Interim Health Care of Topeka

“Based on review of the Emergency Preparedness Plan (EPP) and interview, the Hospice failed to maintain an EPP that includes a documented, facility-based, and community-based risk assessment updated at least every 2 years. Failure to routinely update the risk assessment places patients at risk for harm or injury during an emergency. Findings Include: Review of the Hospice EPP showed the “Hazards Vulnerability Planning Priorities” and the “All-Hazards Vulnerability Analysis” documents were last updated on 03/06/2020. During an interview on 03/26/25 at 11:00 AM, Staff B, Administrator stated that a yearly review of the risk assessment is performed and if no changes have occurred then the risk assessment remains unchanged until the next review.”

“Based on review of the Emergency Preparedness Plan (EPP) and interview, the Hospice failed to ensure the EPP included a complete list of the names and contact information for the staff and other hospices. Failure to ensure a comprehensive list of contacts places patients at risk for unmet care needs during an emergency. Findings Include: Review of the Hospice EPP showed no contact list for hospice staff and other regional hospices. During an interview on 03/26/25 at 11:00 AM, Staff B, Administrator, stated that when the EPP is activated the staff is contacted by phone and the call tree is activated and staff are contacted at that time. Staff B, Administrator, stated that the EPP plan and contact list is reviewed and updated yearly with any changes.”

“Based on policy review, record review, and interview, the Hospice failed to ensure the plan of care (POC) included a complete and accurate list of medications for 2 patients (Patient 6 and 12) of 19 patients sampled. Failure to provide an accurate medication list on the plan of care (POC) places the patient at risk for unmanaged symptoms and poor quality of life. Findings Include: Review of the Hospice policy titled “Drugs and Biologicals – Administration, Use, and Disposal” last dated 06/08/21, showed “The designated RN is responsible for verifying any changes in medication, dose, frequency or route with the patient’s attending physician, if any, or the Hospice Medical Director or physician designee and obtaining appropriate revised physician orders … The medication profile is updated with any medication changes.” Review of the Hospice policy titled “Interdisciplinary Group Plan of Care” last dated 06/21/13, showed “The plan of care includes, but is not limited to the following: … Drugs and treatment, medical supplies and medical appliances necessary to meet the needs of the patient … The documented review and revision of the IDG plan of care occurs at least every 15 calendar days or as required by the patient’s condition …” Patient 6 Review of Patient 6’s medical record showed an 85-year-old residing at an assisted living facility, admitted to hospice services on 12/17/24 with a primary diagnosis of Parkinson’s disease (a progressive neurological disorder causing movement problems). Further review of Patient 6’s medical record showed the hospice medication list included the following discrepancies in comparison with the facility medication list: 1. Vitamin D3 25 MCG, 1 tab daily; the facility medication list did not show Vitamin D3. 2. The hospice medication list did not list a scheduled dose of Miralax; the facility medication list showed Miralax powder 17 GM, PO daily for bowel management. Observation on 03/27/25 at 9:45 AM, showed Patient 6’s facility medication list that it did not match the hospice medication list. Patient 12 Review of Patient 12’s medication record showed an 84-year-old residing at an assisted living facility, admitted to hospice services on 12/13/24 with a primary diagnosis of hypertensive (high blood pressure) heart and chronic kidney disease with heart failure. Further review of Patient 12’s medical record showed the hospice medication list included the following discrepancies in comparison with the facility medication list: 1. Spironolactone 50 MG 1 tablet PO daily, every morning; the facility list showed Spironolactone 25 MG 1 tablet PO daily, every morning for edema. 2. Torsemide 20 MG, 2 tablets PO daily, every morning; the facility list showed Torsemide 20 MG, 1 tablet PO daily, every morning for edema. 3. Donepezil HCl 10 MG, 1 tab PO daily, every morning; the facility list showed Donepezil HCl 10 MG, 1 tab PO daily, every evening for memory. 4. Metolazone 5 MG, 1 tablet daily, PRN for edema; Metolazone 5 MG, 1 tablet PO, weekly PRN for edema. 5. Hydroxyzine was not listed on the hospice medication list; the facility list showed Hydroxyzine 25 MG, 0.5 tablet PO every 8 hours PRN for itching. Observation during a home visit on 03/27/25 at 8:45 AM, showed Patient 12’s facility medication list did not match the hospice medication list. During an interview on 03/27/25 at 9:00 AM, Staff C, Registered Nurse (RN), stated that any new medication changes are given to facility staff at each visit and the hospice medication list is updated at least every 2 weeks after interdisciplinary group (IDG) meetings. Staff C, RN, stated that the facility books are updated at that time and the medications should be matching the hospice medication list.”

“Based on observation, policy review, record review, and interview, the Hospice failed to include in the plan of care (POC) a complete list of durable medical equipment (DME) for 1 patient (Patient 6) of 19 sampled patients. Failure to include the DME required to manage the care needs of the patient, places the patients at risk for unmet care needs. Findings Include: Review of the Hospice policy titled “Interdisciplinary Group Plan of Care” last dated 06/21/13, showed “The plan of care includes, but is not limited to the following: … Drugs and treatment, medical supplies and medical appliances necessary to meet the needs of the patient … The documented review and revision of the IDG plan of care occurs at least every 15 calendar days or as required by the patient’s condition …” Patient 6 Review of Patient 6’s medical record showed an 85-year-old admitted to hospice services on 12/17/24 with a primary diagnosis of Parkinson’s disease (a progressive neurological disorder causing movement problems). Further review of Patient 6’s medical record showed a POC dated 03/13/25 showed no Broda wheelchair (an adjustable reclining wheelchair), wheelchair, or shower chair on the DME list. Observation on 03/27/25 at 9:45 AM, revealed a standard wheelchair, a Broda wheelchair, and a wheeled shower chair were present in Patient 6’s room. During an interview on 03/27/25 at 9:45 AM, Staff D, Registered Nurse (RN), stated that Patient 6 had been using a personal wheelchair until the beginning of January 2025 when the Broda chair was requested by facility staff due to rigidity and positioning difficulties. During an interview on 03/27/25 at 11:30 AM, Staff A, Director of Clinical Services, stated that each patient’s POC and DME needs are reviewed during IDG meetings every 2 weeks and updated with changes.”

“Based on policy review, record review, and interview, the Hospice failed to communicate medication changes with non-hospice caregivers for 2 patients (Patient 6 and 12) of 19 patients sampled. Failure to provide an accurate medication list with non-hospice caregivers places these patients at risk for unmanaged symptoms and negative outcomes. Findings Include: Review of the Hospice policy titled “Drugs and Biologicals – Administration, Use, and Disposal” last dated 06/08/21, showed “The designated RN is responsible for verifying any changes in medication, dose, frequency or route with the patient’s attending physician, if any, or the Hospice Medical Director or physician designee and obtaining appropriate revised physician orders … The medication profile is updated with any medication changes.” Review of the Hospice policy titled “Provision of Hospice Services to Residents of a SNF/NF [skilled nursing facility/nursing facility] or ICF/MR [intermediated care facility for mental retardation]” dated 02/15/13, showed “The IDG is responsible for communicating with, and coordinating the delivery of hospice care with: … The facility staff … The facility in which the patient resides has the following information regarding the hospice patient: … Current hospice medications”. Patient 6 Review of Patient 6’s medical record showed an 85-year-old residing at an assisted living facility, admitted to hospice services on 12/17/24 with a primary diagnosis of Parkinson’s disease (a progressive neurological disorder causing movement problems). Further review of Patient 6’s medical record showed that the medication list did not show a dose of Miralax powder daily for bowel management. Further review of Patient 12’s medical record showed the hospice medication list with the following discrepancies with the facility medication list: 1. Vitamin D3 25 MCG, 1 tab daily; the facility medication list did not show Vitamin D3. 2. The hospice medication list did not list a scheduled dose of Miralax; the facility medication list showed Miralax powder 17 GM, PO daily for bowel management. Patient 12 Review of Patient 12’s medication record showed an 84-year-old residing at an assisted living facility, admitted to hospice services on 12/13/24 with a primary diagnosis of hypertensive (high blood pressure) heart and chronic kidney disease with heart failure. Further review of Patient 12’s medical record showed the hospice medication list with the following discrepancies with the facility medication list: 1. Spironolactone 50 MG 1 tablet PO daily, every morning; the facility list showed Spironolactone 25 MG 1 tablet PO daily, every morning for edema. 2. Torsemide 20 MG, 2 tablets PO daily, every morning; the facility list showed Torsemide 20 MG, 1 tablet PO daily, every morning for edema. 3. Donepezil HCl 10 MG, 1 tab PO daily, every morning; the facility list showed Donepezil HCl 10 MG, 1 tab PO daily, every evening for memory. 4. Metolazone 5 MG, 1 tablet daily, PRN for edema; Metolazone 5 MG, 1 tablet PO, weekly PRN for edema. 5. Hydroxyzine was not listed on the hospice medication list; the facility list showed Hydroxyzine 25 MG, 0.5 tablet PO every 8 hours PRN for itching. During a home visit for Patient 12 on 03/27/25 at 8:45 AM, the observation was made when reviewing the facility medication list that it did not match the hospice medication list. During an interview on 03/27/25 at 9:00 AM, Staff C, Registered Nurse (RN), stated that any new medication changes are given to facility staff at each visit and the hospice medication list is updated at least every 2 weeks after interdisciplinary group (IDG) meetings. Staff C, RN, stated that the facility books are updated at that time and the medications should be matching the hospice medication list. During a home visit for Patient 6 on 03/27/25 at 9:45 AM, the observation was made when reviewing the facility medication list that it did not match the hospice medication list. During an interview on 03/27/25 at 3:00 PM, Staff B, Director of Clinical Services, stated that every IDG medications are updated in the hospice charts and any changes should be communicated by the case manager to the facility staff and vice versa. Staff B, Director of Clinical Services, stated that hospice staff should be reviewing the hospice and facility medication lists at least every 2 weeks for changes or updates needed.”

“Based on interview, record review, document review, and policy review, the agency failed to ensure staff followed their reporting policy for 1 (Patient 1) of 3 sampled patients. Specifically, Home Health Aide (HHA) 4 did not report Patient 1’s 05/06/24 fall to the agency. This failure had the potential to delay the agency from providing Patient 1 the necessary assessment and treatment. Findings Include: Review of an agency policy titled, “Fall Prevention Policy for Hospice Care,” dated 05/11/2028, revealed “ix. Incident Reporting and Follow-up: 1. Require staff to report all fall incidents immediately to the supervisor and document the incident in the patient’s medical record.” Review of Patient 1’s “RN [registered nurse] Initial/Comprehensive Assessment,” dated 01/11/23, revealed the agency admitted Patient 1 on 01/06/23, with diagnoses that included hypertensive heart and chronic kidney disease without heart failure, with stage 1-4 unspecified chronic kidney disease (heart and kidney illness due to long term high blood pressure problems), malignant neoplasm of the right kidney (cancer), mild cognitive impairment (a loss of the ability to think and reason), and age-related osteoporosis without pathological fracture (a disease of reduced bone mass that increased the risk of a bone breaking). The RN Initial/Comprehensive Assessment revealed Patient 1 had a do not resuscitate order, lived in an assisted living facility (ALF), and was at risk for falling. Review of an agency incident report, revealed on 05/06/24, HHA 4 assisted Patient 1 shower while the patient sat on a shower chair, HHA 4 moved a towel, Patient 1 tipped to the right and slid off the shower chair, the patient’s head hit a shower grab bar, and Patient 1 fell to the floor. Further review revealed HHA 4 notified the nurse on duty at Patient 1’s ALF but did not report the incident to the agency per agency policy. On 05/07/24, an ALF nurse contacted the agency for a visit due to Patient 1’s complaint of pain but did not advise the agency the pain was related to a fall. On 05/07/24 around 1:45 PM, Patient 1’s Registered Nurse Case Manager (RNCM) 5 visited Patient 1 and learned of the patient fall on 05/06/24, assessed the patient to have a possible right hip fracture, notified the physician to obtain orders for an x-ray, and the x-ray revealed Patient 1 had a right hip fracture. Further review revealed, the Director of Hospice Services (DHS) was notified of the confirmed fracture, notified the Vice President of Care (VPC) and instructed HHA 4 to stop working immediately. On 05/07/24 at 1:45 PM, the DHS obtained a statement from HHA 4 regarding Patient 1’s fall on 05/06/24, suspended HHA 4 from providing services pending an investigation. HHA 4 did not report Patient 1’s 05/06/24 fall to anyone at the agency because she was scared to tell anyone and hoped the patient would be all right. Patient 1’s condition quickly declined after the fall, and the patient died on 05/11/24. An undated agency document titled, “Complaint Investigation Witness Statement of Facts,” revealed HHA 4 documented statement on Patient 1’s 05/06/24 fall, “About 10:30 AM, I was assisting the patient with shower. When I finished assisting with shower (sic) I was drying (Patient 1). I was putting a dry towel under (Patient 1’s) feet when (Patient 1) slipped out of the chair and collapsed to the ground. (Patient 1) hit (their) head on the bar. I immediately notified the nurse (sic) they checked (Patient 1’s) vitals. We kept asking of (sic) any pain. (Patient 1) doesn’t (sic) complain of any pain.” Patient 1’s, “Care Coordination Note,” dated 05/06/24, revealed an ALF licensed practical nurse (LPN) notified RNCM 5 by a text message that Patient 1 fell at 10:40 AM while in the shower room with an agency aide, the patient denied any pain, had an abrasion to the right elbow, had a small cut on the right eyebrow, and the facility had started checking Patient 1’s neurological status (a series of tests that assesses mental status, reflexes, movements). The “Radiology Report,” dated 05/07/24, revealed Patient 1 had an impacted right hip fracture (refers to a type of fracture where the broken ends of the bone are driven into each other and often occurred in the hip when a fall or other trauma caused the head of the femur (thighbone) to jam into the hip socket) and the bones appeared diffusely demineralized (loss of the minerals that make bones strong). Patient 1’s “Hospice Aide Visit,” dated 05/08/24, revealed on 05/05/24, HHA 4 showered Patient 1, while the patient satin the shower on a shower chair. HHA 4 observed Patient #1 collapsed while HHA 4 removed a towel from the patient’s feet, and HHA 4 “immediately” reported Patient 1’s fall to the facility nurse. Further review did not reveal HHA 4 notified the agency of Patient 1’s fall. A review of Patient 1’s entire clinical record revealed HHA 4 did not report Patient 1’s 05/06/24 fall to agency staff until the agency interviewed HHA 4 on 05/07/24. During an interview on 06/26/24 at 10:14 AM, RNCM 5 stated she provided RNCM services to Patient 1 for at least a year and a half. RNCM 5 stated HHA 4 did not notify her of Patient 1’s 05/06/24 fall, but notified her of other patient changes or needs. RNCM 5 stated on 05/06/24, the ALF LPN told her that Patient 1 fell on 05/06/24 at 10:43 AM, while in the shower room with an agency aide, the patient denied pain, had a cut on the elbow and a slight cut on the eyebrow, and the facility had started doing neurological checks (a series of tests that assessed mental status, reflexes, movements). RNCM 5 confirmed that on 05/06/24, HHA 4 did not call her. RNCM 5 stated on 05/07/24, the facility reported Patient 1 had increased pain. RNCM 5 stated she called Patient 1’s doctor to report the patient’s pain and asked for increased pain medication for the patient, planned to assess Patient 1 later that day, notified Patient 1’s durable power of attorney (DPOA, a person who had been given legal authority to make decisions and act on behalf of the patient) of the patient’s fall, did not know the severity of Patient 1’s fall, and the ALF nurses provided care for Patient 1. RNCM 5 stated she did not recall if the facility identified HHA 4 as the aide with Patient 1 at the time of the patient’s fall. RNCM 5 stated on 05/07/24, she went to the facility, assessed Patient 1, collaborated with facility staff. According to RNCM 5, Patient 1 did not verbally report pain, but when asked about pain, the patient pointed to their right hip. RNCM 5 stated Patient 1’s pedal pulses on the right side were weaker, and the patient’s right leg appeared externally rotated (toes pointed out). RNCM 5 stated she then called the DHS, called the patient’s physician to obtain an x-ray, which showed a broken hip. RNCM 5 stated she called Patient 1’s DPOA to report Patient 1’s broken hip, and the DPOA declined treatment and made the decision for palliative care only. RNCM 5 stated Patient 1 declined after the fall, eventually stopped eating, was kept in bed for pain. During an interview on 06/26/24 at 1:00 PM, the ALF LPN stated on 05/06/24 between breakfast and lunch, the certified medication aide (CMA) called her and said Patient 1 fell while in the shower with the agency aide, HHA 4. The LPN stated she immediately went to Patient 1’s room, observed Patient 1 in a wheelchair in the shower room and there was a visible bump over the patient’s right eyebrow. The LPN stated HHA 4 was present and stated Patient 1 had been seated on the shower chair, HHA 4 tried to put a towel under Patient 1’s feet, Patient 1 leaned to the right side, fell off the shower chair, hit their head on the shower grab bar, and then slid to the floor. The LPN stated she assessed Patient 1 for pain, the patient indicated pain at the right eyebrow, she applied a bandage to Patient 1’s eyebrow cut, provided pain medication, transferred the patient to bed, and then notified RNCM 5 of the patient’s fall while HHA 4 stayed with Patient 1. The LPN stated RNCM 5 assessed Patient 1 on 05/07/24, discovered Patient 1’s fractured hip after an x-ray was taken, and Patient 1 was bedbound after the 05/06/24 fall. During an interview on 06/28/24 at 11:25 AM, the DHS stated RNCM 5 notified her on 05/07/24 around 1:30 PM that Patient 1 needed x-rays due to a fall on the prior day. The DHS stated on 05/07/24 at 2:30 PM or 3:00 PM, HHA 4 came to the office, appeared nervous, and stated that she was present during Patient 1’s fall on 05/06/24. The DHS stated HHA 4 wrote a statement documenting the patient’s fall and told the DHS she did not report the fall to the agency because she was hoping the patient would be OK, that the situation “would disappear” and that the patient was not hurt. The DHS stated HHA 4 verbal and written statements were consistent, HHA 4 did not provide any other patient visits while the agency investigated the fall and did not provide any additional visits until she was terminated from the agency. During an interview on 06/28/24 at 11:52 AM, the VPC stated she and the DHS were notified on 05/07/24 that Patient 1 had fallen on 05/06/24, she gave direction to suspend HHA 4 from patient visits until an investigation of the fall was conducted, they completed the investigation on 05/09/24 and terminated HHA 4’s employment. The VPC stated the agency expectation was HHAs would report changes in patient conditions to the RNCMs, and acknowledged HHA 4 did not follow agency reporting policy in relation to Patient 1’s fall on 05/06/24. An agency document titled, “Change of Status Form,” dated 05/09/24, revealed the agency terminated HHA 4’s employment on 05/09/24 for violating company policy and not meeting job expectations.”

“Based on interview, record review, and policy review, the agency failed to provide nursing supervision of aide service visits every 14 days for 1 (Patient 2) of 3 sampled patients. This failure had the potential for patients to not receive appropriate aide services. Findings Include: Review of an agency policy titled, “Supervision of Employees Who Provide Patient/Family Care,” dated 03/29/13, revealed “Employee supervisory visits are conducted in accordance with applicable law and regulation by designated, qualified supervisors.” Review of Patient 2’s “Face Sheet,” revealed the agency admitted Patient 2 on 12/13/23, with diagnoses that included hypertensive heart and chronic kidney disease without heart failure, with stage 1-4 unspecified chronic kidney disease and dementia. Review of Patient 2’s “Initial Plan of Care,” dated 12/20/23, revealed the physician ordered the agency to provide Patient 2 aide visits one time for one week and then two times per week through 03/11/24. Review of Patient 2’s “Hospice Aide Visit” dated 12/18/223 through 03/04/224, revealed the agency provided Patient 2 aide visits as ordered by the physician. Review of Patient 2’s “Hospice Aide Supervisory Visit,” dated 12/19/23 and 12/27/23, revealed the agency provided Patient 2 aide supervisory visits on those dates. Review of Patient 2’s entire clinical record revealed no evidence the agency provided Patient 2 any aide supervisory visits in 01/2024, 02/24/23 or from 03/01/24 through 03/11/24. During a concurrent review of Patient 2’s clinical record and interview conducted on 06/27/24 at 12:05 PM, the Director of Hospice Services (DHS) stated nurse supervisory visits of home health aides (HHAs) were to be completed once every 14 days by the registered nurse case managers (RNCMs), and Patient 2 received HHA visits from 12/13/23 through 03/04/24. The DHS confirmed there were only two supervisory visits completed, one visit on 12/27/23 and the other visit on 12/19/23. Per the DHS, there were no other nurse supervisory visits of HHAs completed during that time period and acknowledged the agency did not meet expectation. During an interview on 06/28/24 at 11:52 AM, the Vice President of Care (VPC) stated the agency expectation was nurses would complete nursing supervisory visit of HHAs in compliance with the agency policy and federal conditions of participation. The VPC stated supervisory visit should be completed every 14 days and acknowledged that the agency did not follow the agency supervisory visits policy for Patient 2.”