Every finding on record at Hospice Partners of Kansas, LLC

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 clinical record review, interview, and observation. In 1 of 19 (5%) clinical records reviewed and home visits observed, the agency did not ensure that the medications were reviewed and updated to the drug profile. Clinical Record 6/ Home Visit 1: The patient elected hospice care on 08/26/2024 with a diagnosis of unspecified severe protein-calorie malnutrition. The patient resided in a skilled nursing facility (SNF). During the home visit with the Hospice Aide (HA) on 07/23/2025, the hospice medication profile was compared to the medication list provided by the SNF nurse. The hospice medication profile dated 07/23/2025 documented milk of magnesium, morphine sulfate, omeprazole, hyoscyamine, lorazepam, and Losartan as current medications. The SNF medication list included discontinuation for the milk of magnesium (discontinued 12/19/2024), morphine sulfate (discontinued 04/29/2025), omeprazole (discontinued 12/19/2024), hyoscyamine (discontinued 01/09/2025), lorazepam (discontinued 09/23/2024), and Losartan (discontinued 09/09/2024). There was no documented evidence that the patient's medication profile was updated to include the patient's current medication regimen. During a joint record review and interview on 07/23/2025, the Regional Vice President of Quality and Compliance agreed there was no documented evidence that the medications were reviewed and updated to the drug profile.

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 clinical record review and interview. In 1 of 17 (6%) clinical records reviewed of patients who received Hospice Aide services, the hospice did not ensure that the Hospice Aide (HA) received written patient care instructions to meet the patient's needs. CLINICAL RECORD 6: The patient elected hospice care on 08/26/2024 and resided in a skilled nursing facility (SNF). The hospice plan of care dated 05/28/2025 ordered HA services three times a week. The HA care plan documented in the electronic medical record (EMR), completed by the Registered Nurse (RN) dated 06/04/2025 through 06/28/2025, assigned the HA the relevant tasks every visit: bed bath, denture care, oral care, foot care, nail care, perineal care, shampoo, shave, and skin care. However, the contract HA was not able to access the written patient care instructions in the EMR. There was no documented evidence that the RN provided the contracted HA [Personnel Record 12] with the patient's written care plan or assigned tasks for the HA visits dated 06/04/2025, 06/06/2025, 06/09/2025, 06/11/2025, 06/13/2025, 06/16/2025, 06/18/2025, 06/20/2025, 06/23/2025, 06/25/2025, and 06/26/2025. During a joint record review and interview on 07/24/2025, the Patient Care Manager agreed there was no documented evidence that an RN provided the contracted HA with written patient-specific care instructions. The Patient Care Manager stated, "We usually go over it with them on the phone, but nothing is documented. The contracted aides do not have access to our records (EMR)."

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review and interview. In 1 of 17 (6%) clinical records reviewed of patients who received Hospice Aide services, the hospice did not ensure that the patient's record included completed visit notes for Hospice Aide (HA) services. CLINICAL RECORD 6: The patient elected hospice care on 08/26/2024 and resided in a skilled nursing facility (SNF). The hospice plan of care dated 05/28/2025 ordered HA services three times a week. The HA care plan dated 06/04/2025 through 06/28/2025 assigned the HA the relevant tasks every visit: bed bath, denture care, oral care, foot care, nail care, perineal care, shampoo, shave, and skin care. During a review of the clinical record, HA visit notes located in the uploaded documents folder revealed HA visit notes dated 06/04/2025, 06/06/2025, 06/09/2025, 06/11/2025, 06/13/2025, 06/16/2025, 06/18/2025, 06/20/2025, 06/23/2025, 06/25/2025, and 06/26/2025. The visit notes documented that an HA visit was performed; however, they did not specify whether the HA provided services or completed the assigned tasks. During a joint record review and interview on 07/24/2025, the Patient Care Manager agreed there was no documented evidence that hospice aide services were provided as ordered on the plan of care. Additionally, the Patient Care Manager stated, "We identified this problem recently. We added a new checklist for the aides to document which tasks were completed. Unfortunately, this was not added until the beginning of July, and we have no evidence to show the services were provided for these dates."

It is required that the patient’s pain is assessed as part of a comprehensive assessment. The documented assessment of the patient’s pain includes: The patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 2 of 11 (18%) clinical records reviewed revealed the hospice did not ensure the patient’s pain was assessed as part of the comprehensive assessment, to include the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. The agency’ policy, “Pain and Symptom Management,” stated in part: “Pain will be assessed as part of every patient contact if patient reports pain or is at risk for pain. The patient’s pain goal will also be assessed utilizing a pain scale as determined by the Agency. Determine if the patient is satisfied with the established goal and/or the current level of pain control.” Record 3: The patient’s date of election was 1/28/2022 with a primary diagnosis of malignant neoplasm of liver. The following nursing assessments documented a review of the patient's pain scores based on a 10-point scale: On 7/1/2022 the reported pain score was 6 out of 10; on 9/7/2022 the reported pain score was 5 out of 10; on 9/28/2022 the reported pain score was 5 out of 10; and on 10/4/2022 the reported pain score was 4 out of 10. Each of the identified assessments included documentation that described the "worst intensity 0", the "effect on quality of life yes", the acceptable level of pain 0", and "pain is an active problem yes". There was no documented evidence that described the patient's and/or family's satisfaction with the currently level of pain control was assessed. Record 6: The patient’s date of election was 1/28/2022 with a primary diagnosis of malignant neoplasm of liver. The following nursing assessments documented a review of the patient's pain scores based on a 10-point scale: On 9/27/2022 the reported pain score was 3 out of 10; and on 10/3/2022 the reported pain score was 4 out of 10. Each of the identified assessments included documentation that described the "worst intensity 0", the "effect on quality of life yes", the acceptable level of pain 0", and "pain is an active problem yes". There was no documented evidence that described the patient's and/or family's satisfaction with the currently level of pain control was assessed. The Registered Nurse was interviewed on 10/6/2022 and agreed the patient’s goal for pain and the patient’s satisfaction with the currently level of pain control was not assessed. The Registered Nurse stated, “I do not complete those sections because they are not flagged as mandatory, so the goal defaults to zero.” The Director of Clinical Services was interviewed on 10/6/2022 and agreed the assessments did not include patient and/or family goals for pain management and their satisfaction with the current level of pain control. The agency’ policy “Pain and Symptom Management,” stated in part, “Pain will be assessed as part of every patient contact if patient reports pain or is at risk for pain. The patient’s pain goal will also be assessed utilizing a pain scale as determined by the Agency. Determine if the patient is satisfied with the established goal and/or the current level of pain control.” Record 3: The patient’s date of election was 1/28/2022 with a primary diagnosis of malignant neoplasm of liver. The comprehensive nursing assessment on 7/1/2022 was reviewed and revealed the patient had pain 6/10. The comprehensive nursing assessment on 9/7/2022 was reviewed and revealed the patient had pain 5/10. The comprehensive nursing assessment on 9/28/2022 was reviewed and revealed the patient had pain 5/10. The comprehensive nursing assessment on 10/4/2022 was reviewed and revealed the patient had pain 4/10. Each of the identified assessments documented: worst intensity 0, effect on quality of life yes, acceptable level of pain 0, pain is an active problem yes. In the identified assessments, there was no documented evidence the patient’s/family’s satisfaction with the currently level of pain control was assessed. Record 6: The patient’s date of election was 1/28/2022 with a primary diagnosis of malignant neoplasm of liver. The comprehensive nursing assessment on 9/27/2022 was reviewed and revealed the patient had pain 3/10. The comprehensive nursing assessment on 10/3/2022 was reviewed and revealed the patient had pain 4/10. Each of the identified assessments documented: worst intensity 0, effect on quality of life yes, acceptable level of pain 0, pain is an active problem yes. In the identified assessments, there was no documented evidence the patient’s/family’s satisfaction with the currently level of pain control was assessed. The Registered Nurse was interviewed on 10/6/2022 and agreed, the patient’s goal for pain and the patient’s satisfaction with the currently level of pain control was not assessed.” The Registered Nurse was interviewed on 10/6/2022 and stated, “I do not complete those sections because they are not flagged as mandatory, so the goal defaults to zero.” The Director of Clinical Services was interviewed on 10/6/2022 and agreed, the assessments did not include the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control.

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. The medication review process includes the identification of the following: the effectiveness of 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. In 2 of 11 (18%) clinical records reviewed the hospice did not ensure a complete medication review was conducted with each comprehensive assessment and/or when new medication is added or changes are made to existing medication. Record 2: The patient’s date of election was 2/21/2021 with a primary diagnosis of heart failure. The medication profile was reviewed on 10/5/2022 and revealed documentation of the following medications: Bactrim DS twice day for 14 days effective 7/28/2022; Diflucan 150mg one tablet effective 9/16/2021; and Zyrtec 10mg one time a day effective 11/15/2021. During the home visit on 10/5/2022, the patient was interviewed about these medications. The patient confirmed she had stopped taking Bactrim DS over a month ago, had not taken Diflucan for at least 6 months, and confirmed she had not taken Zyrtec since the new allergy medication, Loratadine, was started on 9/13/2022. Record 3: The patient’s date of election was 1/28/2022 with a primary diagnosis of malignant neoplasm of liver. The medication profile was reviewed on 10/5/2022 and contained documentation of the following medications: Fentanyl 25mcg/hr patch every every 3 days effective 1/28/2022; Trazodone 100mg 1 time a day; and Ibuprofen 800mg three times a day. During the home visit on 10/5/2022 with the registered nurse (RN), the RN was not observed completing a medication review. The patient was interviewed at the end of the visit to discuss their use of Fentanyl, Trazodone and Ibuprofen. The patient stated, “I haven’t taken those in at least two months; they do not work.” The Registered Nurse was interviewed on 10/5/2022 and stated: “I need to update the medication list. I have not completed a medication review for either of these two patients in at least two months, since I started this caseload.” The Director of Clinical Services was interviewed on 10/5/2022 and stated, “I did talk to the RN and she is updating the med lists now.” The Director of Clinical Services agreed, there is no documented evidence the comprehensive medication review was completed when changes were made. Record 2: The patient’s date of election was 2/21/2021 with a primary diagnosis of heart failure. The medication profile was reviewed on 10/5/2022 and revealed Bactrim DS twice day for 14 days effective 7/28/2022, Diflucan 150mg one tablet effective 9/16/2021, Zyrtec 10mg one time a day effective 11/15/2021. During the home visit on 10/5/2022, the patient was interviewed about these medications. The patient confirmed she had not taken Bactrim DS since over a month ago. The patient confirmed she had not taken Diflucan for at last 6 months. The patient confirmed she had not taken Zyrtec since the new allergy medication Loratadine was started, 9/13/2022. Record 3: The patient’s date of election was 1/28/2022 with a primary diagnosis of malignant neoplasm of liver. The medication profile was reviewed on 10/5/2022 and revealed Fentanyl 25mcg/hr patch every every 3 days effective 1/28/2022, Trazodone 100mg 1 time a day, Ibuprofen 800mg three times a day. During the home visit on 10/5/2022 with the registered nurse (RN), the RN was not observed completing a medication review. The patient was interviewed at the end of the visit to discuss Fentanyl, Trazodone and Ibuprofen. The patient stated, “I haven’t taken those in at least two months, they do not work.” The Registered Nurse was interviewed on 10/5/2022 and stated, “I need to update the medication list. I have not completed a medication review for either of these two patients in at least two months, since I started this caseload.” The Director of Clinical Services was interviewed on 10/5/2022 and stated, “I did talk to the RN and she is updating the med lists now.” The Director of Clinical Services agreed, there is no documented evidence the comprehensive medication review was completed.

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; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 2 (100%) clinical records reviewed of patients who were discharged from hospice, the hospice did not ensure that the discharge summary provided to the attending physician included a summary of the patient’s stay, the current plan of care and latest physician’s orders. Record 10: The patient’s date of election was 10/31/2021. The patient was discharged to a non-contracted facility on 8/1/2022. There was no documented evidence the discharge summary sent to the attending included a summary of the patient’s stay, the current plan of care and latest physician’s orders. Record 11: The patient’s date of election was 3/29/2022. The patient was discharged when they revoked hospice to seek aggressive treatment on 4/4/2022. There was no documented evidence the discharge summary sent to the attending included a summary of the patient’s stay, the current plan of care and latest physician’s orders. The Director of Clinical Services was interviewed on 10/5/2022 and agreed, the discharge summary sent to the attending did not include a summary of the patient’s stay, the current plan of care or latest physician’s orders. Record 10: The patient’s date of election was 10/31/2021. The discharge was reviewed and revealed the patient was discharged-non contracted facility on 8/1/2022. There was no documented evidence the discharge summary sent to the attending included a summary of the patient’s stay, the current plan of care and latest physician’s orders. Record 11: The patient’s date of election was 3/29/2022. The discharge was reviewed and revealed the patient was discharged revocation seeking aggressive treatment on 4/4/2022. There was no documented evidence the discharge summary sent to the attending included a summary of the patient’s stay, the current plan of care and latest physician’s orders. The Director of Clinical Services was interviewed on 10/5/2022 and agreed, the discharge summary sent to the attending did not include a summary of the patient’s stay, the current plan of care or latest physician’s orders.