Every finding on record at Alpha Hospice, LLC

Based on record review and interview, the agency failed to ensure an All Hazards Risk Assessment was updated every two years for all patients, staff and volunteers. --- Findings: A review of administrative records for the Emergency Preparedness Program showed a document titled, "All Hazards Community/Hospice Based Risk Assessment for Potential Disasters."  The All Hazards was not dated. On 05/28/26 at 8:23 a.m., Staff A stated the All Hazards Risk Assessment did not have a date.

Based on record review and interview, the hospice failed to ensure contact information was listed in the Emergency Preparedness Plan for all patients, staff and volunteer staff. --- Findings: A review of Emergency Preparedness records showed no regional or tribal emergency contact information On 5/28/26 at 8:23 a.m., Staff A stated there was no contact information for tribal or regional emergency resources.

Based on record review and interview, the hospice failed to ensure the plan of care included all services necessary for the palliation and management of their hospice diagnosis for nine (Pt #1, 2, 3, 6, 7, 10, 13, 14, and 18) of seventeen patients. --- Findings: Pt #1 A plan of care dated 03/10/26 to 06/07/26 failed to include interventions for the diagnosis of Cerebral Palsy. Pt #2 A plan of care dated 12/03/25 to 01/31/26 failed to include interventions for the diagnosis of Malignant Neoplasm of bladder. Pt #3 A plan of care dated 05/02/26 to 07/30/26 failed to include interventions for the diagnosis of Malignant Neoplasm of Pancreas. Pt #6 A plan of care dated 04/19/26 to 06/07/26 failed to include interventions for the diagnosis of Senile Degeneration of the Brain. Pt #7 A plan of care dated 04/02/26 to 05/31/26 failed to include interventions for the diagnosis of Cerebral Infarction. Pt #10 A plan of care dated 04/16/26 to 06/14/26 failed to include interventions for the diagnosis of Huntington's Disease. Pt #13 A plan of care dated 05/10/26 to 07/08/26 failed to include interventions for the diagnosis of Hypertensive Heart Disease and Kidney Disease and Heart Failure Stage 1-4. Pt #14 A plan of care dated 05/04/26 to 08/01/26 failed to include interventions for the diagnosis of unspecified Bronchus or Lung. Pt #18A plan of care dated 04/27/26 to 06/25/26 failed to include interventions for the diagnosis of Senile Degeneration of the Brain. On 05/28/26 at 2:00 p.m., Staff A stated the POCs did not include interventions for the hospice diagnosis for Pt #1, 2, 3, 6, 7, 10, 13, 14, and 18.

Based on record review and interview, the hospice failed to ensure the plan of care included interventions and/goals for pain for one (Pt #4) of seventeen patients. --- Findings: Pt #4 A plan of care dated 12/01/25 to 02/28/26 did not show education for rating pain, signs and symptoms of pain if patient were non-verbal, and possible non-pharmaceutical methods for pain management,   On 05/28/26 at 2:05 p.m., Staff A stated the plan of care did not address pain monitoring or education.

Based on record review and interview, the agency failed to ensure that Aide training demonstrated:1. Aide specific in-service training for two (Aide #1 and 2) of two aides.2, Sign-in sheets for in-service training for two (Aide #1 and 2) of two aides.3. Twelve hours of in-service training for two (Aide #1 and 2) of two aides. --- Findings: A review of training records showed a list of training all staff completed annually, no sign-in sheets were present, and the time of each in-service training was not documented. On 05/28/26 at 10:10 a.m., Staff A stated:1. The training was provided to all staff,2. There were no sign-in sheets3, and no documented time required for in-service training.

Based on record review and interview, the hospice failed to ensure the required background check was completed for one (Volunteer #1) of two volunteer staff. --- Findings:The "Long-Term Care Security Act Title 63 of the Oklahoma Statutes" documented requirement for an OKSCREEN national background check with fingerprinting for all hospice employees whose employment began after 06/01/14.Volunteer #1A review of the volunteer personnel record showed an OKSCREEN background check for a different hospice licenseOn 05/28/26 at 10:05 a.m., Staff B stated there was no OKSCREEN background check completed by the hospice for Volunteer Staff #1.

Based on record review and interview, the agency failed to ensure an Emergency Preparedness Communication Plan included updated required information related to the staff and volunteer contact information for the agency for all patients, staff and volunteers. --- Findings: A review of administrative records showed documentation the Emergency Preparedness Communication Plan included staff and volunteer contact information for personnel who no longer worked for the agency and did not include contact information for staff and volunteer personnel who currently work for the agency. On 06/08/22 at 10:15 a.m., Staff A stated the Emergency Preparedness Communication Plan did not show contact information of current staff and volunteers who work for the agency and should have been updated as staff and volunteers changed.

Based on record review and interview, the hospice failed to ensure bereavement services were included in the plan of care for one (Patients #13) of 14 patients. --- Findings: Patient #13 A review of the plan of care dated 06/09/22 to 09/06/22 documented no bereavement care plan and showed no bereavement risk assessment during the comprehensive assessment on 06/09/22 and no bereavement assessment during the chaplain spiritual assessment on 06/12/22. Documentation showed no hospice agency contacts after the patients date of death on 06/10/22. Documentation showed no patient or family/significant other refusal of bereavement services and no changes in the hospice orders. On 06/08/23 at 11:25 a.m., Staff A stated bereavement services were not included in the plan of care for patients #13.

Based on record review and interview, the hospice failed to ensure: 1. Hospice aide services were provided in accordance with the plan of care for six (Patients #1, 2, 4, 5, 6 and #7) of 14 patients and; 2. Bereavement care plan services were provided for one (Patient #14) of 14 patients. --- Findings: Patient #1 A review of the plan of care dated 04/28/23 to 06/26/23 and plan of care updates dated 05/02/23, 05/16/23 and 05/30/23 ordered hospice aide visits at a frequency of two visit per week. Documentation showed hospice aide visits during the week of 05/14/23 to 05/20/23 one visit on 05/18/23 (one visit missed). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency for the hospice aide. Patient #2 A review of the plan of care dated 03/08/23 to 06/05/23 and plan of care updates dated 05/02/23, 05/16/23, 05/30/23 and 06/02/23 ordered hospice aide visits at a frequency of one week one, then two visits per week. Documentation showed hospice aide visits during the week of 03/08/23 to 03/11/23 (one visit missed), 03/26/23 to 04/01/23 one visit on 03/29/23 (one visit missed), 04/23/23 to 04/29/23 one visit on 04/27/23 (one visit missed), 05/14/23 to 05/20/23 one visit on 05/18/23 (one visit missed). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency for the hospice aide. Patient #4 A review of the plan of care dated 04/12/23 to 05/31/23 and plan of care updates dated 05/02/23, 05/16/23 and 05/30/23 ordered hospice aide visits at a frequency of three week eight, then two week one. Documentation showed hospice aide visits during the week of 04/03/23 to 04/08/23 one visit on 04/03/23 and 04/08/23 (one visit missed), 04/23/23 to 04/29/23 one visit on 04/27/23 and 04/28/23 (one visit missed), 04/30/23 to 05/06/23 one visit on 05/04/23 and on 05/05/23 (one visit missed). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency for the hospice aide. Patient #5 A review of the plan of care dated 03/10/23 to 06/07/23 and plan of care updates dated 03/21/23, 04/04/23, 04/18/23, 05/02/23, 05/30/23 and 06/02/23 ordered hospice aide visits at a frequency of one week one, two week 11, then one week one. Documentation showed hospice aide visits during the week of 03/26/23 to 04/01/23 one visit on 03/28/23 (one visit missed), 04/02/23 to 04/08/23 one visit on 04/06/23 (one visit missed), 04/16/23 to 04/22/23 one visit on 04/20/23 (one visit missed). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency for the hospice aide. Patient #6 A review of the plan of care dated 04/13/23 to 06/11/23 and plan of care updates dated 04/18/23, 05/02/23, 05/16/23 and 05/30/23 ordered hospice aide visits at a frequency of one week one, then two week eight. Documentation showed hospice aide visits during the week of 05/07/23 to 05/13/23 one visit on 05/09/ (one visit missed). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency for the hospice aide. Patient #7 A review of the plan of care dated 04/15/23 to 06/13/23 and plan of care updates dated 05/02/23, 05/16/23 and 05/30/23 ordered hospice aide visits at a frequency of three week eight, then one week one. Documentation showed hospice aide visits during the week of 04/30/23 to 05/06/23 one visit on 05/01/23 and 05/05/23 (one visit missed), 05/07/23 to 05/13/23 one visit on 05/11/23 and 05/12/23 (one visit missed), 05/14/23 to 05/20/23 one visit on 05/17/23 and on 05/18/23 (one visit missed). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency for the hospice aide. On 06/08/23 at 10:30 a.m., Staff A stated the hospice aide visit frequencies for patients #1, 2, 4, 5, 6 and #7 were not followed as ordered. Patient #14 A review of the plan of care dated 10/13/22 to 12/11/22 documented a bereavement care plan. Documentation showed a bereavement program mail out at 3 month and 6 month after the patients date of death 11/27/22 but showed no additional hospice agency contact related to bereavement program services. Documentation showed no patient or family/significant other refusal of bereavement services and no changes in the hospice orders. On 06/08/23 at 11:25 a.m., Staff A stated bereavement program services for patient #13 were not provided as indicated on the bereavement care plan.

Based on record review and interview, the hospice failed to ensure the plan of care was fully developed to include all services necessary for the palliation and management of the terminal illness for one (Patient #10) of 14 patients. --- Findings: Patient #10 A plan of care dated 04/30/23 to 06/28/23 failed to include interventions necessary for the palliation and management of the terminal illness Multiple Sclerosis. On 06/08/23 at 11:12 a.m., Staff A stated the plans of care failed to include interventions for the palliation and management of Multiple Sclerosis.

Based on record review and interview, the hospice failed to ensure the plan of care was fully developed to include interventions and/or goals for the palliation and management of pain for two (Patients #7 and 8) of 14 patients. --- Findings: Patient #7 A plan of care dated 04/15/23 to 06/13/23 failed to include interventions and goals necessary for the palliation and management of pain. Documentation showed pain assessments during SN visits dated 04/19/23, 04/27/23, 05/03/23, 05/10/23, 05/17/23, 05/24/23 and on 05/31/23 but documented no interventions and related goals. Patient #8 A plan of care dated 05/12/23 to 07/10/23 failed to include interventions necessary for the palliation and management of pain. Documentation showed pain assessments during SN visits dated 05/15/23, 05/18/23, 05/22/23, 05/25/23, 05/30/23 and on 06/02/23 but documented no interventions and related goals. On 06/08/23 at 11:10 a.m., Staff A stated the plans of care for patients #7 and #8 failed to include interventions for the palliation and management of pain.

Based on record review and interview, the hospice failed to ensure a hospice aide care plan was completed for two (Patients #5 and 7) of 14. --- Findings: Patient #5 A review of the plan of care dated 03/10/23 to 06/07/23 showed a hospice aide care plan was completed on 03/20/23 (three days after the first hospice aide visit was conducted on 03/17/23). Patient #7 A review of the plan of care dated 04/15/23 to 06/13/23 showed the last hospice aide care plan was completed on 08/22/22 and showed no other updates for subsequent certification periods after 08/22/22 (08/22/22 to 11/19/22, 11/20/22 to 02/18/23, 02/19/23 to 04/19/23 and 04/20/23 to 06/18/23). On 06/08/22 at 11:05 a.m., Staff A stated: 1. The hospice aide care plan for patient #5 should have been completed by the IDG prior to the first hospice aide visit conducted on 03/17/23 and; 2. The hospice aide care plan for patient #7 should have been updated by the IDG prior to the beginning of each subsequent certification period since 08/22/22.

Based on record reviews and interview, the hospice failed to ensure a completed discharge summary was provided for two (Patients #11 and 12) of 14. --- Findings: Patient #11 A review of the clinical record documented revocation and discharge from the agency on 05/01/23 to inpatient hospital provider services. Documentation showed no discharge summary of care and no documentation a summary of care was provided to the inpatient hospital service provider. Patient #12 A review of the clinical record documented discharge from the agency for cause on 02/27/23. Documentation showed no discharge summary and no discharge summary of care was provided to the physician service provider. On 06/08/23 at 11:20 a.m., Staff A stated: 1. Patients #11 and 12 did not have a discharge summary of care and; 2. No discharge summary of care was provided to inpatient hospital service provider for patient #11.