Every finding on record at Carter Healthcare Hospice of Central Oklahoma, LLC

Based on record review and interview, the hospice failed to ensure medical social work completion of the initial psychosocial assessment no later than 5 calendar days after the election of hospice care for three (Patients #7, 12 and #14) of 15 patients. --- Findings: Patient #7A review of the clinical record showed an election of the hospice benefit on 03/04/26 with no completion of an initial psychosocial assessment from 03/04/26 to 03/18/26 (14 days after election of the hospice benefit). The clinical record showed a MSW missed visit on 03/13/26 (nine days after the election of the hospice benefit) and showed no other attempts to complete the initial psychosocial assessment until 03/18/26.  Patient #12A review of the clinical record showed an election of the hospice benefit on 02/14/25 with no completion of an initial psychosocial assessment from 02/14/25 to 04/10/25 (55 days after election of the hospice benefit). The clinical record showed no MSW missed visits, no other attempts to complete the initial psychosocial assessment until 04/10/25 and showed no change in orders.  Patient #14A review of the clinical record showed an election of the hospice benefit on 12/19/25 with no completion of an initial psychosocial assessment from 12/19/25 to 01/04/26 (16 days after election of the hospice benefit) and no patient or caregiver refusal of medical social work visits or change in orders. On 05/14/26 at 10:42 a.m. to 11:05 a.m., Staff A stated the initial psychosocial assessments were late for patients #7, 12 and #14.

Based on record review and interview, the hospice failed to ensure plans of care were fully developed to include SN interventions and goals related to the hospice diagnoses for seven (Patients 2, 3, 4, 5, 10, 11 and #13) of 15 patients. --- Findings: Patient #2A review of a POC dated 04/17/26 to 07/15/26 with IDG updates on 04/22/26 and on 05/06/26 showed no SN interventions and goals that addressed the hospice diagnoses of colon and lung cancer and showed no communication between the IDG to update the POC. On 05/14/26 at 10:25 a.m., Staff A stated the POC did not have interventions or goals for colon or lung cancer. Patient #3A review of a POC dated 04/22/26 to 07/22/26 with IDG updates on 04/22/26 and on 05/06/26 showed no SN interventions and goals that addressed the hospice diagnoses of Alzheimer’s disease and chronic kidney disease and showed no communication between the IDG to update the POC. On 05/14/26 at 10:31 a.m., Staff A stated the POC did not have interventions or goals for Alzheimer’s disease or chronic kidney disease. Patient #4A review of a POC dated 04/09/26 to 07/07/26 with IDG updates on 04/22/26 and on 05/06/26 showed no SN interventions and goals that addressed the hospice diagnoses of Alzheimer’s disease and cerebrovascular disease and showed no communication between the IDG to update the POC. On 05/14/26 at 10:35 a.m., Staff A stated the POC did not have interventions or goals for Alzheimer’s disease and cerebrovascular disease. Patient #5A review of a POC dated 04/15/26 to 07/13/26 with IDG updates on 04/22/26 and on 05/06/26 showed no SN interventions and goals that addressed the hospice diagnosis of pancreatic cancer and showed no communication between the IDG to update the POC. On 05/14/26 at 10:40 a.m., Staff A stated the POC did not have interventions or goals for pancreatic cancer. Patient #10A review of a POC dated 01/07/26 to 04/06/26 with IDG updates on 01/14/26 and on 01/28/26 showed no SN interventions and goals that addressed the hospice diagnosis of lung cancer and showed no communication between the IDG to update the POC. On 05/14/26 at 10:50 a.m., Staff A stated the POC did not have interventions or goals for lung cancer. Patient #11A review of a POC dated 03/31/26 to 06/28/26 with IDG updates on 04/08/26 and on 04/22/26 showed no SN interventions and goals that addressed the hospice diagnosis of congestive heart failure and showed no communication between the IDG to update the POC. On 05/14/26 at 10:52 a.m., Staff A stated the POC did not have interventions or goals for congestive heart failure. Patient #13A review of a POC dated 11/23/25 to 02/20/26 with IDG updates on 12/02/25, 12/16/25 and on 12/30/25 showed no SN interventions and goals that addressed the hospice diagnosis of cardiovascular disease and showed no communication between the IDG to update the POC. On 05/14/26 at 11:00 a.m., Staff A stated the POC did not have interventions or goals for cardiovascular disease.

Based on record review and interview, the hospice failed to ensure the POCs were fully developed to include service discipline visit frequencies for four (Patients #4, 5, 8 and #9) of 15 patients. --- Findings: Patient #4A review of the POC dated 04/09/26 to 07/07/26 with IDG plan of care updates dated 04/22/26 and 05/06/26 showed no SN visit frequencies and IDG communication notes showed no changes in the physician orders. Patient #5A review of the POC dated 04/15/26 to 07/13/26 with IDG plan of care updates dated 04/22/26 and 05/06/26 showed no SN or volunteer coordinator visit frequencies and IDG communication notes showed no changes in the physician orders. Patient #8A review of the POC dated 04/01/26 to 06/29/26 with IDG plan of care updates on 04/08/26 showed no SN visit frequency from 04/01/26 to 04/21/26 and showed no changes in the physician orders until 04/22/26. Patient #9A review of the POC dated 04/11/25 to 04/17/25 with no IDG plan of care update showed no SN visit frequency. The clinical record showed a physician’s order dated 01/26/26 for a SN visit frequency effective 04/11/25 of daily SN visits. On 05/14/26 at 10:35 a.m. to 10:45 a.m., Staff A stated the POCs for patients #4, 5 and #8 did not include discipline visit frequencies. At 10:50 a.m., Staff A stated the POC for patient #9 did not include a SN discipline visit frequency until a correction order was entered on 01/07/26.

Based on record review and interview, the hospice failed to ensure an increase in hospice aide visit frequency was communicated and addressed by the IDG for one (Patient #13) of 15 patients. --- Findings: Patient #13A review of a POC dated 11/23/25 to 02/20/26 with IDG updates on 12/02/25 and on 12/16/25 showed an aide visit frequency of one time per week. The clinical record showed from 11/30/25 to 12/27/25 two hospice aide visits were conducted per week. The IDG communication notes showed no increase in the hospice aide visits and no change in the physician orders until the IDG meeting on 12/30/25. On 05/14/26 at 11:00 a.m., Staff A stated the IDG did not address the increase in hospice aide visits until 12/30/25.

Based on record review and interview, the hospice failed to ensure service discipline frequencies were provided in accordance with the POCs for five (Patients #1, 7, 8, 10 and #12) of 15 patients. --- Findings: Patient #1A review of the plan of care dated 02/25/26 to 04/25/26 ordered SN visits at a frequency of two times a week and hospice aide visits at three times a week. During the week of 02/25/26 to 02/28/26 showed a SN visit was conducted on 02/25/26 (two visits ordered, one visit conducted); and hospice aide visits were conducted on 02/25/26 and 02/27/26 (three visits ordered, two visits conducted). The clinical record showed no patient or family refusal of visits and no changes in the ordered frequencies. Patient #7A review of the plan of care dated 03/04/26 to 06/01/26 with IDG POC updates on 03/11/26, 03/25/26,04/08/26, 04/22/26 and on 05/06/26 ordered SN visits at a frequency of two to three times a week and hospice aide visits at two to four times a week. During the week of 03/04/26 to 03/07/26 showed no aide visits were conducted (two to three visits ordered, no visit conducted).During the week of 03/08/26 to 03/14/26 showed a SN visit conducted on 03/12/26 (two to three visits ordered, one visit conducted).During the week of 03/15/26 to 03/21/26 showed a SN visit conducted on 03/17/26 (two to three visits ordered, one visit conducted).During the week of 03/22/26 to 03/28/26 showed a SN visit conducted on 03/26/26 (two to three visits ordered, one visit conducted).During the week of 04/05/26 to 04/11/26 showed a SN visit conducted on 04/09/26 (two to three visits ordered, one visit conducted).During the week of 04/12/26 to 04/18/26 showed a SN visit conducted on 04/18/26 (two to three visits ordered, one visit conducted).During the week of 04/19/26 to 04/25/26 showed a SN visit conducted on 04/25/26 (two to three visits ordered, one visit conducted).During the week of 05/03/26 to 05/09/26 showed a SN visit conducted on 05/07/26 (two to three visits ordered, one visit conducted). The clinical record showed no patient or family refusal of visits and no changes in the ordered frequencies. Patient #8A review of the plan of care dated 04/01/26 to 06/29/26 with IDG POC updates on 04/08/26, 04/22/26 and on 05/06/26 ordered SN visits at a frequency of two to three times a week. During the week of 04/19/26 to 04/25/26 showed a SN visit was conducted on 04/21/26 (two to three visits ordered, one visit conducted). The clinical record showed no patient or family refusal of visits and no changes in the ordered frequencies. Patient #10A review of the plan of care dated 01/07/26 to 04/06/26 with IDG POC update on 01/14/26 ordered hospice aide visits two times a week. The clinical record showed no hospice aide visits were conducted between 01/14/26 and the patient’s death on 01/30/26 (six visits ordered, no visits conducted) and showed no patient or family refusal of visits and no changes in the ordered frequency. Patient #12A review of the plan of care dated 12/11/25 to 02/08/26 with IDG POC update on 12/17/26, 12/31/26, 01/14/26 and on 01/28/26 ordered chaplain visits one time a month and MSW visits one time a month. The clinical record showed no chaplain or MSW visits were conducted between 12/11/26 and the patient’s revocation from hospice services on 01/30/26 (two visits ordered, no visits conducted) and showed no patient or family refusal of visits and no changes in the ordered frequencies. On 05/14/26 at 10:25 a.m. to 10:55 a.m., Staff A stated the visit frequencies were not followed as ordered for patients #1, 7, 8, 10 and #12.

Based on record review and interview, the agency failed to ensure implementation and review of hospice aide care plans for three (Patients #1, 10 and #12) of 15 patients. --- Findings: Patient #1A review of a POC dated 02/25/26 to 04/25/26 and IDG updates to the POC on 03/11/26, 03/25/26, 04/08/26 and 04/22/26 ordered hospice aide visits at a frequency of three visits every week. The clinical record showed no review and update to the hospice aide care plan since 10/28/25. Patient #10A review of a POC dated 01/07/26 to 04/06/26 and IDG updates to the POC on 01/14/26, 01/28/26 and 02/11/26 ordered hospice aide visits at a frequency of two visits every week. The clinical record showed no hospice aide care plan was implemented. On 05/14/26 at 10:50 a.m., Staff A stated the clinical records showed no hospice aide care plan. Patient #12A review of a POC dated 12/11/25 to 02/08/26 and IDG updates to the POC on 12/11/25, 12/30/25, 01/14/26 and 01/28/26 ordered hospice aide visit of one time per quarter. The clinical record showed no review and update to the hospice aide care plan since 08/15/25. On 05/14/26 at 10:25 a.m. to 11:00 a.m., Staff A stated the clinical records showed no review and update to the hospice aide care plans in each certification period for patients #1 and #12.

Based on record review and interview, the hospice failed to ensure aide supervisory visits were completed every 14 days for one (Patient #1) of 15 patients. --- Findings: Patient #1A review of a POC dated 02/25/26 to 04/25/26 and IDG updates to the POC on 03/11/26, 03/25/26, 04/08/26 and 04/22/26 ordered hospice aide visits at a frequency of three visits every week with aide visits conducted on 03/04/26, 03/06/26, 03/09/26, 03/10/26, 03/13/26 and on 03/18/26. The clinical record showed supervisory visits were conducted on 03/03/26 and on 03/19/26 (16 days between supervisory visits). On 05/14/26 at 10:25 a.m., Staff A stated supervisory aide visits were not completed every 14 days.

Based on record review and interview, the agency failed to ensure completion of visit notes for two (Patients #3 and #5) of 15 patients. --- Findings: Patient #3 A review of the clinical record showed SN visits conducted on 05/05/26 and 05/08/26 were designated as ‘not started’ in the electronic medical record and showed no communication or coordination note entries for a delay in the documentation of the visits. On 05/14/26 at 10:31 a.m., Staff A stated the SN visit notes for visits on 05/01/26 and on 05/08/26 were not completed.       Patient #5 A review of the clinical record showed a volunteer coordinator visit conducted on 05/01/26 was designated as ‘not started’ in the electronic medical record and showed no communication or coordination note entries for a delay in the documentation of the visit. On 05/14/26 at 10:40 a.m., Staff A stated the volunteer coordinator note was not completed.

Based on record review and interview, the hospice failed to ensure a required background check was completed for one (Staff D) of five employees reviewed. --- 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 DA review of the personnel record showed no background check through OKSCREEN for employment that began 11/04/24. On 05/13/26 at 2:30 p.m., Staff B stated Staff D had no background check through the OKScreen database.

Based on record review and interview, the Hospice failed to ensure an Emergency Preparedness Communication Plan included updated required information related to the staff contact information for the agency for all patients and staff. --- Findings: A review of administrative records showed no documentation the Emergency Preparedness Communication Plan included staff contact information for the Hospice. On 08/02/22 at 11:00 a.m., Staff B stated the active staff member call list was not included in the Emergency Preparedness Communication Plan for the Hospice.

Based on record review and interview, the hospice failed to ensure development of a bereavement POC for 12 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12) of 14 patients. --- Findings: Patient #1 A review of the clinical record showed an initial bereavement assessment dated 06/26/23. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #2 A review of the clinical record showed an initial comprehensive assessment on 03/01/23. Documentation showed no completion of an initial bereavement assessment with subsequent development of a bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #3 A review of the clinical record showed an initial bereavement assessment dated 01/11/23. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #4 A review of the clinical record showed an initial bereavement assessment dated 05/08/23. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #5 A review of the clinical record showed an initial bereavement assessment dated 03/10/23. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #6 A review of the clinical record showed an initial bereavement assessment dated 03/17/23. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #7 A review of the clinical record showed an initial bereavement assessment dated 06/13/23. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #8 A review of the clinical record showed an initial bereavement assessment dated 11/16/22. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #9 A review of the clinical record showed an initial bereavement assessment dated 07/10/23. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #10 A review of the clinical record showed an initial comprehensive assessment on 04/26/23. Documentation showed no completion of an initial bereavement assessment with subsequent development of a bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #11 A review of the clinical record showed an initial bereavement assessment dated 05/03/23. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #12 A review of the clinical record showed an initial comprehensive assessment on 07/28/22. Documentation showed no completion of an initial bereavement assessment with subsequent development of a bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. On 08/02/23 at 10:30 a.m. to 10:50 a.m., Staff D stated for patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12: 1. there were no bereavement POCs; 2. Bereavement POC were established after a patient died and; 3. Patient family members or significant others identified as the bereaved receive standardized bereavement letters, information mail outs and some telephone contacts over a 13 month period from the date the patient died.

Based on record review and interview, the hospice failed to ensure a plan of care was updated to include individualized intervention and goals for an identified wound site for one (Patient #11) of 14 patients. --- Findings: Patient #11 A review of the plan of care dated 05/01/23 to 06/05/23 and plan of care update dated 05/24/23 identified no wound site to right upper extremity, showed no intervention and goals for wound site, and ordered no wound care until the IDG on 06/07/23 (two days after the patient deceased on 06/05/23). Documentation showed SN visit note dated 05/22/23 documented a wound site to the right upper extremity. Documentation showed wound site assessment and care was conducted by the SN (no wound site care ordered on the POC) during SN visits dated 05/22/23, 05/24/23, 05/26/23, 05/28/23, 05/30/23, 05/31/23 and on 06/01/23. Documentation showed no communications with the IDG and showed no POC update to include intervention and goals for the identified wound site and showed no ordered wound care until the IDG on 06/07/23 (two days after the patient deceased on 06/05/23). On 08/02/23 at 12:15 p.m., Staff B stated the plan of care for patient #11 was not updated to include interventions and goals for the identified wound site until after the patient was discharged from hospice services for in-patient hospital care and subsequently deceased on 06/05/23.

Based on record review and interview, the hospice failed to ensure the plans of care were fully developed to include service disciplines and frequencies to meet individualized patient care for nine (Patients #1, 4, 5, 7, 8, 10, 11, 13 and #14) of 14 patients. --- Findings: Patient #1 A review of the plan of care dated 06/24/23 to 09/21/23 and plan of care update dated 07/05/23 ordered no hospice aide visits, no SN visits and no social work visits. Documentation showed no IDG communications and showed no changes in the ordered disciplines or frequencies between the start of care date of 06/24/23 and the IDG meeting on 07/19/23. Patient #4 A review of the plan of care dated 05/05/23 to 08/02/23 and plan of care updates dated 05/10/23, 05/24/23, 06/07/23, 06/21/23 and 07/05/23 ordered no hospice aide or SN visits. An IDG note dated 07/19/23 showed a hospice aide visit frequency of 1-2 visit a week for 13 weeks and a SN visit frequency of 1-2 visits per week for 14 weeks with a backdated effective date of 05/08/23 (after the hospice aide and SN visits were conducted). Documentation showed no IDG communications and showed no changes in the ordered disciplines or frequencies between the IDG meetings on 05/10/23 and 07/19/23. Patient #5 A review of the plan of care dated 07/06/23 to 09/03/23 and plan of care updates dated 07/05/23 ordered hospice aide visits one to two times a week for nine weeks with a backdated effective date of 05/07/23 (no visits ordered for 07/06/23 to 09/03/23 plan of care recertification period), SN visits two times a week for seven weeks with a backdated effective date of 03/21/23 (no visits ordered for 07/06/23 to 09/03/23 plan of care recertification period). Documentation showed no communications with the IDG and showed no changes in the ordered hospice aide or SN disciplines or frequencies between the IDG meetings on 07/05/23 and 07/19/23. Patient #7 A review of the plan of care dated 06/10/23 to 09/07/23 and plan of care updates dated 06/21/23 (POC developed/implemented on 06/21/23 [11 days from the start of care date]) and 07/05/23 ordered no hospice aide visits and no SN visits. Documentation showed no communications with the IDG and showed no changes in the ordered hospice aide or SN disciplines or frequencies between the start of care date of 06/10/23 and the IDG meeting on 07/19/23. Patient #8 A review of the plan of care dated 07/13/23 to 09/10/23 and plan of care updates dated 07/05/23 ordered hospice aide visits two times a week for 13 weeks with a backdated effective date of 02/13/23 (no visits ordered for 07/13/23 to 09/10/23 plan of care recertification period) and SN visits one to two times a week for 13 weeks with a backdated effective date of 02/13/23 (no visits ordered for 07/13/23 to 09/10/23 plan of care recertification period). Documentation showed no communications with the IDG and showed no changes in the ordered hospice aide or SN disciplines or frequencies between the IDG meetings on 07/05/23 and 07/19/23. Patient #10 A review of the plan of care dated 04/26/23 to 07/24/23 and plan of care updates dated 05/10/23 (POC developed/implemented on 05/10/23 [14 days from the start of care date]), 05/24/23, 06/07/23, 06/21/23, 07/05/23 and on 07/19/23 ordered no SN visits. Documentation showed no communications with the IDG and showed no changes in the ordered SN discipline or frequency in the IDG meetings between 05/10/23 and 07/19/23. Patient #11 A review of the plan of care dated 05/01/23 to 06/05/23 and plan of care updates dated 05/10/23 (POC developed/implemented on 05/10/23 [9 days from the start of care date]), 05/24/23 and on 06/07/23 (two days after the patient deceased on 06/05/23) ordered no SN visits. Documentation showed no communications with the IDG and showed no changes in the ordered SN discipline or frequency in the IDG meetings between 05/10/23 and 06/07/23. Patient #13 A review of the plan of care dated 12/09/23 to 02/06/23 and plan of care updates dated 12/21/23 (POC developed/implemented on 12/21/22 [12 days from the start of care date]) ordered no hospice aide or SN visits. Documentation showed no IDG communications and showed no changes in the ordered hospice aide or SN disciplines or frequencies between the IDG meetings on 12/21/22 and 01/04/23. Patient #14 A review of the plan of care dated 01/04/23 to 03/17/23 and plan of care updates dated 01/18/23 (POC developed/implemented on 01/18/23 [14 days from the start of care date]) ordered no hospice aide or SN visits. Documentation showed no IDG communications and showed no changes in the ordered hospice aide or SN disciplines or frequencies between the IDG meetings on 01/18/23 and 02/01/23. On 08/02/23 at 11:05 a.m. to 12:30 p.m., Staff B stated the plans of care for patients #1, 2, 4, 5, 7, 8, 10, 11, 13 and #14 were not fully developed to include service disciplines and frequencies to meet the patients individualized care needs.

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, 4, 5, 7, 8, 9, 10, 11, 13 and 14); and 2. Hospice aide services discipline was ordered in the plans of care or communicated and coordinated through the IDG for two (Patients #1, 2, 4, 5, 7, 8, 9, 13 and 14) of 14 patients and; 3. MSW services discipline was ordered in the plans of care or communicated and coordinated through the IDG for one (Patients #1). --- Findings: Patient #1 A review of the plan of care dated 06/24/23 to 09/21/23 and plan of care updates dated 07/05/23 ordered no hospice aide visits, no SN visits and no social work visits. Documentation showed hospice aide visits were conducted on 06/27/23, 06/30/23, 07/03/23, 07/06/23, 07/11/23, 07/14/23 and on 07/17/23 (seven visits conducted, no visits ordered); SN visits were conducted on 06/25/23, 06/27/23, 06/30/23, 07/07/23, 07/11/23, 07/14/23 and on 07/18/23 (seven visits conducted, no visits ordered); a medical social work visit was conducted on 06/26/23 (one visit conducted, no visit ordered). Documentation showed no hospice aide, SN or medical social work service discipline needs were identified, ordered and/or communicated and coordinated through the IDG and showed no changes in the ordered disciplines or frequencies between the start of care date of 06/24/23 and the IDG meeting on 07/19/23. Patient #2 A review of the plan of care dated 05/30/23 to 08/27/23 and plan of care updates dated 05/29/23, 06/07/23, 06/21/23, 07/05/23 and on 07/19/23 ordered hospice aide visit one time a week. Documentation showed hospice aide visits were conducted on 05/31/23, 06/02/23 (two visits conducted, one visit ordered), 06/07/23 and 06/09/23 (two visits conducted, one visit ordered), 06/12/23, 06/14/23, and on 06/16/23 (three visits conducted, one visit ordered), 06/19/23, 06/21/23, and on 06/23/23 (three visits conducted, one visit ordered), 06/26/23, 06/28/23, and on 06/30/23 (three visits conducted, one visit ordered), 07/03/23, 07/05/23, and on 07/07/23 (three visits conducted, one visit ordered), 07/10/23, 07/12/23, and on 07/14/23 (three visits conducted, one visit ordered). Documentation showed no hospice aide service discipline needs were identified, ordered and/or communicated and coordinated through the IDG and showed no changes in the ordered discipline or frequency between the IDG meetings on 05/29/23 and 07/19/23. Patient #4 A review of the plan of care dated 05/05/23 to 08/02/23 and plan of care updates dated 05/10/23, 05/24/23, 06/07/23, 06/21/23 and on 07/05/23 ordered no hospice aide or SN visits. Documentation showed hospice aide visits were conducted on 05/12/23, 05/16/23, 05/19/23, 05/23/23, 05/26/23, 05/30/23 and on 06/02/23 (seven visits conducted, no visits ordered). Documentation showed SN visits were conducted on 05/11/23, 05/16/23, 05/19/23, 05/23/23, 05/26/23, 05/30/23, 06/01/23, 06/05/23, 06/08/23, 06/13/23, 06/15/23, 06/20/23, 06/22/23, 06/27/23, 06/29/23, 07/06/23, 07/11/23, 07/13/23, 07/14/23, 07/15/23 and on 07/18/23 (21 visits conducted, no visits ordered). An IDG on 07/19/23 showed documentation of a hospice aide visit frequency of 1-2 visit a week for 13 weeks and a SN visit frequency of 1-2 visits per week for 14 weeks with a backdated effective date of 05/08/23 (after the hospice aide and SN visits were conducted). Documentation showed no hospice aide or SN service discipline needs were identified, ordered and/or communicated and coordinated through the IDG and showed no changes in the ordered disciplines or frequencies between the IDG meetings on 05/10/23 and 07/19/23. Patient #5 A review of the plan of care dated 07/06/23 to 09/03/23 and plan of care updates dated 07/05/23 ordered hospice aide visits 1-2 times a week for nine weeks with a backdated effective date of 05/07/23 (no visits ordered for 07/06/23 to 09/03/23 plan of care recertification period), SN visits two times a week for seven weeks with a backdated effective date of 03/21/23 (no visits ordered for 07/06/23 to 09/03/23 plan of care recertification period). Documentation showed no hospice aide service discipline needs were identified, ordered and/or communicated and coordinated through the IDG showed no changes in the ordered discipline or frequency between the IDG meetings on 07/05/23 and 07/19/23. Patient #7 A review of the plan of care dated 06/10/23 to 09/07/23 and plan of care updates dated 06/21/23 (POC developed/implemented on 06/21/23 [11 days from the start of care date]) and on 07/05/23 ordered no hospice aide visits and no SN visits. Documentation showed hospice aide visits were conducted on 06/12/23, 06/14/23, 06/19/23, 06/21/23, 06/27/23, 07/03/23, 07/05/23, 07/10/23, 07/12/23 and on 07/17/23 (10 visits conducted, no visits ordered); SN visits were conducted on 06/11/23, 06/13/23, 06/15/23, 06/20/23, 06/22/23, 06/29/23, 07/06/23, 07/13/23 and on 07/18/23 (nine visits conducted, no visits ordered). Documentation showed no hospice aide or SN service discipline needs were identified, ordered and/or communicated and coordinated through the IDG and showed no changes in the ordered disciplines or frequencies between the start of care date of 06/10/23 and the IDG meeting on 07/19/23. Patient #8 A review of the plan of care dated 07/13/23 to 09/10/23 and plan of care updates dated 07/05/23 ordered hospice aide visits two times a week for 13 weeks with a backdated effective date of 02/13/23 (no visits ordered for 07/13/23 to 09/10/23 plan of care recertification period) and SN visits one to two times a week for 13 weeks with a backdated effective date of 02/13/23 (no visits ordered for 07/13/23 to 09/10/23 plan of care recertification period). Documentation showed hospice aide visits were conducted on 07/14/23 and on 07/18/23 (two visits conducted, no visits ordered); SN visits were conducted on 07/13/23 and on 07/18/23 (two visits conducted, no visits ordered). Documentation showed no hospice aide or SN service discipline needs were identified, ordered and/or communicated and coordinated through the IDG and showed no changes in the ordered disciplines or frequencies between the IDG meetings on 07/05/23 and 07/19/23. Patient #9 A review of the plan of care dated 07/07/23 to 10/04/23 and plan of care updates dated 07/19/23 (POC developed/implemented on 07/19/23 [12 days from the start of care date]) ordered no hospice aide visits or SN visits. Documentation showed hospice aide visits were conducted on 07/13/23 and on 07/17/23 (two visits conducted, no visits ordered); SN visits were conducted on 07/08/23, 07/11/23, 07/14/23, 07/15/23 and on 07/18/23 (five visits conducted, no visits ordered). Documentation showed no hospice aide or SN service discipline needs were identified, ordered and/or communicated and coordinated through the IDG and showed no changes in the ordered disciplines or frequencies in IDG meetings on 07/19/23. Patient #10 A review of the plan of care dated 04/26/23 to 07/24/23 and plan of care updates dated 05/10/23 (POC developed/implemented on 05/10/23 [14 days from the start of care date]), 05/24/23, 06/07/23, 06/21/23, 07/05/23 and on 07/19/23 ordered no SN visits. Documentation showed SN visits were conducted on 05/03/23, 05/10/23, 05/17/23, 05/31/23, 06/07/23, 06/14/23, 06/21/23, 06/28/23, 07/05/23, 07/12/23 and on 07/20/23 (11 visits conducted, no visits ordered). Documentation showed no SN service discipline needs were identified, ordered and/or communicated and coordinated through the IDG and showed no changes in the ordered discipline or frequency in the IDG meetings between 05/10/23 and 07/19/23. Patient #11 A review of the plan of care dated 05/01/23 to 06/05/23 and plan of care updates dated 05/10/23 (POC developed/implemented on 05/10/23 [9 days from the start of care date]), 05/24/23 and on 06/07/23 (two days after the patient deceased on 06/05/23) ordered no SN visits. Documentation showed SN visits were conducted on 05/08/23, 05/15/23, 05/22/23, 05/28/23, 05/29/23, 05/30/23, 06/01/23, 06/02/23 and on 06/05/23 (9 visits conducted, no visits ordered). Documentation showed no SN service discipline needs were identified, ordered and/or communicated and coordinated through the IDG and showed no changes in the ordered discipline or frequency in the IDG meetings between 05/10/23 and 06/07/23. Patient #13 A review of the plan of care dated 12/09/23 to 02/06/23 and plan of care updates dated 12/21/23 (POC developed/implemented on 12/21/22 [12 days from the start of care date]) ordered no hospice aide or SN visits. Documentation showed hospice aide visits were conducted on 12/12/22, 12/15/22, 12/16/22, 12/20/22, 12/28/22, 12/29/22 and on 12/30/22 (seven visits conducted, no visits ordered); SN visits were conducted on 12/11/22, 12/12/22, 12/14/22, 12/19/22, 12/21/22, 12/23/22, 12/26/22, 12/28/22 and on 12/30/22 (nine visits conducted, no visits ordered). An IDG on 01/04/23 showed documentation of a hospice aide visit frequency of one week one with a backdated effective date of 12/09/22, then two to three visits a week for 13 weeks with a backdated effective date of 12/12/22 and a SN visit frequency of one week one, then two to three visits per week for 13 weeks with a backdated effective date of 12/09/22 (after the hospice aide and SN visits were conducted). Documentation showed no hospice aide or SN service discipline needs were identified, ordered and/or communicated and coordinated through the IDG and showed no changes in the ordered disciplines or frequencies between the IDG meetings on 12/21/22 and 01/04/23. Patient #14 A review of the plan of care dated 01/04/23 to 03/17/23 and plan of care updates dated 01/18/23 (POC developed/implemented on 01/18/23 [14 days from the start of care date]) ordered no hospice aide or SN visits. Documentation showed hospice aide visits were conducted on 01/05/23, 01/09/23, 01/12/23, 01/16/23, 01/19/23, 01/20/23, 01/23/23 and on 01/26/23 (eight visits conducted, no visits ordered); SN visits were conducted on 01/06/23, 01/10/23, 01/13/23, 01/16/23, 01/19/23, 01/20/23, 01/23/23 and on 01/26/23 (eight visits conducted, no visits ordered). Documentation showed no hospice aide or SN service discipline needs were identified, ordered and/or communicated and coordinated through the IDG and showed no changes in the ordered disciplines or frequencies between the IDG meetings on 01/18/23 and 02/01/23. On 08/02/23 at 11:05 a.m. to 12:30 p.m., Staff B stated: 1. SN service discipline was not ordered in the plans of care or communicated and coordinated through the IDG for patients #1, 4, 5, 7, 8, 9, 10, 11, 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, 2, 4, 5, 7, 8, 9, 13 and 14 and; 3. MSW services discipline was ordered in the plans of care or communicated and coordinated through the IDG for patient #1.

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: A review of QAPI records showed no QAPI program data collection sources or analysis/reporting of collected data activities or reporting for time periods of 04/09/21 to 12/31/21, 07/01/22 to 12/31/22 and 01/01/23 to 06/30/23. Additional requests for administrative records yielded no results. On 08/02/23 at 9:00 a.m., Staff B stated the hospice had no administrative records which showed data collection sources or analysis/reporting of collected data that showed improved quality of patient care for 04/09/21 to 12/31/21, 07/01/22 to 12/31/22 and 01/01/23 to 06/30/23.

Based on record review and interview, the hospice failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities for all patients and employees. --- Findings: A review of administrative records showed no governing body oversite of ongoing QAPI program activities to improve the care, services, and operations of the agency for calendar year 2022. On 08/02/23 at 11:00 a.m., Staff B stated the hospice had no documentation which showed governing body oversite of ongoing QAPI program activities for calendar year 2022.

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: A review of QAPI records showed no hospice infection control program or inclusion in QAPI program activities for time periods of 04/09/21 to 12/31/21, 07/01/22 to 12/31/22 and 01/01/23 to 06/30/23. On 08/02/23 at 11:00 a.m., Staff B stated there was no infection control program included in QAPI activities for time periods of 04/09/21 to 12/31/21, 07/01/22 to 12/31/22 and 01/01/23 to 06/30/23.

Based on record review and interview, the agency failed to ensure continued review and update of a home health aide care plan for two (Patients #5 and 8) of 14 patients. --- Findings: Patient #5 A review of the plan of care dated 07/06/23 to 09/03/23 and plan of care updates dated 07/05/23 ordered hospice aide visits one to two times a week for nine weeks with a backdated effective date of 05/07/23. Documentation showed no update to the hospice aide care plan dated 05/08/23. On 08/02/23 at 11:55 a.m., Staff B stated the clinical record showed no update to the documented hospice aide care plan for CHHA visits beginning 07/06/23 through 09/03/23. Patient #8 A review of the plan of care dated 07/13/23 to 09/10/23 and plan of care updates dated 07/05/23 ordered hospice aide visits two times a week for 13 weeks with a backdated effective date of 02/13/23. Documentation showed no update to the hospice aide care plan dated 11/15/22. On 08/02/23 at 12:05 p.m., Staff B stated the clinical record showed no update to the documented hospice aide care plan for CHHA visits beginning 07/13/23 through 09/10/23.

Based on record review and interview, the hospice failed to ensure on-site supervisory visits were completed every 14 days for three (Patients #4, 7 and 14) of 14 patients. --- Findings: Patient #4 A review of the plan of care dated 05/05/23 to 08/02/23 showed a home health aide visit frequency of one to two visit a week for 13 weeks. Documentation showed hospice aide visits were conducted on 05/12/23, 05/16/23, 05/19/23, 05/23/23, 05/26/23, 05/30/23 and on 06/02/23. Documentation showed no supervisory visits were made from 05/19/23 to 06/13/23 (25 days between supervisory visits). On 08/02/23 at 11:52 a.m., Staff B stated supervisory aide visits were not conducted every 14 days for patient #4. Patient #7 A review of the plan of care dated 06/10/23 to 09/07/23 and plan of care updates dated 06/21/23 and on 07/05/23 ordered no hospice aide visits. Documentation showed hospice aide visits were conducted on 06/21/23, 06/26/23, 07/03/23, 07/05/23, 07/10/23, 07/12/23, and on 07/17/23. Documentation showed no supervisory visits were made from 06/20/23 to 07/18/23 (28 days between supervisory visits). On 08/02/23 at 11:52 a.m., Staff B stated supervisory aide visits were not conducted every 14 days for patient #7. Patient #14 A review of the plan of care dated 01/04/23 to 03/17/23 and plan of care updates dated 01/18/23 (POC developed/implemented on 01/18/23 [14 days from the start of care date]) ordered no hospice aide visits and an IDG update dated 02/01/23 ordered hospice aide visits one to two times a week for 14 weeks. Documentation showed hospice aide visits were conducted on 01/19/23, 01/20/23, 01/23/23, 01/26/23, 02/01/23, 02/03/23, 02/06/23, 02/09/23, 02/13/23, 02/16/23 and on 02/20/23. Documentation showed no supervisory visits were made from 01/16/23 to 02/21/23 (35 days between supervisory visits). On 08/02/23 at 11:52 a.m., Staff B stated supervisory aide visits were not conducted every 14 days for patient #14.

Based on record review and interview, the hospice failed to ensure it had a contracted in-patient service provider to meet in-patient service needs necessary for the palliation and management of the terminal illness for all of its patients. --- Findings: A request for in-patient contract agreements yielded no results. On 08/02/23 at 11:00 a.m., Staff B stated: 1. The hospice did not have a contracted in-patient service provider to meet any in-patient service needs necessary for the palliation and management of a patients terminal illness and; 2. Any in-patient service needs would have to be negotiated on a patient by patient basis.