Every finding on record at Kindred Hospice

Based on interview and document review the hospice agency failed to meet the Condition of Participation: L536 at 42 CFR 418.104. The agency failed to provide a coordinated discharge plan was for the necessary care and services provided post-discharge for 1 of 3 (P1) records reviewed for discharge.  Finding include: --- Refer to L554 for additional information

Based on interview and document review the hospice agency failed to coordinate a discharge plan for the necessary care and services provided post-discharge for 1 of 3 (P1) records reviewed for discharge. --- Findings include: P1’s plan of care (POC), for his first hospice benefit period from 12/17/24 through 3/21/25, indicated his primary hospice diagnosis was hereditary spastic paraplegia (a genetic condition that causes muscle weakness and tightness in the legs). P1 also had a diagnosis of dysphagia (difficulty swallowing foods or liquids). The POC directed skilled nursing visits twice weekly, medical social worker (SW) once as needed, and chaplain once as needed.A hospice interdisciplinary group (IDG) note, dated 3/12/25, indicated the hospice medical director certified the patient’s prognosis was six months or less if the disease runs its normal course. The same note indicated P1 does not qualify for hospice and discuss discharge. It also indicated no communication occurred with non-hospice providers. A care coordination note, dated 3/13/25, indicated termination of hospice services were discussed with the last covered day of hospice as 3/16/25, which was only three days prior to discharge. A letter from the Benefit and Family Centered Care-Quality Improvement Organizations (BFCC-QIO), dated 3/17/25, determined a review of the medical records received showed the patient had a life expectancy of less than six months. The patient met criteria for hospice care and termination of hospice services was not appropriate.A physician’s order written by the hospice medical director, dated 3/20/25, with an effective date of 3/17/25, directed to discharge patient. P1’s discharge summary, dated 3/21/25, indicated P1was discharged for an "extended prognosis" and was dependent on others. The discharge summary indicated the hospice medical director was notified of the hospice discharge. The discharge summary indicated patient/family discharge treatment preferences included to refer to home health, hospice, and to community, but did not specify what resources in the community or list agencies for services. The form indicated a medication profile was not provided to the patient/family.  An IDG note, on 3/26/25, indicated the hospice executive director indicated patient was discharged due to wanting to see a spine doctor and look into aggressive treatment. She also noted P1’s family member (FM) appealed the discharge, but the patient was no longer eligible to remain on hospice services at that time and patient was discharged due to no longer meeting eligibility requirements. The registered nurse case manager (RNCM) indicated P1 did not qualify for recertifying the hospice benefit, that P1 wanted to live, and had no desire to be on the hospice benefit. The form indicated the attending was notified. The social worker (SW) indicated no resources were need at the time of discharge even though P1 required assistance with his care. P1 was referred back to hospice and readmitted on 4/7/25. A physician's order, dated 4/9/25, indicated his physician certified the patient's prognosis was six months or less. P1’s plan of care (POC), for his second hospice benefit period from 4/7/25 through 7/5/25, indicated his primary hospice diagnosis was hereditary spastic paraplegia and a diagnosis of dysphagia. The POC directed skilled nursing visits three times for the first week, then twice weekly. It also directed SW once to evaluate, and chaplain once to evaluate. A nurse note, dated 5/1/25, indicated the RNCM informed FM-A he would be off for surgery at the end of the month and there were no other male nurses. A nurse note, dated 5/20/25, indicated the RNCM gave FM-A the Notice of Medicare Non-Coverage (NOMNC) form and FM-A refused to sign the document. An IDG note, dated 5/21/25, indicated P1 was no longer hospice eligible and was issued the NOMNC form on 5/20/25, with a discharge date of 5/22/25. The note indicated FM-A was aware and home health resources provided. The form lacked indication of coordination of care with non-hospice providers and only gave a list of agencies for the family and patient to contact without the hospice agency assisting with an appropriate transfer to a home care agency.  A letter from the BFCC-QIO, dated 5/23/25, determined the physician/peer reviewer disagreed with the termination of services due to a lack of medical records.P1’s discharge summary, dated 5/24/25, indicated P1was discharged for an "extended prognosis" and was dependent on others. The discharge summary indicated the hospice medical director was notified of the hospice discharge on 5/23/25. The discharge summary indicated patient/family discharge treatment preferences included refer to home health for physical therapy evaluation and assist with contacting home health agency and getting a physical therapy referral. Although the record identified refer to HHA services for therapy there was no indication this had been completed.A note by the executive director, dated 6/3/25, indicated FM-A was not happy with the decision to discharge P1 and appealed the decision. She noted the agency’s national hospice director felt P1 was not eligible and therefore would not readmit P1 despite the BFCC-QIO review, not to discharge P1. There was no indication communication was provided to P1 or FM-A in regards to discharge planning for both instances when he was discharged from hospice. The chart lacked evidence that a coordinated discharge was provided with the attending physician and other providers for home care agencies or alternative hospice agencies were completed. The chart lacked documentation to indicate necessary medical supplies and equipment were arranged after the patient was discharged from hospice. P1 required incontinent briefs, wipes, wound care supplies, skin care protectant, wheelchair, a full body mechanical lift, and a hospital bed with alternating pressure mattress.On 7/23/25, FM-A stated P1 was on hospice with the agency twice and services abruptly ended both times. He stated he was advised on 3/13/25 that services were ending on 3/16/25, giving him a three day notice. The agency proceeded with the discharge despite him winning the appeal through the BFCC-QIO. He stated on 5/20/25 he was advised P1 was being discharged from hospice services effective 5/22/25. He stated the agency did not make any visits after 5/20/25. FM-A stated he appealed the second hospice discharge as well and won. FM-A stated he was aware the only male nurse at the hospice agency was having surgery on 5/25/25 and felt P1 was discharged because he was only comfortable with male caregivers. FM-A stated the agency did not assist him to arrange for another hospice agency, make any referrals to home care agencies, assist him with arranging for medical equipment or medical supplies. FM-A stated he spoke with the executive director multiple times but she was not helpful and refused to continue hospice services.  On 7/24/25, at 10:07 a.m., RNCM-A stated he was the case manager for P1. He stated P1 was discharged from his first benefit period as he didn’t meet hospice criteria to recertify. The RNCM stated FM-A and P1 only wanted male staff and only the RNCM and the chaplain were male. He stated he provided a verbal list of home care agencies, nothing was written down for FM-A to reference. RNCM denied making any calls or other efforts to coordinate care through other agencies. RNCM-A stated the attending physician was not made aware of the discharge, only the hospice medical director. He stated P1 was readmitted to hospice, on 4/7/25, but the compliance department felt he was not appropriate for hospice. RNCM-A stated FM-A refused to sign the NOMNC form. RNCM-A stated he did not make efforts to assist with the coordination of care at the time of the second hospice discharge, but believed P1 was going to get home care services. He stated he was aware of the appeal filed for the second discharge, and that it was upheld, but stated the agency would not resume care. RNCM-A stated P1 had nurse visits twice weekly, a full body mechanical lift, incontinence briefs, disposable under pads, wipes, and a wheelchair provided by the hospice agency. On 7/24/25, at 10:22 a.m., the hospice medical director stated P1 only wanted male caregivers and the agency did not have enough male staff. She stated P1 had high care needs but was not showing a decline. She stated the decision to discharge P1 was made by the corporate team based on lack of P1’s decline. She stated once his pain was controlled, he plateaued. On 7/24/25, at 10:40 a.m., the area director of clinical operations (ADCO) stated the agency did not have a policy for handling hospice discharge appeals, but they had a standard operating procedure. He stated P1 did not have a terminal diagnosis, rather the diagnosis listed was a condition he was born with and this was the diagnosis listed for both hospice benefit periods. On 7/24/25, at 10:47 a.m., the executive director stated P1 only wanted male staff. She stated the agency was unaware FM-A appealed the discharge in March 2025, but was aware of the appeal for the second discharge in May, 2025. She stated the agency provided information to the BFCC-QIO but did not receive a determination, so they proceeded with the discharge. She stated FM-A informed the agency the BFCC-QIO determined P1 should remain on hospice services. She stated the national medical director directed to end services. The executive director stated she assumed the nurse and the medical director made a document for discharges. She stated she was not sure if the hospice had any responsibility to assist in coordinating medical supplies and equipment at the time of discharge. She stated she was “not clinical” and was not sure if the attending physician was to be notified of hospice discharges. On 7/24/25, at 11:19 a.m., the vice president of operations (VPO) stated P1 was discharged from his first hospice benefit period due to the national medical director determining he was not eligible for hospice. He stated although P1 won the appeal, the agency did not feel he was eligible and proceeded with the discharge. The VPO stated P1 had an acute issue when he was readmitted for his second hospice benefit period. He was not aware of the appeal with the second discharge. The VPO stated P1 and FM-A were offered several options for continued care and it should have been documented in his chart. On 7/24/25, at 1:49 p.m., the regional vice president of clinical operations stated the attending physician should be notified of hospice discharges. She stated if the BFCC-QIO determined the patient should remain on hospice, but if the agency was not in agreement, they should assist in coordinating a transfer to another agency. On 7/25/25, at 9:34 a.m., the ADCO emailed it was his understanding there was no evidence the attending physicians were notified of the hospice discharges for P1. On 7/25/25, at 11:35 a.m., the national medical director stated P1 was discharged for a prognosis that exceeded six months. He stated if the patient appealed the discharge and won, the hospice’s responsibility was to help the patient find another hospice in the area. He stated he was not aware the first hospice discharge was appealed and upheld. A facility policy Live Discharge and Discharge Planning Process, dated 6/30/25, directed:4. As soon as the IDG determines the patient will be discharged because his/her condition has plateaued the organization personnel will:   a) Contact/consult with the patient’s attending physician prior to discharge;   b) Consult with the patient and family/caregiver regarding the need for discharge;   c) Establish the need to refer to another entity. Provide a list of resources to the patient or caregiver  to make a selection and make referrals as indicated;6. Documentation in the medical record: upon discharge, the case manager and or clinical supervisor will ensure that all relevant information is documented in the clinical record. Relevant information includes, but is not limited to:    b) Physical and psychosocial status at the time of discharge, including specific medical, psychosocial, or other problems requiring interventions or follow up   c) Follow up to be provided by other providers   f) Instruction and referrals provided to the patient   h) Patient/family goals and discharge goals and treatment preferences   j) Correspondence with the QIO, if applicable7. Upon discharge, notice must also be provided to:    a) Attending physicianA facility document, Discharge: Patient Appeal of Discharge Decision, standard operating procedure, dated 6/14/22, directed: 12. If the QIO disagrees with the discharge decision, the medical director may recertify the patient if they agree with the QIO rationale/continued eligibility of the patient.    b) If the medical director refuses to recertify, the patient will be notified of their right to seek care with another hospice and discharge will proceed as planned. 13. All patient/representative, QIO/independent review entity (IRE), and other contacts related to the appeal and follow-up will be documented in the electronic medical record (EMR). 14. All documentation received from the QIO/IRE will be scanned in the EMR.

Based on interview and document review, the agency failed to inform the attending physician of the hospice discharge for 1 of 3 (P1) patients reviewed for clinical records. --- Findings include: P1’s plan of care (POC), for hospice benefit period from 12/17/24 through 3/21/25, indicated his primary hospice diagnosis was hereditary spastic paraplegia (a genetic condition that causes muscle weakness and tightness in the legs). P1 also had a diagnosis of dysphagia (difficulty swallowing foods or liquids). The POC directed skilled nursing visits twice weekly, medical social worker (SW) once as needed, and chaplain once as needed. A hospice interdisciplinary group (IDG) note, dated 3/12/25, lacked communication occurred with non-hospice providers, in anticipation of discharge. P1’s discharge summary, dated 3/21/25, indicated P1was discharged for an extended prognosis and was dependent on others. The discharge summary indicated the hospice medical director was notified of the hospice discharge. An IDG note, on 3/26/25, indicated the hospice executive director indicated patient was discharged due to wanting to see a spine doctor and look into aggressive treatment. The form indicated the attending physician was notified, although it did not indicate how or when the notification occurred.P1’s plan of care (POC), for hospice benefit period from 4/7/25 through 7/5/25, indicated his primary hospice diagnosis was hereditary spastic paraplegia and a diagnosis of dysphagia. The POC directed skilled nursing visits three times for the first week, then twice weekly. It also directed SW once to evaluate, and chaplain once to evaluate. An IDG note, dated 5/21/25, indicated P1 was not longer eligible for hospice with a discharge date of 5/22/25. The form lacked indication of coordination of care with non-hospice providers. P1’s discharge summary, dated 5/24/25, indicated P1was discharged for an extended prognosis and was dependent on others. The discharge summary indicated the hospice medical director was notified of the hospice discharge on 5/23/25. The form lacked indication the attending physician was notified of the discharge from hospice services. On 7/24/25, at 10:07 a.m., registered nurse case manager (RNCM)-A stated he was the case manager for P1. He stated P1 was discharged from his first benefit period as he didn’t meet hospice criteria to recertify. RNCM-A stated the attending physician was not made aware of the discharge, only the hospice medical director. He stated P1 was readmitted to hospice, on 4/7/25, but the compliance department felt he was not appropriate for hospice. RNCM-A stated he did not make efforts to inform the attending physician of the discharge. RNCM-A stated P1 had nurse visits twice weekly, a full body mechanical lift, incontinence briefs, disposable under pads, wipes, and a wheelchair provided by the hospice agency. On 7/24/25, at 10:47 a.m., the executive director stated she was “not clinical” and was not sure if the attending physician was notified of hospice discharges. On 7/24/25, at 1:49 p.m., the regional vice president of clinical operations stated the attending physician should be notified of hospice discharges.On 7/25/25, at 9:34 a.m., the area director of clinical operations emailed there was no evidence the attending physician were notified of the hospice discharge for P1. A facility policy Live Discharge and Discharge Planning Process, dated 6/30/25, directed: 4. As soon as the IDG determines the patient will be discharged because his/her condition has plateaued the organization personnel will:   a) Contact/consult with the patient’s attending physician prior to discharge;7. Upon discharge, notice must also be provided to:    a) Attending physician

Upon patient record review, 2 of 19 (Patient #1, 9) 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 1: The medication profile at the facility for the patient who resides in an assisted living facility does not match or include orders from hospice on 5/9/23 for Metoprolol 25mg give 1/2 tab twice daily. The medication profile at the assisted living facility for Miralax 17g powder give 8.5 grams in water and take by mouth once daily for constipation does not coordinate with the hospice order on 3/10/22 Miralax 17g by mouth daily mix in 6-8 ounces of water or beverage of choice. (Corrected on site.) Patient 9: The medication profile includes Clotrimazole AF 1% apply 1G twice a day topically as needed for rash, this does not include an application site. (Corrected on site.)

Upon patient record review, 1 of 19 (Patient #3) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 3: The patient was admitted on 3/29/23, the bereavement risk assessment was completed on 4/6/23.

Upon patient record review, 1 of 19 (Patient #6) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 6: The patient was prescribed Bactrim 400mg-80mg PO BID x 7 days for a UTI on 6/25/23, there is no evidence in the patient record of the reassessment of the patient's response to the medication, resolution of the UTI symptoms, or progress towards the desired outcome to resolve the UTI.

Upon patient record review, 2 of 19 (Patient #1, 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 1: The medication order on 5/9/23 for Metoprolol 25mg give 1/2 tab twice daily is not included in the orders at the ALF where the patient resides. . The medication order on 3/10/22 for Miralax 17g by mouth daily mix in 6-8 ounces of water or beverage of choice does not match the medication profile at the assisted living facility for Miralax 17g powder give 8.5 grams in water and take by mouth once daily for constipation. (Corrected on site.) Patient 9: The medication order on 4/4/23 for Clotrimazole AF 1% apply 1G twice a day topically as needed for rash, this does not include an application site. (Corrected on site.)

Upon client record review, 2 of 19 (Patient #5, 14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5: The initial assessment for Spiritual Care indicates that the patient will be seen 1x week as entered by the spiritual care counselor, the plan of care orders indicate 1x wk for 12 weeks. The patient was not seen by the SCC during the week of 12/25/22 - 12/31/22 or 1/1/23 - 1/7/23, there is no evidence in the patient record of a missed visit. Patient 14: The initial plan of care and SW assessment indicates the patient will be seen 2x monthly. The patient received 1 visit in the month of June.

Upon patient record review 1 of 19 (Patient #5) 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: A supervisory visit was performed on 6/21/23, there is no evidence of a supervisory visit made again for 16 days until 7/7/23.