Kansas Palliative & Hospice Care

“Based on policy review, record review, observation, and interview, the Hospice Agency (HA) failed to develop an individualized written plan of care (POC) that reflected problems, goals, and interventions identified in the comprehensive assessments for 8 (Patients 2, 3, 6, 8, 10, 11, 13 and 14) of 14 patients reviewed. Failure to ensure that each written POC included problems, goals, and interventions identified in the comprehensive assessment, places patients at risk for unmet needs and progress towards desired goals. Findings Include: Review of HA policy titled, “INTERDISCIPLINARY TEAM PLAN OF CARE,” last revised 10/06/15, showed “At the time of initial assessment, the admitting RN and one other interdisciplinary team member develops a plan of care based upon the patients identified needs. ... The interdisciplinary team reviews and revises the plan of care as frequently as deemed necessary but at a minimum of every 15 days. ... A comprehensive review of the plan of care is done when based on significant changes, at the end of a certification period or at least every 90 days, ... The interdisciplinary team conducts ongoing assessments of the patient, family or caregiver. ... The plan of care will include: Nursing assessments and plans for interventions and expected outcomes ... The medication profile and plans for interventions and expected outcomes ... procedures to protect the patient from accident, injury and infection.” Review of the HA policy titled, “HOSPICE AIDE SERVICES,” last revised 10/06/15, showed, “The Kansas Hospice Care RN Case Manager arranges for Hospice Aide services and develops and supervises the HHAs assignments. ... The clinical record, developed by the Kansas Hospice Care RN Case Manager, contains the Hospice Aides assignment, plans of care, and interventions.” Patient 2 Review of Patient 2’s record showed an admission date of 12/28/23 with a primary diagnosis of malignant neoplasm of the prostate (prostate cancer) with additional diagnosis of essential primary hypertension (high blood pressure), and hyperlipidemia (abnormally high levels of fat in the blood.) Review of Patient 2’s record showed a POC beginning on 06/25/24 that showed a Certified Home Health Aide (CHHA) visit frequency of one time weekly for two weeks ending on 07/06/24, then increasing to two times weekly for seven weeks. The POC showed a CHHA care plan problem and goal to maintain personal hygiene. The POC did not have documented interventions or tasks for the CHHA to perform during visits Observation made during a home visit for Patient 2, on 07/16/24 at 12:00 PM, showed, Staff D, CHHA, assisted Patient 2 during a shower with washing his back and helping with clothing selection. When reviewing the POC, Staff D, CHHA, stated that there were no interventions written on Patient 2’s POC when reviewing it. Staff D, CHHA stated that at the end of the visit, a phone call to Patient 2’s Registered Nurse Case Manager (RNCM) would be performed to get an updated CHHA POC. Patient 3 Review of Patient 3’s record showed an admission date of 05/23/24 with a primary diagnosis of Unspecified systolic congestive heart failure (a progressive heart disease that affects pumping action of the heart) with additional diagnosis of acute kidney failure, and atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (a condition where the arteries become clogged and hardened due to a buildup of fats with chest pain.) Further review of Patient 3’s record showed a fall that occurred on 06/29/24 resulted in a laceration and hematoma to the left temple. Review of the POC found no new interventions or goals under the, “;Fall Prevention Protocol” problem after the fall occurred. No problems, goals, or interventions regarding the wound care or facility ordered Physical Therapy (PT) were documented on the POC. Observation made during a home visit for Patient 3, on 07/16/24 at 1:05 PM, showed, Staff B, Medical Social Worker (MSW), asked Patient 3 about a wound on the left temple. Patient 3 stated, “I fell in the bathroom a week or two ago and hit my head.” Patient 3 had a noted hematoma to the left temple approximately 2 cm in diameter with several Steri-Strips (adhesive strips to seal two sides of skin together) over the site. During the visit with Patient 3, an unidentified Physical Therapist (PT) from the facility entered the room and stated, “I am from PT here for your treatment but it looks like you have visitors so I will come back in a little bit.” No problems, goals, or interventions regarding the wound care or facility ordered Physical Therapy (PT) were documented on the POC. During an interview on 07/18/24, at 2:00 PM, Staff A, Administrator (AD), stated that Patient 3s facility staff confirmed that PT treatments are being done, and the treatments would need to be reviewed to see if they were for covered from hospice. Patient 6 Review of Patient 6’s record showed an admission date of 04/05/23 with a primary diagnosis of cerebral infarction (a stroke causing poor blood flow to the brain causing cell death) with additional diagnosis of essential primary hypertension (high blood pressure), and dysphagia (difficulty swallowing.) Review of Patient 6’s record showed the antibiotic Macrobid was started on 03/11/24 for a urinary tract infection (UTI). The antibiotic Ciprofloxacin was started on 06/13/24 with no documented diagnosis or reason for use. No problems, goals or interventions regarding the antibiotics or infection were documented on the POC. Review of Patient 6’s record showed a fall occurred on 04/21/24. No problems, goals, or interventions regarding the fall were documented on the POC. Patient 8 Review of Patient 8’s record showed an admission date of 12/11/23 with a primary diagnosis of senile degeneration of the brain (a state of mental, emotional, and social deterioration of brain) with additional diagnosis of essential primary hypertension (high blood pressure), chronic kidney disease stage 3, and depression (a mood disorder causing a persistent feeling of sadness and loss of interest.) Review of Patient 8’s record showed a fall occurred on 05/11/24 with a facial laceration and a visit to the emergency room. No problems, goals, or interventions were documented regarding the fall, wound, or wound care on the POC. Patient 10 Review of Patient 10’s record showed an admission date of 02/23/24 with a primary diagnosis of chronic lymphocytic leukemia of B-cell type (blood and bone marrow cancer) with additional diagnosis of essential primary hypertension (high blood pressure), syncope (fainting) heart failure, and edema (fluid retention.) Review of Patient 10’s record showed the antibiotic Macrobid was started on 02/23/24, 03/31/24, and 04/02/24. No problems, goals or interventions regarding the antibiotic or infection were documented on the POC. Patient 11 Review of Patient 11’s record showed an admission date of 08/30/23 with a primary diagnosis of malignant neoplasm of the rectum (rectal cancer) with additional diagnosis of secondary malignant neoplasm of liver and intrahepatic bile duct (liver cancer), and severe protein-calorie malnutrition (poor diet causing weight loss.) Review of Patient 11’s record showed the antibiotic Keflex was started on 09/05/24. No problems, goals, and interventions regarding the antibiotic or infection was documented on the POC. Patient 13 Review of Patient 13’s record showed an admission date of 03/29/24 with a primary diagnosis of osteomyelitis (infection of the bone) with additional diagnosis of peripheral vascular disease (a disorder of the blood vessels outside of the heart), sepsis (a blood infection), and diabetes mellitus (a condition of poor insulin production causing high blood sugar.) Review of Patient 13’s record showed the antibiotic Cefdinir started on 03/30/24, with no documented diagnosis or reason for use. The antibiotic Clindamycin was started on 03/30/24 for sepsis. No problems, goals, and interventions regarding either antibiotic or infection was documented on the POC. Patient 14 Review of Patient 14’s record showed an admission date of 08/09/23 with a primary diagnosis of Parkinsons Disease (a progressive neurological disorder causing movement problems) with additional diagnosis of hyperlipidemia (abnormally high levels of fat in the blood), essential primary hypertension (high blood pressure), and gastroesophageal reflux disease (stomach acid flowing repeatedly back into the esophagus.) Review of Patient 14’s record showed the antibiotic Amoxicillin started on 09/16/23, with no listed diagnosis or reason for use. No problems, goals, and interventions regarding the antibiotic or infection shown on the POC. During an interview on 07/18/24, at 1:30 PM, Staff E, Compliance Officer (CO), stated that each patient should have a comprehensive care plan that reflects any problems, goals, and interventions needed. Staff E, CO, stated that the RNCM, MSW, and Chaplain (CH) are responsible for creating and updating each patients POC. Staff E, CO, stated that routine audits are performed on several patients every month to ensure accuracy, and the Clinical Director (CD) also reviews every patient on service for accurate charting. Staff E, CO, stated when any errors or missing documentation is found, the protocol of the HA is to contact the staff who made the error and correct it as soon as possible. Staff E, CO, stated that incidents, infections, wounds, and falls are routinely tracked and should be reflected on each patients individualized POC.”

“Based on observation, policy review, record review, and interview, the Hospice Agency (HA) failed to ensure that the plan of care (POC) include all drugs and treatments necessary to meet the needs of 2 (Patient 2 and 3) of 14 sample patients. Failure to ensure all medications are on the POC places patients at risk for potential adverse effects, ineffective medication therapy, medication to medication interaction, medication duplication, and ineffective goal and symptom management. Findings Include: Review of HA policy titled, “INTERDISCIPLINARY TEAM PLAN OF CARE,” last revised 10/06/15, showed, “At the time of initial assessment, the admitting RN and one other interdisciplinary team member develops a plan of care based upon the patients identified needs. ... The interdisciplinary team reviews and revises the plan of care as frequently as deemed necessary but at a minimum of every 15 days. ... A comprehensive review of the plan of care is done when based on significant changes, at the end of a certification period or at least every 90 days, ... The interdisciplinary team conducts ongoing assessments of the patient, family or caregiver. ... The plan of care will include: Nursing assessments and plans for interventions and expected outcomes ... The medication profile and plans for interventions and expected outcomes ... procedures to protect the patient from accident, injury and infection.” Review of HA policy titled, “HOSPICE MEDICATION OVERSIGHT,” last revised 09/01/18, showed, “Hospice medication oversight resources shall take an active role in proactively putting policies and procedures in place that mitigate the likelihood of medication errors. ... Medication Oversight shall be conducted by the Medical Director, Clinical Director, and the Pharmacy Benefit Management (PBM) Organization. ... The Pharmacy Benefit Management Organization will provide a review and evaluation of the patients medication list at the time of admission, and with each change in the medications administered to the patient at a minimum of every two weeks. ... The RN Case Manager will generate a Drug to Drug interaction Report ... at the start of care and with each the [sic] addition of new medications.” Patient 2 Review of Patient 2’s record showed an admission date of 12/28/23 with a primary diagnosis of malignant neoplasm of the prostate (prostate cancer) with additional diagnosis of essential primary hypertension (high blood pressure), and hyperlipidemia (abnormally high levels of fat in the blood.) Review of Patient 2’s record showed a plan of care (POC) with medication order that stated, “Voltaren Arthritis Pain External Gel 1% ... Apply 1 application to L shoulder twice daily as needed for arthritis pain greater than 1/10.” Patient 2’s facility medical record (FMR) showed “DICLOFENAC GEL 1% ... APPLY EVERY DAY ON LOWER BACK FOR PAIN.” Review of Patient 2s record showed a POC with order that stated, “;Ondansetron by Mouth Tablet Disintegrating 4 MG ... Dissolve 1 tablet under the tongue every 6 hours as needed for nausea.” Review of Patient 2s FMR showed no order for Ondansetron. Review of Patient 2’s record showed a POC with medication order that stated, “Acetaminophen By Mouth Tablet 325 MG ... Take 1 tablet every 6 hours as needed for generalized pain greater than 2/10.” Review of Patient 2’s FMR showed “ACETAMIN TAB 325MG ... TAKE 1 TABLET BY MOUTH TWICE DAILY – NOT TO EXCEED 3GM APAP IN ALL MEDS IN 24 HOURS; TAKE 1 TABLET BY MOUTH TWICE DAILY AS NEEDED FOR PAIN.” Review of Patient 2’s record showed a POC with medication order that stated, “Tramadol HCl By Mouth Tablet 50 MG ... 1-2 tablets every 6 hours PO ... Take 1 tablet every 6 hours for generalized pain greater than 3/10 on pain scale.” Review of the Patient 2’s FMR showed no order for Tramadol. Review of Patient 2’s record showed a POC with medication order that stated, “Senexon-S By Mouth Tablet 8.6-50 MG ... Take 2 tablets twice a day as needed for constipation.” Review of the Patient 2s FMR showed no order for Senexon-S. Review of Patient 2’s record showed a POC with medication order that stated, “MiraLAX by Mouth Powder 17 GM/SCOOP ... 17gm/1 scoop Gram daily PO ... Mix 17gm/1 scoop into 8 oz of water or juice. Take daily as needed for constipation.” Review of the Patient 2’s FMR showed no order for MiraLAX. Observation made during a home visit for Patient 2 on 07/16/24 at 12:00 PM, showed a review of the FMR with the facility medication aide that confirmed four medications were not listed and dosages of two medications did not match that of the HA provided POC and medication list. Discussion of HA communication and facility staff conducted with the facility Director of Nursing (DON) and facility nurse. The facility staff stated that when a new patient was admitted to the facility, the HA sends any orders and a POC for the facility staff to follow and then places it in the patient communication book. No evidence of order changes confirmed in Patient 2s communication book upon review. No evidence of hospice aide visit notes was confirmed within the communication book. Patient 3 Review of Patient 3’s record showed an admission date of 05/23/24 with a primary diagnosis of unspecified systolic congestive heart failure (a progressive heart disease that affects pumping action of the heart) with additional diagnosis of acute kidney failure, and atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (a condition where the arteries become clogged and hardened due to a buildup of fats with chest pain.) Review of Patient 3’s record showed a POC with medication order that stated, “CVS Lubricant Eye Drops Ophthalmic Solution 0.25% ... 1 Drop daily OP ... PRN dry eyes.” Review of Patient 3’s FMR showed no order for lubricant eye drops. Review of Patient 3’s record showed a POC with medication order that stated, “MiraLAX by Mouth Packet 17 GM ... 17 Gram daily PO ... PRN CONSTIPATION.” Review of Patient 3’s FMR showed “POLYETH GLYC POW 3350 NF – Give 17GM/SCOOP Powder by mouth One time per day Every week on Monday, Wednesday, Friday at AM. MIX 17G (1 CAPFUL) OF POWDER IN 6-8 OUNCES OF JUICE OR WATER & DRINK EVERY OTHER DAY.” Review of Patient 3’s FMR showed “ESCITALOPRAM TAB 5MG – Give 5 MG Tablet by mouth One time per day Every day at AM. TAKE 1 TABLET BY MOUTH ONE DAILY.” Review of Patient 3s record showed no order for escitalopram on the POC. Review of Patient 3’s FMR showed “MELATONIN TAB 3MG – Give 3MG Tablet by mouth One Time Per Day at Bedtime Every day at Bedtime.” Review of Patient 3’s record showed no order for melatonin. Review of Patient 3’s FMR showed “MILK OF MAGN SUS – Give 7.75% Suspension by mouth as Needed. GIVE 30ML BY MOUTH DAILY AS NEEDED FOR CONSTIPATION.” Review of Patient 3s record showed no order for milk of magnesia. Observation made during a home visit for Patient 3 on 07/16/24 at 1:05 PM, showed a review of the FMR conducted with the facility nurse that confirmed three medications were not listed and dosages of one medication did not match that of the HA provided POC and medication list. The POC and medication list provided by the HA showed one medication not listed on the FMR. Discussion of HA communication and facility staff was conducted with facility nurse. The facility nurse stated that any orders received from the HA or the primary care physician are entered in the patient’s FMR and placed in the patient communication book. No evidence of order changes were confirmed in Patient 3s communication book. During an interview on 07/18/24, at 1:30 PM, Staff E, Compliance Officer (CO), stated that each patient should have a comprehensive care plan that reflects all medications they are prescribed accurately including the dosage, the route, the frequency, and the reason they are prescribed. Staff E, CO, stated that the Registered Nurse Case Manager (RNCM) assigned to the patient is responsible for entry of the medication list at admission and updating each patients medication list with any changes. Staff E, CO, stated that every patient residing at a facilitys RNCM should be checking in routinely with facility staff for updates on the patient, new orders, and medication changes. Staff E, CO, also stated that any medication changes performed by hospice should be faxed to facility staff. Staff E, CO stated that routine monthly audits are performed on several patients of the HA to ensure accuracy of medication entry and changes. Staff E, CO, stated when any missed medications or medication errors are found, the protocol of the HA is to contact the RNCM to correct it as soon as possible. Staff E, CO, stated that incidents, infections, wounds, and falls are routinely tracked and should be reflected on each patients individualized POC.”

“Based on policy review, record review, and staff interview, the Hospice Agency (HA) failed to ensure that care and services are provided in accordance with the plan of care (POC) for 6 (Patients 2, 3, 6, 7, 12, and 13) of 14 patients reviewed. The Hospice’s failure to ensure care and services were provided in accordance with the POC has potential for failure to ensure optimal management of needs and progress towards desired goals of the hospice patient. Findings Include: Review of HA policy titled, “INTERDISCIPLINARY TEAM PLAN OF CARE,” last revised 10/06/15, showed “At the time of initial assessment, the admitting RN and one other interdisciplinary team member develops a plan of care based upon the patients identified needs. ... The interdisciplinary team reviews and revises the plan of care as frequently as deemed necessary but at a minimum of every 15 days. ... A comprehensive review of the plan of care is done when based on significant changes, at the end of a certification period or at least every 90 days, ... The interdisciplinary team conducts ongoing assessments of the patient, family or caregiver. ... The plan of care will include: Nursing assessments and plans for interventions and expected outcomes ... The medication profile and plans for interventions and expected outcomes ... procedures to protect the patient from accident, injury and infection”. Review of the HA policy titled, “HOSPICE AIDE SERVICES,” last revised 10/06/15, showed, “The Kansas Hospice Care RN Case Manager arranges for Hospice Aide services and develops and supervises the HHAs assignments. ... The clinical record, developed by the Kansas Hospice Care RN Case Manager, contains the Hospice Aide’s assignment, plans of care, and interventions.” Review of the HA policy titled, “SKILLED NURSING AND HOSPICE AIDE VISIT FREQUENCY,” last revised 09/01/2014, showed the Kansas Hospice RN will determine the frequency of skilled nursing and hospice aide visits following the completion of a comprehensive assessment of the patient.” Review of the HA policy titled, “PSYCHOSOCIAL SERVICES,” last revised 09/01/14, showed, “The following guidelines for Social Worker visits may be used: ... Monthly Visits With a Phone Check In-Between: ... Patient/caregiver/family decline services but have needs as assessed by the team. Visit monthly if they will allow it, to assess and attempt to facilitate and alliance.” The HA policy failed to specify if a monthly visit is measured by days or the written calendar month. Patient 2 Review of Patient 2’s record showed an admission date of 12/28/23 with a primary diagnosis of malignant neoplasm of the prostate (prostate cancer) with additional diagnosis of essential primary hypertension (high blood pressure), and hyperlipidemia (abnormally high levels of fat in the blood.) Review of Patient 2’s record showed the POC dated 12/28/23 and 03/27/24, with Skilled Nursing (SN) visits two times weekly for 13 weeks. The record showed one SN visit documented as performed the week of 3/24/24. Patient 3 Review of Patient 3’s record showed an admission date of 05/23/24 with a primary diagnosis of Unspecified systolic congestive heart failure (a progressive heart disease that affects pumping action of the heart) with additional diagnosis of acute kidney failure, and atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (a condition where the arteries become clogged and hardened due to a buildup of fats with chest pain.) Review of Patient 3’s record showed a POC dated 05/23/24, with Certified Home Health Aide (CHHA) visits two times weekly for 12 weeks starting on 05/26/24. A frequency change order for the CHHA was noted on 06/16/24 decreasing the CHHA visits to one time weekly for 8 weeks. The record showed one CHHA visit documented the week of 6/9/24. The visits made on the weeks of 6/23/24, 6/30/24, and 7/7/24 were greater than the ordered CHHA frequency on the POC. Patient 6 Review of Patient 6’s record showed an admission date of 04/05/23 with a primary diagnosis of cerebral infarction (a stroke causing poor blood flow to the brain causing cell death) with additional diagnosis of essential primary hypertension (high blood pressure), and dysphagia (difficulty swallowing.) Review of Patient 6’s record showed on the POC dated 03/31/24, CHHA visits two times weekly for eight weeks. The record showed one CHHA visit was documented the week of 05/05/24. Patient 7 Review of Patient 7’s record showed an admission date of 12/23/22 with a primary diagnosis of senile degeneration of the brain (a state of mental, emotional, and social deterioration of brain) with additional diagnosis of unspecified dementia (memory loss) without behavioral disturbance, and schizophrenia (a mental disorder causing delusions, hallucinations, and disorganized thoughts.) Review of Patient 7s record showed the POC dated 04/16/24, with SN visits one time weekly for nine weeks. The record showed no SN visit documented the week of 05/05/24. Patient 12 Review of Patient 12’s record showed an admission date of 08/25/23 with a primary diagnosis of neurocognitive disorder with Lewy bodies (a progressive brain disorder of memory loss caused by protein deposits on nerve cells in the brain) with additional diagnosis of cardiomyopathy (a disease of the heart muscle causing difficulty with the pumping of blood to the body), and adult failure to thrive (a decline in mental and physical wellbeing.) Review of Patient 12’s record showed the POC dated 08/25/24, with CHHA visits two times weekly starting 08/27/24. The record showed no CHHA visits were documented for the week of 08/27/23 or 09/03/23. Patient 13 Review of Patient 13s record showed an admission date of 03/29/24 with a primary diagnosis of osteomyelitis (infection of the bone) with additional diagnosis of peripheral vascular disease (a disorder of the blood vessels outside of the heart), sepsis (a blood infection), and diabetes mellitus (a condition of poor insulin production causing high blood sugar.) Review of Patient 13’s record showed a POC dated 03/29/24, with SN visits one time weekly for 13 weeks. A frequency change order for the SN was noted on 04/08/24 that showed visits one time weekly for one week. Another frequency change order for the SN was noted on 04/14/24 that showed SN visits two times weekly for 11 weeks. Another frequency change order for the SN was noted on 05/05/24 that showed SN visit two times weekly for seven weeks. the record showed one SN visit was documented for the week of 5/12/24. Review of Patient 13’s record showed a POC dated 03/29/24, with Medical Social Worker (MSW) visits ordered one time monthly for three months. The initial MSW visit was performed on 04/01/24 and subsequent visit performed on 05/20/24 with a distance between visits of 49 days. During an interview on 07/18/24, at 1:30 PM, Staff E, Compliance Officer (CO), stated that patient visit frequencies are determined by the skilled service, based on the assessed patient needs. Staff E, CO stated that the Registered Nurse Case Manager (RNCM) is responsible for obtaining orders and updating frequency changes for patients. Staff E, CO, stated that the policy titled, “PSYCHOSOCIAL SERVICES,” does not specify if a 1-month frequency was measured by days or the actual calendar month. Staff E, CO, stated that the expectation of a monthly visit would fall within a 31-day window to ensure adequate management of a patient. Staff E, CO, stated that a 49-day period between visits on any patient is too long of a period between visits for a monthly frequency.”

“Based on policy review, record review, observation and interview, the Hospice Agency (HA) failed to maintain a system of communication to provide for ongoing sharing of information with other non-hospice healthcare providers furnishing services for 2 (Patient 2 and 3) of 14 sample patients. Failure to ensure ongoing communication with patients’ healthcare providers places patients at risk for unmanaged symptoms and unmet care needs. Findings Include: Review of the HA policy titled, “;PROVIDING HOSPICE CARE FOR PATIENT/RESIDENT OF CONTRACTED FACILITY,” last revised 10/16/15, showed, “;When Kansas Hospice Care provides services to a hospice patient who is a resident of a licensed nursing home, licensed intermediate care home, or licensed personal care home, there shall be written communication evidencing agreement that specifies that Kansas Hospice Care assumes responsibility for overall professional management of the hospice services provided in accordance with the hospice plan of care and the hospice conditions of participation. ... to facilitate collaboration the facility staff need to: Notify Kansas Hospice Care in the event of ... changes in medical orders/medications, ... To facilitate collaboration, Kansas Hospice Care staff need to: ... assume professional management in collaboration with the contracted facility ... Kansas Hospice Care RN Case Manager assigned to the patient ... Reports to the facility charge nurse prior to giving care or before leaving the unit and requesting changes in orders as needed... reviews the medical record for new and changed orders.” Patient 2 Review of Patient 2s record showed an admission date of 12/28/23 with a primary diagnosis of malignant neoplasm of the prostate (prostate cancer) with additional diagnosis of essential primary hypertension (high blood pressure), and hyperlipidemia (abnormally high levels of fat in the blood.) Further review of Patient 2s record showed a plan of care (POC) with medication order that stated, “;Voltaren Arthritis Pain External Gel 1% ... Apply 1 application to L shoulder twice daily as needed for arthritis pain greater than 1/10.” Patient 2s facility medical record (FMR) showed, “;DICLOFENAC GEL 1% ... APPLY EVERY DAY ON LOWER BACK FOR PAIN.” Further review of Patient 2s record showed a POC with medication order that stated, “;Ondansetron by Mouth Tablet Disintegrating 4 MG ... Dissolve 1 tablet under the tongue every 6 hours as needed for nausea.” Review of Patient 2s FMR showed no order for Ondansetron. Further review of Patient 2s record showed a POC with medication order that stated, “;Acetaminophen By Mouth Tablet 325 MG ... Take 1 tablet every 6 hours as needed for generalized pain greater than 2/10.” Review of Patient 2s FMR showed “;ACETAMIN TAB 325MG ... TAKE 1 TABLET BY MOUTH TWICE DAILY – NOT TO EXCEED 3GM APAP IN ALL MEDS IN 24 HOURS; TAKE 1 TABLET BY MOUTH TWICE DAILY AS NEEDED FOR PAIN.” Further review of Patient 2s record showed a POC with medication order that stated, “;Tramadol HCl By Mouth Tablet 50 MG ... 1-2 tablets every 6 hours PO ... Take 1 tablet every 6 hours for generalized pain greater than 3/10 on pain scale.” Review of the Patient 2s FMR showed no order for Tramadol. Further review of Patient 2s record showed a POC with medication order that stated, “;Senexon-S By Mouth Tablet 8.6-50 MG ... Take 2 tablets twice a day as needed for constipation.” Review of the Patient 2s FMR showed no order for Senexon-S. Further review of Patient 2s record showed a POC with medication order that stated, “;MiraLAX By Mouth Powder 17 GM/SCOOP ... 17gm/1 scoop Gram daily PO ... Mix 17gm/1 scoop into 8 oz of water or juice. Take daily as needed for constipation.” Review of the Patient 2s FMR showed no order for MiraLAX. Patient 3 Review of Patient 3s record showed an admission date of 05/23/24 with a primary diagnosis of unspecified systolic congestive heart failure (a progressive heart disease that affects pumping action of the heart) with additional diagnosis of acute kidney failure, and atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (a condition where the arteries become clogged and hardened due to a buildup of fats with chest pain.) Further review of Patient 3s record showed a POC with medication order that stated, “;CVS Lubricant Eye Drops Ophthalmic Solution 0.25% ... 1 Drop daily OP ... PRN (as needed) dry eyes.” Review of Patient 3s FMR showed no order for lubricant eye drops. Further review of Patient 3s record showed a POC with medication order that stated, “;MiraLax By Mouth Packet 17 GM ... 17 Gram daily PO ... PRN (as needed) CONSTIPATION.” Review of Patient 3s FMR showed “;POLYETH GLYC POW 3350 NF – Give 17GM/SCOOP Powder by mouth One time per day Every week on Monday, Wednesday, Friday at AM. MIX 17G (1 CAPFUL) OF POWDER IN 6-8 OUNCES OF JUICE OR WATER & DRINK EVERY OTHER DAY.” Further review of Patient 3s FMR showed, “;ESCITALOPRAM TAB 5MG – Give 5 MG Tablet by mouth One time per day Every day at AM. TAKE 1 TABLET BY MOUTH ONE DAILY.” Review of Patient 3s record showed no order for escitalopram on the POC. Further review of Patient 3s FMR showed, “;MELATONIN TAB 3MG – Give 3MG Tablet by mouth One Time Per Day at Bedtime Every day at Bedtime.” Review of Patient 3s record showed no order for melatonin. Further review of Patient 3s FMR showed, “;MILK OF MAGN SUS – Give 7.75% Suspension by mouth as Needed. GIVE 30ML BY MOUTH DAILY AS NEEDED FOR CONSTIPATION.” Review of Patient 3s record showed no order for milk of magnesia. Observation made during a home visit for Patient 2 on 07/16/24 at 12:00 PM, showed a review of the FMR with the facility medication aide that confirmed four medications were not listed and dosages of two medications did not match that of the HA provided POC and medication list. Discussion of HA communication and facility staff conducted with the facility Director of Nursing (DON) and facility nurse. The facility staff stated that when a new patient was admitted to the facility, the HA sends any orders and a POC for the facility staff to follow and then places it in the patient communication book. No evidence of order changes were confirmed in Patient 2s communication book upon review. No evidence of hospice aide visit notes were confirmed within the communication book. Observation made during a home visit for Patient 3 on 07/16/24 at 1:05 PM, showed a review of FMR with the facility nurse and confirmed three medications were not listed and dosages of one medication did not match that of the HA provided POC and medication list. The POC and medication list provided by the HA showed one medication not listed on the FMR. Discussion of HA communication and facility staff conducted with the facility nurse. The facility nurse stated that any orders received from the HA or the primary care physician are entered in the patient’s FMR and placed in the patient communication book. No evidence of order changes were confirmed in Patient 3s communication book. During an interview on 07/16/24 at 12:00 pm, Staff D, Certified Home Hospice Aide (CHHA), stated that Patient 2 was newly assigned. Staff D, CHHA, also stated unfamiliarity with the facility protocol as it is not one the HA has had patients in before. Staff D, CHHA, confirmed being unsure of the communication process with the facility but would check in with the front desk prior to leaving and contact the hospice nurse with any concerns. During an interview on 07/16/24 at 4:30 pm, Staff E, Compliance Officer (CO), stated that communication with facilities should occur for each patient with any order changes and should be communicated between the Registered Nurse Case Manager (RNCM) and the facility nurse. Staff E, CO, stated that communication logs should be utilized by all the HA staff for any visits and order updates. Staff E, CO stated that they would be reviewing the communication process that is being performed and determine what happened.”

“Based on record review, policy review, and interview the Hospice Agency (HA) failed to ensure hospice aide supervisory visits were completed no less than every 14 days by a registered nurse (RN) for 1 (Patient 14) of 14 sample patients. Failure to complete supervisory visits of certified home hospice aide (CHHA) services has the potential to place patients at risk for inadequate quality of care to meet the changing needs of the patient. Findings Include: Review of the HA policy titled, “;HOSPICE AIDE SERVICES,” last reviewed date of 10/06/15 showed, “;The Kansas Hospice Care RN Case Manager arranges for Hospice Aide services and develops and supervises the HHAs assignments. The clinical record, developed by the Kansas Hospice Care RN Case Manager, contains the Hospice Aides assignment, plans of care, and interventions. ... The Kansas Hospice Care RN Case Manager assigns and supervises the Hospice Aide.” The HA policy did not show a frequency for the supervisory visits of the Certified Home Health Aide (CHHA.) Review of Patient 14s record showed an admission date of 08/09/23 with a primary diagnosis of Parkinsons Disease (a progressive neurological disorder causing movement problems) with additional diagnosis of hyperlipidemia (abnormally high levels of fat in the blood), essential primary hypertension (high blood pressure), and gastroesophageal reflux disease (stomach acid flowing repeatedly back into the esophagus.) Patient 14s plan of care (POC) dated 08/09/23 showed a CHHA visit frequency of one time weekly for one week then increased to two times weekly for 12 weeks. Further review of Patient 14s record showed an RN supervisory visit performed on 08/24/23 and a subsequent RN supervisory visit performed on 09/14/24 that confirmed a gap of 21 days between RN supervisory visits for the CHHA. During an interview on 07/18/24 at 2:00 PM, Staff E, Compliance Officer (CO), stated after review of Patient 14s chart, no supervisory visit for the CHHA was found between 08/24/23 and 09/14/23. Staff E, CO, stated that a supervisory visit is to be performed by the RN case manager at least every 14 days.”

“Based on document review and interview the Hospice Agency (HA) failed to ensure volunteers provided a day-to-day administrative and/or direct patient care in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff. Failure of the HA to provide adequate volunteer care does not allow for increased quality of care and effective cost saving measures. Findings Include: Review of the HA performance improvement document titled, “;Volunteer Program Performance Improvement Plan,” dated 05/13/24, showed, “;Office fell short of meeting 5% match in 2023 and is needing to grow efforts to meet or exceed this percentage for 2024. Root Cause Evaluation: Turnover in this role and changes in ownership. Action Steps: ... Create, Apply, and Pursue New and Existing Ways to Recruit and retain Volunteers. ... Timeframe: 5/13/24-12/31/24.” Review of the HA document titled, “;Volunteer Program – 2023,” showed, “;Employee Direct Pt Care ... Total Hours 7854.80 ... Volunteer Total Hrs ... Total Hours ... 309.48 ... Volunteer % Total ... 3.94%.” Review of the HA document titled, Volunteer Program – 2024,” showed, “;Employee Direct Pt Care ... Total Hours 4126.06 ... Volunteer Total Hrs ... Total Hours ... 100.28 ... Volunteer % ... January 3.48% ... February 1.76% ... March 4.01% ... April 1.97% ... May 1.11% ... June 2.15% ... Total ... 2.41%.” During an interview on 07/17/24 at 2:00 PM, Staff F, Volunteer Coordinator (VC), stated that there are currently nine volunteers performing direct and indirect duties. Staff F, VC, stated that current total hours for 2024 are below the 5 percent total care goal for the program. Staff F, VC stated that current volunteer recruitment efforts are increasing for additional volunteer recruitment with one new volunteer currently undergoing the background check.”

“Based on record review, policy review, and interview the Hospice Agency (HA) failed to ensure nursing services be made routinely available on a 24-hour basis 7-days a week for 3 (Patient 6, 7, and 8) of 14 patients reviewed. Failure to ensure nursing services are routinely available on a 24-hour basis, 7-days a week places all hospice patients at risk for unmet care needs and unmanaged symptoms. Findings Include: Review of the HA policy titled, “;ON-CALL SERVICES,” showed, “;Kansas Palliative & Hospice Care provides on-call coverage ... operators will pass on every call to the designated nurse on-call. The nurse responds to the call and when needed provides a home visit. ... On-call guidelines: This list guides the on-call nurse. It is not an exhaustive list but includes many problems that may require a visit from a Hospice nurse ... Report of a patient falling.” Patient 6 Review of Patient 6s record showed an admission date of 04/05/23 with a primary diagnosis of cerebral infarction (a stroke causing poor blood flow to the brain causing cell death) with additional diagnosis of essential primary hypertension (high blood pressure), and dysphagia (difficulty swallowing.) Further review of Patient 6s record showed a fall that occurred on 04/21/24. The on-call triage note from Skilled Nursing (SN) dated 04/21/24 stated Patient 6 sustained a fall and confirmed no follow up visit from the on-call SN was documented. Patient 7 Review of Patient 7s record showed an admission date of 12/23/22 with a primary diagnosis of senile degeneration of the brain (a state of mental, emotional, and social deterioration of brain) and additional diagnosis of unspecified dementia (memory loss) without behavioral disturbance, and schizophrenia (a mental disorder causing delusions, hallucinations, and disorganized thoughts.) Further review of Patient 7s record showed a fall that occurred on 04/21/24 that resulted in an x-ray for potential injury. The on-call triage notes from Skilled Nurse (SN) dated 04/21/24 confirmed a follow up visit was to be made. There was no documentation to support an on-call follow up visit was completed on 04/21/24. Patient 8 Review of Patient 8s record showed an admission date of 12/11/23 with a primary diagnosis of senile degeneration of the brain (a state of mental, emotional, and social deterioration of brain) with additional diagnosis of essential primary hypertension (high blood pressure), chronic kidney disease stage 3, and depression (a mood disorder causing a persistent feeling of sadness and loss of interest.) Further review of Patient 8s record showed a SN on-call triage note with report of a fall that occurred on 5/11/24 and patient was sent to the emergency room (ER) with a facial laceration. There was no documentation to support an on-call follow up visit was completed on 05/11/24. During an interview on 07/18/24 at 2:00 PM, Staff E, Compliance Officer (CO), stated that the policy of the HA is to make an on-call visit with any significant injury, complaint, or concern that a patient or caregiver reports. Staff E, CO, stated that a fall with suspected or confirmed injury, as reported on Patient 7 and Patient 8, should receive an on-call visit. Staff E, CO stated that an investigation into the on-call services provided on 04/21/24 and 5/11/24 would be reviewed and followed up with discussions with the on-call nursing staff.”