Every finding on record at Cherokee Nation Home Health Services, Inc.

Based on record review and interview, the hospice failed to ensure completion of the initial bereavement assessment no later than 5 calendar days after the election of hospice care for one (Patient #1) of 14 patients. --- A review of the clinical record showed an election of the hospice benefit on 03/27/24 with no completion of the initial bereavement assessment from 03/27/24 to 05/22/24 (56 days after the election of the hospice benefit) with no documentation of patient or caregiver refusal of the initial bereavement risk assessment. On 05/22/24 at 12:34 pm., Staff B stated the initial bereavement assessment for Patient #1 should have been completed in the first five days after election of the hospice benefit.

Based on record review and interview, the hospice failed to ensure hospice aide visits were provided in accordance with the plan of care for four (Patients #1, 4, 6 and 8) of 14 patients. --- Patient #1 A review of the plan of care dated 03/27/24 to 06/24/24 showed a hospice aide frequency of three visits per week for 12 weeks and one visit per week for one week. A review of the clinical record showed the following: A hospice aide missed visit note dated 03/29/24 documented the reason for the missed visit as patient/caregiver decline due to "Holiday", for the week of 03/24/24 to 03/30/24 (only two of three completed visits for this week). Documentation showed no attempts to reschedule the visit and no change in the ordered frequency. A hospice aide missed visit note dated 04/27/24 documented the reason for the missed visit as patient/caregiver declined, for the week of 04/21/24 to 04/27/24 (only two of three completed visits for this week). Documentation showed no attempts to reschedule the visit and no change in the ordered frequency. A hospice aide missed visit note dated 05/03/24 documented the reason for the missed visit as patient/caregiver declined, for the week of 04/28/24 to 05/11/24 (only two of three completed visits for this week). Documentation showed no attempts to reschedule the visit and no change in the ordered frequency. A hospice aide missed visit note dated 05/17/24 documented the reason for the missed visit as patient/caregiver declined, for the week of 05/12/24 to 05/18/24 (only two of three completed visits for this week). Documentation showed no attempts to reschedule the visit and no change in the ordered frequency. A hospice aide missed visit note dated 05/20/24 documented the reason for the missed visit as patient/caregiver declined, for the week of 05/19/24 to 05/25/24 (only two of three completed visits for this week). Documentation showed no attempts to reschedule the visit and no change in the ordered frequency. Patient #4 A review of the plan of care dated 02/28/24 to 05/27/24 showed a hospice aide frequency of one visit per week for one week, two visits per week for 12 weeks and one visit per week for one week. A review of the clinical record showed the following: A hospice aide missed visit note dated 03/05/24 documented the reason for the missed visit as patient already had shower, for the week of 03/03/24 to 03/09/24 (only one of two completed visits for this week). Documentation showed no offer or refusal of other hospice aide services, no attempts to reschedule the missed visit and no change in the ordered frequency. A hospice aide missed visit note dated 03/28/24 documented the reason for the missed visit as patient did not want a shower, for the week of 03/24/24 to 03/30/24 (only one of two completed visits for this week). Documentation showed no offer or refusal of other hospice aide services, no attempts to reschedule the missed visit and no change in the ordered frequency. Patient #6 A review of the plan of care dated 03/21/24 to 05/19/24 showed a hospice aide frequency of two visits per week for 8 weeks. A review of the clinical record showed the following: A hospice aide missed visit note dated 03/29/24 documented the reason for the missed visit as patient/caregiver decline due to "Holiday"", for the week of 03/24/24 to 03/30/24 (only one of two completed visits for this week). Documentation showed no attempts to reschedule the visit and no change in the ordered frequency. Patient #8 A review of the plan of care dated 01/19/24 to 04/17/24 showed a hospice aide frequency of three visits per week for 13 weeks and two visits per week for one week. A review of the clinical record showed the following: A hospice aide missed visit note dated 03/29/24 documented the reason for the missed visit as patient/caregiver decline due to "Holiday", for the week of 03/24/24 to 03/30/24 (only two of three completed visits for this week). Documentation showed no attempts to reschedule the visit and no change in the ordered frequency.On 05/22/24 at 12:50 p.m., Staff B stated there were no documented efforts to reschedule the missed visits for Patients #1, 4, 6 and 8.

Based on record review and interview, the hospice failed to maintain evidence of the use of quality indicator data in the QAPI program. This failed practice had the potential to negatively affect patient care due to hospice failure to collect and correct areas of deficient practices for all 22 current patients and any new patient admitted to the hospice. --- A review of administrative records showed no use of quality indicator data in their QAPI program for 2023 and from 01/01/24 to 05/22/24. On 05/22/24 at 1:15 pm, Staff C stated the QAPI program did not include the use of quality indicator data for 2024 and from 01/01/24 to 05/22/24.

Based on record review and interview, the hospice failed to ensure supervisory visits were completed every 14 days for four (Patients #4, 6, 7 and 8) of 14 patients. --- Patient #4 A review of the plan of care dated 02/28/24 to 05/27/24 showed a hospice aide frequency of one visit per week for one week, two visits per week for 12 weeks and one visit per week for one week. A review of the clinical record showed the following: Hospice aide visits were performed on 03/05/24 (missed visit), 03/07/24, 03/12/24, 03/14/24, 03/19/24 and 03/21/24 (missed visit), Documentation showed no supervisory aide visits from 02/28/24 to 03/26/24 (27 days with no supervisory aide visit performed). Hospice aide visits were performed on 03/28/24, 04/02/24, 04/04/24 (missed visit), 04/09/24 (missed visit. Documentation showed supervisor aide visits performed on 03/27/24 and 04/11/24 (15 days between supervisory aide visits). Patient #6 A review of the plan of care dated 03/21/24 to 05/19/24 showed a hospice aide frequency of three visits per week for eight weeks. A review of the clinical record showed the following: Hospice aide visits were performed 03/27/24, 03/29/24 (missed visit), 04/01/24, 04/03/24, 04/05/24, 04/08/24, 04/10/24 and 04/12/24. Documentation showed supervisory aide visits performed on 04/28/24 and 05/12/24 (15 days between supervisory aide visits). Patient #7 A review of the plan of care dated 03/13/24 to 06/10/24 showed a hospice aide frequency of two visits per week for 13 weeks. A review of the clinical record showed the following: Hospice aide visits were performed on 03/14/24, 03/19/24, 03/21/24, 03/22/24, 03/26/24, 03/28/24, 04/02/24 and 04/04/24. Documentation showed supervisory aide visits performed on 03/20/24 and 04/04/24 (15 days between supervisory visits). Patient #8 A review of the plan of care dated 01/19/24 to 04/17/24 showed a hospice aide frequency of three visits per week for 12 weeks. A review of the clinical record showed the following: Hospice aide visits were performed 02/12/24, 02/14/24 (missed visit), 02/16/24, 02/19/24 (missed visit), 02/21/24, 02/23/24, 02/26/24, 02/28/24 and 03/01/24. Documentation showed supervisory aide visits performed 03/14/24 and 04/01/24 (16 days between supervisory aide visits). On 05/22/24 at 12:55 pm., Staff B stated supervisory aide visits were to be completed every 14 days for Patients #4, 6, 7 and 8.

Based on record review and interview, the hospice failed to ensure orientation to the hospice philosophy for five (Staff G, H, I, J and K) of five employees. --- Staff G A review of the employee file showed no orientation to the hospice philosophy for Staff G. Staff H A review of the employee file showed no orientation to the hospice philosophy for Staff H. Staff I A review of the employee file showed no orientation to the hospice philosophy for Staff I. Staff J A review of the employee file showed no orientation to the hospice philosophy for Staff J. Staff K A review of the employee file showed no orientation to the hospice philosophy for Staff K. On 05/22/24 at 1:25 pm., Staff F stated there was no documentation of orientation to the hospice philosophy for Staff G, H, I, J and K.

Based on record review and interview, the hospice failed to ensure it provided the skilled nursing facility with the plan of care and assessments for one (Patient #7) of 14 patients. --- A plan of care dated 03/13/24 to 06/10/24 showed a skilled nurse frequency of two visits per week for 13 weeks and documented a primary diagnosis of Parkinson's disease. A review of the skilled nursing facility hospice record showed no plan of care and no assessments accessible to the facility. On 05/22/24 at 10:00 am, skilled nursing facility staff X stated the hospice did not provide them with any records pertaining to Patient #7. On 05/22/24 at 12:50 pm, Staff B stated the hospice provided the skilled nursing facility with a plan of care earlier that morning.

Based on record review and interview, the agency failed to ensure required background checks were completed by the surveyed hospice for four (Staff G, H, I and J) of five employees. --- 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. Staff G A review of the personnel record showed a background check performed by another agency license number. No background check was performed for the surveyed hospice through OKSCREEN for Staff G. Staff H A review of the personnel record showed a background check performed by another agency license number. No background check was performed for the surveyed hospice through OKSCREEN for Staff H. Staff I A review of the personnel record showed a background check performed by another agency license number. No background check was performed for the surveyed hospice through OKSCREEN for Staff I. Staff J A review of the personnel record showed a background check performed by another agency license number. No background check was performed for the surveyed hospice through OKSCREEN for Staff J. On 05/22/24 at 1:30 pm, Staff F stated the OKSCREEN for Staff G, H, I and J were not completed by the surveyed hospice.