Every finding on record at Hospice Partners of Kansas, LLC

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the initial comprehensive assessment, to include the spiritual assessment, was completed no later than five (5) calendar days after the election of hospice care. Clinical Record 7: The patient elected the hospice benefit on 01/14/2025 and accepted Chaplain services on admission. On 01/27/2025, the Chaplain documented, "This writer just returned from vacation to find that the patient's former chaplain had not yet completed the initial assessment. This Chaplain will do so ASAP, therefore." The initial spiritual assessment was documented on 01/28/2025, which was outside the 5-day requirement. On 06/12/2025, during an interview and the joint record review, the Director of Clinical Services stated, "It shouldn't have been missed, that Chaplain no longer works here."

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 volunteers provided day-to-day 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 agency's volunteer cost savings report for the calendar year 2024 documented that the average volunteer hours equaled 3.13%. The documentation for January 2025 through May 2025 revealed that the hours averaged 0.36%. During an interview on 06/10/2025, the Volunteer Coordinator (VC) reported that the agency had struggled with volunteer recruitment and utilization. The VC said that in the two months that they had been in the role, they had increased recruitment activities and had three (3) individuals interested in starting, which would increase the total number of volunteers to five. The Administrator confirmed the struggle with recruiting volunteers and said that they are confident that with the new Volunteer Coordinator in place, they will have better results. A review of the volunteer cost savings report revealed that the agency did not ensure the volunteers provided day-to-day 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.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 11 (18%) of records reviewed revealed the hospice did not ensure that the drug profile was updated and contained the current orders for oxygen. Record #8 was reviewed and identified the patient elected hospice care on 8/22/2022. The comprehensive assessment dated 8/22/2022, documented the patient's use of oxygen per nasal canula on an as needed basis. The plan of care dated 8/22/2022 included orders for "oxygen at 2L/min per NC PRN." Oxygen was not included on the medication profile dated 8/22/2022. Record #0 was reviewed and identified the patient elected hospice care on 12/10/2021. The recertification comprehensive assessment dated 7/25/22 read in part, "patient now needs oxygen 2L for 30 minutes after meals." Oxygen was not included on the medication profile dated 12/10/2021. The clinical record did not include updates of the patient's medication profile. The Director of Clinical stated in interview on 8/29/2022, you are correct, the oxygen is not on the medication profile. We will get them updated. 2 of 11 (18%) of clinical records reveal that the hospice did not ensure that the drug profile was updated and contained the current orders for oxygen.

It is required that the hospice designates a registered nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 11 (9%) of records reviewed revealed that the hospice did not ensure the care provided followed the individualized plan of care. Record #1 was reviewed and identified the patient elected hospice care on 6/8/22. The plan of care dated 8/14/2022 ordered, "hospice nurse to measure wound weekly." A review of the completed skilled nursing visit notes dated 8/18/22, 8/23/22, 8/25/22, and 8/29/2022, revealed missing documentation of wound measurements for 12 days, 5 days outstanding. During an interview on 8/30/2022, the Director of Clinical Services stated in part, you are correct, there are no measurements of the wound as ordered on the plan of care. 1 of 11 (9%) of clinical records revealed that the hospice did not ensure that the care provided followed the individualized plan of care.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 11 (9%) records reviewed of patient receiving aide services revealed that the agency did not ensure that the aide care plan provided sufficient instruction to the aide to perform the appropriate care within the aide's scope of practice. Record #0 was reviewed and identified the patient elected hospice care on 12/10/2021. The skilled nursing (SN) assessment dated 7/25/2022, noted the patient had declined, required oxygen, and had a stage 4 pressure ulcer. The plan of care dated 7/25/2022 included orders for oxygen and wound care. The aide's care plans dated 7/25/2022 and 8/30/2022, did not include direction to the aide regarding the wound dressing or oxygen. During the interview 8/29/2022, the Director of Clinical Services stated in part, you are correct, there is nothing on the aide care plan guiding the aide, we will re-educate nurses now and get the care plans updated. 1 of 11 (9%) clinical records with aide services revealed that the agency did not ensure that the aide care plan provided sufficient instruction to the aide to perform appropriate care within the aide scope of practice.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 11 (18%) records reviewed of patients receiving aide services revealed that the hospice did not ensure the aide provided services as ordered on the aide plan of care. Record #2 was reviewed and identified the patient elected hospice care on 7/12/2022. The aide care plan dated 7/13/2022, included the assigned tasks; bathroom assistance, draw sheet, incontinence pads, clothing assist, complete bed bath, foot care, nail care, perineal care, shampoo, and skin care. The aide visit note dated 7/15/2022, the aide documented that the assigned tasks were acknowledged, but did not document that the tasks were complete. In addition, the aide visit note dated 7/22/2022, the aide did not document the assigned tasks; complete bed bath, foot care, nail care, oral care, and shampoo as completed. The reasons the tasks were not completed were not documented. Record #0 was reviewed and identified the patient elected hospice care on 12/10/2021. The aide care plans dated 7/25/2022 and 8/30/2022, included the assigned tasks; nail care, and shave every visit. The aide visit note dated 8/5/2022, the assigned tasks; nail care and shave every visit were not marked as completed. The reasons the tasks were not completed were not documented. During an interview on 8/29/2022, the Director of Clinical Services stated in part, I don't know why the aide would not have completed those tasks. We had trouble with that aide and she is no longer here. 2 of 11 (18%) clinical records with aide services revealed that the hospice did not ensure that the aide provided services as ordered on the aide plan of care.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following; a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 1 (100%) records reviewed of a discharged patient, revealed the hospice did not ensure the discharge summary included current physician orders, treatments, and pain management. Record #10 was reviewed and identified the patient elected hospice care on 1/26/2022. The discharge summary dated 4/20/2022, faxed to attending physician on 4/21/2022, included patient demographics, diagnosis, staff assignments, durable medical equipment provider, pharmacy provider, allergies and discharge reason. Review of the clinical record revealed the patient was prescribed Tramadol for the management of chronic pain. The discharge summary was missing a summary of the treatments, pain management, medications, and current physician orders. The Director of Clinical Services stated in interview on 8/29/2022, I see what you mean. We are going to have to start including the plan of care with the discharge summary. We were just following the software process and didn't realize it wasn't all being included. 1 of 1 (100%) records with a live discharge reveal that agency did not ensure that the discharge summary included all of the required elements including latest physician orders, treatments and pain management.