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

Based on record review and interview, the hospice failed to ensure an initial spiritual/bereavement assessment was conducted by the for one (Patient #9) of 11 patients. --- Findings: Patient #9 A review of the clinical record showed an election of the hospice benefit on 08/23/23 with no completion of the spiritual/bereavement assessment prior to the patients death on 9/22/23 (29 days after the election of the hospice benefit and initial comprehensive assessment). Documentation showed no changes in orders. On 04/17/24 at 10:10 p.m., Staff D stated the patient had not conducted the initial spiritual/bereavement assessment for patient #9 within the five-day timeframe required to complete the initial comprehensive assessment.

Based on record review and interview, the hospice failed to ensure and maintain evidence that it's QAPI Program showed measurable improvement in indicators related to improved palliative outcomes and hospice services. --- Findings: An agency policy titled Quality Assurance and Performance Improvement Program stated (agency name withheld) ensures continuing resources for key elements of the QAPI plan. Objectives of the QAPI plan include: to measure, analyze and track quality indicators, including patient events and performance indicators and demonstrate measurable improvements in indicators. The objective of the QAPI plan will be implemented, monitored and assessed using data and benchmarking. A review of administrative record documentation showed no evidence quality indicators were a part of the QAPI program and documentation showed no measurable improvements in indicators related to improved palliative outcomes and hospice services for calendar years 2022 and 2023. On 04/17/24 at 1:30 p.m., Staff A stated the hospices QAPI program for 2022 and 2023 showed no measurable improvement in indicators related to palliative outcomes and hospice services.

Based on record review and interview, the hospice failed to ensure complete reporting, to include measurable goals and outcomes in the implementation and evaluation of PIPs for all patients and employees. --- Findings: A review of administrative records showed incomplete and fragmented quarterly reporting of PIPs undertaken by the hospice and showed no measurable goals and outcomes in the implementation and evaluation of PIPs for calendar years 2022 and 2023. On 04/17/24 at 1:30 p.m., Staff A stated administrative records of PIPs undertaken by the hospice showed incomplete and fragmented quarterly reporting of PIPs undertaken by the hospice and showed no measurable goals and outcomes in the implementation and evaluation of PIPs for calendar years 2022 and 2023.

Based on record review and interview, the hospice failed to ensure its governing body reviewed, approved and directed its QAPI program activities for all patients and employees. --- Findings: An agency policy titled Quality Assurance and Performance Improvement Program stated (agency name withheld) ensures continuing resources for key elements of the QAPI plan. Objectives of the QAPI plan include: to measure, analyze and track quality indicators, including patient events and performance indicators and demonstrate measurable improvements in indicators. The objective of the QAPI plan will be implemented, monitored and assessed using data and benchmarking. The Governing Board are responsible for the development and governance of the QAPI program and is responsible for oversight and direction of the QAPI program. A review of administrative records showed no governing body oversight and direction of the QAPI program activities, to include review and approval of quality indicator reporting for calendar years 2022 and 2023. On 04/17/24 at 1:30 p.m., Staff A stated the governing body administrative records showed no oversight and direction of the QAPI program activities, to include review and approval of quality indicator reporting for calendar years 2022 and 2023.

Based on a record review and interview, the agency failed to ensure documentation showed completion of alternative training requirements to meet the qualifications of a Certified Home Health [Hospice] Aide for one (Staff F) of four employees reviewed. --- Findings: Staff F A review of personnel records showed certification as a Long-Term Care Aide. Documentation showed no current Home Health Aide certification and showed no completion of alternative training requirements to meet the qualifications of a Certified Home Health [Hospice] Aide. Additional request for information yielded no results. On 04/17/24 at 1:30 p.m., Staff A stated Staff F personnel record showed no documentation of current Home Health Aide certification or completion of alternative training requirements to meet the qualifications of a Certified Home Health [Hospice] Aide.

Based on record review and interview, the hospice failed to ensure on-site aide supervisory visits were completed every 14 days for two (Patient #3 and #7) of 11 patients. --- Findings: Patient #3 A review of the plan of care dated 03/03/24 to 05/01/24 showed a home health aide visit frequency of two times per week. Documentation showed supervisory visits were made on 03/18/24 and on 04/02/24 (15 days between supervisory visits). On 04/17/24 at 12:37 p.m., Staff A stated supervisory aide visits were not conducted every 14 days for patient #3. Patient #7 A review of the plan of care dated 02/02/24 to 05/01/24 showed a home health aide visit frequency of two times per week. Documentation showed supervisory visits were made on 02/26/24 and on 03/13/24 (16 days between supervisory visits). On 04/17/24 at 12:55 p.m., Staff A stated supervisory aide visits were not conducted every 14 days for patient #7.

Based on record review and interview, the hospice failed to ensure volunteer orientation and training related to hospice care and philosophy for three (Volunteer #1, 2 and #3) of three volunteers reviewed. --- Findings: Volunteer #1 A review of volunteer personnel records showed no orientation or training related to hospice care and philosophy. Additional request for personnel records yielded no results. On 04/17/24 at 1:15 p.m., Staff A stated the hospice had no personnel record documentation that showed Volunteer #1 was provided orientation and training related to hospice care and philosophy. Volunteer #2 A review of volunteer personnel records showed no orientation or training related to hospice care and philosophy. Additional request for personnel records yielded no results. On 04/17/24 at 1:15 p.m., Staff A stated the hospice had no personnel record documentation that showed Volunteer #2 was provided orientation and training related to hospice care and philosophy. Volunteer #3 A review of volunteer personnel records showed no orientation or training related to hospice care and philosophy. Additional request for personnel records yielded no results. On 04/17/24 at 1:15 p.m., Staff A stated the hospice had no personnel record documentation that showed Volunteer #3 was provided orientation and training related to hospice care and philosophy.

Based on record review and interview, the hospice failed to ensure personnel records were maintained with required volunteer acknowledged job descriptions for three (Volunteer #1, 2 and #3) of three volunteer files reviewed. --- Findings: Volunteer 1 A review of personnel records showed no signed job description for hospice volunteer role, responsibilities and limitations. Additional request for information yielded no results. Volunteer 2 A review of personnel records showed no signed job description for hospice volunteer role, responsibilities and limitations. Additional request for information yielded no results. Volunteer 3 A review of personnel records showed no signed job description for hospice volunteer role, responsibilities and limitations. Additional request for information yielded no results. On 04/17/24 at 1:30 p.m., Staff A stated personnel records were provided in their entirety and did not contain all required information for Volunteers #1, 2 and #3.

Based on record review and interview, the hospice failed to ensure personnel records were maintained with required annual employee performance evaluations for four (Volunteer 1, 2 and 3; and Staff F) of three volunteers and four employees. --- Findings: Volunteer 1 A review of personnel records showed a date of hire of 04/12/22. Documentation showed no annual performance evaluation for a hospice volunteer for 2023. Additional request for information yielded no results. Volunteer 2 A review of personnel records showed no date of hire. Documentation showed no annual performance evaluation for a hospice volunteer. Additional request for information yielded no results. Volunteer 3 A review of personnel records showed no date of hire. Documentation showed no annual performance evaluation for a hospice volunteer. Additional request for information yielded no results. Staff F A review of personnel records showed a date of hire of 10/24/22. Documentation showed no annual performance evaluation for 2023. Additional request for information yielded no results. On 04/17/24 at 1:30 p.m., Staff A stated personnel records were provided in their entirety and did not contain all required information for Volunteers #1, 2 and #3 and Staff F.

Based on record review and interview, the hospice failed to ensure completion and provision of a discharge summary of care for one (Patient #11) of 11 patients. --- Findings: Patient #11 A review of the clinical record showed the patient was discharged from the hospice on 05/28/23 to in-patient hospital care services. Documentation showed no discharge summary of care was completed or provided to the in-patient hospital service provider or the attending physician. On 04/17/24 at 1:10 p.m., Staff A stated the hospice failed to complete and provide a discharge summary of care to the in-patient hospital service provider or the attending physician for patient #11.

Based on record review and interview, the agency failed to ensure required background checks were completed for one (Volunteer #1) of three volunteers and four employee files reviewed. --- Findings: A review of 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. Volunteer #1 A review of the personnel record showed no documentation of a background check through OKSCREEN. Additional request for information yielded no results. On 04/17/24 at 1:30 p.m., Staff A stated Volunteer #1 had no background check through the OkScreen database.