Every finding on record at Comanche County Hospital Authority

Based on record review and interview, the hospice failed to ensure 1. hospice aide visits were provided in accordance with the plan of care for three (Patients #1, 6 and 13) of 19 patients; and 2. volunteer visits were provided in accordance with the plan of care for three (Patient #6, 11 and 12) of 19 patients. --- 1. Patient #1 A review of the plan of care dated 04/02/24 to 06/30/24 showed a hospice aide frequency of two visits per week for thirteen weeks. A review of the clinical record showed the following: The week of 05/05/24 to 05/11/24 showed no documented hospice aide visits (zero of two completed visits). Documentation showed no patient or family refusal of visits, no attempts to reschedule visits and no change in the ordered frequency. The week of 05/05/24 to 05/11/24 showed no documented hospice aide visits (zero of two completed visits). Documentation showed no patient or family refusal of visits, no attempts to reschedule visits and no change in the ordered frequency. The week of 05/12/24 to 05/18/24 showed no documented hospice aide visits (zero of two completed visits). Documentation showed no patient or family refusal of visits, no attempts to reschedule visits and no change in the ordered frequency. The week of 05/19/24 to 05/25/24 showed no documented hospice aide visits (zero of two completed visits). Documentation showed no patient or family refusal of visits, no attempts to reschedule visits and no change in the ordered frequency. Patient #6 A review of a plan of care dated 05/23/24 to 08/20/24 and plan of care updates dated 05/31/24, 06/14/24, 06/28/24 and 07/12/24 documented a hospice aide frequency of two visits per week for thirteen weeks. A review of the clinical record showed the following: A hospice aide missed visit note dated 05/28/24 documented the reason for the missed visit as "family assisted with shower" for the week of 05/26/24 to 06/01/24 (one of two completed visits for this week). Documentation showed no offer of other services outlined in the hospice aide care plan, no attempts to reschedule the missed visit and no change in ordered frequency. A hospice aide missed visit note dated 06/21/24 documented the reason for the missed visit as "didn't want shower" for the week of 06/16/24 to 06/29/24 (one of two completed visits for this week). Documentation showed no offer of other services outlined in the hospice aide care plan, no attempts to reschedule the missed visit and no change in ordered frequency. A hospice aide missed visit note dated 06/28/24 documented the reason for the missed visit as "no shower" for the week of 06/23/24 to 06/29/24 (one of two completed visits for this week). Documentation showed no offer of other services outlined in the hospice aide care plan, no attempts to reschedule the missed visit and no change in ordered frequency. Patient #13 A review of a plan of care dated 04/17/24 to 07/17/24 and plan of care updates dated 04/19/24, 05/03/24, 05/17/24, 05/31/24, 06/14/24 and 07/12/24 documented a hospice aide frequency of two visits per week. Documentation showed no hospice aide visits were completed from 04/17/24 to 07/17/24. 2. Patient #6 A review of a plan of care dated 05/23/24 to 08/20/24 and plan of care updates dated 05/31/24, 06/14/24, 06/28/24 and 07/12/24 documented a volunteer frequency of two visits per week for thirteen weeks. A review of the clinical record showed no volunteer visits were made from 05/23/24 to 08/20/24. Patient #11 A review of a plan of care dated 06/21/24 to 09/18/24 and plan of care updates dated 06/28/24, 07/12/24 and 07/26/24 documented a volunteer frequency of two visits per month for thirteen weeks. A review of the clinical record showed no volunteer visits were made from 06/21/24 to 09/28/24. Patient #12 A review of a plan of care dated 06/19/24 to 09/16/24 and plan of care updates dated 06/28/24, 07/12/24 and 07/26/24 documented a volunteer frequency of two visits per month for thirteen weeks. A review of the clinical record showed no volunteer visits were made from 06/19/24 to 09/16/24.On 08/08/24 at 1:50 p.m., Staff C stated: 1. the hospice aide frequency was not followed as ordered for Patients #1, 6 and 13; and 2. the volunteer frequency was no followed as ordered for Patients #6, 11 and 12.

Based on record review and interview, the hospice failed to ensure an individualized plan of care was fully developed to include all services necessary for the palliation and management of the terminal illness for fourteen (Patients #1, 2, 3, 4, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16 and 17) of 19 patients reviewed. --- Patient #1 A plan of care dated 04/02/24 to 06/30/24 documented a primary diagnosis of end stage heart failure and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #2 A review of the plan of care dated 05/29/24 to 08/26/24 documented a primary diagnosis of acute on chronic diastolic (congestive) heart failure and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #3 A plan of care dated 04/19/24 to 06/17/24 documented a primary diagnosis of secondary malignant neoplasm of breast and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #4 A plan of care dated 05/30/24 to 07/28/24 documented a primary diagnosis of secondary malignant neoplasm of unspecified site and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #6 A plan of care dated 05/23/24 to 08/20/24 documented a primary diagnosis of chronic systolic (congestive) heart failure and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #7 A plan of care dated 06/25/24 to 09/22/24 documented a primary diagnosis of lung cancer and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #8 A plan of care dated 05/10/24 to 07/08/24 documented a primary diagnosis of Huntington's disease and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #9 A plan of care dated 05/28/24 to 07/26/24 documented a primary diagnosis of end stage heart disease and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #11 A plan of care dated 06/21/24 to 09/18/24 documented a primary diagnosis of rectal cancer and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #12 A plan of care dated 06/19/24 to 09/16/24 documented a primary diagnosis of end stage heart failure and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #13 A plan of care dated 04/17/24 to 07/15/24 documented a primary diagnosis of colon cancer and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #14 A plan of care dated 05/06/24 to 08/03/24 documented a primary diagnosis of senile degeneration of the brain and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #15 A plan of care dated 05/14/24 to 08/11/24 documented a primary diagnosis of lung cancer and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #16 A plan of care dated 05/28/24 to 08/21/24 documented a primary diagnosis of chronic obstructive pulmonary disease and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #17 A plan of care dated 04/29/24 to 07/27/24 documented a primary diagnosis of congestive heart failure and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. On 08/08/24 at 1:45 pm, Staff C stated the plans of care for Patients #1, 2, 3, 4, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16 and 17 failed to include individualized services necessary for the palliation and management of the terminal illness.

Based on record review and interview, the hospice failed to ensure the plan of care was revised to reflect increased Chaplain services for two (Patient #1 and 9) of 19 patients. --- Patient #1 A review of the plan of care dated 04/02/24 to 06/30/24 and plan of care updates dated 04/05/24k 04/19/24, 05/03/24, 05/27/24 and 05/31/24 which showed a Chaplain frequency of two visits per month for thirteen weeks. A review of the clinical record showed the following: Chaplain visits dated 04/05/24, 04/09/24, 04/15/24 and 04/22/24 (four visits for the month of April) with no orders for increased services and no update for increased frequencies in the plan of care. Chaplain visits dated 05/06/24, 05/16/24, 05/24/24 and 05/31/24 (four visits for the month of May) with no orders for increased services and no update for increased frequencies in the plan of care. Patient #9 A review of the plan of care dated 05/28/24 to 07/26/24 and plan of care updates dated 05/31/24, 06/14/24, 06/28/24 and 07/12/24 which showed a Chaplain frequency of two visits per month for nine weeks. A review of the clinical record showed the following: Chaplain visits dated 06/05/24, 06/12/24, 06/19/24 and 06/26/24 (four visits for the month of June) with no orders for increased services and no update for increased frequencies in the plan of care. Chaplain visits dated 07/03/24, 07/10/24, 07/17/24 and 07/24/24 (four visits for the month of July) with no orders for increased services and no update for increased frequencies in the plan of care. On 08/08/24 at 1:45 pm, Staff C stated the plan of care should have been updated to reflect the increased Chaplain services provided for Patients #1 and 9.

Based on record review and interview, the hospice failed to the ensure plans of care were coordinated with the long-term care facility for four (Patients #1, 2, 3 and 4) of 19 patients reviewed. --- Patient #1 A plan of care dated 01/06/24 to 06/30/24 showed a primary diagnosis of end stage heart disease and documented no patient specific interventions to be provided by the nursing home or the hospice for the palliation and management of the terminal illness. Patient #2 A plan of care dated 05/29/24 to 08/26/24 showed a primary diagnosis of acute on chronic diastolic congestive heart failure and documented no patient specific interventions to be provided by the nursing home or the hospice for the palliation and management of the terminal illness. Patient #3 A plan of care dated 04/19/24 to 06/17/24 showed a primary diagnosis of cancer of breast (secondary neoplasm of breast) and documented no patient specific interventions to be provided by the nursing home or the hospice for the palliation and management of the terminal illness. Patient #4 A plan of care dated 05/30/24 to 07/28/24 showed a primary diagnosis of secondary malignant neoplasm and documented no patient specific interventions to be provided by the nursing home or the hospice for the palliation and management of the terminal illness. On 08/08/24 at 2:50 pm, Staff stated the plan of care for Patients #1, 2, 3 and 4 did not outline the patient specific interventions to be to be provided by the nursing home or the hospice for the palliation and management of the terminal illness.

Based on record review and interview, the agency failed to ensure required background checks were completed by the surveyed hospice for five (Staff H, I, J, K and L) 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 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 agency 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 agency 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 agency through OKSCREEN for Staff J. Staff K A review of the personnel record showed a background check performed by another agency license number. No background check was performed for the surveyed agency through OKSCREEN for Staff K. Staff L A review of the personnel record showed a background check performed by another agency license number. No background check was performed for the surveyed agency through OKSCREEN for Staff L. On 08/08/24 at 1:30 pm, Staff B stated the OKSCREEN for Staff H, I, J, K and L were not completed by the surveyed hospice.

Based on record review and interview, the hospice failed to ensure: 1. Completion of the initial spiritual assessment no later than 5 calendar days after the election of hospice care for one (Patient #7) of 11 patients; and 2. Completion of the initial psychosocial assessment no later than 5 calendar days after the election of hospice care for one (Patient #7) of 11 patients. Findings: Patient #7 A review of the clinical record showed an election of the hospice benefit on 10/21/21 with no completion of the initial spiritual assessment and no completion of the initial psychosocial assessment from 10/21/21 to 01/18/22 (90 days after election of the hospice benefit) with no documentation of attempts to contact the patient made by the Chaplain or the Medical Social Worker and no patient or caregiver refusal of Chaplain or Medical Social Worker visits. On 03/01/22 at 1:40 pm, Staff C stated the initial spiritual and psychosocial assessments were not completed within the first five days after the election of the hospice benefit for Patient #7.

Based on record review and interview, the hospice failed to ensure imminence of death was assessed during the comprehensive assessment for seven (Patients #2, 3, 6, 7, 8, 9 and 11 ) of 11 patients. Findings: Patient #2 A review of the Initial Assessment dated 10/12/21 showed no assessment of imminence of death. Patient #3 A review of the Initial Assessment dated 12/06/21 showed no assessment of imminence of death. Patient #6 A review of the Initial Assessment dated 11/03/21 showed no assessment of imminence of death. Patient #7 A review of the Initial Assessment dated 10/21/21 showed no assessment of imminence of death. Patient #8 A review of the Initial Assessment dated 01/27/21 showed no assessment of imminence of death. Patient #9 A review of the Initial Assessment dated 12/27/21 showed no assessment of imminence of death. Patient #11 A review of the Initial Assessment dated 01/12/22 showed no assessment of imminence of death. On 03/01/22 at 1:33 pm, Staff C stated imminence of death was not assessed on the comprehensive assessment for Patients #2, 3, 6, 7, 8, 9 and 11.

Based on record review and interview, the hospice failed to ensure spiritual (Chaplain) services were provided in accordance with the plan of care frequency for one (Patient #2) of 11 patients; Findings: Patient #2 A review of the plan of care dated 10/12/21 to 01/09/22 and plan of care updates dated 10/20/21, 11/03/21, 11/17/21 and 12/01/21 ordered Chaplain visits at a frequency of two visits per month. A review of the electronic medical record showed one missed Chaplain visit dated 11/17/21 from 11/01/21 to 11/30/21 (one visits attempted). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency for the Chaplain. On 03/01/22 at 12:56 pm, Staff C stated the Chaplain frequency was not followed as ordered for Patient #2.

Based on record review and interview, the hospice failed to ensure the plan of care was fully developed to include all services necessary for the palliation and management of the terminal illness for five (Patient #1, 2, 3, 8 and 10) of 11 patients reviewed. Findings: Patient #1 A review of the plan of care dated 12/15/21 to 02/12/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #2 A plan of care dated 10/12/21 to 01/09/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #3 A plan of care dated 12/06/21 to 03/05/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #8 A plan of care dated 01/27/22 to 04/26/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #10 A plan of care dated 10/31/21 to 12/29/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. On 03/01/22 at 1:20 pm, Staff C stated the plans of care for Patients #1, 2, 3, 8 and 10 failed to include services necessary for the palliation and management of the terminal illness.

Based on record review and interview, the hospice failed to ensure documentation of a QAPI Program was maintained for all 27 patients on service and all personnel employed by the hospice. Findings: A review of agency records showed no documentation of a QAPI Program for 2019, 2020 and 2021. On 03/01/22 at 11:50 am, Staff C stated there was no development of the QAPI Program for 2019, 2020 and 2021.

Based on record review and interview, the agency failed to ensure the Infection Control Program included documentation of comprehensive infection control surveillance activities and interventions to reduce future infections and promote learning and preventative measures throughout the agency for 27 patients and all staff. Findings: A review of administrative records showed no documentation of an ongoing infection control program for the agency and no infection control surveillance for the calendar years of 2018, 2019 and 2020. On 03/01/22 at 12:00 pm, Staff C stated the agency had no documented infection control program or surveillance activity for the calendar years of 2019, 2020 and 2021.