Every finding on record at Brighton Hospice Kansas, LLC

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that hospice volunteers provided administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. A review of the Hospice Volunteer Requirement Report on 01/23/2025 for 01/01/2024 through 12/31/2024 revealed a cost savings of 2.26%. The agency did not ensure that day-to-day administrative or direct patient care services were provided in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff in 2024. During a joint review of the Hospice Volunteer Requirement Report and interview on 01/23/2025, the Administrator stated, "We didn’t have diversity in our volunteer approach, so we dipped in Q4. We are now working on our partnerships with community centers to create more volunteer opportunities.” During a joint review of the Hospice Volunteer Requirement Report and interview on 01/23/2025, the Volunteer Coordinator agreed the hospice agency did not meet the minimum five percent cost savings requirement for 2024, stating, "We have a PIP, and we are working on getting the numbers up."

It is required that the hospice provides information on advance directives upon initiation of hospice care. Whether or not the patient has executed an advance directive is documented in a prominent part of the patient’s record. This standard was not met as evidenced by clinical record review and interview. 1 of 9 (11%) clinical records reviewed revealed that information on the advance directive was not documented in the clinical record. Clinical record #52087 was reviewed and identified that the patient elected the hospice benefit on 12/17/2021 . The initial assessment identified that the patient was a DNR but there was no signed DNR in the clinical record. The DON was interviewed on 2/23/2022 and had no additional information to provide .