Every finding on record at Harbor Hospice of Kansas LP

Observed in Record Review. In 1 of 17 resident records reviewed, it was noted that the comprehensive assessment was incomplete. For example in record RRHV#3 the patient had 5 open wounds, however the documentation for the initial and second nurse visits stated that bruising was in place with wounds, some with dressings in place. No documentation of wound assessment, measurements, locations or dressing changes. This was confirmed and discussed with the Regional Director, QA nurse and DON/Administrator.

Observed in Record Review. In 1 of 17 patient records reviewed, During record review it was noted that the organization had not completed the comprehensive assessment. For example, in record RRBR#1 the initial bereavement assessment was not completed. This was confirmed and discussed with the Regional Director, DON/Administrator and QA nurse present. Observed in Record Review. In 2 of 17 patient records reviewed, it was noted that the organization had not completed the comprehensive assessment. For example, in record RRBR#1 and RRBR#2 an assessment at death was not done to assess bereavement risk in order to inform the decisions made by the IDG. This was confirmed and discussed with the Regional Director, DON/Administrator and QA nurse present.

Observed in Record Review. In 11 of 14 patient records reviewed, it was noted that the written plan of care was not completed based on the patient's goals, settings, and services required to meet needs. For example, in RRNHV#1 the goal Patient will be able to demonstrate improved safety awareness as evidenced by:_____ was incomplete. For example, in record RRNHV#5 the plan of care had no nursing or spiritual goals or interventions documented although both services visited the patient and had visit frequency orders. For example in record RRNHV#7 the plan of care goal for volunteer services Educate patient and family on volunteer services to determine needs and frequency of visits. For example, in record RRNHV#9 the plan of care wound goal was incomplete, Perform wound care/dressing change:______ For example in record RRHV#4 the goal Change foley catheter as ordered:___ was incomplete. For example, in record RRHV#1 the pain goal was not individualized Patient's pain will be well controlled. This was confirmed and discussed with the Regional Director, DON/Administrator and QA nurse present.

Observed in Record Review. In 1 of 14 patient records reviewed, it was noted that care was not provided according to hospice plan of care. For example, in RRHV#1 the plan of care for the patient's foley catheter stated 16Fr, 10 cc balloon however nurse assessment stated that the patient had a 18 Fr foley catheter with 20cc balloon in place on one visit and at the next nurse visit stated 18 Fr with 30cc balloon. This was confirmed with and discussed with the DON/Administrator and Quality Nurse.

Observed in Record Review. In 10 of 14 patient records reviewed, that included hospice aide services it was noted during record review that the hospice had not completed aide supervision every 14 days. For example, in record RRHV#2 the aide supervision was documented one time at 15 days and one additional time with 55 days between supervision. In record RRNHV#2 the aide supervision was documented one time with 40 days between documented supervision. In record RRNHV#7 the aide supervision was documented one time at 30 days and one additional time with 16 days between supervision. In record RRNHV#10 the aide supervision was documented one time at 15 days and one additional time with 41 days between supervision. In record RRNHV#9 the aide supervision was documented one time with 56 days between documented supervision. In record RRNHV#3 the aide supervision was documented one time with 20 days between documented supervision. In record RRNHV#5 the aide supervision was documented one time with 69 days between documented supervision. In record RRHV#3 and RRNHV#8 there was no aide supervision documented. This was confirmed and discussed with the Regional Director, DON/Administrator and QA nurse present.

Observed in Tracer Activities. During discussion with the Volunteer Coordinator and Quality Nurse and review of documentation it was noted that volunteers did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff. For example during 2024 it was reported that volunteers provided 3.67% of total patient care hours. This was discussed and the leaders reported that the current Volunteer Coordinator had been in place for the past 6 months and that the organization had been without a Volunteer Coordinator for some time in 2024.

Observed in Record Review. In 4 of 9 patient records reviewed, for active patients, it was noted by the nurse surveyor that for RR#4, RR#5, RR#7, and RR#9, the Chaplain did not complete the comprehensive assessment within five calendar days of the election of hospice care. There was no documentation in the electronic medical record to indicate why this was not completed. Findings were verified by the DON of Kansas and the DON of Missouri.

Observed in Record Review. In 2 of 9 patient records reviewed, for active patients, it was noted by the nurse surveyor that in RR#5 and RR#7, the bereavement risk assessment was not completed as part of the comprehensive assessment. This was confirmed by the DON of Kansas and the DON of Missouri.

Observed in Record Review. In 9 of 9 patient records reviewed, for active patients, it was noted by the nurse surveyor that for HV#1/RR#1,HV#2/RR#2, HV#3/RR#3, RR#4, RR#5, RR#6, RR#7, RR#8, and RR#9 the goals were not measurable. For example, “Patient will demonstrate understanding of appropriate use of medications for pain management” or “Patient will maintain optimum bowel functioning with food intake and stage of disease process.” Additionally, there were no short-term goals at start of care to address issues of immediate needs such as understanding medication management, symptom management, pain management, mobility, or safety, most were to be achieved by the end of the certification period, within a year, or they did not have a time frame at all. This was verified by the DON of Kansas and the DON of Missouri.

Observed in Record Review. In 3 of 9 patient records reviewed, of active patients, it was noted by the nurse surveyor that for HV#1/RR#1, HV#2/RR#2, and HV#3/RR#3 the patient’s IDG report date was being transitioned to another team that meets on a different day of the week. The transition occurred during the month of September and the IDG was held and documented twenty-two days apart. Which exceeds the maximum time apart of fifteen days. This was verified by the DON of Kansas and the DON of Missouri.

Observed in Record Review. In 3 of 9 patient records reviewed, of active patients, the nurse surveyor noted that care was not provided according to the hospice plan of care. HV#2/RR#2, there was a missed HHA visit with no explanation for the missed visit. HV#3/RR#3 there were three missed HHA visits with no explanation for the missed visit. RR#7, there were seven missed HHA visits over a three month period with no explanation for the missed visits. This was verified by the DON of Kansas and the DON of Missouri.

Observed in Patient Home. In 2 of 3 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned per their “Hand Hygiene Policy” and “Bag Technique Policy”. For example, during HOSHV#1/RR#1 the hospice aide washed her hands with soap and water in the patient’s sink then donned gloves. She then ran the shower to get the water warm, turned the shower off, put the patient’s bathmat in place on the floor, then went over to the patient and began helping take his clothes off without changing gloves or hand sanitizing. During HOSHV#2/RR#2 with a skilled nurse, proper hand technique was broken. The nurse removed her gloves without hand sanitizing and went in and out of her nursing bag without hand sanitizing. She did have a barrier for her bag and a small area of barrier where she laid out the packet with a disinfecting wipe for her equipment. She took her equipment out of her bag and took the patient’s vital signs without gloves on. In between taking a reading, she put the dirty equipment on the barrier on top of the disinfecting wipe packet and then pulled a pen out of her hair and documented in her notebook. The nurse then went back to the patient, got another reading, put the equipment down, and documented until all vital signs were taken and all dirty equipment was on the barrier. She then hand sanitized, put-on gloves, cleaned the equipment and laid all of the pieces of equipment back on the barrier where the dirty equipment had been. She then removed her gloves without hand sanitizing. During HV#3, the chaplain hand sanitized at her car then entered the home and began interacting with the patient and her husband. The chaplain touched the patient’s sock feet several times and at one point fished in her pocket for hand sanitizer which she could not find. She then asked to use the surveyor’s hand sanitizer. At the close of the visit, she held the patient’s hands for a closing prayer. After leaving the home she stated she did not know what she had done with her hand sanitizer.

Observed in Record Review. In 7 of 9 patient records reviewed, of active records with the HHA, it was noted by the nurse surveyor that for HV#2/RR#2, HV#3/RR#3, RR#4, RR#5, RR#7, RR#8, and RR#9 there were not any Hospice Aide Supervisory visits documented the required every fourteen days. Findings were verified with the DON of Kansas and the DON of Missouri.