Every finding on record at Home Health & Hospice of Kansas

Based on record review, policy review, and interview, the Hospice Agency (HA) failed to ensure the immediate investigation of alleged violations and immediate action to prevent further potential violation for 1 (Patient 1) of 1 patient allegation that required immediate investigation. The hospice's failure to immediately investigate alleged complaints had the potential to place all patients at risk for compromised preservation of individual patient rights, compromised patient safety and inadequate management of the hospice patient's rights in the home. --- Findings Include: Review of the HA policy titled, ";Nondiscrimination Policy and Grievance Process," revised February 2017, showed, ";Any person who believes she or he has been subjected to discrimination or who believes he or she has witnessed discrimination, in contradiction of the policy stated above, may file a grievance under this procedure. It is against the law for Home Health of Kansas, LLC to retaliate against anyone who files a grievance or cooperates in the investigation of a grievance. ... Grievances must be submitted to the Section 504 Coordinator within 30 days of the date the person filing the grievance becomes aware of the alleged discriminatory action. ... A complaint may be filed in writing, or verbally, containing the name and address of the person filing it ("the grievant"). The complaint must state the problem or action alleged to be discriminatory and the remedy or relief sought by the grievant. ... The Section 504 Coordinator (or her/his representative) will conduct an investigation of the complaint to determine its validity. This investigation may be informal, but it must be thorough, affording all interested persons an opportunity to submit evidence relevant to the complaint. The Section 504 Coordinator will issue a written decision on the grievance no later than 30 days after its filing." Patient 1 Review of Patient 1s record showed a 95 year old male admitted to HA on 02/27/23 with a primary diagnosis of unspecified severe protein-calorie malnutrition, and additional diagnoses of adult failure to thrive, unspecified dementia with other behavioral disturbance, hallucinations, restlessness, agitation, metabolic encephalopathy, dysphagia, cognitive communication deficit, mixed receptive-expressive language disorder, dysarthria, anarthria, essential primary hypertension, type 2 diabetes mellitus with diabetic polyneuropathy, chronic pain, depression, benign prostatic hyperplasia, gastro-esophageal reflux disease without esophagitis, vitamin d deficiency, spondylolysis, actinic keratosis, inflamed seborrheic keratosis, cholelithiasis without obstruction, hemangioma, solitary pulmonary nodule, rash, nontoxic single thyroid nodule, and nevus non-neoplastic. Patient 1s record showed patient death and discharge from HA on 11/22/24. Review of Patient 1s record showed on 10/12/24 a Home Health Aide (HHA) visit note from Staff B, Home Health Aide (HHA,) and Assistant Bereavement Coordinator (ABC,) documented in the patient record. Further review of Patient 1s record showed on 10/13/24 a HHA visit note from Staff B, HHA, ABC, documented in patient record. During an interview on 01/22/25, at 3:35 PM, Staff B, HHA, ABC, stated that private duty hours were provided for Patient 1 from 4:00 PM-7:00 PM, Monday- Friday and additional hours from 10:00 AM- 7:00 PM on Saturday, throughout the private duty care for Patient 1. Staff B, HHA, ABC confirmed providing private duty services for Patient 1 and Patient 1s spouse since 2020. Staff B, HHA, ABC, confirmed knowing Patient 1 very well and on several occasions throughout care when there was an issue, like the air conditioner breaking, Patient 1 was brought to Staff Bs home for a week or two. Staff B, HHA, ABC, also stated that on multiple occasions Staff B and Staff Bs family stayed at a lake house with Patient 1 and Patient 1s spouse. Staff B, HHA, ABC, confirmed handling all finances for Patient 1, having access to the check book, credit cards, and bank accounts. Staff B, HHA, ABC stated that Patient1's Family Member (F) 1, would frequently request errands be run by Staff B for F1 and Family member (F)2, requesting the credit card or items to be purchased by Staff B from the trust and given to the family members. Staff B, HHA, ABC, stated that finances or the trust was never discussed by F1 until after the 2-week notice was given. Staff B, HHA, ABC, kept all messages from the F1 and family regarding Patient 1s private duty care in Staff Bs phone. Staff B was able to recall the month of April 2024 and no conversation was documented in the messages regarding concern for the amount of money left in Patient 1s trust. Staff B, HHA, ABC, confirmed not providing private duty for any other clients or patients for the HA. Staff B, HHA, ABC, confirmed not performing any duties that involved finance for any of the hospice patients. During an interview on 01/22/25 at 12:10 PM, Staff C, Director of Nursing (DON) stated that a phone call was made to Patient 1s family a few days after the complaint stating that Patient 1s family member F1 was notified that an Adult Protective Services (APS) report regarding the complaint involving Staff B, Home Health Aide (HHA), Assistant Bereavement Coordinator (ABC), had been filed. Staff C, DON, stated that no grievance letter with investigation findings and actions was sent to Patient 1s family. Staff C, DON, stated that no further investigation beyond initial questioning and filing of the APS report had been performed as Staff B, HHA, ABC, denied the allegations and had no previous history of complaint or concerns with any other patients, families, or staff in the 7+ years of working for the HA. Staff C, DON, stated that no investigation of any other patients that Staff B, HHA, ABC, was caring for at that time were completed. Staff C, DON, stated that Staff B, HHA, ABC, was not assigned to provide any cares for Patient 1 after the time of the complaint. Staff C, DON stated that Staff B, HHA, ABC, had made 2 visits to Patient 1 after the complaint was filed on 10/12/24 and 10/13/24 during an on-call need and was instructed after that time to make no further visits on Patient 1.

Based on document review, policy review, and interview, the Hospice Agency (HA) failed to ensure verified violations were reported within 5 working days to the state survey agency for 1 (Patient 1) of 1 patients reviewed who required reporting to the state survey agency. The hospice's failure to report verified violations had the potential to place all patients at risk for compromised preservation of individual rights and compromised health and safety of the hospice patient in the home. --- Findings Include: Review of the HA policy titled, ";Nondiscrimination Policy and Grievance Process," revised February 2017, showed, ";Any person who believes she or he has been subjected to discrimination or who believes he or she has witnessed discrimination, in contradiction of the policy stated above, may file a grievance under this procedure. It is against the law for Home Health of Kansas, LLC to retaliate against anyone who files a grievance or cooperates in the investigation of a grievance. ... Grievances must be submitted to the Section 504 Coordinator within 30 days of the date the person filing the grievance becomes aware of the alleged discriminatory action. ... A complaint may be filed in writing, or verbally, containing the name and address of the person filing it ("the grievant"). The complaint must state the problem or action alleged to be discriminatory and the remedy or relief sought by the grievant. ... The Section 504 Coordinator (or her/his representative) will conduct an investigation of the complaint to determine its validity. This investigation may be informal, but it must be thorough, affording all interested persons an opportunity to submit evidence relevant to the complaint. The Section 504 Coordinator will issue a written decision on the grievance no later than 30 days after its filing." Patient 1 Review of Patient 1s record showed a 95 year old male admitted to HA on 02/27/23 with a primary diagnosis of unspecified severe protein-calorie malnutrition, and additional diagnoses of adult failure to thrive, unspecified dementia with other behavioral disturbance, hallucinations, restlessness, agitation, metabolic encephalopathy, dysphagia, cognitive communication deficit, mixed receptive-expressive language disorder, dysarthria, anarthria, essential primary hypertension, type 2 diabetes mellitus with diabetic polyneuropathy, chronic pain, depression, benign prostatic hyperplasia, gastro-esophageal reflux disease without esophagitis, vitamin d deficiency, spondylolysis, actinic keratosis, inflamed seborrheic keratosis, cholelithiasis without obstruction, hemangioma, solitary pulmonary nodule, rash, nontoxic single thyroid nodule, and nevus non-neoplastic. Patient 1s record showed patient death and discharge from HA on 11/22/24. Review of Patient 1s record showed on 10/12/24 a Home Health Aide (HHA) visit note from Staff B, Home Health Aide (HHA,) and Assistant Bereavement Coordinator (ABC,) documented in the patient record. Further review of Patient 1s record showed on 10/13/24 a HHA visit note from Staff B, HHA, ABC, documented in patient record. During an interview on 01/22/25, at 3:35 PM, Staff B, HHA, ABC, stated that private duty hours were provided for Patient 1 from 4:00 PM-7:00 PM, Monday- Friday and additional hours from 10:00 AM- 7:00 PM on Saturday, throughout the private duty care for Patient 1. Staff B, HHA, ABC confirmed providing private duty services for Patient 1 and Patient 1s spouse since 2020. Staff B, HHA, ABC, confirmed knowing Patient 1 very well and on several occasions throughout care when there was an issue, like the air conditioner breaking, Patient 1 was brought to Staff Bs home for a week or two. Staff B, HHA, ABC, also stated that on multiple occasions Staff B and Staff Bs family stayed at a lake house with Patient 1 and Patient 1s spouse. Staff B, HHA, ABC, confirmed handling all finances for Patient 1, having access to the check book, credit cards, and bank accounts. Staff B, HHA, ABC stated that Patient1's Family Member (F) 1, would frequently request errands be run by Staff B for F1 and Family member (F)2, requesting the credit card or items to be purchased by Staff B from the trust and given to the family members. Staff B, HHA, ABC, stated that finances or the trust was never discussed by F1 until after the 2-week notice was given. Staff B, HHA, ABC, kept all messages from the F1 and family regarding Patient 1s private duty care in Staff Bs phone. Staff B was able to recall the month of April 2024 and no conversation was documented in the messages regarding concern for the amount of money left in Patient 1s trust. Staff B, HHA, ABC, confirmed not providing private duty for any other clients or patients for the HA. Staff B, HHA, ABC, confirmed not performing any duties that involved finance for any of the hospice patients. During an interview on 01/22/25 at 12:10 PM, Staff C, Director of Nursing (DON) stated that a phone call was made to Patient 1s family a few days after the complaint stating that Patient 1s family member F1 was notified that an Adult Protective Services (APS) report regarding the complaint involving Staff B, Home Health Aide (HHA), Assistant Bereavement Coordinator (ABC), had been filed. Staff C, DON, stated that no grievance letter with investigation findings and actions was sent to Patient 1s family. Staff C, DON, stated that no further investigation beyond initial questioning and filing of the APS report had been performed as Staff B, HHA, ABC, denied the allegations and had no previous history of complaint or concerns with any other patients, families, or staff in the 7+ years of working for the HA. Staff C, DON, stated that no investigation of any other patients that Staff B, HHA, ABC, was caring for at that time were completed. Staff C, DON, stated that Staff B, HHA, ABC, was not assigned to provide any cares for Patient 1 after the time of the complaint. Staff C, DON stated that Staff B, HHA, ABC, had made 2 visits to Patient 1 after the complaint was filed on 10/12/24 and 10/13/24 during an on-call need and was instructed after that time to make no further visits on Patient 1.

Based on document review, policy review and interview the hospice failed to ensure a home health aide plan of care was developed for provision of hospice aide services for 1 (Patient 2) of 3 patients reviewed. Failure of the hospice to ensure the hospice aides followed a written plan of care has the potential to affect the type, quality, and provision of individualized personal care needs to hospice patients. --- Findings Include: Review of a hospice policy titled, "Hospice Aide Services: Policy No. H:2-005.1", revised January 2017, showed hospice aide services may be included when personal care is needed. These activities in accordance with the plan of care and physicians orders will be assigned and supervised by a hospice registered nurse. Hospice Aide assignments, plan of care and interventions will be documented and included in the patients medical record. Hospice aides will document care provided in accordance with the hospice aide assignment. Patient 2 Review of Patient 2's medical record, showed she was home patient admitted for service on 08/12/22 with a primary diagnosis pancreatic cancer with metastasis (cancer in secondary locations). The patients granddaughter was her primary caregiver with paid caregivers who provided assistance around the clock. She was ordered to receive hospice aide services 2 times a week. Review of Patient 2's Hospice Plan of Care (POC) for the Certification Period of 8/12/22 to 11/9/22 showed Discipline Orders/Treatments (Physician Orders): Aide, 2 wk x 12 wk (two times a week for twelve weeks), beginning during week of 8/14/22, ending 11/5/22. The POC did not include ";Interventions" (instructions for the aide for personal care) nor ";Goals" for Aide services that were ordered to be provided to the patient two times a week. Review of Patient 2s Aide Visit Note for the date of 08/17/22, completed by Staff C, Hospice Aide (HA) showed the aide assigned to the patient to provide personal care completed a HHA missed visit at 6:10 AM indicating personal care services were not completed. Review of Patient 2s Aide Visit Note for the date of 08/17/22 completed by Staff D, HA at 2:45 PM showed ";Gave bath with RNCM (Registered Nurse Case Manager)" confirming the completion of personal care services. Review of Patient 2s Aide Visit Note for the date of 08/20/22, completed by Staff E, HA from 3:05 PM through 6:08 PM was signed, but did not contain documentation of hospice aide services provided to Patient 2. During an interview on 02/01/23 at 11:15 AM, with the hospice administrator and nursing director, Staff A, RN, Chief Administrative Officer (administrator), confirmed Staff D, sat vigil (observation) at bedside in the patients home, to be a presence for the patient and family at the end of the patients life during the visit on 08/20/22. She confirmed personal care services were not performed during the 08/20/22 visit and that the visits frequency for hospice aide personal care services was not met. During the same interview, the Administrator confirmed a Hospice Aide plan of care had not been developed for Patient 2.