Three Rivers Hospice West

“Based on policy review, record review, and interview, the hospice provider failed to ensure that the hospice clinical staff notified the adult abuse hotline when a vulnerable patient was in an unsafe home situation in one of two revocation records reviewed (Record/Patient #9). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Abuse Reporting,” updated 2018, showed that employees and contracted staff must ensure that the administrator was informed immediately of any alleged violations involving, but not limited to, mistreatment or neglect. Hospice will take appropriate action if the alleged violation was verified by the hospice administration or an outside body having jurisdiction, such as the state survey agency or local law enforcement agency and will ensure that verified violations are reported to local bodies having jurisdiction within five working days of becoming aware of the violation. RECORD/PATIENT #9:Review of the clinical record showed the patient was admitted to hospice services on 07/13/2026 with a terminal diagnosis of peripheral vascular disease (a blood circulation disorder that narrows, blocks, or spasms blood vessels outside of the heart and brain). The patient had multiple amputations (surgical removal) of portions of his/her lower extremities and wore a prosthetic (artificial) foot to assist with transfers and ambulation. The patient resided in his/her own residence with the assistance of his/her parent. Review of the clinical staff’s documentation showed in part the following: - On 07/14/2026, the skilled nurse visit (SNV) documentation showed that: * The patient’s parent (PP) tried to assist the patient to stand and pivot for a transfer. The patient was wearing his/her prosthesis and wearing a gait belt, and the patient was too weak to complete the task: * The PP was short of breath and holding onto furniture to move around the room during the SNV; and * The PP was notified that the patient could not be left alone at home, and that he/she required 24-hour supervision.- On 07/16/2026, SNV documentation showed that: * The PP was at the hospital with another family member and was not at the home with the patient; * The provider sent a staff member to the patient’s home, was unable to enter, and called 911 to do a wellness check on the patient; * The police arrived at the patient’s home, were unable to enter the home, but were able to speak with the patient who informed them that he/she was unable to answer the door; and * The PP was notified again that the patient could not be left alone at the home.- On 07/20/2026, the medical social worker visit (MSWV) documentation showed that: * The PP was pulling up to the patient’s home as the hospice worker arrived; * The PP stated that he/she did not realize hospice care was for terminally ill patients; and * The PP requested that the patient be discharged from hospice services.- On 07/20/2026, the SNV documentation showed that: * The PP reported that the care of the patient was too much for him/her, he/she was unaware that hospice was care for terminally ill patients, and he/she would not let the patient live in a facility; * The patient stated that he/she wanted hospice care to stop effective this date; and * The patient was discharged from hospice care effective 07/20/2026.- The clinical record failed to contain documentation to show if the provider had reported that the patient was being left alone in his/her home by his/her caregivers, or if referrals to community services for continued care once hospice services stopped had been initiated.During an interview on 09/02/2026 at 09:30 AM, the Kansas City Regional Administrator stated that: - It was unsafe for the patient to be home alone; - The record failed to contain documentation that the provider had notified the adult abuse hotline of the PP leaving the patient at home alone, and- They would expect their staff to report unsafe home environments to the adult abuse hotline.”

“Based on policy review, record review, observation, and interview, the hospice provider failed to ensure an accurate/updated medication profile was maintained in two of five full records reviewed (Records/Patients #2 and #4). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Medication,” updated 2018, showed the provider would ensure safe and effective use of medications in accordance with accepted professional standards and applicable laws and regulations. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 06/17/2026 with a terminal diagnosis of senile degeneration of the brain (a decline in memory, behavior, and cognitive abilities). The patient lived in a long-term care facility (LTCF). Observation of the facility’s medication profile (FMP), printed 09/01/2026 at 11:02 AM during the home visit, and the provider’s medication profile (PMP), printed 08/31/2026, showed the FMP included an order, dated 08/13/2026, for morphine sulfate oral solution 20 milligrams (mg)/5 milliliters (ml) give 0.25 ml every two hours as needed for pain (this would be one (1) mg). The PMP showed an order for morphine sulfate oral solution 100 mg/5 ml administer 0.25 ml every two hours as needed for pain (this would be 20 mg). During a telephone interview on 09/02/2026 at 12:40 PM, a LTCF staff member confirmed that the bottle of morphine in the LTCF was 100 mg/5 ml and that the facility’s medication list was incorrect.RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 06/10/2026 with a terminal diagnosis of Parkinson’s disease with dyskinesia (a neurological disorder that causes unintended or uncontrollable movements or stiffness). The patient lived in a LTCF.Observation of the FMP, printed 09/02/2026 at 9:38 AM during the home visit, and the PMP, dated 08/31/2026, showed the following medication discrepancies:- The FMP showed an order, dated 08/22/2026, for Dulcolax (laxative) 10 milligrams (mg) one every 24 hours if no bowel movement for three days and Milk of Magnesia (laxative) was ineffective. The PMP failed to include this medication; and- The FMP showed an order with a start date of 04/11/2026 and a discontinued date of 08/09/2026 for escitalopram (antidepressant) 5 mg daily and a new order dated 08/09/2026 for escitalopram 10 mg daily. The PMP showed escitalopram 5 mg daily. During an interview on 09/02/2026 at 1:00 PM, the registered nurse coordinator stated that medication reconciliation was done at the first visit of every month. The Kansas City Regional Administrator stated that medication reconciliation was done at every visit.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure the plan of care (POC) included individualized, measurable goals anticipated from implementing and coordinating the treatment of pain in two of five full records reviewed (Records/Patients #1 and #4). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Comprehensive Assessment / Care Plan Development,” updated 2018, showed in part, the plan of care clearly identifies each problem individualized to the client (patient) with measurable goals and outcome criteria. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 06/10/2026 with a terminal diagnosis of Parkinson’s disease with dyskinesia (a neurological disorder that causes unintended or uncontrollable movements or stiffness). The patient lived in a long-term care facility (LTCF).Review of the interdisciplinary group (IDG) meeting note, dated 08/11/2026, showed the pain goal was that the patient would experience enhanced comfort and well-being as illustrated by patient reported satisfaction of pain relief by the end of the current benefit period.Review of the skilled nursing notes dated 08/12/2026 through 08/25/2026 failed to include if the patient reported satisfaction of pain relief in three of three skilled nursing notes.During an interview at 12:50 PM, the RNC stated that the pain goal could not be measured and should be written as a number for the pain goal. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 06/04/2026 with a terminal diagnosis of stage four breast cancer with metastasis (the spread of cancer cells to other parts of the body) to the bone and lung. The patient lived in a long-term care facility (LTCF). Review of the initial comprehensive assessment, dated 06/04/2026, showed:- The patient reported frequent pain in his/her right knee and currently had pain in his/her jaw that was rated as eight (8) on a numerical zero (0) to 10 pain scale (where 0 equals no pain and 10 equals the worst possible pain);- He/she described the pain as a dull ache;- The patient reported that activity made the pain worse and rest and medication relieved the pain;- Pain medications included Tylenol (an over-the-counter pain reliever for mild to moderate pain) 500 milligrams (mg) every four hours as needed (PRN) and Norco (an opioid medication used to relieve moderate to moderately severe pain) 10/325 mg every eight hours PRN;- An acceptable pain intensity goal of two (2) was established; and- The assessment also showed that further pain management steps would be taken if the patient’s pain reached a level of 8. Review of the POC, dated 06/08/2026, showed a problem of pain with the following goal:- (Named patient) will see enhancement of comfort and well-being as demonstrated by patient reported satisfaction of pain relief by the end of the current benefit period (end of benefit period is 90 days after admission);- The POC failed to include measurable elements that indicated when “enhancement of comfort and well-being” was achieved; and- The POC failed to include the patient’s self-reported pain goal of 2, or that additional pain management steps would be taken if the patient’s pain level reached an 8. During an interview on 09/02/2026 at 1:00 PM, the registered nurse coordinator stated that the patient was asked, on admission, to identify their acceptable level of pain and the pain goals should have included the measurable data.”

“Based on policy review, job description review, record review, observation, and interview, the hospice provider failed to ensure the registered nurse (RN) updated the aide’s written assignments in the plan of care (POC) to reflect changes in patient condition in one of four records reviewed of patients who received aide services (Record/Patient #3). Findings included: Review of the provider’s policy titled, “Care Plans – Updates,” updated 2018, showed in part:- Updates to the POC are to be initiated by any professional staff that identify necessary changes in the POC to ensure continued appropriateness of the care plan; and- Changes in care plans should be made under the supervision and guidance of the RN care coordinator in conjunction with the care planning team. These changes should be documented within 24 hours of identification from the visit. Review of the provider’s job description titled, “RN (Registered Nurse) Case Manager, Patient Care Coordinator,” updated 2018, showed in part the duties/responsibilities of the RN included:- Responsible for updated and correct information on the hospice chart, care plan, medication, and treatment orders;- Participate as a member of the interdisciplinary group (IDG) as assigned. Seek input from and provide information to other IDG members regarding the client’s (patient’s) POC; and- Hold hospice weekly case conferences and facilitate discussion of issues from caseload for full staff discussion, consultation, and evaluation. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 07/02/2026 with a terminal diagnosis of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood). He/she lived at home, and the spouse was the primary caregiver. Review of the POC, dated 07/02/2026, showed the hospice aide (HA) was to visit the patient two times a week (2x/week) and the assigned duties included:- Provide shower to promote hygiene and self-esteem (2x/week);- Provide shower with use of shower chair (2x/week);- Utilize wheelchair for ambulation support (2x/week); and- Weigh patient (2x/week). Review of the HA notes, dated 08/04/2026 and 08/06/2026, showed the following duties were not performed:- Provide shower to promote hygiene and self-esteem; and- Provide shower with use of shower chair. Review of the HA note, dated 08/11/2026, showed the following duties were not performed:- Provide shower to promote hygiene and self-esteem;- Provide shower with use of shower chair;- Weigh patient; and- The HA included a clinical note to inform the RN of the duties that were not completed because the patient was in bed and a bed bath was given. Review of the RN visit notes, dated 08/14/2026 and 08/17/2026, showed the RN documented the patient was bed bound. Review of the HA note, dated 08/18/2026, showed the following duties were not performed:- Utilize wheelchair for ambulation support;- Weigh patient; and- The HA included a clinical note to inform the RN of the duties that were not completed because the patient was bed bound. Review of the HA note, dated 08/20/2026, showed the following duties were not performed:- Provide shower to promote hygiene and self-esteem; and- Provide shower with use of shower chair. Review of the licensed practical nurse (LPN) visit note, dated 08/21/2026, showed the patient was “totally dependent” on his/her caregiver for activities of daily living (ADLs), was “non ambulatory” and “totally bed bound”. Review of the RN visit note, dated 08/24/2026, showed the RN documented the patient was bed bound. Review of the IDG meeting note, dated 08/25/2026, showed the meeting included the care coordination notes from the nursing visits on 08/14/2026, 08/17/2026, 08/21/2026, and 08/24/2026 in which the patient was identified as bed bound. The IDG note failed to show an update of the HA care plan to reflect changes in the patient’s status. The RN failed to update the HA assigned duties and the aide care plan continued to direct the HA to do the following:- Provide shower to promote hygiene and self-esteem (2x/week);- Provide shower with use of shower chair (2x/week);- Utilize wheelchair for ambulation support (2x/week); and- Weigh patient (2x/week). Review of the HA visit notes, dated 08/25/2026 and 08/27/2026, showed the HA could not perform the following duties:- Provide shower to promote hygiene and self-esteem;- Provide shower with use of shower chair; and- The tasks to use wheelchair for ambulation support and weigh patient were marked as completed. Observation and interview on 09/01/2026 at 8:00 AM showed HA-B and HA-C arrived at the patient’s home and handed this state agent a new, undated, HA care plan assignment that showed the following tasks, “provide shower to promote hygiene and self-esteem” and “provide shower with use of shower chair”, had been removed and “provide complete bed bath” had been added to the assignments. The care plan continued to include the task of utilizing wheelchair for ambulation support at all visits and weigh the patient at all visits. The hospice aides did not ambulate the patient and did not weigh the patient during the home visit observation. HA-B and HA-C stated that the patient had been bed bound for approximately two weeks, and they had informed their RN case manager. On 09/02/2026 at approximately 11:30 AM, a list of patient weights for August was requested. During an interview at approximately 11:50 AM, the regional nurse coordinator stated that weights were not performed due to the patient was bed bound for a month. There were no weights for the month of August, but they did measure the mid-arm circumference. He/she agreed the aide care plan should have been updated to address the patient’s change in condition. During an interview on 09/02/2026 at 1:00 PM, the RN Coordinator stated that the RN case manager should have updated the aide care plan when the changes were reported.”

“Based on policy review, record review, and observation, the hospice provider failed to ensure that the document used to coordinate care with the facility, the Long-Term Care/Hospice Coordination of Care Form, was accurate and updated in one of three facility visit records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Coordinating Provider,” updated 2018, showed that the hospice provider used the state approved Coordinated Task Plan of Care (form) in all long-term care facilities (LTCF). The instructions were included with the policy and showed that the form would be updated with any changes as needed. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 06/17/2026 with a terminal diagnosis of senile degeneration of the brain (a decline in memory, behavior, and cognitive abilities). The patient lived in a LTCF. Review of the document titled, “Long-Term Care/Hospice Coordination of Care Form, “ dated 06/17/2026, provided with the patient’s clinical record showed the following:- The hospice nurse would visit on Wednesday and Friday; and- The hospice aide would visit on Tuesday and Friday.Review of clinical record included nursing and aide visit notes dated 08/05/2026 through 09/01/2026 that showed:- The hospice nurse visited the patient three Tuesdays, one Wednesday, and four Fridays; - The hospice aide visited the patient two Mondays, one Tuesday, and three Thursdays; and- The hospice nurse and aide failed to consistently provide care on the coordinated days of the week or update the coordination form timely with changes. Observation of the hospice binder during the home visit at the LTCF on 09/01/2026 at 11:50 AM showed two Long-Term Care/Hospice Coordination of Care Forms that showed: - One form was dated 06/17/2026 and included two additional update signatures on 07/02/2026 and 08/05/2026. The hospice nurse and aide visit days were not changed/updated; and - A new form dated 09/01/2026 that showed the hospice nurse would visit on Tuesday and Friday and the hospice aide would visit on Monday and Thursday.”

“Based on procedure review, record review, observation, and interview, the hospice provider failed to provide the long-term care facility (LTCF) all the required information to assure that the patient received the necessary care and services in one of three facility visit records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s procedure form titled, “Facility/Home Chart Review Check-Off List,” revised 09/2025, showed that the hospice provider would provide the LTCF with the hospice current interdisciplinary group (IDG) meeting documents, most recent medication profile, and hospice physician/attending physician orders. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 06/17/2026 with a terminal diagnosis of senile degeneration of the brain (a decline in memory, behavior, and cognitive abilities). The patient lived in a LTCF. During the home observation at the LTCF on 09/01/2026 at 11:50 AM, the hospice social worker provided the hospice binder that was kept at the LTCF nurses station and stated that all the paperwork that hospice provided was in that binder. Review of the binder showed that the binder included an IDG note from 08/11/2026. The binder failed to contain the current IDG meeting document from 08/25/2026, the most recent medication profile, and the hospice physician/attending physician orders. The social worker agreed that these items were missing and called the hospice office to request that they be sent to the LTCF. During an interview on 09/02/2026 at 11:50 AM, the registered nurse coordinator stated that the current IDG which includes a current list of medications should have been in the binder.”

“Based on clinical record review, observation, and interview the hospice provider failed to ensure staff maintained an accurate updated medication profile in two of five full records reviewed (Records/Patients #1 and #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: RECORD/PATIENT #1: Observation and interview on 02/20/2024, beginning at 2:45 PM, during the patients home visit, showed the following discrepancies between the providers medication profile and the patients home medications: - The providers medication profile showed an order dated 01/23/2024, for erythromycin (antibiotic) 250 milligrams (mg), give one tablet three times a day for gastroparesis. The patient stated that he/she was done with that; - The providers medication profile showed an order dated 01/23/2024, for cetirizine (allergy medication) 10 mg one tablet daily for allergies. The patient stated that he/she took this a couple of months ago but no longer took it; - The patient had a bottle dated 09/14/2023, of metoprolol (blood pressure/heart medication) 25 mg once daily. The patient stated that he/she had been on this a long time. The medication profile failed to include this medication; and - The patient had a bottle of meclizine (used for dizziness) 25 mg one tablet as needed for dizziness. The patient stated he/she had this prescription for a few months. The medication profile failed to include this medication. During an interview on 02/22/2024, at 2:20 PM, the regional registered nurse (RN) coordinator (Governing body designee-A) stated that they had talked to the patients family member about the medication discrepancies. The patient no longer took erythromycin or cetirizine. The patient did take the metoprolol and the meclizine was as needed. The medication profile should have been updated before 02/22/2024. RECORD/PATIENT #2: Review of the providers current medication profile and long-term care facility (LTCF) physician orders showed the following discrepancies: - The providers medication profile showed an order dated 12/20/2024, for timolol maleate (used to treat glaucoma) 0.5% eye drops, administer one drop in both eyes two times daily for optic edema. The LTCF physician orders showed an order dated 02/15/2024, for timolol maleate 0.5% eye drops, administer one drop between 6:00 AM and 12:00 PM and 5:00 PM and 12:00 AM in the left eye only; and - The LTCF orders showed an order dated 01/26/2024, for antacid-anti gas 400 milligrams (mg)-40 mg/5 milliliters (ml), give 30 ml every four hours as needed for gastrointestinal upset. The provider’s medication profile failed to include this medication During an interview on 02/22/2024, beginning at 12:45 PM, the regional RN coordinator stated that at the visits staff look at the chart at the facilities or ask the caregivers in the home about medication changes. If the facilities have an electronic system they can ask for a print out of medications and get a copy of the signed physician orders sheets every month to review medications.”

“Based on policy review, clinical record review and interview, the hospice provider failed to obtain an initial bereavement assessment in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the providers policy titled, “;Initial/Comprehensive Assessment,” dated 2018, showed, in part, the following: - An initial bereavement assessment of the needs of the patients family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patients death; - The initial bereavement assessment is placed in the clients chart; and - Information gathered from the initial bereavement assessment must be incorporated into the plan of care and considered in the bereavement plan of care. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 09/13/2023 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). The patient lived alone in an assisted living facility and had adult children who were involved in his/her care. Review of the document titled, “;Durable Power of Attorney (POA) for Health Care and Health Care Directive,” dated/signed 12/17/2012, showed the patient appointed two adult children as powers of attorney (POA #1 and POA #2). Review of the hospice patient face sheet showed POA #1 lived out of state and was listed as the primary contact/caregiver. A third adult child was also listed as a patient contact. Review of the initial assessment, dated 09/13/2023, showed the registered nurse (RN) documented that communication with the patients children occurred and their questions were answered. On 02/22/2024, at approximately 9:30 AM, the initial bereavement assessment was requested from the provider. The regional registered nurse (RN) coordinator (Governing body designee-A) stated that a bereavement assessment was not done and provided this surveyor with three clinical notes that showed the following: - On 09/15/2023 the licensed master social worker (LMSW) attempted contact with POA#1 by phone without success with intention of completing a bereavement assessment. LMSW left a message requesting a return call; - A note from the visit date of 09/19/2023 stated that the BC (bereavement coordinator) had been unable to reach POA #1 to complete initial assessment. The note was electronically signed by the bereavement coordinator on 10/02/2023; and - A note, dated 09/20/2023, that showed the BC attempted to call POA#1 to complete initial assessment and a left voicemail requesting a return call. Review of the interdisciplinary group (IDG) meeting notes, dated 09/18/2023 and 09/19/2023, showed in part, the following: - The family was involved with the patients care but not with the physical care; - The patients children stated that they would get a copy of the POA document to the provider; - Social work, spiritual care, volunteer, bereavement, hospice aide, and homemaker services were explained and offered to the patient and family members; - The IDG notes failed to contain documentation that showed staff were having difficulty reaching POA #1 for the initial bereavement assessment; and - The IDG notes failed to show an attempt to perform a bereavement assessment with any of the other children/family members. During an interview immediately following a home visit on 02/20/2024 at 2:30 PM, the social worker (bachelor of social work, BSW) stated that he/she always called the patients children after the visits to let them know how the visit went. They may not always answer when he/she called but they were good about calling back. During an interview on 02/22/2024, the director of clinical services (Governing body designee-B), the regional RN coordinator, and the administrator from the Kansas City Region (Governing body designee-C) all stated that the LMSW should have kept trying to reach the family members and, if not successful, coordinated with the nurses (who were getting return calls from the family) so an initial bereavement assessment could be completed. Even completing it late would have been better than not doing one at all.”

“Based on policy review, clinical record review, and interview the hospice provider failed to ensure the plan of care (POC) was revised to address the patients wounds in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the providers policy titled, “;Care Plans – Updates,” updated 2018, showed in part: - An interdisciplinary group (IDG), in coordination with the client, his/her family, or representative, develops and maintains a comprehensive care plan for each client; - The POC shall be a direct link between the needs identified in the patient/family comprehensive assessment and POC; - Updates are to be initiated by any professional staff member that identifies necessary changes in the POC to ensure continued appropriateness of the care plan; and - Changes in care plans should be made under the guidance of the registered nurse care coordinator in conjunction with the care planning team. These changes should be documented within 24 hours of identification from the visit. RECORD/PATIENT #2: Review of the clinical record showed the patient elected hospice services on 12/20/2024. The patient had been transferred from the hospital back to a long-term care facility (LTCF) on 12/20/2024. Diagnoses included fractured ribs and infection due to ESBL (a bacteria found in the bowel). Review of the skilled nurse (SN) visit notes showed: - On 01/31/2024, licensed practical nurse (LPN) A documented the patient complained of discomfort to his/her bottom. The patient had two open Stage 2 (partial thickness loss of skin presenting as a shallow open ulcer with a red or pink wound bed) pressure ulcers. He/she cleaned the ulcers and applied an Allevyn (foam) dressing. He/she coordinated care with the registered nurse (RN) A. New order to apply Allevyn dressing to open sores on buttock, change every other day and as needed. - On 02/02/2024, LPN A documented the patient had two Stage 2 sores to the buttock and had a dressing intact (unsure if LPN A or LTCF applied the dressing). The nurse coordinated with RN A with no new orders; and -On 02/07/2024, RN B documented under the skin integrity section that the patient had Stage 1 (reddened skin that does not blanch when pressed and is not open) wounds to the buttocks with bright pink skin and no open areas. The skin assessment form showed that the patient had a Stage 2 decubitus ulcer to the coccyx (tailbone) without tunneling/undermining (openings underneath the surface of the skin) or odor (this contradicted what was documented under the skin integrity section). The treatment included turning every two hours and Allevyn every other day. Review of the combined IDG assessment dated 02/08/2024, showed the patient had Stage 1 wounds to the buttocks with bright pink skin and no open areas. Review of the IDG POC dated 02/08/2024, showed the patient was at risk to develop pressure wounds. Interventions included to turn the patient every two hours if unable to turn self in bed and use pillows to offset potential wounds. Staff failed to update the POC to address the patients current wound status with revised interventions and goals. During an interview on 02/22/2024, beginning at 12:45 PM, the regional RN coordinator (Governing body designee-A) stated that when a wound developed, the POC should be updated right away.”

“Based on policy review, clinical record review, and interview the hospice provider failed to obtain a discharge summary from the inpatient facility after discharge in one of one acute inpatient record reviewed (Record/Patient #7). This deficient practice has the potential to affect all patients that receive inpatient care. Findings included: Review of the provider’s policy titled, “Inpatient Services,” dated 2010, showed in part that a copy of the discharge summary shall be made available to the hospice. RECORD/PATIENT #7: Review of the clinical record showed the patient had been admitted to an inpatient facility after a fall on 08/25/2023 and discharged on 08/30/2023. The record did not include a discharge summary from the inpatient facility. During an interview on 02/22/2024, at 9:45 AM, the regional registered nurse (RN) coordinator (Governing body designee-A) provided a discharge summary. He/she stated that it had been obtained on 02/21/2024 (175 days after discharge). He/she stated that it should have been obtained at the patient’s discharge.”

“Based on policy review, clinical record review, observation, and interview the hospice provider failed to ensure staff followed acceptable standards of practice for infection control in one of four home visit observations (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the providers policy titled, “Nursing Bag Technique,” updated 2018, showed in part, to select a clean surface for the nursing bag, spread a clean barrier down on the selected surface, then place the bag on the suitable barrier. Review of the providers undated policy titled, “;Infection Control Program,” showed in part, that gloves must be changed between different body sites of the same patient. RECORD/PATIENT #2: Review of the clinical record showed the patient elected hospice services on 12/20/2024. The patient had been transferred from the hospital back to a long-term care facility (LTCF) on 12/20/2024. Diagnoses included fractured ribs and infection due to ESBL (a bacteria found in the bowel). Observation and interview on 02/21/2024, beginning at 9:50 AM, during the patients home visit, the nurse placed a zippered pouch that contained his/her supplies on an overbed table without a barrier, then without cleaning the pouch when finished, the nurse left the room and placed the zippered pouch on the LTCF nursing desk. The nurse checked the patient’s groin area with gloves on then removed the gloves, applied clean gloves but failed to sanitize his/her hands before applying the new gloves. The nurse then gathered several cleansing wipes in his/her hand and cleaned the patients groin folds. The nurse failed to change his/her gloves, sanitize his/her hands, and obtain a clean wipe before performing catheter care. The nurse stated that the patient was starting on intravenous antibiotics that day due to ESBL in the urine. He/she usually put a barrier under his/her supplies, and that he/she had a hand full of wipes and used one at a time then threw them away. During an interview on 02/22/2024, beginning at 12:45 PM, the regional registered nurse (RN) coordinator (Governing body designee-A) stated that he/she would expect a barrier to be placed under a supply bag, and would expect the nurse to change his/her gloves, wash hands, apply new gloves, and obtain a clean wipe before providing catheter care.”

“Based on policy review, clinical record review and interview, the hospice provider failed to ensure staff documented complete wound assessments and failed to follow physician orders for changing the patients urinary catheter in one patient (Record/Patient #2) and failed to notify the physician of missed nursing visits in one patient (Record/Patient #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice services with a terminal diagnosis of hypertensive heart disease with heart failure (changes in function of the heart muscle due to high blood pressure causing a decrease in the ability of the heart to pump blood). The patient had additional diagnoses of atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat) and hepatitis C with cirrhosis from a history of alcohol abuse. He/she lived at home with his/her adult child and continued to smoke and drink daily whiskey shots. Review of the physician orders, dated 12/21/2023, showed skilled nursing (SN) visits twice weekly. Review of the SN notes, with dates ranging from 12/22/2023 to 02/13/2024, showed in part: - A SN visit occurred on 01/10/2024; - A missed SN visit note due to patient refusal on 01/12/2024; - The SN failed to notify the physician of the missed visit (01/12/2024); - A SN visit occurred on 02/13/2024; - A missed SN visit note due to patient refusal on 02/16/2024; and - The SN failed to notify the physician of the missed visit (02/16/2024). During an interview on 02/22/2024, at 12:50 PM, the director of clinical services and the regional registered nurse coordinator stated that they agreed the SN should have notified the physician when they could not complete the physicians order for twice weekly visits. Findings included: Review of the hospice providers policy titled, “;Physician Orders,” dated 2018, showed in part: - All client medications, treatments, diets and overall plan of treatment are approved by the hospice interdisciplinary group (IDG) in consultation with the attending physician; - The plan of treatment services shall include the specific procedures and modalities to be used and the amount, frequency, and duration of the treatments; - The total plan of treatment shall be reviewed by the attending physician and the hospice personnel as often as the severity of the clients condition requires, but at least weekly during case conferencing; and - Hospice professional nursing staff shall promptly alert the attending physician to any changes that suggest a need to alter the plan. Review of the hospice providers policy titled, “;Comprehensive Assessment/Care Plan Development,” dated 2018, showed in part: - The written plan of care (POC) will be developed by the interdisciplinary group (IDG) with the attending physician involvement; and - All care provided to the individual will be in accordance with the POC. RECORD/PATIENT #2: Review of the record showed the patient elected hospice services on 12/20/2024. The patient had been transferred from the hospital back to a long-term care facility (LTCF) on 12/20/2024. Diagnoses included fractured ribs and infection due to ESBL (a bacteria found in the bowel). The patients primary hospice diagnosis was hypertensive heart disease without heart failure. Other diagnoses included benign prostatic hyperplasia (enlarged prostate) and spinal stenosis (a narrowing of the space around the spinal cord). Review of the physician orders showed an order dated 12/26/2023, to change the urinary catheter every month and as needed using a 16 french (diameter size of the catheter) coude catheter (a catheter designed to maneuver around obstructions in the urethra (the tube through which urine leaves the body). The order failed to include the balloon/bulb size (a balloon is inflated with sterile water to hold it in place) of the catheter. Review of the skilled nurse (SN) visit notes showed: - On 01/31/2024, licensed practical nurse (LPN) A documented the patient complained of discomfort to his/her bottom. The patient had two open Stage 2 (partial thickness loss of skin presenting as a shallow open ulcer with a red or pink wound bed) pressure ulcers. The nurse failed to document further assessment of the wound to include wound bed, drainage, odor, surrounding skin or measurements. He/she cleaned the ulcers and applied an Allevyn (foam) dressing. He/she coordinated care with the hospice registered nurse (RN) B. New order to apply Allevyn dressing to open sores on buttock, change every other day and as needed. - On 02/02/2024, LPN A documented the patient had two Stage 2 sores to the buttock and had a dressing intact (unsure if LPN A or LTCF applied the dressing). The nurse failed to document further assessment and measurements of the Stage 2 sores. The nurse coordinated with RN B with no new orders; - On 02/07/2024, RN B documented under the skin integrity section that the patient had Stage 1 (reddened skin that does not blanch when pressed and is not open) wounds to the buttocks with bright pink skin and no open areas. The skin assessment form showed that the patient had a Stage 2 decubitus ulcer to the coccyx (tailbone) without tunneling/undermining or odor. The drainage was was thin yellow, and wound bed was pink and open (this contradicted the documentation in the skin integrity section). The bottom of the assessment showed that hospice was responsible for wound care on Wednesdays and Fridays. The treatment included turning every two hours and Allevyn every other day; - On 02/09/2024, LPN A documented the sore to the bottom was healed and just red; - On 02/14/2024, LPN A documented no skin concerns; - On 02/16/2024, RN B documented no new issues or concerns. The skin assessment showed the patient had redness to the groin that was fading; and - On 02/19/2024, RN C documented the patient had Stage 2 pressure areas to both buttocks. The coccyx area was dark red with fragile skin. RN C failed to document measurements, description of the wound bed, odor, or drainage. During an interview on 02/22/2024, at 9:00 AM, LPN A stated that he/she used a 16 french 30 cc bulb. He/she did not use a coude catheter. During an interview on 02/22/2024, at 9:10 AM, RN B stated that he/she could not remember but thought he/she used an 18 french catheter with a 30 cc balloon. He/she used a regular catheter not a coude catheter. He/she did not think it was necessary to include the balloon size with the order. During an interview on 02/22/2024, beginning at 12:45 PM, the regional RN coordinator stated that when a wound developed, he/she would expect the nurse to do a full assessment and measure the area. Staff should follow the physician order for a coude catheter and document that was what they used. The order should include a bulb size.”

“Based on policy review, clinical record review and interview, the hospice provider failed to obtain physician orders for interventions and treatments provided in two of five full records reviewed (Records/Patients #1 and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the hospice providers policy titled, “;Physician Orders,” dated 2018, showed in part: - All client medications, treatments, diets and overall plan of treatment are approved by the hospice interdisciplinary group (IDG) in consultation with the attending physician; - The plan of treatment services shall include the specific procedures and modalities to be used and the amount, frequency, and duration of the treatments; - The total plan of treatment shall be reviewed by the attending physician and the hospice personnel as often as the severity of the clients condition requires, but at least weekly during case conferencing; and - Hospice professional nursing staff shall promptly alert the attending physician to any changes that suggest a need to alter the plan. RECORD/PATIENT #5: Review of the skilled nurse (SN) notes, dated 02/06/2024 and 02/09/2024, showed the patient had a skin tear to the left elbow and the SN cleaned with wound cleanser, applied triple antibiotic ointment and a foam bordered dressing. The SN failed to obtain orders for this dressing change. During an interview on 2/22/2024 at 12:50 PM, the regional registered nurse coordinator stated that he/she could not find an order in the clinical record for the intervention to the skin tear. The director of clinical services stated that the SN should have obtained an order for the dressing change. RECORD/PATIENT #1: Review of a nursing visit report dated 02/09/2024, showed that the nurse administered an enema to the patient. Review of the record failed to show a physician order for the enema. During an interview on 02/22/2024, beginning at 12:45 PM, the regional registered nurse (RN) coordinator showed where the nurse had communicated with the physician and obtained an order for an enema via their secure system. When they receive the order they print it out and scan it into the medical record. The nurse should have written the order and scanned it in.”

“Based on review of the respite contract and interview, the hospice provider failed to include the requirement that a copy of the facilitys discharge summary be supplied to the hospice provider at the time of discharge. This deficient practice has the potential to affect all patients served by the hospice provider. Findings included: Review of the provider’s policy titled, “Hospice Service Agreements,” dated 2018, showed in part, hospice agreements with contracted providers will include the following: - Identification of the services to be provided; - A stipulation that the services may be provided only with the express authorization of the hospice; - The manner in which the contracted services are coordinated, supervised, and evaluated by the hospice; - The delineation of the role(s) of the hospice, and the contractor in the admission process, patient/family assessment, and the interdisciplinary group care conferences; - Requirements for documenting that the services are furnished in accordance with the agreement; and - The qualifications of the personnel providing the services. Review of the providers respite contract showed the document failed to include the requirement that the contracted facility provide the hospice with a copy of the discharge summary and/or clinical record at the time of discharge. During an interview on 02/22/2024, at 10:30 AM, the administrator for the Kansas City region (Governing body designee-C) stated that the provision regarding the discharge summary was not in the respite contract but they would make sure they got it added and they had already started working on it.”

“Based on review of the respite contract and interview, the hospice provider failed to include the requirement that the facility identified a staff person responsible for implementations of the provisions of the agreement. This deficient practice has the potential to affect all patients served by the hospice provider. Findings included: Review of the provider’s policy titled, “Hospice Service Agreements,” dated 2018, showed in part, hospice agreements with contracted providers will include the following: - Identification of the services to be provided; - A stipulation that the services may be provided only with the express authorization of the hospice; - The manner in which the contracted services are coordinated, supervised, and evaluated by the hospice; - The delineation of the role(s) of the hospice, and the contractor in the admission process, patient/family assessment, and the interdisciplinary group care conferences; - Requirements for documenting that the services are furnished in accordance with the agreement; and - The qualifications of the personnel providing the services. Review of the providers respite contract showed the document failed to include the requirement that the contracted facility identify a staff person responsible for implementations of the provisions of the agreement. During an interview on 02/22/2024, at 10:30 AM, the administrator for the Kansas City region (Governing body designee-C) stated that the provision regarding the identification of a staff person was not in the respite contract but they would make sure they got it added and they had already started working on it.”