Every finding on record at Kindful Hospice Wichita, LLC

Upon patient record review, 3 of 14 (Patient #3, #6, #7) 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 #3: Daughter reported changes in patient medication that are older than last SN visit. Daughter reported discontinuing, Escitalopram, Forteo, Wellbutrin and Hydrocodone. Corrected on site with Director of Clinical Services providing written plan of correction to address with staff. Patient #6: Records indicate oxygen order on POC however, there is no evidence of oxygen on Medication profile upon SOC on 9/22/23 until date of survey 03/28/24. Patient #7: Records indicate oxygen order on POC however, there is no evidence of oxygen on Medication Profile upon SOC on 01/26/24 until date of survey 03/28/24.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient #3: Records indicated that there was no evidence of patient/family receiving teaching of symptom management, level of their understanding and the patients level of progress towards meeting goals including written instructions provided to the patient/family on 2/13/24, 2/15/24, 2/20/24, and 2/22/24.

Upon patient record review, 1 of 14 (Patient #5) 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 #5: Record indicate worsening dyspnea contributing to patient decline with no evidence of any interventions performed upon SOC on 10/23/23.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions which including interventions to manage pain and symptoms. Patient #3: Records indicate that there was no evidence of interventions performed to manage active symptoms, dyspnea, hallucinations and irregular heart rate, on 2/13/24, 2/15/24, 2/20/24, and 2/22/24.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient #3: Records indicate that RN Comprehensive Assessment identified abnormal symptoms of disabling dyspnea with use of accessory muscles, hallucinations, bounding, irregular heartbeat with amber color urine in collection bag with sediment on 2/13/24, 2/15/24, 2/20/24, and 2/22/24. No evidence of Medical Director notification of active symptoms.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. During on site visit with nurse , there was no evidence that RN was following agency policy for bag technique. Policy was reviewed on site.

Upon patient record review 2 of 14 (Patient #5, #6) 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 # 5: Records indicate there is no evidence of HHA supervisory visit between 10/25/23-11/28/23. Patient #6: Records indicate there is no evidence of HHA supervisory visit between 09/25/23-11/29/23.

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.

Upon patient client record review, 1 of 14(Patient #1) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1: Records indicate that patient/family signed Change of Choice of attending form on 6/16/23 however, agency form required signature of new Attending physician which was blank. SOC, 06/16/23