Every finding on record at Commonspirit Kansas, Inc.

Observed in Record Review. In 4 of 14 patient records reviewed, the organization failed to document a patient specific comprehensive assessment that identified the patient's need for hospice services. On review of RRHV#1 the documentation noted the patient with a wound to the coccyx yet there was no wound assessment conducted as part of the comprehensive assessment or reassessment. On review of RRHV#3 during home observation there was discussion of a wound to the coccyx, and also documentation in the record of a wound that healed, yet there was no documentation of an assessment of the wound. In RRNHV#5 there was no documentation of vital signs in the initial comprehensive assessment and reassessment yet vital signs are required documentation per organization policy 14721832 for comprehensive assessment and reassessment. Further, the patient had documentation of weight loss and poor appetite yet no assessment of weight or mid arm circumference, and a history of diabetes and no assessment of the endocrine system on admission. In RRNHV#8 there were no vital signs documented on the initial comprehensive assessment as required. There was documentation of multiple skin tears but no documentation of a wound assessment. These observations were reviewed with the RN.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to ensure the patient record was complete, promptly and accurately documented. On review of RRHV#3 there was documentation on the plan of care noting the patient was not on any high risk medications yet the patient was on opioids. Per the RN opioids were considered by the organization to be a high risk medication. This observation was reviewed with the RN.

Observed in Record Review. In 14 of 14 patient records reviewed, the organization failed to ensure the plan of reflect the patient and family goals that were Individualized, specific, measurable, and time-bound. In review of the records almost all goals were noted to not be individualized to the patient's needs as most of the goals were to noted at the end of the certification period or throughout the certification period. In RRHV#1 an example was an Oxygen safety goal that noted Patient/caregiver will understand ordered oxygen therapy including administration, safety, and care of equipment by return demonstration and reporting any increased needs t/o cert period and Patient/caregiver will demonstrate safe and appropriate use of bedside rails as well as understanding of instruction by return demonstration and report and concerns or needs t/o cert period. In RRHV#2 an example of a non-specific goal that was not measurable or time-bound was Patient/caregiver/family will demonstrate understanding of and ability to manage respiratory symptoms at end of life and Patient/caregiver will demonstrate home colostomy management as evidenced by ability to manage ostomy by end of cert period. In RRHV#3 an example of a goal was MSW will listen, support and be present for patient, caregivers and family. In RRHV#4 an example was Patient/caregiver/family: caregiver and family will verbalize understanding of diagnosis, prognosis, and the appropriate management of the symptoms of terminal diagnosis by asking appropriate questions t/o disease process. In RRNHV#5 a goal was Patient/caregiver/family: patient, caregiver and family will verbalize understanding of medication regimen by/within: by end of first cert period. Patient/caregiver will demonstrate understanding and effective home management of skin conditions: redness by keeping patient clean dry and frequent repositioning was a goal in RRNHV#10 that was not specific and time-bound. Goals that were not specific, measurable, and time-bound were noted throughout all records reviewed. These observations were reviewed with the RN.

Observed in Record Review. In 11 of 14 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of RRHV#1 there was documentation that a wound to the coccyx was covered with a Mepilex dressing yet there was no order for Mepilex nor was the dressing reflected in the plan of care. In RRHV#2 there was nursing documentation that the patient had increased pain that required an increased dosage of fentanyl and the social worker documented working on getting the patient Meals on Wheels. Neither of the issues noted in the record were reflected on the plan of care. In RRNHV#5 there was documentation of dysphagia and thickened liquids yet there were no orders for thickened liquids nor were the issues reflected on the plan of care. In RRNHV#6 the documentation noted oxygen use but no oxygen orders. There was also documentation of dysphagia and transitioning to end of life yet the issues were not reflected on the care plan. In RRNHV#7 the documentation noted a foley catheter but no orders for the catheter nor a urinary care plan to guide the care. In RRNHV#8 the documentation noted wound treatment of antibiotic cream with tegaderm but no physicians order for the treatment. In RRNHV#9 there was oxygen use but no oxygen orders. There was documentation of generalized edema that was not reflected on the care plan. In RRNHV#10 there was no order for oxygen but documentation of its use in the record. Further, there was documentation of wound care treatments yet no physicians order for the treatment provided. In RRNHV#12 the documentation noted increased fentanyl from one to two patches yet no physicians order noted in the record for the increase, nor was the increase in pain reflected in the plan of care. In RRNHV#13 the documentation noted a UTI with antibiotics orderd but no infection care plan to guide the care. In RRNHV#14 the patient was admitted at the end of life and documentation noted not swallowing yet the issue was not reflected in the plan of care. These observations were reviewed with the RN.

Observed in Record Review. In 3 of 14 patient records reviewed, the organization failed to ensure the plan of care revisions were based on information from updates to the patient's comprehensive assessment and addressed the patient's progress to goals and outcomes. On review of RRHV#2 and RRHV#3 there was no documentation on the patient's progress toward goals and outcome noted in the record. The plan of care goals and interventions remained the same and unupdated from admission and continued IDT to IDT meeting. In RRNHV#5 all of the goals were noted to be completed by the end of the 1st certification period, yet the patient was in the 2nd benefit period. There was no progress toward goals and outcomes and the goals had not been updated based on the comprehensive assessment. These observations were reviewed with the RN.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to ensure collaboration in the care of the patient and coordinate the efforts to support the goals outlined in the plan of care. On review of RRNHV#12 the documentation noted a change in the patients condition yet there was no documentation that the physician was informed of the change. This observation was reviewed with the RN.

Observed in Data Session. The hospice surveyor noted the QAPI program did not include indicators that were related to improved palliative outcomes as evidenced by the organization was not able to produce this documentation at the time of survey This observation was reviewed with the Chief Nursing Officer. Observed in Data Session. The surveyor noted the HCO did not have an effective, ongoing, organization wide, data-driven QAPI program as evidenced by the HCO was not able to produce this documentation at the time of survey. This observation was reviewed with the Chief Nursing Officer. Observed in Data Session. The surveyor noted the HCO was not able to demonstrate the operation of its QAPI program as evidenced by the HCO was not able to produce the documentation of the program at the time of survey. This observation was reviewed with the Chief Nursing Officer.

Observed in Data Session. The surveyor noted the hospice did not use patient care indicator data in the design of its quality assessment and improvement program as evidenced by the HCO was not able to produce this documentation at the time of survey. This observation was reviewed with the Chief Nursing Officer.

Observed in Data Session. The surveyor noted the governing body did not approve the frequency and detail of data collection as evidenced by the HCO was not able to produce this documentation at the time of survey. The last documented QAPI plan presented by the organization was dated for fiscal year 2021. This observation was reviewed with the Chief Nursing Officer.

Observed in Data Session. The surveyor noted the organization failed to document what performance improvement projects were being conducted, the reasons for conducting and the measurable progress achieved as evidenced by the HCO was not able to produce this documentation at the time of survey. There was documentation of an action plan in response to an audit from 2025 yet no further performance improvement plans and no documentation of performance improvement from 2023, 2024. This observation was reviewed with the Chief Nursing Officer.

Observed in Data Session. during data management discussion the surveyor noted performance improvement was not organization wide as evidenced by there was no documentation of an ongoing Quality Assessment Performance Improvement program for the hospice. This observation was reviewed with the Chief Nursing Officer.

Observed in Data Session. The surveyor noted the hospice governing body did not designate one or more individuals to be responsible for the QAPI program as evidenced by the HCO was not able to produce this documentation at the time of survey. The organization noted that a former employee was responsible for the QAPI program but there had not been someone named as responsible since that time. This observation was reviewed with the Chief Nursing Officer.

Observed in Data Session. The surveyor noted licensed professionals did not participate in the QAPI program as evidenced by there was no evidence of an ongoing QAPI program documented.

Observed in HR File Review. In 2 of 6 HR files reviewed, the organization failed to ensure staff competence was assessed and documented once every three years or more frequently as required by organization policy. On review of HR#3 for the Bereavement Coordinator and HR#5 for the Volunteer Coordinator there was no documentation of competency assessment. This observation was reviewed with the Chief Nursing Officer.

Observed in Tracer Activities. Upon review of all tracer activities, it was noted that there was a pattern of staff failing to follow established organization policy and the governing body/leadership did not ensure that the Conditions of Participation for 418.100, 418.56, and 418.58 were met per policy as determined through observations, documentation, and staff interviews.

Observed in Patient Home. In 1 of 2 home visits conducted, where medication reconciliation was observed, the organization failed to ensure the patient record reflect the patient's care, treatment, and services. On observation at RRHV#3 there were medications that were noted on the skilled nursing facility medication profile that were not included on the Hospice plan of care. The medication not reflected on the hospice plan of care were, Quetiapine, Senna, Prostat supplement, and Carnation breakfast supplement. This observation was reviewed with the RN and Interim CNO.

Observed in Record Review. In 2 of 2 patient records reviewed, for live discharge, the organization failed to ensure if the patient revoked the election of hospice care or is discharged the patient's physician was provided with a copy of the hospice discharge summary. On review of RRDC#1, and RRDC#2 there was no documentation that the discharge summary was sent to the patient's physician. This observation was reviewed with the RN and MSW.

Observed in Record Review. In 2 of 2 patient records reviewed, the organization failed to ensure the hospice discharge summary included all required elements. On review of RRDC#1, and RRDC#2 the hospice discharge summary only included a reason for discharge and did not include a summary of the patient's stay, to include treatments, symptoms, and pain management, the patient's current plan of care, and the latest physician's orders. This observation was reviewed with the RN.

Observed in Patient Home. In 1 of 1 home observations in a skilled nursing facility, the organization failed to provide all required information to the skilled nursing facility (SNF) to include the patient's hospice election form and any advance directives, and the physician certification and recertification of the patient's terminal illness. On review of RRHV#3 there was a binder provided to the SNF that contained the Plan of Care but lacked the patient hospice election, advance directives, and the certification/recertification of the patient's terminal illness. This observation was reviewed with the Interim CNO.

Observed in Record Review. In 2 of 13 patient records reviewed, the organization did not assess/reassess its patients by ensuring updates of the comprehensive assessment included information about the patient's progress toward desired outcomes and a reassessment of the patient's response to care. In HV#1 and RR#2, the plan of care continued to reflect the patient's start of care goals, and the interdisciplinary group meeting notes did not include updates to the plan of care and goals to reflect the patient's and family's current status/changing needs. This was reviewed and verified with the Clinical Coordinator.

Observed in Record Review. In 8 of 13 patient records reviewed, the organization did not plan the patient's care by including all services needed for the palliation and management of the terminal illness and related conditions, including medications and treatments necessary to meet the patient's needs. In review of the record for HV#2, the patient's indwelling foley catheter and high risk for developing a pressure ulcer (per the documented Braden Scale) was not included in the patient's hospice plan of care. In RR#2, RR#3, RR#4, RR#5, RR#8, and RR#9, the patient's plan of care did not include a complete order for the patient's home oxygen. In RR#1, the plan of care/medication profile it was documented the patient was on a Scopolamine transdermal patch 1mg over 3 days. The actual order for the patch was prn/as needed. This was reviewed and verified with the Clinical Coordinator.

Observed in Data Tracer. The organization's governing body did not ensure the hospice quality assessment and performance improvement (QAPI) program reflected the complexity of its organization/services, and involved all hospice services provided by the organization (including those provided under contract or arrangement). In review of the hospice QAPI measures, it was noted the hospice QAPI program did not include pharmacy, DME, bereavement, or volunteer services. This was reviewed and verified with the Clinical Coordinator.

Observed in Record Review. In 1 of 13 patient records reviewed, the plan of care did not contain information that reflected the patient's care, treatment, or services. In RR#8, the RN visit note and skilled nursing interventions performed in response to the death of the patient was not documented in the hospice record. This was reviewed and verified with the Clinical Coordinator.