Every finding on record at Anthem Hospice of Oklahoma City LLC

Based on record review and interview, the hospice failed to ensure bereavement care planning for seven (Patients #5, 7, 10, 17, 18, 19 and #20) of 20 patients. --- Findings: Patient #5A review of the clinical record showed an election of the hospice benefit on 08/25/25 with a completion of the initial spiritual and bereavement assessment on 08/26/25. A review of a POC dated 04/22/26 to 06/20/26 and IDG updates to the POC on 04/14/26 and on 04/28/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC.   Patient #7A review of the clinical record showed an election of the hospice benefit on 08/19/25 with a completion of the initial spiritual and bereavement assessment on 08/19/25. A review of a POC dated 04/16/26 to 06/14/26 and IDG updates to the POC on 04/14/26 and on 04/28/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC.  Patient #10A review of the clinical record showed an election of the hospice benefit on 03/18/26 with a completion of the initial spiritual and bereavement assessment on 03/19/25. A review of a POC dated 03/18/26 to 06/15/26 and IDG updates to the POC on 03/24/26, 04/07/26, 04/21/26 and on 05/05/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC.  Patient #17A review of the clinical record showed an election of the hospice benefit on 11/15/25 with a completion of the initial spiritual and bereavement assessment on 11/17/25. A review of a POC dated 02/13/26 to 05/13/26 and IDG updates to the POC on 02/03/26, 02/17/26, 03/03/26, 03/10/26, 03/24/26 and on 04/07/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC.  Patient #18A review of the clinical record showed an election of the hospice benefit on 11/18/25 with a completion of the initial spiritual and bereavement assessment on 11/18/25. A review of a POC dated 02/16/26 to 05/16/26 and IDG updates to the POC on 02/03/26, 02/17/26 and on 03/03/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC.  Patient #19A review of the clinical record showed an election of the hospice benefit on 08/05/25 with a completion of the initial spiritual and bereavement assessment on 08/06/25. A review of a POC dated 11/03/25 to 01/31/26 and IDG updates to the POC on 11/04/25, 11/21/25, 12/02/25, 12/16/25 and on 12/23/25 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC.  Patient #20A review of the clinical record showed an election of the hospice benefit on 11/13/25 with a completion of the initial spiritual and bereavement assessment on 11/13/25. A review of a POC dated 11/13/25 to 02/10/26 and IDG updates to the POC on 11/25/25 and on 12/19/25 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC.  On 05/07/26 at 10:45 a.m. to 11:52 a.m., Staff A stated the Patients #5, 7, 10, 17, 18, 19 and #20 did not have bereavement care plans in place.

Based on record review and interview, the hospice failed to ensure plans of care: 1.Included interventions and goals for the hospice diagnosis for two (Patients #2 and #3) of 20 patients.  2.Were updated to meet patient care needs for one (Patients #19) of 20 patients. --- Findings: INTERVENTIONS Patient #2A review of a POC dated 04/13/26 to 06/11/26 with IDG updates on 04/14/26 and on 04/28/26 showed no SN service discipline interventions and goals for the hospice diagnosis of nutritional marasmus. The clinical record showed no communications between the IDG members related to the hospice diagnosis. On 05/07/26 at 10:35 a.m., Staff A stated the POC did not show SN interventions or goals for the hospice diagnosis.  Patient #3A review of a POC dated 04/21/26 to 06/11/26 with IDG updates on 04/21/26 and on 05/05/26 showed no SN service discipline interventions and goals for the hospice diagnosis of unspecified protein calorie malnutrition. The clinical record showed no communications between the IDG members related to the hospice diagnosis. On 05/07/26 at 10:37 a.m., Staff A stated the POC did not show SN interventions or goals for the hospice diagnosis. UPDATED Patient #19A review of a POC dated 11/03/25 to 01/31/26 with IDG updates on 11/04/25, 11/21/25, 12/02/25, 12/16/25 and on 12/23/25 showed a SN service discipline visit frequency of one time a week.  The clinical record showed SN visits were conducted for the weeks of:11/03/25 to 11/09/25 on 11/04/25 and 11/06/25 (one visit ordered, two visits conducted).11/10/25 to 11/16/25 on 11/11/25 and 11/13/25 (one visit ordered, two visits conducted).11/17/25 to 11/23/25 on 11/18/25 and 11/20/25 (one visit ordered, two visits conducted).12/01/25 to 12/07/25 on 12/02/25 and 12/04/25 (one visit ordered, two visits conducted).12/08/25 to 12/14/25 on 12/09/25, 12/11/25 and 12/13/25 (one visit ordered, three visits conducted).  The clinical records showed no communications between the IDG members about the need to increase the SN visit frequency and showed no changes in the orders. On 05/07/26 at 10:37 a.m., Staff A stated the POC did not show an increase in the SN visits.

Based on record review and interview, the hospice failed to maintain a QAPI program for all patients and employees. --- Findings: A review of QAPI program records showed no QAPI activities, data or meeting minutes in the calendar year of 2024.  On 05/07/26 at 10:05 a.m., Staff B stated:1.The hospice was bought out at the end of 2024, and the previous owner did not give access to the QAPI records. 2.There were no QAPI program records for calendar year 2024.

Based on record review and interview, the hospice failed to ensure QAPI PIPs reflected the needs of its patient population for all patients and employees. --- Findings: A review of QAPI program records showed no QAPI PIP activities, data or meeting minutes in the calendar year of 2024.  A review of QAPI program records for first quarter 2025 on 04/29/25 showed no identification, data analysis or monitoring activities of a PIP. A review of QAPI program records for second quarter 2025 on 09/10/25 showed no identification, data analysis or monitoring activities of a PIP. A review of QAPI program records for third quarter 2025 on 10/14/25 showed no identification, data analysis or monitoring activities of a PIP. On 05/07/26 at 10:05 a.m., Staff B stated:1.The hospice was bought out at the end of 2024, and the previous owner did not give access to the QAPI records.2.There were no QAPI program records for calendar year 2024.3.There were no PIPs in place for calendar year 2025.

Based on record review and interview, the agency failed to ensure continued review and update of a hospice aide care plan for eight (Patients #2, 4, 5, 6, 8, 9, 11 and 19) of 20 patients. --- Findings: Patient #2A review of a POC dated 04/21/26 to 06/19/26 and IDG updates to the POC on 04/21/26 and on 05/05/26 which ordered hospice aide visits at a frequency of three times a week. The clinical record showed no such update to the hospice aide care plan and showed no update to the frequency of aide services since 02/20/26. On 05/07/26 at 10:35 a.m., Staff A stated the aide care plan was not reviewed or updated during the RN recertification visit. Patient #4A review of a POC dated 04/16/26 to 07/14/26 and IDG updates to the POC on 04/14/26 and on 04/28/26 which ordered hospice aide visits at a frequency of one time a week. The clinical record showed no update to the hospice aide care plan and showed no update to the frequency of aide services since 01/20/26. On 05/07/26 at 10:40 a.m., Staff A stated the aide care plan was not reviewed or updated during the RN recertification visit. Patient #5A review of a POC dated 04/22/26 to 06/20/26 and IDG updates to the POC on 04/14/26 and on 04/28/26 which ordered hospice aide visits at a frequency of one time a week. The clinical record showed no update to the hospice aide care plan and showed no update to the frequency of aide services since 02/16/26. On 05/07/26 at 10:45 a.m., Staff A stated the aide care plan was not reviewed or updated during the RN recertification visit. Patient #6A review of a POC dated 04/19/26 to 06/17/26 and IDG updates to the POC on 04/21/26 and on 05/05/26 which ordered hospice aide visits at a frequency of two times a week. The clinical record showed no update to the hospice aide care plan and showed no update of the frequency of aide services since 02/18/26. On 05/07/26 at 10:45 a.m., Staff A stated the aide care plan was not reviewed or updated during the RN recertification visit.  Patient #8A review of a POC dated 04/17/26 to 06/15/26 and IDG updates to the POC on 04/14/26 and on 04/28/26 which ordered hospice aide visits at a frequency of three times a week. The clinical record showed no update to the hospice aide care plan and showed no update to the frequency of aide services since 02/20/26. On 05/07/26 at 10:45 a.m., Staff A stated the aide care plan was not reviewed or updated during the RN recertification visit. Patient #9A review of a POC dated 03/23/26 to 05/21/26 and IDG updates to the POC on 03/24/26, 04/07/26, 04/21/26 and on 05/05/26 which ordered hospice aide visits at a frequency of two times a week. The clinical record showed no update to the hospice aide care plan and showed no update to the frequency of aide services since 01/22/26. On 05/07/26 at 11:05 a.m., Staff A stated the aide care plan was not reviewed or updated during the RN recertification visit. Patient #11A review of a POC dated 04/06/26 to 06/04/26 and IDG updates to the POC on 03/31/26, 04/16/26 and on 04/28/26 which ordered hospice aide visits at a frequency of three times a week. The clinical record showed no update to the hospice aide care plan and showed no update to the frequency of aide services since 02/20/26. On 05/07/26 at 11:20 a.m., Staff A stated the aide care plan was not reviewed or updated during the RN recertification visit. Patient #19A review of a POC dated 11/03/25 to 01/31/26 and IDG updates to the POC on 11/04/25, 11/21/25, 12/02/25, 12/16/25 and on 12/23/25 which ordered hospice aide visits at a frequency of one time a week. The clinical record showed no update to the hospice aide care plan and showed no update to the frequency of aide services since 08/05/25. On 05/07/26 at 11:45 a.m., Staff A stated the aide care plan was not reviewed or updated during the RN recertification visit.

Based on record review and interview, the hospice failed to ensure a record of volunteer program cost savings for all patients, employees and volunteers. --- Findings: A review of volunteer program records showed no cost savings reports for calendar year 2024. On 05/05/26 at 12:35 p.m., Staff B stated:1.The hospice was bought out at the end of 2024, and the previous owner did not give access to the volunteer program records.2.There were no volunteer program records for calendar year 2024.

Based on record review and interview, the hospice failed to ensure it maintained access to the eMR system clinical records for all hospice patients. --- Findings.A request for access to the clinical records for patients who were on services through 12/31/24 yielded no results.On 05/05/26 at 12:35 p.m., Staff B stated:1.The hospice was bought out at the end of 2024, and the previous owner did not give access to the clinical records (eMR system) for patients who were on hospice services through 12/31/24.2.They were unable to locate the previous owner.

Based on record review and interview, the agency failed to ensure emergency preparedness disaster declaration, table-top exercises, drills, community drills or plan activation events were conducted for 02/01/2021 to 12/31/21 and calendar year 2022 for all patients and employees. --- Findings: A review of administrative records related to emergency preparedness showed no emergency preparedness disaster declaration, table-top exercises, drills, community drills or plan activation events for 02/01/2021 to 12/31/21 and calendar year 2022. On 07/07/23 at 10:50 a.m., Staff B stated: The agency had no emergency preparedness disaster declaration, table-top exercises, drills, community drills or plan activation events for 02/01/2021 to 12/31/21 and calendar year 2022.

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 three (Patients #1, 3 and #9) of 14 patients and; 2. SN services were provided in accordance with the plan of care for one (Patient #4) of 14 patients. The failed practice had the potential to place patients at risk for ineffective palliative health outcomes by not receiving care and services as ordered by their physicians. See Tag L543. Based on record review and interview, the hospice failed to ensure individualized plans of care were fully developed for three (Patients #7, 9 and #10) of 14 patients. The failed practice had the potential to affect a patients response to health care interventions to achieve desired palliative care levels for functional and physical health for all patients. See Tag L547. Based on record review and interview, the hospice failed to ensure IDG meetings to update and revise individualized patient care plans were conducted every 14 days for eight (Patients #2, 3, 4, 5, 6, 8, 9 and #10) of 14 patients. The failed practice had the potential to affect a patients response to health care interventions to achieve functional and physical health needs for all patients. See Tag L552. Based on record review and interview, the hospice failed to ensure: 1. SN visit frequencies were ordered in the plans of care for eight (Patients #1, 2, 5, 8, 9, 12, 13 and #14); 2. Hospice aide visit frequencies were ordered in the plan of care for two (Patients #1 and #2) of 14 patients; 3. Social Work visit frequencies were ordered in the plans of care for three (Patients #9, 12 and #14) of 14 patients and; 4. Chaplain visit frequencies were ordered in the plans of care for three (Patients #9, 12 and #14) of 14 patients. The failed practice had the potential to impact the health, safety and well-being of patients to receive appropriate care and services ordered by their physician for all patients. See Tag L555. --- .

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 three (Patients #1, 3 and #9) of 14 patients and; 2. SN services were provided in accordance with the plan of care for one (Patient #4) of 14 patients. --- Findings: Patient #1 A review of the plan of care dated 06/16/23 to 08/14/23 and plan of care update dated 06/16/23 showed an ordered SN visit frequency of one time a week every week. Documentation showed during the weeks of 06/16/23 to 06/17/23 no SN visit was conducted (one visit ordered). Documentation showed no patient or family refusal of visits and no changes in the ordered visit frequency for the SN. Patient #3 A review of the plan of care dated 05/21/23 to 08/18/23 and plan of care update dated 06/02/23 and 06/16/23 showed an ordered hospice aide visit frequency of two times a week for 13 weeks. Documentation showed during the weeks of 06/11/23 to 06/17/23 no hospice aide visit was conducted (aide visits on 06/12/23 and 06/15/23 were not started/documented). Documentation showed no patient or family refusal of visits and no changes in the ordered visit frequency for the hospice aide. Patient #4 A review of the plan of care dated 05/22/23 to 07/20/23 and plan of care updates dated 06/02/23 and 06/16/23 showed an ordered SN visit frequency of two times a week every week. Documentation showed during the weeks of 05/23/23 to 05/27/23 no SN visit was conducted (two visits ordered, one visit declined on 05/23/23), 05/28/23 to 06/03/23 one SN visit on 06/30/23 (two visits ordered, one visit conducted), 06/04/23 to 06/10/23 one SN visit on 06/06/23 (two visits ordered, one visit conducted), 06/04/23 to 06/10/23 one SN visit on 06/06/23 (two visits ordered, one visit conducted), 06/11/23 to 06/17/23 one SN visit on 06/12/23 (two visits ordered, one visit conducted), 06/18/23 to 06/24/23 one SN visit on 06/20/23 (two visits ordered, one visit conducted) and 06/25/23 to 07/01/23 one SN visit on 06/27/23 (two visits ordered, one visit conducted). Documentation showed no patient or family refusal of visits and no changes in the ordered visit frequency for the SN. Patient #9 A review of the plan of care dated 05/09/23 to 07/07/23 (with no plan of care updates documented after 04/20/23) showed an ordered hospice aide visit frequency of one week one then, two times a week for 12 weeks dated 06/01/23. Documentation showed no hospice aide visits were conducted from 06/01/23 to 07/06/23. Documentation showed no patient or family refusal of visits and no changes in the ordered visit frequency for the hospice aide. On 07/07/23 at 12:45 p.m. to 1:35 p.m., Staff C stated: 1. Patients #1 and #4 did not receive SN visits/services as ordered in the plans of care and; 2. Patients #3 and #9 did not receive hospice aide visits/services as ordered in the plans of care.

Based on record review and interview, the hospice failed to ensure individualized plans of care were fully developed for three (Patients #7, 9 and #10) of 14 patients. --- Findings: Patient #7 A review of the plan of care dated 06/26/23 to 08/24/23 with no update to the plan of care showed no ordered service discipline frequencies and durations for SN, Hospice aide, Medical Social Work or Chaplain Services. Documentation showed a SN visit was conducted on 06/26/23 and a SN visit was missed on 06/30/23; Hospice aide visits were conducted on 06/26/23 and on 06/29/23; initial Medical Social Work visit was conducted on 06/26/23 and an initial Chaplain visit was conducted on 06/26/23. Documentation showed no follow up service discipline visits during the week of 07/02/23 to 07/06/23, no patient/caregiver refusal of services and no changes in orders. On 07/07/23 at 1:28 p.m., Staff C stated the individualized POCs for Patients #7 did not contain ordered service discipline visit frequencies and durations. Patient #9 A review of the clinical record showed a start of care date of 03/10/23 and documented a primary diagnosis of disorder of the brain (unspecified). Documentation showed no plan of care for episode dated 05/09/23 to 07/07/23. Documentation showed an IDG meeting on 04/20/23, showed no other IDG meeting documentation and no coordination of care communications with the physician related to hospice services through 07/06/23 (77 days). Documentation showed SN visits were conducted on 05/11/23, 05/16/23 and on 05/23/23; MSW visits were conducted on 05/23/23 and on 06/29/23; and Chaplain Visit was conducted on 06/29/23. Documentation showed no IDG meetings to update and revise the individualized care plan every 14 days from 04/20/23, no coordination of care communications with the physician related to ongoing hospice services, no patient/caregiver refusal of services and no changes in orders. On 07/06/23 at 2:35 p.m., Staff C stated patient #9 did not have a plan of care should for the current episode dated 05/09/23 to 07/07/23. Patient #10 A review of the plan of care dated 05/22/23 to 08/19/23 with no update to the plan of care showed no ordered service discipline frequencies and durations for SN, Medical Social Work or Chaplain Services. Documentation showed a SN visit was conducted on 05/26/23 and on 06/29/23; Medical Social Work visit was conducted on 05/23/23 and on 06/28/23 and a Chaplain visit was conducted on 06/28/23. Documentation showed no patient/caregiver refusal of services and no changes in orders. On 07/07/23 at 1:40 p.m., Staff C stated the individualized POCs for Patients #10 did not contain ordered service discipline visit frequencies and durations.

Based on record review and interview, the hospice failed to ensure IDG meetings to update and revise individualized patient care plans were conducted every 15 days for eight (Patients #2, 3, 4, 5, 6, 8, 9 and #10) of 14 patients. --- Findings: Patient #2 A review of the clinical record showed a start of care date of 02/10/23, a plan of care dated 05/11/23 to 08/08/23 documented a primary diagnosis of advanced Alzheimers disease. Documentation showed an IDG meeting on 05/19/23, showed no other IDG meeting documentation and no coordination of care communications with the physician related to hospice services through 07/06/23 (48 days). On 07/06/23 at 12:55 p.m., Staff C stated patient #2 should have had IDG meetings to update and revise the individualized care plan every 15 days from 05/19/23 and should have shown documentation of coordination of care communications with the physician related to ongoing hospice services. Patient #3 A review of the clinical record showed a start of care date of 02/20/23, a plan of care dated 05/21/23 to 08/18/23 documented a primary diagnosis of advanced Alzheimers disease. Documentation showed an IDG meeting on 06/02/23 and 06/16/23, showed no other IDG meeting documentation and no coordination of care communications with the physician related to hospice services through 07/06/23 (20 days). On 07/06/23 at 1:05 p.m., Staff C stated patient #3 should have had IDG meetings to update and revise the individualized care plan every 15 days from 06/16/23 and should have shown documentation of coordination of care communications with the physician related to ongoing hospice services. Patient #4 A review of the clinical record showed a start of care date of 01/27/22, a plan of care dated 05/22/23 to 07/20/23 documented a primary diagnosis of end stage renal disease. Documentation showed an IDG meeting on 06/02/23 and 06/16/23, showed no other IDG meeting documentation and no coordination of care communications with the physician related to hospice services through 07/06/23 (20 days). On 07/06/23 at 1:10 p.m., Staff C stated patient #4 should have had IDG meetings to update and revise the individualized care plan every 15 days from 06/16/23 and should have shown documentation of coordination of care communications with the physician related to ongoing hospice services. Patient #5 A review of the clinical record showed a start of care date of 02/15/23, a plan of care dated 06/15/23 to 08/13/23 documented a primary diagnosis of congestive heart failure. Documentation showed an IDG meeting on 06/16/23, showed no other IDG meeting documentation and no coordination of care communications with the physician related to hospice services through 07/06/23 (20 days). On 07/06/23 at 1:20 p.m., Staff C stated patient #5 should have had IDG meetings to update and revise the individualized care plan every 15 days from 06/16/23 and should have shown documentation of coordination of care communications with the physician related to ongoing hospice services. Patient #6 A review of the clinical record showed a start of care date of 04/11/20, a plan of care dated 05/26/23 to 07/24/23 documented a primary diagnosis of atherosclerotic heart disease. Documentation showed an IDG meeting on 06/02/23 and 06/16/23, showed no other IDG meeting documentation and no coordination of care communications with the physician related to hospice services through 07/06/23 (20 days). On 07/06/23 at 1:25 p.m., Staff C stated patient #6 should have had IDG meetings to update and revise the individualized care plan every 15 days from 06/16/23 and should have shown documentation of coordination of care communications with the physician related to ongoing hospice services. Patient #8 A review of the clinical record showed a start of care date of 02/07/23, a plan of care dated 05/08/23 to 08/05/23 documented a primary diagnosis of Parkinsons disease. Documentation showed an IDG meeting on 06/02/23 and 06/16/23, showed no other IDG meeting documentation and no coordination of care communications with the physician related to hospice services through 07/06/23 (20 days). On 07/06/23 at 1:25 p.m., Staff C stated patient #8 should have had IDG meetings to update and revise the individualized care plan every 15 days from 06/16/23 and should have shown documentation of coordination of care communications with the physician related to ongoing hospice services. Patient #9 A review of the clinical record showed a start of care date of 03/10/23 and documented a primary diagnosis of disorder of the brain (unspecified). Documentation showed no plan of care for episode dated 05/09/23 to 07/07/23. Documentation showed an IDG meeting on 04/20/23, showed no other IDG meeting documentation and no coordination of care communications with the physician related to hospice services through 07/06/23 (77 days). On 07/06/23 at 2:35 p.m., Staff C stated patient #9 should have had a plan of care for episode dated 05/09/23 to 07/07/23, IDG meetings to update and revise the individualized care plan every 15 days from 04/20/23 and should have shown documentation of coordination of care communications with the physician related to ongoing hospice services. Patient #10 A review of the clinical record showed a start of care date of 02/21/23, a plan of care dated 05/22/23 to 08/19/23 documented a primary diagnosis of congestive heart failure. Documentation showed an IDG meeting on 06/02/23, showed no other IDG meeting documentation and no coordination of care communications with the physician related to hospice services through 07/06/23 (34 days). On 07/06/23 at 1:20 p.m., Staff C stated patient #10 should have had IDG meetings to update and revise the individualized care plan every 15 days from 06/02/23 and should have shown documentation of coordination of care communications with the physician related to ongoing hospice services.

Based on record review and interview, the hospice failed to ensure: 1. SN services discipline was ordered in the plans of care or communicated and coordinated through the IDG for eight (Patients #1, 2, 5, 8, 9, 12, 13 and #14); 2. Hospice aide services discipline was ordered in the plans of care or communicated and coordinated through the IDG for two (Patients #1 and #2) of 14 patients; 3. Social Work services discipline was ordered in the plans of care or communicated and coordinated through the IDG for three (Patients #9, 12 and #14) of 14 patients and; 4. Chaplain services discipline was ordered in the plans of care or communicated and coordinated through the IDG for three (Patients #9, 12 and #14) of 14 patients. The failed practice had the potential to impact the health, safety and well-being of patients to receive appropriate care and services as ordered by their physician or communicated and coordinated through the IDG for all patients. --- Patient #1 A review of the plan of care dated 06/16/23 to 08/14/23 and plan of care update dated 06/16/23 showed an ordered SN visit frequency and duration one time a week every week and showed no HA service discipline needs were communicated and coordinated through the IDG. Documentation showed during the weeks of 06/18/23 to 06/24/23 two SN visits were conducted on 06/19/23 and 06/22/23 (one visit ordered, two visits conducted [no PRN visit use documented]) and HA visits were conducted on 06/19/23, 06/20/23, 06/21/23, 06/22/23 and 06/23/23 (no HA visits ordered, five visits conducted); 06/25/23 to 07/01/23 three SN visits were conducted on 06/26/23, 06/29/23 and on 06/30/23 (one visit ordered, three visits were conducted [no PRN visit use documented]) and HA visits were conducted on 06/26/23, 06/27/23, 06/28/23, 06/29/23 and 06/30/23 no HA visits ordered, five visits conducted). Documentation showed no changes to the ordered visit frequency for the SN and no HA service discipline needs were communicated and coordinated through the IDG. Patient #2 A review of the plan of care dated 05/11/23 to 08/08/23 and plan of care update dated 05/19/23 showed no ordered SN or hospice aide visit frequency or duration. Documentation showed during the weeks of 05/16/23 to 05/20/23 one hospice aide visit was conducted on 05/17/23 (no visits ordered) and SN visit conducted on 05/16/23 (no visit ordered); 06/04/23 to 06/10/23 one hospice aide visit was conducted on 06/07/23 (no visits ordered) and SN visit conducted on 06/10/23 (no visit ordered); 06/11/23 to 06/17/23 one hospice aide visit was conducted on 06/14/23 (no visits ordered [visit not documented]); 06/18/23 to 06/24/23 one hospice aide visit was conducted on 06/20/23 (no visits ordered [visit not documented]); 06/25/23 to 07/01/23 one hospice aide visit was conducted on 06/27/23 (no visits ordered [visit not documented]). Documentation showed no SN or HA service discipline needs were identified, ordered and/or communicated and coordinated through the IDG. Patient #5 A review of the plan of care dated 06/15/23 to 08/13/23 and plan of care update dated 06/16/23 showed an ordered SN visit frequency or duration one time a week for 13 weeks. Documentation showed during the weeks of 06/18/23 to 06/24/23 two SN visits were conducted on 06/19/23 and 06/23/23 (one visit ordered, two visits conducted [no PRN visit use documented]), 06/25/23 to 07/01/23 two SN visits were conducted on 06/26/23 and 06/29/23 (one visit ordered, two visits were conducted [no PRN visit use documented]). Documentation showed no SN service discipline frequency changes were identified, ordered and/or communicated and coordinated through the IDG. Patient #8 A review of the plan of care dated 05/08/23 to 08/05/23 and plan of care updates dated 05/19/23, 06/02/23 and on 06/16/23 showed no ordered SN visit frequency or duration. Documentation showed [no hospice service discipline visits from 05/08/23 to 06/01/23], then during the weeks of 06/02/23 to 06/03/23 one SN visit was conducted on 06/02/23 (no visits ordered), 06/04/23 to 06/10/23 one SN visit was conducted on 06/09/23 (no visits ordered), 06/11/23 to 06/17/23 one SN visit was conducted on 06/16/23 (no visits ordered), 06/18/23 to 06/24/23 one SN visit was conducted on 06/23/23 (no visits ordered), 06/25/23 to 07/01/23 one SN visit was missed on 06/30/23 (no visits ordered). Documentation showed no SN service discipline needs were identified, ordered and/or communicated and coordinated through the IDG. Patient #9 A review of the clinical record showed no plan of care dated 05/09/23 to 07/07/23. Documentation showed no plan of care update since 04/20/23. Documentation showed no SN, Medical Social Work and Chaplain service discipline needs were identified and ordered by the physician. Documentation showed during the weeks of 05/09/23 to 05/13/23 an LPN supervisory visit was conducted on 05/10/23 and one SN visit was conducted on 05/11/23 (no visits ordered), 05/14/23 to 05/20/23 one SN visit was conducted on 05/16/23 (no visits ordered), 05/21/23 to 05/27/23 one SN visit was conducted on 05/23/23 (no visits ordered) and one Medical Social Work visit was conducted on 05/23/23 (no visit ordered), [No hospice service discipline visits were conducted between 05/28/23 and 06/24/23] then, during the week of 06/25/23 to 07/01/23 one SN, MSW and Chaplain visits were conducted on 06/29/23 (no visits ordered). Documentation showed no SN, MSW or Chaplain service discipline needs were identified, ordered and/or communicated and coordinated through the IDG and showed no documentation of patient/caregiver refusal of services. Patient #12 A review of the clinical record showed no plan of care dated 12/30/23 to 01/23/23 (date of death). Documentation showed no plan of care updates dated 01/05/23, 01/19/23 and on 02/09/23. Documentation showed no SN, Medical Social Work and Chaplain service discipline needs were identified and ordered by the physician. Documentation showed during the weeks of 12/30/22 to 12/31/22 a SN, Medical Social Work and Chaplain Visits were conducted on 12/30/22. During the week of 01/01/23 to 01/06/23 SN visits were conducted on 01/02/23, 01/05/23 and on 01/06/23 (no visits ordered), 01/08/23 to 01/04/23 SN visits were conducted on 01/09 and on 01/13/2; and a MSW visit was conducted on 01/12/23 (no visits ordered), 01/15/23 to 01/21/23 SN visits were conducted on 01/16/23 and on 01/20/23 (no visits ordered) and during the week of 01/22/23 to 01/23/23 SN visits were conducted on 01/22/23 and 01/23/23 (no visits ordered). Documentation showed no SN, MSW or Chaplain service discipline needs were identified, ordered and/or communicated and coordinated through the IDG and showed no documentation of patient/caregiver refusal of services. Patient #13 A review of the plan of care dated 03/01/23 to 03/16/23 (date of live dc) with no plan of care updates showed no ordered SN service discipline. Documentation showed during the weeks of 03/01/23 to 03/16/23 one SN visit was conducted on 03/01/23 (no visit ordered, one visits conducted), 03/05/23 to 03/11/23 one SN visit was conducted on 03/08/23 (no visit ordered, one visits conducted), 03/12/23 and 03/16/23 one SN visit was conducted on 03/15/23 (no visit ordered, one visits conducted). Documentation showed no SN service discipline needs were identified, ordered and/or communicated and coordinated through the IDG. Patient #14 A review of the plan of care dated 11/23/22 to 01/06/23 (date of live discharge) with plan of care updates dated 11/29/22, 12/02/22, 12/13/22 and on 01/05/23. Documentation showed no SN, Medical Social Work and Chaplain service discipline needs were identified and ordered by the physician. Documentation showed during the weeks of 11/23/22 to 11/26/22 SN visits were conducted on 11/23/22 and on 11/25/22, MSW visit was conducted on 11/23/22 and a Chaplain visit was conducted on 11/23/22 (no SN, MSW or Chaplain Visits ordered), 11/27/22 to 12/03/22 SN visits were conducted on 11/30/22 and on 12/02/22 (no visits ordered), 12/03/22 to 12/10/22 SN visits were conducted on 12/06/22 and on 12/08/22 (no visits ordered) and an MSW visit was conducted on 12/07/22 (no visit ordered), 12/11/22 to 12/17/22 SN visits were conducted on 12/12/22, 12/13/22 and on 12/15/22 (no visits ordered) and an Chaplain visit was conducted on 12/16/22 (no visit ordered), 12/18/22 to 12/24/22 SN visits were conducted on 12/20/22 and on 12/23/22 (no visits ordered), 12/25/22 to 12/31/22 SN visits were conducted on 12/27/22 and on 12/30/22 (no visits ordered), 01/01/23 to 01/06/23 SN visits were conducted on 01/05/23 and on 01/06/23 (no visits ordered) and a MSW visit was conducted on 01/04/23 (no visit ordered). Documentation showed no SN, MSW or Chaplain service discipline needs were identified, ordered and/or communicated and coordinated through the IDG and showed no documentation of patient/caregiver refusal of services. On 07/07/23 at 12:45 p.m. to 2:00 p.m., Staff C stated: 1. SN service discipline was not ordered in the plans of care or communicated and coordinated through the IDG for patients #1, 2, 5, 8, 9, 12, 13 and #14; 2. Hospice aide services discipline was ordered in the plans of care or communicated and coordinated through the IDG for patients #1 and #2; 3. Social Work services discipline was ordered in the plans of care or communicated and coordinated through the IDG for patients #9, 12 and #14 and; 4. Chaplain services discipline was ordered in the plans of care or communicated and coordinated through the IDG for patients #9, 12 and #14.

Based on record review and interview, the hospice failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees. The failed practice had the potential to place all patients at risk of repeated agency mishaps, ineffective management of care and poor quality of care. See Tag L563. Based on record review and interview, the hospice failed to ensure documentation, of QAPI PIPs and showed no review and status update of designated PIPs through the QAPI Program for 02/01/21 to 12/31/21, calendar year 2022 and 01/01/23 to 03/01/23 for all patients and employees. The failed practice had the potential to place the agency, all patients and employees at risk for stagnated efforts for improvement as a result of unidentified problematic clinical, administrative, infection control or personnel problems. See Tag L573. --- .

Based on record review and interview, the hospice failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees. --- Findings: Administrative records of ongoing patient centered QAPI program for the hospice which showed data collection activities utilized in the hospices QAPI Program from 02/01/21 to 12/31/21, calendar year 2022 and 01/01/23 to 03/01/23 or available year to date records were requested. No administrative records for the requested time periods were provided. Additional requests for administrative records yielded no results. On 07/07/23 at 11:00 a.m., Staff B stated the hospice had no administrative records which showed data collection sources nor analysis of collected data that showed improved quality of patient care for 02/01/21 to 12/31/21, calendar year 2022 and 01/01/23 to 03/01/23.

Based on record review and interview, the hospice failed to ensure QAPI PIPs and showed no review and status update of designated PIPs through the QAPI Program for 02/01/21 to 12/31/21, calendar year 2022 and 01/01/23 to 03/01/23 for all patients and employees. --- Findings: Administrative records of ongoing patient centered QAPI program PIPs for 02/01/21 to 12/31/21, calendar year 2022 and 01/01/23 to 03/01/23 were requested. Documentation showed no QAPI program PIPs for 02/01/21 to 12/31/21, calendar year 2022 and 01/01/23 to 03/01/23. Additional requests for administrative records yielded no results. On 07/07/23 at 11:00 a.m., Staff B stated the hospice had no administrative records which showed QAPI program PIPs for 02/01/21 to 12/31/21, calendar year 2022 and 01/01/23 to 03/01/23.

Based on record review and interview, the hospice failed to ensure its infection control program included surveillance monitoring and reporting and was included in QAPI program activities for all patients and staff. --- Findings: Administrative records which showed documentation of the agencys infection control program and its surveillance data was included in QAPI program activities for 02/01/21 to 12/31/21, calendar year 2022 and 01/01/23 to 03/01/23 were requested. No documentation was provided. . On 07/07/23 at 2:30 p.m., Staff B stated there was no documentation which showed the agencys infection control program and its surveillance data was included in QAPI program activities for 02/01/21 to 12/31/21, calendar year 2022 and 01/01/23 to 03/01/23.

Based on record review and interview, the hospice failed to ensure medical social services were provided by a qualified social worker for all patients. --- Findings: On 07/05/23 at 9:00 a.m., OSDH arrived on site at the agency to conduct an unannounced survey. During the entrance conference Staff A identified self as the MSW, Bereavement Coordinator and Chaplain for the hospice agency. A review of personnel records showed no qualifying background experience documented on the job application or proof of mandatory educational levels of a Medical Social Worker. On 07/07/23 at 3:00 p.m., Staff I stated personnel records were provided in their entirety and did not contain all required information to qualify Staff A as a Medical Social Worker. Additional request for information yielded no results. At 3:15 p.m., Staff A stated he had no proof of qualifying documentation as a MSW.

Based on record review and interview, the hospice failed to: 1. Ensure establishment of a hospice aide care plan for two (Patients #1 and #2) of 14 patients and; 2. Ensure continued review and update of the hospice aide care plan for four (Patients #3 and #5) of 14 patients. --- Findings: Patient #1 A review of the clinical record showed no hospice aide care plan for episode of 06/16/23 through 08/14/23 for visits conducted on 06/16/23, 06/19/23, 06/20/23, 06/21/23, 06/22/23, 06/23/23, 06/26/23, 06/27/23, 06/28/23, 06/29/23 and 06/30/23. On 07/06/23 at 12:42 p.m., Staff C stated the clinical record showed no hospice aide care plan for HA for visits conducted on 06/16/23, 06/19/23, 06/20/23, 06/21/23, 06/22/23, 06/23/23, 06/26/23, 06/27/23, 06/28/23, 06/29/23 and 06/30/23. Patient #2 A review of the clinical record showed no hospice aide care plan for the episode of 05/11/23 through 08/08/23 for visits conducted on 05/17/23, 06/07/23, 06/14/23 (visit not started/documented), 06/20/23 (visit not started/documented) and 06/27/23 (visit not started/documented). On 07/06/23 at 12:55 p.m., Staff C stated the clinical record showed no hospice aide care plan for HA visits beginning 05/17/23 through 06/27/23. Patient #3 A review of the clinical record showed a hospice aide care dated 02/20/23 hospice aide visits were conducted on 05/22/23, 05/25/23, 05/29/23, 06/01/23, 06/05/23, 06/08/23, 06/12/23 (visit not started/documented), 06/15/23 (visit not started/documented), 06/19/23, 06/22/23, 06/26/23 (visit not started/documented) and 06/29/23.Documentation showed no updated of the POC or orders for the visits. On 07/06/23 at 1:05 p.m., Staff C stated the clinical record showed the hospice aide care plan dated 02/20/23 was not reviewed and updated for HA visits beginning 05/22/23 through 06/30/23. Patient #5 A review of the clinical record showed a hospice aide care plan for the episode of 06/15/23 through 08/13/23 dated 02/16/23. An IDG POC update dated 06/16/23 documented orders for hospice aide visits of two to five times a week for 13 weeks. Documentation showed hospice aide visits were conducted on 06/20/23, 06/23/23, 06/27/23 and 06/30/23 and no updated hospice aid assignment of duties/care plan for the visits.. On 07/06/23 at 1:20 p.m., Staff C stated the clinical record showed the hospice aide care plan dated 02/16/23 was not reviewed and updated for HA visits beginning 06/20/23 through 06/30/23.

Based on record review and interview, the hospice failed to ensure certified hospice aide supervisory visits were completed every 14 days for one (Patients #3) of 14 patients. --- Findings: Patient #3 A plan of care dated 05/21/23 to 08/18/23 and IDG POC updates dated 06/02/23 and 06/16/23 documented orders for hospice aide visits two times a week for 13 weeks. Documentation showed hospice aide visits were conducted on 05/22/23, 05/25/23, 05/29/23, 06/01/23, 06/05/23, 06/08/23, 06/12/23 (visit not started/documented), 06/15/23 (visit not started/documented), 06/19/23, 06/22/23, 06/26/23 (visit not started/documented) and 06/29/23 with supervisory visits completed on 05/30/23 and on 06/12/23. Documentation showed the scheduled aide supervisory visit on 06/26/23 was not started/documented and showed no supervisory visits through 07/06/23 (25 days). Documentation showed no change in orders, patient /caregiver refusal or physician notification of missed visits. On 07/06/23 at 1:05 p.m., Staff C stated the clinical record showed no hospice aide supervisory visits from 06/12/23 to 07/06/23 and HA supervisory visits should be conducted every 14 days.

Based on record review, observation and interview, the hospice failed to ensure notification of an operating branch location to OSDH and CMS for one (Patient #6) of 14 patients. --- Findings: On 07/05/23 at 9:00 a.m., OSDH arrived on site at the agency to conduct an unannounced survey. During the entrance conference Staff A was identified as the administrator designee. Staff A stated the hospice had one operating branch location in Walters, Oklahoma which currently provided services to one patient out of that office location. At 10:15 a.m., the OSDH survey observed a hospice agency brochure which documented the agencys covered services and listed the hospice agency locations as Oklahoma City, Oklahoma and Walters, Oklahoma. At 10:30 a.m., Staff B was identified as the hospice administrator. Staff B stated the hospice had one operating branch location in Walters, Oklahoma which currently provided services to one patient out of that office location. On 07/06/23 at 11:45 a.m., Staff B stated: 1. The hospice agency did not have an official branch office location because the patients case management and IDGs occurred from the Oklahoma City office location; 2. The hospice staff who provided care to the patient was located at the Walters, Oklahoma branch office location and; 3. Neither OSDH nor CMS were notified of the operating branch location in Walters, Oklahoma.

Based on record review and interview, the hospice failed to ensure personnel records were maintained with required employee acknowledged job descriptions/duties for three (Volunteer 1, Staff A and D) of one volunteer and five employees. --- Findings: Volunteer 1 A review of personnel records showed no specific duty assignment or signed job description for hospice volunteer role, responsibilities and limitations. Staff A A review of personnel records showed no specific duty assignment or signed job description for Medical Social Worker role and responsibilities. Staff D A review of personnel records showed no specific duty assignment or signed job description for Volunteer Services Coordinator role and responsibilities. On 07/07/23 at 3:00 p.m., Staff I stated personnel records were provided in their entirety and did not contain all required information for Volunteer 1, Staff A and D.

Based on record review and interview, the hospice failed to ensure personnel records were maintained with required annual employee performance evaluations and skill competency evaluations for four (Volunteer 1, Staff A and D) of one volunteer and five employees. --- Findings: Volunteer 1 A review of personnel records showed no annual performance evaluations and no skill competency evaluation for a hospice volunteer. Staff D A review of personnel records showed no skill competency evaluation for Volunteer Services Coordinator. Staff F A review of personnel records showed no skill competency evaluation for registered nurse. Staff H A review of personnel records showed no skill competency evaluation for hospice aide. On 07/07/23 at 3:00 p.m., Staff I stated personnel records were provided in their entirety and did not contain all required information for Volunteer 1, Staff D, F and H.

Based on record review and interview, the hospice failed to ensure documentation of physician certificate of terminal illness for subsequent certification periods for 9 (Patients #1, 2, 3, 4, 5, 6, 8, 10 and #13) of 14 patients. --- Findings: Patient #1 A review of the clinical record showed a plan of care dated 06/16/23 to 08/14/23. Documentation showed an initial certificate of terminal illness dated 06/21/22 (hospice admission date). Clinical documentation showed no certificate of terminal illness for subsequent certification periods after the hospice admission date of 06/21/22. Patient #2 A review of the clinical record showed a plan of care dated 05/11/23 to 08/08/23. Documentation showed a certificate of terminal illness dated 02/10/23 (hospice admission date). Clinical documentation showed no certificate of terminal illness for subsequent certification periods after the hospice admission date of 02/10/23. Patient #3 A review of the clinical record showed a plan of care dated 05/21/23 to 08/18/23. Documentation showed an initial certificate of terminal illness dated 02/20/22 (hospice admission date). Clinical documentation showed no certificate of terminal illness for subsequent certification periods after the hospice admission date of 02/20/22. Patient #4 A review of the clinical record showed a plan of care dated 05/22/23 to 07/20/23. Documentation showed an initial certificate of terminal illness dated 01/27/22 (hospice admission date). Clinical documentation showed no certificate of terminal illness for subsequent certification periods after the hospice admission date of 01/27/22. Patient #5 A review of the clinical record showed a plan of care dated 06/15/23 to 08/13/23. Documentation showed an initial certificate of terminal illness dated 02/15/23 (hospice admission date). Clinical documentation showed no certificate of terminal illness for subsequent certification periods after the hospice admission date of 02/15/23. Patient #6 A review of the clinical record showed a plan of care dated 05/26/23 to 07/24/23. Documentation showed a certificate of terminal illness dated 04/11/20 (hospice admission date). Clinical documentation showed no certificate of terminal illness for subsequent certification periods after the hospice admission date of 04/11/20. Patient #8 A review of the clinical record showed a plan of care dated 05/08/23 to 08/05/23. Documentation showed a certificate of terminal illness dated 02/07/23 (hospice admission date). Clinical documentation showed no certificate of terminal illness for subsequent certification periods after the hospice admission date of 02/07/23. Patient #10 A review of the clinical record showed a plan of care dated 05/22/23 to 08/19/23. Documentation showed a certificate of terminal illness dated 02/21/23 (hospice admission date). Clinical documentation showed no certificate of terminal illness for subsequent certification periods after the hospice admission date of 02/21/23. Patient #13 A review of the clinical record showed a plan of care dated 03/01/23 to 03/16/23 (date of death). Documentation showed a certificate of terminal illness dated 09/28/22 (hospice admission date). Clinical documentation showed no certificate of terminal illness for subsequent certification periods after the hospice admission date of 09/28/22. On 07/07/23 at 12:45 p.m. to 2:00 p.m., Staff C stated patients #1, 2, 3, 4, 5, 6, 8, 10 and #13 had no certificate of terminal illness or related physician statement of imminence of death for subsequent certification periods.

Based on record review and interview, the hospice failed to ensure documentation of imminence of death at time of the initial comprehensive assessments for 2 (Patients #7 and #12) of 14 patients. --- Findings: Patient #7 A review of the clinical record showed a plan of care dated 06/26/23 to 08/24/23 and a comprehensive assessment dated 06/26/23 (hospice admission date). Clinical documentation showed no physician certificate of terminal illness. Patient #12 A review of the clinical record showed a plan of care dated 12/30/22 to 01/23/23 and a comprehensive assessment dated12/30/22 (Hospice admission date). Clinical documentation showed nophysician certificate of terminal illness. On 07/07/23 at 12:45 p.m. to 2:00 p.m., Staff C stated patients #7 and #12 had no certificate of terminal illness.

Based on record review and interview, the hospice failed to ensure personnel records were maintained with required certification for one (Staff H) of one volunteer and five employees. --- Findings: Staff H A review of personnel records showed no current hospice aide certification. On 07/07/23 at 3:00 p.m., Staff I stated personnel records were provided in their entirety and did not contain all required information for Staff H.

Based on record review and interview, the hospice failed to ensure personnel records were maintained with proof of background experience and/or educational requirements to meet qualifications as a Medical Social Worker for one (Staff A) of one volunteer and five employees. --- Findings: Staff A A review of personnel records showed no qualifying background experience documented on the job application or proof of mandatory educational levels of a Medical Social Worker. Additional request for information yielded no results. On 07/07/23 at 3:00 p.m., Staff I stated personnel records were provided in their entirety and did not contain all required information to qualify Staff A as a Medical Social Worker.

Based on record review and interview, the hospice failed to ensure required background checks were completed for one (Staff F) of five employees and one volunteer. --- 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 employees of a home care agency whose employment began after 07/01/14. Staff F A review of the personnel record showed no documentation of a background check through OKSCREEN for employment that began 04/01/21. On 07/07/23 at 2:05 p.m., Staff I stated Staff K had no background check through the OkScreen database.