Every finding on record at Kindstar Inc

It is required that each patient’s individualized written plan of care: Includes all services necessary for the palliation and management of the terminal illness, including the following: measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy "Plan of Care" (2127 Protocol) (revised 04/11/2024), stated in part, "Care plans should contain S.M.A.R.T goals ... Those goals should be measurable, attainable, relevant to the current condition/scenario, and have an identified time frame we would expect to achieve them. Hospice IDG members are taught to individualize the care plan by identifying patient and caregiver(s) names, using patient-centered language in the goal when applicable, and relating the care plan to current challenges/needs of the specific patient and caregiver(s) rather than generically to the diagnosis or problem … If it is monitored/assessed, the time frame will likely be 'each visit' … If it needs to be demonstrated by patient/caregiver, the time frame may be at first nursing visit after training has been provided.' Short-term goals are often related to symptom management and may state 'by nursing visit' or 'within 7 days.' ... As evidenced by (AEB) language for a patient specific measures are used to show the IDG how to know if the goal has been met. (e.g., pain will be managed at a level the patient states is acceptable AEB his ability to play with his grandchildren at least 2 X week)…" In 9 of 19 (47%) clinical records reviewed, the agency did not ensure that the patient's plan of care goals were patient-specific and measurable. Clinical Record 1: The patient, who resided in a nursing facility, elected the hospice benefit on 07/12/2024 with a diagnosis of Alzheimer's disease. The plan of care for the benefit period dated 01/08/2025 to 03/08/2025 documented the patient goals: "a nursing plan of care will be established that meets the needs of the patient, the facility caregiver will be able to verbalize and demonstrate an understanding of how to manage cardiopulmonary symptoms within the constraints of the disease process, the facility caregiver will be able to understand the effects of urinary incontinence at each visit, oxygen levels will be monitored as appropriate at each nursing visit. The POC goals were non-specific and did not document measurable outcomes. Clinical Record 2: The patient, who resided at home, elected the hospice benefit on 03/18/2023 with a diagnosis of malignant neoplasm of the stomach. The plan of care for the benefit period dated 01/06/2025 to 03/06/2025 documented the patient goals: ' a nursing plan of care will be established that meets the needs of the patient, the patient will be able to verbalize and demonstrate a reduction or relief of cardiopulmonary symptoms at each nursing visit, that the patient/caregiver will be able to verbalize and demonstrate an understanding of how to use oxygen safely and effectively each visit, changes in the patient's neurologic status will be addressed as appropriate each visit, the patient/caregiver will be able to verbalize an understanding of the effects of urinary incontinence at each visit, the patient/caregiver will be able to verbalize and demonstrate an understanding of the care required secondary to bowel incontinence at each visit, the patient will follow an effective bowel regimen to prevent/relieve constipation at each visit, the caregiver will be able to demonstrate the ability to assist the patient with activities of daily living at each visit, oxygen levels will be monitored as appropriate/as needed at each visit, the patient/caregiver will be able to verbalize and demonstrate compliance with the patient's medication regimen at each visit, the patient/caregiver will demonstrate competency in the management of self-administered medications at each visit, and the social worker will establish a plan of care. The POC goals were non-specific and did not document measurable outcomes. Clinical Record 5: The patient, who resided at home, elected the hospice benefit on 04/03/2024 with a diagnosis of chronic obstructive pulmonary disease. The plan of care for the benefit period dated 11/29/2024 to 01/27/2025 documented the patient goals: a nursing plan of care will be established that meets the needs of the patient, the patient will be able to verbalize and demonstrate appropriate pain management, the patient will be able to verbalize and demonstrate an understanding of how to manage cardiopulmonary symptoms within the constraints of the disease process, will be able to verbalize and demonstrate an understanding of how to use oxygen safely and effectively, the patient will be able to demonstrate independent administration of inhalation therapy and care for the equipment, oxygen levels will be monitored as appropriate, the patient will demonstrate competency in the management of self-administered medications, the patient will have safety needs met, and a chaplain and social work plan of care will be established. The POC goals were non-specific and did not document measurable outcomes. Clinical Record 6: The patient, who resided at home, elected the hospice benefit on 07/22/2024 with a diagnosis of unspecified cerebral vascular disease. The plan of care for the benefit period dated 01/18/2025 to 03/18/2025 documented the patient goals: a nursing plan of care will be established that meets the needs of the patient, changes in the patient's neurologic status will be addressed as appropriate at each visit, the patient/caregiver will be able to verbalize and demonstrate compliance with the patient's medication regimen at each visit, the caregiver will be able to verbalize and demonstrate an understanding of the care required secondary to bowel incontinence at each visit, the caregiver will demonstrate competency of self-administered mediations at each visit, and a chaplain and social work plan of care will be established. The POC goals were non-specific and did not document measurable outcomes. Clinical Record 7: The patient, who resided at home, elected the hospice benefit on 02/07/2024 with a diagnosis of malignant neoplasm of the sigmoid colon. The plan of care for the benefit period dated 12/03/2024 to 01/31/2025 documented the patient goals: a nursing plan of care will be established that meets the needs of the patient, the patient will be able to verbalize an understanding of the effects of urinary incontinence at each visit, the patient will be able to verbalize and demonstrate an understanding of the care required secondary to bowel incontinence at each visit, the patient will be able to verbalize and demonstrate compliance with the medication regimen at each visit, the patient's safety needs will be met, and the chaplain and social worker plan of care will be established. Clinical Record 8: The patient, who resided at home, elected the hospice benefit on 05/28/2024 with the diagnosis of Parkinson's disease. The plan of care from 11/24/2024 to 01/22/2025 was reviewed. It included the following non-specific, unmeasurable goals: a nursing plan of care will be established that meets the needs of the patient, the patient would verbalize and demonstrate a reduction or relief of cardiopulmonary symptoms, that oxygen levels would be monitored as appropriate at each nursing visit, that the patient/caregiver would verbalize and demonstrate compliance with the patient's medication regimen, that the patient/caregiver would demonstrate competency in the management of self-administered medications, and that a chaplain and social work plan of care would be established. Clinical Record 11: The patient, who resided at home, elected the hospice benefit on 12/19/2024 with a diagnosis of hypertensive heart disease without heart failure. The plan of care for 12/19/2024 to 02/16/2025 documented the patient goals: a nursing plan of care will be established that meets the needs of the patient, the patient/caregiver will demonstrate independence in the administration of inhalation therapy, a pulse oximetry reading will be obtained and appropriate interventions initiated, the patient/caregiver will be able to verbalize an understanding of measures to manage immediate cardiac/respiratory symptoms and if not effective - to call hospice, and the patient will exhibit a reduction or relief of any cardiopulmonary symptoms. Clinical Record 15: The patient, who resided at an assisted living facility, elected the hospice benefit on 07/12/2024 with a diagnosis of sequelae of cerebrovascular disease. The plan of care dated 07/12/204 to 10/09/2024 documented the patient goals: changes in the patient's neurologic status will be addressed appropriately as evidenced by the facility staff verbalizing an understanding of changes in cognition within a week, the patient/caregiver will verbalize knowledge of preventative measures and response in the event of a hemorrhage, and a chaplain and social work plan of care will be established. Clinical Record 19: The patient, who resided at home, elected the hospice benefit on 05/15/2024 with a diagnosis of multiple myeloma. The plan of care dated 08/13/2024 to 11/10/2024 documented the patient goals: a nursing plan of care will be established that meets the needs of the patient, the patient will be able to verbalize and demonstrate an understanding of the management of cardiopulmonary symptoms within the constraints of the disease process, the patient will verbalize and demonstrate a reduction or relief of any cardiopulmonary symptoms, the patient will be able to verbalize and demonstrate an understanding of how to use oxygen safely and effectively, the patient will have safety needs met, and a social work and chaplain plan of care will be established. During a joint clinical record review and interview on 01/23/2024, the Director of Clinical Operations and the Team Director confirmed that the included goals were not specific or measurable as they appeared in the patient's plan of care and that within the Electronic Medical Record, the goals are editable to include specific and measurable data.

It is required that licensed professionals participate in hospice sponsored in-service training. This standard was not met as evidenced by document review, interview, and personnel record review. The state administrative code stated in part, "(d) A first-time administrator and alternate administrator must complete an additional 16 clock hours of educational training before the end of the first 12 months after designation to the position. Any of the additional 16 clock hours may be completed prior to designation, if completed during the 12 months immediately preceding the date of designation to the position. The additional 16 clock hours must include the following subjects and may include other topics related to the duties of an administrator...." In 1 of 1 (100%) personnel record reviews requiring Administrator hours, the agency did not ensure that the required hours were completed during the first year of the appointment. Personnel Record 2: The Executive Director/Administrator was hired on 12/06/2021 and appointed the Administrator by the Governing Body on 12/21/2021. The initial eight (8) hours of the required twenty-four Administrator hours were completed on 12/13/2021. From the appointment on 12/31/2021 to 12/31/2022, the first twelve months after the designation as the Administrator, the sixteen additional hours of Administrator education were not completed. During a joint personnel record review and interview on 01/23/2024, the Executive Director/Administrator confirmed that they had not completed the additional sixteen hours within their first year of appointment.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy “Hospice Aide Plan of Care” (2112 Protocol), (revised 06/10/2024), read in part, “Hospice Aide … Delivers care according to the Aide Care Plan... If the Aide Care Plan cannot be completed as ordered … Contact RN Case Manager (RNCM), or TD (Team Director) during the visit to report concern via phone... Notify the RNCM/TD and include who was notified in the documentation. If unable to complete a visit - document reason and who was notified...” In 2 of 10 (20%) clinical records reviewed in which Hospice Aide services were accepted, the agency did not ensure that the Hospice Aide (HA) reported changes related to the patient’s plan of care to the Registered Nurse (RN). Clinical Record 7: The patient, who resided at home, elected the hospice benefit on 02/07/2024 with a diagnosis of malignant neoplasm of the sigmoid colon. The plan of care for the benefit period dated 12/30/2024 to 01/31/2025 ordered HA services three (3) times a week. The HA care plan dated 11/19/2024 assigned the HA the relevant tasks to be performed during every visit: bed bath, denture care, perineal care, and skin care. Additionally, the HA was provided instructions to shampoo and style the patient’s hair each visit and assist the patient in dressing. On 12/09/2024, the HA visit note documented that the patient refused the shampoo. 12/13/2024, the HA visit note documented that the patient refused all care. The HA visit note dated 01/06/2024 documented that the patient refused the shampoo and wished to have her hair washed once a week. On 01/13/2024, the HA visit note documented that the patient refused the shampoo and requested her hair be washed on Wednesdays only. A clinical record review revealed no evidence that the HA notified the Registered Nurse (RN) of the changes to the care plan. Clinical Record 15: The patient, who resided in an assisted living facility, elected the hospice benefit on 07/12/2024 with a diagnosis of sequelae of cerebrovascular disease. The plan of care for the benefit period 07/12/2024 to 10/09/2024 ordered HA services once weekly. The HA care plan dated 07/14/2024 assigned the HA the relevant tasks to be performed each week: assist the patient to the toilet, provide a standing shower, shampoo, and style the patient’s hair, shave the patient, and perform nail care, apply lotion and deodorant, and to assist the patient with dressing. On 08/14/2024, the HA visit note documented the patient’s refusal of the following tasks: assistance to the toilet, showering, shampooing/styling hair, providing skin and nail care, shaving the patient, and applying deodorant. The HA visit note dated 08/21/2024 documented the patient refused his shower, shampoo, shave, and nail care, and the tasks of assisting to the toilet, applying deodorant, and skin care had already been completed. The HA visit note dated 08/28/2024 documented that the patient refused assistance with toileting, showering, shampooing, shaving, skincare, and application of deodorant. The HA visit notes dated 09/04/2024 and 09/11/2024 documented that the patient’s shower, shampoo, and application of deodorant had already been completed, and the patient refused the shave, skin and nail care, and assistance with dressing. A clinical record review revealed no evidence that the Registered Nurse (RN) was notified of the changes to the care plan. During a joint record review on 01/23/2025 and 01/24/2025, the Director of Clinical Operations and the Team Director confirmed that there was no documentation that the Registered Nurse Case Manager (RNCM) was notified that the HA care plan was not completed as written.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by review of clinical records and interview. In 2 of 13 (15%) clinical record reviews the written plans of care did not identify planned interventions based on problems identified in the updated comprehensive assessments. Record #45866: The RN comprehensive assessment dated 2/10/22 identified problems of shortness of breath, losing weight, diabetes, dysphagia, and anxiety. On record review it was revealed the updated plans of care dated 2/11/22, 2/25/22, 3/11/22 and 3/25/22, did not identify interventions based on problems of shortness of breath, losing weight, and diabetes, dysphagia, and anxiety. Record #36672: The RN comprehensive assessment dated 2/28/22 identified problems of safety hazards of inadequate lighting, inadequate stair railing, lack of fire safety devices and abnormal integumentary assessment findings. On record review it was revealed the updated plan of care dated 3/11/22 did not identify interventions based on problems of safety hazards of inadequate lighting, inadequate stair railing, lack of fire safety devices and abnormal integumentary assessment findings. The Director of Clinical Services agreed with these findings during an interview on 3/25/22.

It is required that each patient’s individualized written plan of care includes: a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by review of clinical records and interview. In 2 of 13 (15%) clinical record reviews the plans of care did not include a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. Record #36672: The plans of care dated 1/28/22, 2/11/22, 2/25/22, and 3/11/22 documented "MSW 2 PRN visits for coping, crisis management" and "CH 2 PRN for spiritual support, crisis management". Neither order identified a duration for visit orders. Record #42896: The plans of care dated 2/4/22, 2/18/22, 3/4/22, and 3/18/22 documented frequency orders for chaplain visits as "2 PRN for spiritual support, crisis management". The visit frequency orders did not identify a duration for visit orders. During a joint clinical review on 3/25/22 the Director of Clinical Services agreed with these findings.

It is required that each patient’s individualized written plan of care identifies treatments necessary to meet the needs of the patient. This standard was not met as evidenced by joint record review and interview. 1 of 13 (8%) clinical records reviewed revealed a plan of care did not identify treatments necessary to meet the needs of the patient. Record #25048: The RN assessment dated 2/21/22 documented a wound that resulted in treatment with a wound care order on 2/21/22. During record review it was revealed the revised plans of care dated 2/25/22, 3/11/22, and 3/25/22 did not include treatment for the wound. During a joint clinical review on 3/25/22 the Director of Clinical Services agreed with this finding.

It is required that bags used to carry medical equipment (e.g., BP cuff) or supplies into or out of the care environment are transported and used in a manner consistent with organizational policy to prevent the spread of infections and communicable diseases. This standard was not met as evidence by observation on home visits and review of documentation. In 1 of 3 (33%) home visit observations, adherence to bag technique as defined in hospice policy was not performed. Hospice policy 14.01 "Bag Technique" states, in relevant parts, “In general, a barrier is not needed for clinician bag, unless the visible or known conditions in the home indicate the need,” and “Perform hand hygiene immediately prior to entering/re-entering bag.” Record #36672: During a home observation visit on 3/24/2022, it was noted that the home was noticeably unkempt. The nurse placed the bag on a cushioned chair that was visibly dirty without placing a clean barrier underneath the bag. The nurse proceeded to complete a hands-on assessment and reached into the bag without donning a clean set of gloves or sanitizing hands. During an interview on 3/24/22 the Director of Clinical Services was unable to provide an explanation for why the bag technique policy was not followed.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum physician orders. This standard was not met as evidenced by a review of clinical records and interview. 1 of 13 (8%) record reviews revealed skilled nursing interventions were provided without physician orders. Record #36672: The RN documented providing interventions of completing a blood sugar test on 1/27/22 It was revealed during the review of the plans of care dated 1/28/22, 2/11/22, 2/25/22, 3/11/22, and 3/25/22, did not include orders to obtain blood sugar levels. During a joint clinical record review with the Director of Clinical Services on 3/25/22, the Director of Clinical Services stated, “not aware that patient clinical records required physician orders for blood sugar tests."