Every finding on record at Abiding Hospice, LLC

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, 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 observation and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure an accurate review of the medications the patient was currently using to identify any potential adverse effects and drug reactions. HOME VISIT 1: During the home visit observation on 11/04/2025 with the Registered Nurse (RN) (Personnel Record 2), a medication review was completed by comparing the hospice medication profile printed 11/04/2025 to the patient’s home medications. The patient’s home medications included Allopurinol 300 mg, one tablet daily, the bottle dated 11/20/2023; Tamsulosin 0.4 mg capsule, one capsule daily, the bottle dated 01/05/2024; Omeprazole 20 mg capsule, one capsule twice daily, the bottle dated 03/11/2025; Vitamin D2 1.25 mg capsule, one capsule weekly, the bottle dated 08/17/2025; Phenylephrine HCl 1% nasal spray, one spray each nostril 1-2 times a day, patient reported taking this for "a couple of years;" and Azelastine HCl 0.1% nasal spray, one spray each nostril, patient reported taking for four months. The patient reported pouring newer prescription refills into the "original" bottle. The bottles had the medications listed on the lids for easier identification. The hospice medication profile did not include the patient’s current medications, and the medications were not included in the medication review process. During a joint record review and interview on 11/04/2025, the Patient Care Director confirmed that there was no documented evidence that a medication reconciliation had been completed or that medications had been updated in the medication profile.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed with patient discharge, the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 4: The patient elected the hospice benefit on 08/30/2025 and elected to revoke the hospice benefit on 10/22/2025. There was no documented evidence in the clinical record that the discharge summary dated 10/22/2025 was forwarded to the patient's attending physician. The discharge summary included the documentation, "Patient attending physician notified: no." During a joint record review and interview on 11/05/2025 the Patient Care Director confirmed that the record lacked evidence that the discharge summary was forwarded to the patient’s attending physician.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed with patient discharge, the agency did not ensure the discharge summary included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. CLINICAL RECORD 4: The patient elected the hospice benefit on 08/30/2025 and elected to revoke the hospice benefit on 10/22/2025. The discharge summary dated 10/22/2025 did not include a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. During a joint record review and interview on 11/05/2025 the Patient Care Director confirmed that the discharge summary did not include a summary of the patient’s hospice stay, including treatments, symptoms, and pain management.

It is required that all hospice professionals who provide services directly, under an individualized contract, or under arrangements with a hospice: Are legally authorized (licensed, certified or registered) in accordance with local, state, and federal law and regulation. This standard was not met as evidenced by document review, personnel record review, and interview. In 1 of 7 (14%) personnel records for hospice professionals, the agency did not ensure verification of licensure for the hospice social worker. Agency Document: Position Description Social Worker, dated 04/2020, stated in part, "Minimum Position Qualifications: License/Certification: Current and valid license approved by the State in which services are provided; CPR certification; driver's license and proof of current auto liability insurance." The (State) Hospice Licensing Act Title 63 of the (State) Statutes Section 1-860.1 et seq. As amended in 2017, stated in part, "A hospice team shall consist of, as a minimum, a physician, a registered nurse, and a social worker or counselor, each of whom shall be licensed as required by the laws of this state." State Document: Board of Licensed Social Workers Title 59 O.S. Section 1250 - 1273, not dated, stated in part, "§59-1251. License required - Exemptions. A. In order to safeguard the welfare of the people of the State of (State), no person shall engage in the practice of social work for compensation or hold himself or herself forth as performing the services of a social worker unless he or she is licensed under the Social Worker's Licensing Act, nor may any person participate in the delivery of social work service unless under the supervision of a person licensed under these provisions, and no person may use any title, abbreviation, sign, card or device incorporating the words "social worker" or a derivative thereof unless such person has been duly licensed under the provisions of this law. B. Nothing contained herein shall be construed to prevent qualified persons from doing work within the standards and ethics of their respective professions. Provided, that such persons shall not hold themselves out to the public by any title or description of services as being engaged in the practice of social work. C. Employees of agencies of the state shall be exempt from the requirements of the Social Worker's Licensing Act as to the performance of their duties as state employees or health care facilities or employees of health care facilities licensed by the state. This exemption shall not apply to persons licensed by the Board of Licensed Social Workers, regardless of their employment." PERSONNEL RECORD 6: Master's Social Worker date of hire 07/07/2025. Personnel record review revealed the social worker obtained a master's in social work on 12/15/2023. The record contained a medical social worker competency signed and dated 07/16/2025. However, there was no documented evidence of state licensure verification for the master's prepared social worker. During a joint personnel record review and interview on 11/03/2025, the Administrator reported that the social worker did have a master's in social work but did not have a license in the state as per the initialed agency job description. During a discussion on 11/04/2025, the Social Worker stated that the (State) State Board of Licensed Social Workers was contacted that provided information on an exemption for social workers not requiring a license to work in a hospice setting. The Social Worker stated that she had worked at other hospice agencies that did not require a license for social work. The Social Worker has submitted a request to sit for the state licensing exam and is awaiting a response.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document review and interview. In 2 of 6 (33%) hospice contracts reviewed, the agency did not ensure that hospice contracts required that contracted entities obtain criminal background checks on contracted employees who have direct patient contact or access to patient records. CONTRACT 5: The hospice contract for the Medical Director dated 07/01/2025 did not include the requirement that contracted employees who have direct patient contact or access to patient records obtain a criminal background check. CONTRACT 6: The hospice contract for the Associate Medical Director dated 04/09/2025 did not include the requirement that contracted employees who have direct patient contact or access to patient records obtain a criminal background check. During a joint review of contracts and interview on 11/03/2025, the Administrator confirmed that the Directorship Agreements for the physicians lacked the verbiage that hospice contracts require contracted employees who have direct patient contact or access to patient records to obtain criminal background checks.