Every finding on record at Ahc Home Health of Kansas City, LLC

Upon patient record review, 6 of 19 (Patient #6, 7, 8, 11, 16, 18) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #6 Medication profile contained Triamcinolone 0..5% topical cream 1 application every 6 hours for rash - did not specify site of application. Patient #7 Medication profile contains Ketoconazole topical 2 % apply 1 gm every 12 hours as needed for rash - did not specify site. Patient #8 Medication profile contained Timolol Maleate 0.5% ophthalmic solution 1 drop 1x day did not specify which eye. Patient #11 Medication profile contained Timolol Maleate 0.5% ophthalmic solution 1 drop 1x day did not specify which eye. Latanoprost 0.005% ophthalmic solution 1 drop 1x a day did not specify which eye. Patient #16 Medication profile contains Ketoconazole topical 2% apply 1 application 2 times a day as needed for rash - did not specify site. Patient #18 Medication profile contained Oxygen PRN, did not specify amount, route, rate and no modifier for PRN.

Upon patient record review, 2 of 19 (Patient #8, 10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions Patient #8 Patient admitted on 05/30/25 with reddened area to buttock, there were no related problems, goals, interventions related skin integrity. Patient #10 Admitted 05/21/25 with G-tube, there were no related problems, goals, interventions related to the G-tube.

Upon patient record review, 7 of 19 (Patient #6, 7, 8, 10, 11, 16, 18) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments Patient #6 POC contained Triamcinolone 0..5% topical cream 1 application every 6 hours for rash - did not specify site. Patient #7 Medication profile contains Ketoconazole topical 2 % apply 1 gm every 12 hours as needed for rash - did not specify site. Patient #8 POC contained Timolol Maleate 0.5% ophthalmic solution 1 drop 1x day did not specify which eye. Patient #10 The record indicated the patient was admitted with a G-tube with no related orders for the care and management of the G-tube. Patient #11 POC contained Timolol Maleate 0.5% ophthalmic solution 1 drop 1x day did not specify which eye. Latanoprost 0.005% ophthalmic solution 1 drop 1x a day did not specify which eye. Patient #16 POC contains Ketoconazole topical 2 % apply 1 application 2 times a day as needed for rash - did not specify site. Patient #18 POC contained Oxygen PRN - did not specify amount, route, rate and no modifier for PRN.

Upon patient record review, 3 of 19 (Patient #12, 14 15) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #12 On 05/22/25, the record indicated a call from ALF patient was refusing medications and pocketing food. There was no evidence the care plan was revised to include the changes in the patient. Patient #14 MSW documented on 06/25/25 of depression and loneliness. There was no evidence the care plan was revised to include the changes in the patient. Patient #15 On 06/03/25, the RN documented poor intake and increased weakness there was no evidence the care plan was revised to include the changes in the patient.

Upon patient record review, 1 of 19 (Patient #10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #10 SN documented "cleaned around PEG tube site and placed skin prep around site, placed new woven pad and secured with tape". There are no orders for nurse to perform PEG tube site care.

Upon patient record review 2 of 19 (Patient #8,14) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #8 SN documented patient is lonely on visit 06/18/25 and could benefit from a volunteer, no referral to Volunteer Coordinator. Patient #14 SN documented patient is lonely on visit 04/28/25 and could benefit from a volunteer, no referral to Volunteer Coordinator. In addition, the MSW documented that patient would like to have the Chaplain to visit, MSW stated she would reach out to the Chaplain - no documentation that the MSW discussed with Chaplain or made referral.

Upon patient record review 1 of 19 (Patient #15) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #15 RN documented aide supervisory visit on 06/19/25 then again on 07/09/25.

Upon patient record review, 1 of 19 (Patient #7) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #7 RN documented a LPN supervisory visit on 07/03/25, but LPN has not made any visits.

Upon patient record review, 2 of 11 (Patients #3, 11) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient #3 Medication profile did not contain oxygen but patient is on O2 4L/M nasal cannula. Patient #11 Medication profile did not contain oxygen but patient is on O2 8L/M nasal cannula.

Upon patient record review, 2 of 11 (Patients #3 and 11) did not have evidence the plan of care included oxygen. Patient #3 POC dated 07/19/2022 did not contain oxygen but patient is on O2 4L/M nasal cannula. Patient #11 POC dated 05/14/2022 did not contain oxygen but patient is on O2 8L/M nasal cannula.

Upon patient record review, 2 of 8 applicable (Patients #7, 8) did not have evidence in the patient record that hospice aide assignments and duties are: • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patients #7 and 8 - Aide care plan contained both bed bath and shower bath without documentation that the patient was "functionally and cognitively able to make decision".

Upon patient client record review, 1 of 11 (Patient #7) did not have evidence that all entries are legible. Patient #7 SN visit 06/29/2022 "catheter changed, lab drawn and specimen collected as ordered". SN did not document catheter size or balloon, what labs were drawn, access site or supplies used and did not document how UA specimen was collected.