff D and that the volunteer coordinator was responsible for the criminal background checks on all volunteers. During an interview on 11/29/23 at 12:04 PM, Staff B, Administrator confirmed the hospice did not obtain criminal background checks for the identified staff and volunteers.”