Every finding on record at Novus Lifecare Hospice of Kansas LLC

Upon patient record review, 1 of 14 (Patient #4) did not contain evidence a current/comprehensive Medication Profile: Patient #4: The patient was on Oxygen 3 lpm continuous. The Oxygen had not been added to the Medication Profile.

Upon patient record review, 1 of 14 (Patient #4) did not contain evidence that a Registered Nurse was designated to ensure the continuous assessment of the patient and family's needs, and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family: Patient #4: An LPN had identified/documented a new wound on her 12/10/24 visit. Wound care was ordered for, "Pressure ulcer stage II left buttocks. Cleanse wound cleanser, pat dry with gauze, apply barrier cream to wound bed, and cover with border bandage. Change 2x per week and as needed for soiling. Family educated and taught." An attempted RN visit was documented on 12/13/24 for the delivery of supplies. The patient/family refused to allow the RN into the home at that time. There was no evidence of the RN attempting to re-schedule a visit for evaluation of the wound until a 12/19/24 visit was made.

Upon patient record review, 1 of 14 (Patient #10) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments: Patient #10: The wound care order obtained on 03/21/25 did not identify the 'location' of the second-listed, wound intervention entry. The IDG POC dated 05/07/25 included: 1) Cleanse BLE, apply zero-form, then Kling wrap. Change QD. The order did not include 'who' was to be providing this QD wound care. This patient lived in an ALF; and 2) Apply Barrier Cream to coccyx daily, and p.r.n. The order did not include 'who' was to be providing this daily intervention, nor for what reason to initiate such p.r.n. intervention.

Upon patient record review, 1 of 14 (Patient #7) did not contain evidence that a revised Plan of Care included information from the patient's updated comprehensive assessment(s): Patient #7: The IDG Plan(s) of Care dated 03/26, 04/09, 04/23, and 05/07/25 all included the following problem/need, "Caregiver struggling with caregiver burn-out. SW to assist with resources to lessen caregiver burn-out." This patient initially lived in his private home with an in-home caregiver. However, he moved into a SNF in the Fall of 2024. The POC had not been updated, as a result of this change.

Upon patient record review, 2 of 14 (Patients #2 and 6) did not contain evidence that the IDG had ensured that all care and services were provided in accordance with the Plan of Care: Patient #2: The SW was assigned to make home visits at a frequency of 1x per month. A visit was made 01/02/25 and 02/27/25. There was no SW made in 03/2025. The SW had made a 03/31/25 entry in the clinical record, "The SW unable to visit patient at this time", with no additional documentation to support the reason for this. Patient #6: The IDG POC ordered SW visits at a frequency of, "Effective 04/23/25 SW 1x per month. There was no visit made in April 2025.

Upon patient record review, 1 of 14 (Patient #8) did not contain evidence that the Hospice Aide assignment/Plan of Care included all pertinent information: Patient #8: The current Aide POC included, "Advance Directives on file? NO" An Out-of-Hospital DNR had been signed/dated 04/28/25. The Aide home visit report dated 05/02/25 included the demographics of, "Signed Advance Directive on file? YES DNR." The Aide POC was not current.

Upon patient record review, 1 of 14 (Patient #5) did not contain evidence that all entries were clear/complete: Patient #5: A verbal order was obtained on 04/17/25 for, "DC current treatment to open area LUQ abdomen. Change to cleanse LUQ with wound cleanser, pat dry, apply skin prep to peri-wound, apply border foam, then tape. Change 2x weekly, SN one time, and in-home caregiver over weekend." The RN documented a visit note on 04/23/25 of, "Wound 70% healed". But does not document the details of the wound care she provided during that visit.

Upon Inpatient contract review, 1 of 2 (Two Trails/GIP/RIP) did not contain verbiage that the inpatient provider has established patient care policies, consistent with those of the Hospice, and agrees to abide by such palliative care protocols and Plan of Care as established by the Hospice for its patients.

Upon Inpatient contract review, 1 of 2 (Two Trails/GIP/RIP) did not contain verbiage that the Hospice patient's inpatient clinical record shall include: 1) A record of all inpatient services furnished, and events regarding care that occurred at the facility; 2) That a copy of the Discharge Summary shall be provided to the Hospice at the time of discharge from inpatient facility; and 3) That a copy of the inpatient clinical record is available to the Hospice at the time of discharge.

Upon personnel record review, 3 of 10 (Personnel #3, 4, and 5) did not contain evidence of a Criminal Background Check (CBC) having been obtained in accordance with State requirements. In the absence of State requirements, Criminal Background Checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years: Personnel #3, 4, and 5: There was no documented evidence of a criminal background checks having been conducted for these personnel.

Upon client record review, 6 of 9 (Patient #1,4,5,6,7,8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 SN frequency on POC dated 2/25/22 1w1, 2w13. Visits for first week effective 2/25/22 were performed 2/25/22 and 2/26/22 without evidence of PRN or order to correct. Patient #4 MSW orders 1mo4, 2 prn on POC dated 2/15/22. Visits performed 2/18, 2/22, 2/23, no visits denoted PRN Patient #5 MSW order frequency written 1x 3/qtr, 2 prn for poc starting 1/5/22. Visits performed 1/10, 1/26 (prn), 2/4 and 2/9. No PRN denoted for month of February. Patient #6 SN frequency 2w13, 3 prn for POC dated 3/21/22. Week #1 visits 3/21, 3/23, and 3/25. No evidence of any of those marked PRN. Patient #7 SN ordered 2w13, 3 prn on POC dated 2/13/22. Visits on 2/13, 2/14, 2/18- no evidence of any denoted as PRN. Patient #8 SN ordered 2w13, 2 prn for POC dated 4/4/22. Visits on 4/4, 4/5, and 4/8/22- no evidence of any denoted as PRN

Upon patient record review 1 of 6 (Patient #1) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1 Aide is ordered 2w12, 1w1 on POC dated 2/25/22. Aide visits began on 3/1/22. No order correcting delay in start of Aide services evident.