Every finding on record at Hospice Care of Kansas, LLC

Upon patient record review, 1 of 23 (Patient #13) 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 13: Medication list reflects Triple Antibiotic Ointment for right heel wound only. No evidence of update to reflect new order for left heel effective 5/13/24.

Upon patient record review, 2 of 23 (Patient #6 & 7) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 6: MSW documents at 5/2/24 visit pt. "appears disheveled. Pt presents lethargic. Pt denies pain but pt. displays s/s of pain." Further states, "SW notes pt. appears more confused". "IDG team updated" There is no evidence of RN follow up with patient and/or facility either by visit or telephone, after "IDG team" notification to assess increased confusion, s/s pain, lethargy, or lack of grooming. Patient 7: RN documentation reveals change in respiratory status at visit on 5/1/24. Crackles noted to left lower lung in pt. with significant history of aspiration per prior visit notes. There is no evidence of report and coordination of care with physician.

Upon patient record review, 1 of 23 (Patient #1) 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 1: At the time of admission on 03/20/24 Volunteer services were accepted. There were no visit frequencies added to the Plan of Care, no problem(s), interventions, or goals present related to volunteer services and no evidence that volunteer services were initiated.

Upon patient record review, 1 of 23 (Patient #9) 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 9: RN initial assessment states patient blood sugar levels are checked 7 times daily. There is no evidence of FSBS checks and their frequency on the Plan of Care.

Upon patient record review, 3 of 23 (Patient #5,#7,#11) 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 5: Documentation shows Spiritual Care was declined per pt/cg. Plan of Care noted to have interventions and goals open for spiritual care services. Patient 7: Documentation shows Spiritual Care and MSW were declined per pt/cg. Plan of Care noted to have interventions and goals open for both spiritual care and MSW services. Patient 11: Oxygen precautions present on Plan of Care but no documentation of Oxygen therapy present in visit notes, interventions/goals, or medication list from SOC to present date. In addition, LPN documents on 2/1/24 and 2/6/24 visits the use of "Health Shakes PRN". The updated plan of care does not contain this supplement.

Upon client record review, 2 of 23 (Patient #3,#11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: Volunteer services requested upon admission, 8/3/23. Supplemental order completed 8/16/23 with frequency of once monthly. There was no volunteer visit completed September 2023 or November 2023. There is no evidence of an MD order to decrease frequency or any documentation of a refused visit. In December 2023 there were two volunteer visits conducted on 12/5/23 & 12/28/23 with no evidence of a change in frequency per MD order. Patient 11: Plan of Care lists frequency for Spiritual Care Services at 1M1, 2M2 until discontinued on 3/1/24. There are no spiritual care visits for the month of February and no evidence of missed/refused visits. Also, HHA visit frequency of twice weekly was not met the week of 2/25/24. No evidence of missed/refused visit documented.

Upon patient record review, 2 of 23 (Patient #21 & 22) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 21: No evidence of any bereavement support offered/provided past patient expiration. Patient had no family or friends listed as contacts however, patient did reside in a facility. No evidence found of facility staff refusal or acceptance r/t bereavement needs and services. Patient 22: Bereavement services were initiated for survivors at the patients' time of death 10/08/23. Services were continued through third month with bereavement activity documented 12/23/23. There is no further documentation present with bereavement services ended in EMR on2/9/24. There is no evidence of the bereaved requesting services to end.

Upon patient record review, 3 of 23 (Patient #5, 11, & 16) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • 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 Patient 5: Aide instructions at the time of chart review, dated 5/10/24 did not contain Oxygen precautions, address the presence and instructions for dressing to right knee, nor alert for infectious disease. Patient 11: Patient noted to have decreased visual acuity requiring glasses and hearing impairment at time of initial assessment. These are not listed on the aide instructions for patient safety and communication needs. Patient 16: Patient noted to have decreased visual acuity requiring glasses and hearing impairment at time of initial assessment4/26/24. These are not currently listed on the aide instructions for patient safety and communication needs. Fall precautions are not listed on the aide instructions but are present on patient plan of care.

Upon patient record review 4 of 23 (Patient #8, 11, 12, &13) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 8: HHA visit 5/6/24 includes "other" task documented per aide, " assisted with eating lunch". The task of offering/assisting with meals is not included in the aide instructions. Patient 11: HHA visit frequency of twice weekly was not met the week of 2/25/24. No evidence of missed/refused visit documented. Patient 12: HHA frequency of twice weekly per Plan of Care. HHA visits the week of 5/5/24 reflect no evidence of missed visit documentation or refusal for the first visit of the week. Patient 13: HHA frequency twice weekly. There is only one visit documented the week of 4/15/24 with no evidence of missed/refused visit.

Upon patient record review 1 of 23 (Patient #11) 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 11: No evidence of RN supervisory visit performed from initiation of HHA services on 1/15/24 until 2/23/24. Also, supervisory visit completed for HHA services on 3/19/24 but not again until 4/16/24.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Annual volunteer services for 2023 equals 3.23% of the total patient care hours of all paid hospice employees and contract personnel.

Based on document review, policy review and interviews, the hospice failed to ensure the patient received effective pain management that was free from significant medication error, for 1 (Patient 2) of 4 records reviewed. This deficient practice has the potential to affect the safely all patients who have medications managed by the hospice. --- Findings Include: Review of hospice policy titled ";Patient Bill of Rights", Policy, No. 2–002, Revised 1/12/23, showed patients have a right to receive effective pain management. Review of hospice policy titled ";Pain Assessment", Policy No. 4–046, Revised 8/30/18, showed patient/ family, and caregiver education would focus on the use of and side effects of analgesics and or adjuvant meds, expected responses to therapy and importance of administering medication according to prescribed dosage and frequency. Patient 2 Review of the hospice IDG [Interdisciplinary Group] Comprehensive Assessment and Plan of Care Update Report for the benefit dates of 09/07/23 through 09/24/23, showed the patient was admitted to hospice, in her own home, with a primary diagnosis of Ischemic Cardiomyopathy (reduced blood flow cardiac disease) with additional diagnose(s) of Hypertension (high blood pressure), Atrial Fibrillation (fast, irregular heartbeat) and Primary Osteoarthritis, Right Shoulder (progressive breakdown of joint cartilage and bone). Review of a "Visit Note Report" completed by Staff A, Registered Nurse (RN) on admission, dated 09/07/23, showed Patient 2 suffered from severe, uncontrollable pain in her right shoulder due to osteoarthritis and that she had been having episodes of palpitations with light headedness, dizziness and increased perspiration that had resulted in falls and a steady decline in function, and admission to hospice. Review of a "Visit Note Report" completed by Staff B, RN on 09/11/23 showed the patient and her husband reported bone on bone pain and had been preparing to undergo shoulder replacement but could not because of her cardiac status. The patient rated her pain at ";7" (pain scale where 0 is least pain and 10 is most pain) and confirmed taking Tylenol only. The patient and her husband confirmed past pain meds were ineffective or caused drowsiness, that her antidepressant was not effective and requested assistance securing respite care for the patient. The Visit Note Report confirmed orders were received to increase the antidepressant and add Tramadol (analgesic/anti-inflammatory) 50 milligram (mg) added every 6 hours by mouth for pain. Review of a "Visit Note Report" completed by Staff C, RN on 09/15/23 showed the RN answered questions from the patients husband and then reviewed medications with the physician. An order for Morphine ER 30 mg, Extended Release (analgesic/anti-inflammatory), 1 tablet by mouth at bedtime, was obtained for pain. Review of a "Visit Note Report" completed by Staff D, Medical Social Worker, on 09/19/23 showed the social worker met the patient and family at the nursing facility to assist with the transition to the scheduled 5-day respite stay (An in-patient stay in a Medicare-approved nursing home, for short-term relief for caregivers in the home) and confirmed admission to the nursing facility. Review of a "Visit Note Report" completed by Staff B, RN on 09/19/23 showed the patient verbalized new pain located in the abdomen, reporting abdominal soreness due to vomiting earlier in the day from a headache. An order was obtained for Morphine 10 mg/5 ml oral solution, 5 mg, two times daily, for pain. Review of a "Client Care Coordination Note", completed by the answering service (on call), dated 09/22/23 at 11:03 PM, showed the nursing facility called to report the patient was having hallucinations believed to may have been due to changes in medications. The nursing facility reported Morphine 5 mg was new and was held this evening due to changes in levels of consciousness. Review of a "Visit Note Report" completed by Staff A, RN (on-call), on 09/22/23 at 11:37 PM showed PRN (as needed) visit for agitation and hallucinations. The assessment showed the patients pain at ";10" and was evaluated using an assessment tool for confused and non-verbal patients and ";upon arrival to facility patient is found in bed hollering out nonsensical words and phrases. She is extremely diaphoretic [sweating] but does not have a fever. Pupils are pinpoint despite it being dark in room. She cries frequently throughout visit. Staff report her being combative earlier in the evening which is extremely out of character for her. She is tachycardic (fast heart rate) and appears to be short of air. Orders received for pulse Oximetry (at 85%) and oxygen. Discussion with staff shows that the patients evening dose of MSIR [Morphine] was held per family request as patient has been extremely somnolent, unable to speak, eat, etc. today. Last dose given around 9 AM (approx. 15 hours ago). Staff report that for the last 36 hours patient has mostly slept and has been very difficult to arouse. Her family did not like this and requested the scheduled morphine be stopped as this is a new medication for her. Medication review and visual inspection of MSIR shows that patient has inadvertently been receiving the incorrect dose of MSIR. Order faxed from the hospice agency is for 5mg BID [twice a day] of Morphine concentrate 10 mg/5 ML [milliliter]. Order entered into the facility computer matching agency order equating to 2.5 MLs be given to make the 5 MG. However, the concentration of the medication is actually 100mg/5ML, not 10mg/5MLs, therefore patient should have only received 0.25 MLS, not 2.5MLS. [Pt received a total of 3 doses at 50 mg per dose; 45 milligrams per dose more than ordered by the physician]. Doctor notified of error, orders received to continue 5 mg order and for 5-10mg hourly prn (as needed). On call Pharm D (pharmacist) also consulted and they agreed with orders and did not recommend any further action. Patients husband was notified of the error and agrees to having another dose of morphine being given as patient appears to be in a large amount of pain. 5Mg of MSIR administered. This RN sat with patient and held her hand until she was calmed down." Review of a "Visit Note Report" completed by Staff A, RN, dated 09/23/23, showed a visit was made to follow up on the patients decline; patient was found with excessive secretions; Oral suctioning and Medications for secretions were ordered for ";breathing very labored with a loud rattle," with patient diaphoretic and tense; non-responsive to questions. The Visit Report showed medications were administered for symptoms, with little improvement and family requesting no further medications be given. Review of a "Visit Note Report" completed by Staff A, RN, dated 09/24/23, showed the patient expired at 5:03 PM at the nursing facility. During an interview conducted on 10/18/23 at 10:30 AM, Staff E, Hospice Administrator, confirmed the nursing facilitys practice was to accept medications from the patients home for administration to the patient, while a patient is admitted for a short-term, respite stay. She stated the husband provided the medications directly to the nursing facility when the patient was admitted for respite and that included the bottle of Morphine with the 100mg/5Ml concentration administered to the patient incorrectly by nursing facility staff. She confirmed the hospice was not aware of that bottle nor of any dosing concerns, until after the hospice was notified, on-call, by the nursing facility of the condition change of the patient, that led to the hospice nursing visit where the medication error was discovered by hospice and reported to the physician and pharmacist. The hospice failed to ensure the patient received effective pain management that was free from medication errors.

Based on document review, policy review and interviews, the hospice failed to maintain a system of communication to ensure the interdisciplinary group (IDG) maintained responsibility for coordination of services provided through contracted services for one of three patient records reviewed (Patient 2). This deficient practice has the potential to place patients, families, and caregivers at risk for unmet needs, expectations, and services. --- Review of a policy titled ";Care/Coordination Policy No. 4-099," Revised 11/2020 showed the purpose was to ensure the coordination of services for each patient and to minimize the potential for missed, competing or duplicated services. It showed timely and ongoing communication was the responsibility of each team member and would be appropriate to the needs and abilities of the patient/patient caregiver, and relevant to the care services provided. The policy showed organization personnel, including those providing contractor services, would communicate changes in a timely manner and that all organizations involved in patient care, including those who provided contracted services, would have access to the plan of care and all other relevant patient information to ensure coordination and continuity; all personnel would be knowledgeable regarding patient needs, goals of care, and services. Patient 2 Review of Patient 2s medical record showed the patient was admitted for services on 12/14/22 and lived at home with his wife as primary caregiver. Family members assisted in the home with care. Patient 2s primary diagnosis was Malignant Neoplasm of Prostate with metastasis to the femur bone, bladder, spine, pelvis, lymph nodes in groin, brain, shoulders and hips. Review of the hospice Coordination Note, dated 12/22/22, completed by Staff C, RN Case Manager, showed 12/20/22 the nurse added scheduled daily visits by nursing staff to the patient, due to his health decline. Review of hospice documentation titled ";Message Report", on-call logs transcribed by the answering service to the hospice for the date of 12/24/22 at 9:42 AM, showed Patient 2s wife phoned the answering service to request the supervisor call and to report discolored foaming from patient. The log showed the answering service referred the call to the supervisor on-call and to the on-call nurse for follow up. The log confirmed follow-up contact was completed by the hospice supervisor and a visit completed by the on-call nurse on 12/24/22 at 10:15 AM. During an interview on 01/04/23 at 8:45 AM the patients wife confirmed she tried to call the main supervisor (supervisor was not on call) for the hospice who admitted the patient, then called the answering service, the morning of 12/24/22. She confirmed she was told by the answering service that she was being disrespectful and rude to the operator and that they could not help her if she was upset and rude. She confirmed that she was very upset during the call and that her husband passed away later that day. Review of hospice administrative documentation dated 12/28/22 at 3:53 PM showed Staff A, Administrator received and communicated the answering service complaint to the Corporate Quality staff for review with the answering service. During an interview conducted on 01/04/23 at 2:05 PM, Staff A, Administrator confirmed the hospice had received the wifes complaint and reported the answering service call to the hospice corporate office, for review, follow up and corrective action with the answering service (contracted provider) leadership. Staff A confirmed the answering service provider completed an investigation and determined that the agent spoke inappropriately to the wife and that disciplinary action was in progress for the agent. The hospice failed to maintain a system of communication to ensure contracted services on call were handled appropriately.