Every finding on record at Duncan Regional Hospital, Inc.

Based on record review and interview, the hospice failed to ensure the plan of care was individualized and fully developed to include all interventions necessary for the palliation and management of the terminal illness for 11 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 10, 11 and 12) of 19 patients reviewed. --- Patient #1 A review of the plan of care dated 02/01/24 to 04/30/24 showed a primary diagnosis of unspecified systolic (congestive) heart failure and documented no patient specific interventions related to the management and palliation of the terminal disease. Patient #2 A review of the plan of care dated 12/18/23 to 03/17/24 showed a primary diagnosis of malignant neoplasm of prostate and documented no patient specific interventions related to the management and palliation of the terminal disease. Patient #3 A review of the plan of care dated 12/27/23 to 03/25/24 showed a primary diagnosis of intrahepatic bile duct carcinoma and documented no patient specific interventions related to the management and palliation of the terminal disease. Patient #4 A review of the plan of care dated 10/22/23 to 01/19/24 showed a primary diagnosis of malignant neoplasm of lower lobe, left bronchus or lung and documented no patient specific interventions related to the management and palliation of the terminal disease. Patient #5 A review of the plan of care dated 12/18/23 to 03/16/24 showed a primary diagnosis of malignant neoplasm of upper lobe, left bronchus or lung and documented no patient specific interventions related to the management and palliation of the terminal disease. Patient #6 A review of the plan of care dated 01/29/24 to 04/27/24 showed a primary diagnosis of unspecified atrial fibrillation and documented no patient specific interventions related to the management and palliation of the terminal disease. Patient #7 A review of the plan of care dated 11/02/23 to 12/31/23 showed a primary diagnosis of malignant neoplasm of lower lobe, right bronchus or lung and documented no patient specific interventions related to the management and palliation of the terminal disease. Patient #8 A review of the plan of care dated 11/30/23 to 01/28/24 showed a primary diagnosis of pulmonary fibrosis and documented no patient specific interventions related to the management and palliation of the terminal disease. Patient #10 A review of the plan of care dated 12/02/23 to 01/30/24 showed a primary diagnosis of chronic kidney disease and documented no patient specific interventions related to the management and palliation of the terminal disease. Patient #11 A review of the plan of care dated 01/26/24 to 04/24/24 showed a primary diagnosis of chronic atrial fibrillation and documented no patient specific interventions related to the management and palliation of the terminal disease. Patient #12 A review of the plan of care dated 11/07/23 to 02/04/24 showed a primary diagnosis of centrilobular emphysema and documented no patient specific interventions related to the management and palliation of the terminal disease. On 02/14/24 at 2:30 pm., Staff A stated the plan of care for patients 1, 3, 5, 7, 10 and 12 documented no individualized patient specific interventions for the management and palliation of the terminal illness. Staff C stated the plan of care for Patients #2, 4, 6, 8 and 11 documented no individualized patient specific interventions for the management and palliation of the terminal illness.

Based on record review and interview, the hospice failed to ensure supervisory visits were completed every 14 days for two (Patient #10 and 14) of 19 patients. --- Patient #10 A review of the plan of care dated 12/02/23 to 01/30/24 showed a hospice aide frequency of one visit per week for nine weeks. A review of the clinical record showed the following: A hospice aide visit dated 12/13/23 for the week of 12/10/23 to 12/16/23. A hospice aide visit dated 12/20/23 for the week of 12/17/23 to 12/23/23. A hospice aide visit dated 12/27/23 for the week of 12/24/23 to 12/30/23. A supervisory aide visit dated 12/14/23 for the week of 12/10/23 to 12/16/23. A supervisory aide visit dated 12/29/23 (15) days after the last supervisory aide visit) for the week of 12/24/23 to 12/30/23. Patient #14 A hospice aide visit dated 10/13/23 for the week of 10/08/23 to 10/14/23. A hospice aide visit dated 10/18/23 for the week of 10/15/23 to 10/21/23. A hospice aide visit dated 10/25/23 for the week of 10/22/23 to 10/28/23. A supervisory aide visit dated 10/11/23 for the week of 10/08/23 to 10/14/23. A supervisory aide visit dated 10/26/23 (15) days after the last supervisory aide visit) for the week of 10/08/23 to 10/14/23. A hospice aide visit dated 11/17/23 for the week of 11/12/23 to 11/18/23. A hospice aide visit dated 11/24/23 for the week of 11/19/23 to 11/25/23. A hospice aide visit dated 12/01/23 for the week of 11/26/23 to 12/02/23. A supervisory aide visit dated 11/15/23 for the week of 11/12/23 to 11/18/23. A supervisory aide visit dated 12/06/23 (21) days after the last supervisory aide visit) for the week of 12/03/23 to 12/09/23. On 02/14/24 at 2:40 pm., Staff C stated the supervisory aide visits for Patients #10 and 14 were not completed within 14 days.

Based on record review and interview, the hospice failed to ensure orientation to the hospice philosophy for five (Staff H, I, J, K and L) of five employees. --- Staff H A review of personnel records showed no orientation to the hospice philosophy. Staff I A review of personnel records showed no orientation to the hospice philosophy. Staff J A review of personnel records showed no orientation to the hospice philosophy. Staff K A review of personnel records showed no orientation to the hospice philosophy. Staff L A review of personnel records showed no orientation to the hospice philosophy. On 02/14/24 at 12:35 pm, Staff B stated there was no documented orientation to the hospice philosophy for Staff H, I, J, K and L.

Based on record review and interview, the agency failed to complete and maintain a copy of the OKSCREEN background check for this hospice in the personnel record for five (Staff H, I, J, K and L) of five employees. --- A review of the "Long Term Care Act" documented requirements for hospices to acquire and maintain an OKSCREEN background check on all employees with access to patients and patient records and whose employment began after 06/01/14. Staff H A review of personnel records showed no OKSCREEN background check for the hospice being surveyed. Staff I A review of personnel records showed no OKSCREEN background check for the hospice being surveyed. Staff J A review of personnel records showed no OKSCREEN background check for the hospice being surveyed. Staff K A review of personnel records showed no OKSCREEN background check for the hospice being surveyed. Staff L A review of personnel records showed no OKSCREEN background check for the hospice being surveyed. On 02/14/24 at 12:25 pm, Staff B stated the OKSCREEN background check for Staff H, I, J, K and L had been completed by another provider and not been completed by the surveyed hospice.