Central Plains Hospice

“Based on record review, policy and procedure review, and staff interview, the agency failed to ensure communication with the Interdisciplinary Team (IDT) and/or the patient’s attending physician when visits were not completed as ordered on the plan of care for 4 of 14 (Patient 2, 4, 10, and 11) records reviewed and failed to have a policy and procedure to ensure the agency has a process in place for communication when visits are missed. The census was 8. Findings are: A. Review of the agency’s policy and procedures revealed the agency did not have a policy and procedure in place for communication and documentation with the Interdisciplinary Team (IDT) and/or the patient’s attending physician when visits were not completed as ordered on the plan of care. B. Review of Patient 2’s clinical record revealed: 1. The Plan of Care for the benefit period of 4/29/26 through 7/27/26 included orders for skilled nurse (SN) 1-3 times per week for 9 weeks, and Hospice Aide (HA) services 1-2 times per week for 9 weeks to provide personal cares and bathing assistance. 2. There was no documentation that a HA visit was conducted 5/10/26 through 5/16/26.3. There was no documentation of the reason for the missed visit or if the staff attempted to reschedule the missed visit. 4. There was no documentation that the patient’s attending physician or the IDT was notified of the missed visit. C. Review of Patient 4’s clinical record revealed: 1. The Plan of Care for the benefit period of 3/12/26 through 5/10/26 and 5/11/26 through 7/09/26 included orders for SN 1-3 times per week for 9 weeks, and HA services 1-2 times per week for 9 weeks to provide personal cares and bathing assistance. 2. There was no documentation that a HA visit was conducted 4/26/26 through 5/02/26.3. There was no documentation of the reason for the missed visit or if the staff attempted to reschedule the missed visit. 4. There was no documentation that the patient’s attending physician or the IDT was notified of the missed visit. D. Review of Patient 10’s clinical record revealed: 1. The Plan of Care for the benefit period of 1/12/26 through 4/10/26 included orders for SN 1-2 times per week for 9 weeks, and HA services 1-2 times per week for 9 weeks to provide personal care and bathing assistance. 2. There was no documentation that a HA visit was conducted 1/12/26 through 1/17/26 and 1/18/26 through 1/24/26.3. There was no documentation of the reason for the missed visits or if the staff attempted to reschedule the missed visits. 4. There was no documentation that the patient’s attending physician or the IDT was notified of the missed visits. E. Review of Patient 11’s clinical record revealed: 1. The Plan of Care for the benefit period of 5/21/25 through 8/18/25 and 8/19/25 through 11/13/25 included orders for SN 1-2 times per week for 9 weeks, and HA services 1-2 times per week for 9 weeks, to provide personal care and bathing assistance. 2. There was no documentation that a HA visit was conducted 8/31/25 through 9/6/25.3. There was no documentation of the reason for the missed visit or if the staff attempted to reschedule the missed visit. 4. There was no documentation that the patient’s attending physician or the IDT was notified of the missed visit. F. During an interview on 6/11/26 at 1:30 PM, the Director of Hospice (Director) and the Clinical Care Coordinator confirmed the agency failed to ensure communication with the IDT and/or the patient’s attending physician when visits were not completed as ordered on the plan of care for Patient 2, 4, 10, and 11. The Director also confirmed the agency failed to have a policy and procedure to ensure the agency has a process in place for communication when visits are missed.”

“Based on record review, policy and procedure review, and staff interview, the agency failed to ensure a registered nurse (RN) made an onsite visit to the patient’s home at least every 14 days for 5 of 14 (Patient 2, 4, 10, 11, and 13) patients who received hospice aide services, to ensure those services meet the needs of the hospice patient. The total sample size was 14. The census was 8. Findings are: A. Review of the agency policy and procedure titled, Home Health & Hospice Aide, No. HH-300.1, revised 12/2022 revealed: 1. Hospice aide services must be supervised by an RN every 2 weeks.2. The policy does not clearly state the supervision must be completed not less than every 14 days, as required by regulation. 3. This policy does not include the criteria being assessed by the RN. B. Review of Patient 2’s clinical record revealed: 1. The Plan of Care for the benefit period of 4/29/26 through 7/27/26 included orders for skilled nurse (SN) 1-3 times per week for 9 weeks, and Hospice Aide (HA) services 1-2 times per week for 9 weeks to provide personal cares and bathing assistance. 2. Documentation revealed a supervisory visit was conducted on 5/13/26 and the next supervisory visit was conducted on 5/28/26 (15 days). C. Review of Patient 4’s clinical record revealed: 1. The Plan of Care for the benefit period of 3/12/26 through 5/10/26 and 5/11/26 through 7/9/26 included orders for SN 1-3 times per week for 9 weeks, and HA services 1-2 times per week for 9 weeks to provide personal cares and bathing assistance. 2. Documentation revealed a supervisory visit was conducted on 4/6/26 and the next supervisory visit was conducted on 4/21/26 (15 days). D. Review of Patient 10’s clinical record revealed: 1. The Plan of Care for the benefit period of 1/12/26 through 4/10/26 included orders for SN 1-2 times per week for 9 weeks, and HA services 1-2 times per week for 9 weeks, to provide personal cares and bathing assistance. 2. There was no documentation that a supervisory visit was conducted from 1/12/26 through 2/9/26 (29 days). E. Review of Patient 11’s clinical record revealed: 1. The Plan of Care for the benefit period of 5/21/25 through 8/18/25 and 8/19/25 through 11/13/25 included orders for SN 1-2 times per week for 9 weeks, and HA services 1-2 times per week for 9 weeks to provide personal cares and bathing assistance. 2. There was no documentation that a supervisory visit was conducted from 8/21/25 through 10/14/25 (56 days). E. Review of Patient 13’s clinical record revealed: 1. The Plan of Care for the benefit period of 7/14/25 through 9/10/25 included orders for SN 1-3 times per week for 9 weeks, and HA services 1-2 times per week for 9 weeks, to provide personal and comfort care assistance to patient/family/caregiver. 2. Documentation revealed a supervisory visit was conducted on 8/18/25 and the next supervisory visit was conducted on 9/2/25 (15 days). F. During an interview on 6/11/26 at 1:30 PM the Director of Hospice and the Clinical Care Coordinator confirmed the agency failed to conduct onsite supervisory visits by an RN at least every 14 days for Patient 2, 4, 10, 11, and 13 to ensure the hospice aide services provided meet the needs of the hospice patients.”