Every finding on record at Kingfisher Health LLC

It is required that the written Patient Bill of Rights includes the right to: Receive information about the services covered under the hospice benefit. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 14 (14%) records reviewed where the patients' medication profiles were compared to the Certificates of Terminal Illness (CTI) used for determination of financial medication coverage, it was revealed that the agency did not ensure patients received information that fully notified them of all the medications that were covered under the hospice benefit. The agency's policy, "PE.5, Patient Assessments (revised 100121)", stated in part at sub-section "G 8": "A review of the patient's prescription and over-the-counter drugs, and other alternative treatments that could affect drug therapy will be identified and reviewed during the following: RN will contact the attending physician, and if not available, the Medical Director, to coordinate medication profile review to determine if each medication is related to the terminal diagnosis." Clinical Record 7: The record for this patient with a hospice benefit election date of 10/4/2022 had a CTI signed by the Medical Director on 10/4/2022 that stated in part: "Primary diagnosis of chronic kidney disease stage 5. Patient's additional diagnoses include HTN (hypertension), Type 2 DM (diabetes mellitus), Hyperphosphatemia, Hyperlipidemia." The care plan dated 10/4/2022 - 10/14/2022 included documentation of the following medications as "Not Covered" under the patient's hospice benefit even though they were drugs directly associated with their hospice diagnoses: "Furosemide 20 mg... diuretic; Sodium Bicarbonate 325 mg... for acidosis; Atorvastatin 10 mg... for hyperlipidemia". A joint record review and interview with the Alternate Director of Nursing (ADON) on 5/3/2023 confirmed that the medication entries incorrectly stated the listed medications were "not covered" as part of the patient's hospice benefit. The Alternate Director of Nursing further stated that the medications may have been documented as "not covered" on the plan of care because the patient may not have needed refills of those medicines at the time of admission to hospice, but the documentation would have been revised and the medicines covered under the hospice program at the time the refills were initiated. The ADON was unable to access the patient's medication list of covered medications through the pharmacy benefit manager because the patient was deceased at the time of the record review on 5/3/2023, and that information was not available. Clinical Record 2: The record for this patient with a hospice benefit election date of 4/21/2023 had a CTI dated and signed on 4/21/2023 that stated in part: "Terminal diagnosis is Parkinson's disease with co-morbidities of dementia, dysphagia, depression, and overactive bladder." The patient's care plan dated 4/21/2023 - 7/19/2023 included documentation of the following medications as "Not Covered" under the patient's hospice benefit even though they were drugs directly associated with their hospice diagnoses: "Tamsulosin HCL 0.4 mg... for an overactive bladder; Carbidopa-Levodopa 25-100 mg... for Parkinson's; Memantine HCL 10 mg... for memory; Neurotransdermal Patch 24 hour 4mg/24 hr... for Pakinson's, Antiparkinson and related therapy." A joint record review and interview with the Alternate Director of Nursing (ADON) on 5/2/2023 confirmed that the medication entries were incorrect, as the documentation stated the listed medications were "not covered". The ADON further stated that the medications were actually covered by the hospice agency and due to the patient's short length of stay, refills were not needed at the time of admission, and the hospice would provide coverage for the medications upon initiation of refills. The ADON reported that she believed once refills for the patient were needed, the agency would update the medication profile to state the medications were "covered." However, she was not able to confirm this with the pharmacy benefit manager, as the patient was not enrolled with the pharmacy benefit manager at the time of the record review on 5/2/2023.

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 medication review process includes the identification of the following: The effectiveness of drug therapy; Drug side effects; Actual or potential drug interactions; Duplicate drug therapy; Drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. 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 2 of 3 (67%) home visits conducted where a medication reconciliation was performed comparing the hospice agency's medication profile to the medications being administered in the home, it was revealed that the agency did not ensure medication profiles were updated accurately to include all of the patient's current medications in the review of the medication regimen for side effects and interactions. The agency's policy, "PC.85, Medication List and Monitoring (revised 100121)", stated in part at sub-section "1": "The hospice will maintain a current, accurate list of all prescription and over-the-counter (OTC) medications taken by the patient. (Medication Profile)." Sub-section "VII A" stated in part: "The medication profile will be updated as frequently as necessary to reflect changes in the medication regimen, keeping the profile accurate". Home Visit 1: A home visit was conducted on 5/2/2023 with an RN (Staff 7) at an Assisted Living Facility (ALF) for the patient (Record 1) with a hospice benefit election date of 12/27/2022. The hospice agency's medication profile included documentation of the following medication entries: "Bisacodyl Rectal Suppository 10 mg. One (1) suppository BID (two times daily) PRN (as needed) every twelve (12) hours for constipation; Acetaminophen Rectal Suppository 650 mg. One (1) suppository every six (6) hours PRN (as needed); and Tramadol 50 mg. Take one-half (0.5) tablet BID (two times daily) for pain". The ALF’s medication profile included documentation of the following medication entries that did not match the entries on the hospice medication profile: "Bisacodyl Rectal Suppository 10 mg. One (1) suppository every twenty-four (24) hours PRN (as needed) for constipation; Acetaminophen Rectal Suppository 650 mg. One (1) suppository every eight (8) hours PRN (as needed); Tramadol 50 mg. Take one-half (0.5) every six (6) hours PRN (as needed) for pain." The ALF also had medication entries on the medication profile for: "Acetaminophen 325 mg. Take two (2) tabs every eight (8) hours PRN (as needed) for pain”; and “Fleets enema. Give one (1) enema every twenty-four (24) hours PRN (as needed)". However, the hospice agency's medication profile did not contain an entry for use of oral Acetaminophen or the Fleets Enema, as ordered in the ALF. A joint record review and interview with the patient's Hospice RN Case Manager (Staff 7) confirmed the hospice agency medication profile did not match the ALF medication profile and all medications ordered were not included in the complete review of the patient's medication regimen. Home Visit 2: A home visit was conducted on 5/3/2023 with a MSW (Staff 6) at the private residence of the patient (Record 3) with a hospice benefit election date of 3/1/2023. The hospice agency's medication profile included documentation of the following medication entries: "Insulin Aspart Subcutaneous Soultion 100 units/ml. Take one (1) unit TID (three times a day) for DM (Diabetes Mellitus); Fentanyl Transdermal Patch 72 hour 50MCH/HR. Change patch every three days; Bupropion oral tablet 100mg. Take one (1) tablet daily for depression". The patient's daughter, who was identified as the primary caregiver and administers the patient's medications, was present during the home visit observation and reported that the patient has not received the Insulin Aspart Subcutaneous injections in over two weeks and has not received either the Fentanyl Transdermal Patch or the Bupropion oral tablet for several weeks. A joint record review and interview with the Alternate Director of Nursing (ADON) on 5/3/2023 confirmed the hospice agency medication profile was not updated to address changes in the patient's medication regimen, as described in agency policy.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: Hand hygiene. This standard was not met as evidenced by document review, interview and observation. During 1 of 3 (33%) home visits it was revealed the agency did not ensure hand hygiene was completed in compliance with the agency's policy and accepted standard precautions. The agency's policy, "IC.15 Hand Hygiene (revised 081522)", stated in part in sub-section "D 4: Staff may use an alcohol-based hand rub in the clinical situations described below, after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings and used supplies (PPE) if hands are not visibly soiled." Sub-section "5" stated in part: "Before moving from a contaminated body site to a clean body site during patient care." Sub-section D 7 stated in part: "... after contact with blood, body fluids, or contaminated surfaces." Home Visit 3: A home visit was conducted on 5/3/2023 with a hospice aide (Staff 2) at the Assisted Living Facility (ALF) where the patient, with a hospice benefit election date of 4/21/2023 (Record 2), resided. During the visit the hospice aide was observed removing a soiled brief from the patient while wearing clean gloves and discarded the brief in the trash. The aide did not remove the soiled gloves and proceeded to go to the patient's bathroom to obtain lemon glycerin swabs for oral care. The hospice aide opened the lemon glycerin swabs and proceeded to swab the patient's mouth while still wearing the same gloves. When oral care was completed, the aide proceeded to provide a bed bath and did not change their gloves at any time during the care provided. During an interview on 5/4/2023 with the Alternate Director of Nursing, they confirmed the practice of not changing gloves after removing a soiled brief did not follow the agency's policy on hand hygiene and infection prevention.

It is required that the hospice is responsible for providing all hospice services to the residents/hospice patients, including: Financial management responsibilities for all supplies, appliances, medications, and biologicals related to the terminal illness and related conditions. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 6 (17%) records reviewed of patients who resided in an Assisted Living Facility (ALF) it was revealed the hospice did not ensure they provided financial responsibility for all medications related to the patient's terminal prognosis. The agency's policy, "PE.5 Patient Assessments (revised 100121)", stated in part in sub-section "G 8": "A review of the patient's prescription and over-the-counter drugs, and other alternative treatments that could affect drug therapy will be identified and reviewed during the following: RN will contact the attending physician, and if not available, the Medical Director, to coordinate medication profile review to determine if each medication is related to terminal diagnosis." Clinical Record 1: The record for this patient had a Certificate of Terminal Illness (CTI) dated and signed on 11/9/2022 that stated in part: "... primary diagnosis of SDN (Senile Degeneration of the Brain). Comorbidities include hypothyroidism...". The subsequent CTI dated and signed 3/9/2023 stated in part: "... hospice diagnosis of senile degeneration of the brain: she also has the following diagnosis hypothyroidism...". The care plans dated 11/10/2022 - 1/8/2023 and 1/9/2023 - 3/9/2023 contained documentation that stated the patient's use of Thyroid medication, "NP Thyroid Oral Tablet sixty (60) mg. Take one (1) tablet orally every morning before breakfast", was not covered under the hospice benefit. During a joint record review and interview with the Alternate Director of Nursing, it was confirmed the hospice agency was not paying for the Thyroid medication and also confirmed the diagnosis of hypothyroidism was listed as a co-morbidity on the CTI.