Every finding on record at Freedom Hospice, LLC

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan at least every two years. The community based exercise provided summarized reaction to a theoretical tornado with community injuries at a school. There was no evidence of the hospice summarizing how patient and personnel would be reached for the account of hospice community needs.

Upon patient record review, 1 of 19 (Patient # 15) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient #15: The nurse indicates in note from 10/18/23 patient having respiratory distress. Nurse administered Lorazepam, Morphine, and a duo neb treatment. The nurse called DME who informed her the concentrator could not go any higher. There was no documentation indicating if respiratory distress symptoms were managed with medications. There was documentation of the oxygen saturations increasing from 88% to 90%. Patient passed 10/19/23.

Upon client record review, 4 of 19 (Patient #6, #7, #11, #13) did not have evidence that the plan of care included IDG's documentation of the patient's or families level of understanding, involvement and agreement with the plan of care. Patient #6: The record review indicated the DNR was signed only by hospice physician on day of admit 3/30/24. The election of benefit was signed by the patient's daughter on admission date 3/30/24. There is no documentation as to the hospice physician's relationship with patient, previous knowledge of patient, conversation or communication with family or with patient as required by Oklahoma statute Title 63, Chapter 61A, section 3135. Patient #7: The record review indicated the DNR was signed only by hospice physician 4/12/24. The DNR states patient is incapacitated and physician making the determination for DNR on behalf of patient. However, election of benefit was signed by patient 4/12/24. Documentation indicates patient is oriented to person place and time. Patient #11: The record review indicated the DNR was signed only by the hospice physician on 4/12/24. Consents signed by POA on admission 4/12/24. There is no documentation as to hospice physician's relationship with patient, previous knowledge of patient, conversation or communication with family or with patient as required by Oklahoma statute Title 63, Chapter 61A, section 3135. Patient #13: The record review indicated the DNR was signed only by Dr Hammond 6/13/24. The DNR states patient is incapacitated and physician making the determination for DNR on behalf of patient. However, the election of benefit was signed by patient 6/6/24. The records indicate that patient was alert oriented on 6/6/24. Upon further review of records it was noted that documentation indicates patient being oriented to person place and time on visits before 6/13/24 and visits after 6/13/24. Patient records indicate patient remain alert and oriented during visit on 6/21/24 which is after the physician signed the DNR. There was no documentation regarding knowledge of patient wishes or any discussion with patient or family as required by Oklahoma statute Title 63, Chapter 61A, section 3135.

Upon patient review 5 of 19 records (Patients #1,#5,#6,#10, and #14) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy Patient #1: The record indicated muscle rub cream for topical use, however there was no area defined for administration. Corrected on site. Patient #5: The record indicated that there was no review of the medication list for purpose, side effects, or interactions for Aspirin and melatonin. Corrected on site. Patient #6: The record indicated 2 active orders for metoprolol on medication profile. One order from 5/7/24 for metoprolol 50mg daily. Another order on 6/11/24 for metoprolol 12.5 mg BID. Corrected on site Patient #10: The medication profile contained diclofenac topical gel, however there was no area defined for administration. Corrected on site Patient #14: Upon home visit observation, it was identified that lactulose and Milk of Magnesia are listed as active medications on the facility medication profile. There was no evidence of these medications on the hospice profile. Corrected on site.

Upon patient record review, 2 of 19 (Patient #7,#8) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component. Which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #7: The patient was admitted on 4/12/24. The medical record indicated an initial bereavement assessment completed on 6/3/24. Patient #8: The patient was admitted on 5/6/24. The medical record indicated an initial bereavement assessment completed 5/16/24.

Upon patient record review, 2 of 19 (Patient #1,#2) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #1: During review of record it was noted that wound to left medial foot were measured on 6/5/23 and 6/18/24 only The left heel, coccyx, right flank and right foot had no measurements and assessments documented since 6/5/24. The right buttock wound had no measurements or assessment noted. All wounds are active. Patient #2: During review of record it was noted that wound to left great toe was measured and assessed 4/17/24 and 4/26/24. The wound was inactivated 5/14/24. Documentation for wound to left buttock was measured and assessed 4/22/24 and 5/3/24. This wound was inactivated 5/14/24. Agency policy is to complete wound measurements weekly.

Upon patient record review, 3 of 19 (Patient #1,#2,#5) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: Nursing documentation indicates the patient is at high risk for falls since admission. No evidence of problems goals, or interventions related to fall safety were noted on the plan of care. Corrected on site. Patient #2: Nursing documentation indicates patient has wounds documented to left great toe and buttocks. No evidence of problems, goals, or interventions related to impaired skin integrity were noted on the plan of care. Corrected on site Patient #5: Documentation indicates the patient has a diagnosis of Alzheimer's. There is no evidence of problems, goals, or interventions related to neurological needs on the plan of care. Corrected on site.

Upon patient review 4 of 19 records (Patients #1,#4,#10,#14) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: The record indicated muscle rub cream for topical use, however no area defined for administration. Plan of care is missing wound orders for wounds on Lt medial foot, Lt medial heel, and sacral ulcer, and Rt mid back in hospice chart. Corrected on site 6/24 during survey. Patient #4: During home visit it was noted that Cyclobenzaprine was no longer being taken. This medication was listed as current on the plan of care. Patient #10: The record indicates topical medication diclofenac, however no defined area for administration on MAR or order. Corrected on site . Patient #14: The record indicates Lactulose and Milk of Magnesia are listed as active on facility medication profile, however there is no order or listing on hospice profile. Corrected on site.

Upon review of records, in 6 of 19 records (Patients #1, #2,#4,#6,#9, and#10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1: The nursing Documentation indicates the use of half rails. There was no evidence of orders for half rails that were included in plan of care. Corrected on site. Patient #2: The medical record contained nursing documentation upon admission identifying patient use of cane and oxygen. There was no evidence of orders for the DME included in plan of care. Corrected on site. Patient #4: The medical record contained nursing documentation identifying patient use of nebulizer. There is no evidence of orders for the nebulizer included in the plan of care. Corrected on site Patient #6: The medical record contained nursing documentation identifying patient use of cane and walker. There is no evidence of orders for DME included in plan of care. Corrected on site. Patient #9: The medical record contained nursing documentation since admission identifying patient use of a walker. There was no evidence of an order for the walker included in the plan of care. Corrected on site. Patient #10: The medical record contained nursing documentation upon recertification 5/9/24 identifying patient use of a hospital bed, walker, shower chair, and nebulizer. There was no evidence of orders for the these DME items included in the plan of care. Corrected on site.

Upon patient record review in 2 of 19 records (Patients #4,and#5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4: The skilled nurse visit frequency in plan of care indicates visits are ordered 3 times a week. On the week of 6/2/24 there is documentation of 1 in person visit completed and 1 missed visit. Corrected on site. Patient #5: The skilled nurse visit frequency in the plan of care indicates visits are ordered 2 times a week. On the week of 5/5/24 only 1 visit is documented in the medical record. Corrected on site.

Upon patient record review 3 of 19 records (Patient #15,#16,#17) did not have evidence that the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery, and following the bereavement plan of care.: Patient #15,16,17: There was no evidence of completion of 3 tasks that were on the bereavement plan of care. There was no evidence the invitation to memorial was sent, or that the holiday card was sent, and no indication of a 6-month assessment included in the 6-month mailing.

Upon personnel record review, 1 of 12 (Personnel #5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: Reading and recording temperature, pulse, and respiration The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel 5: There was no evidence the aide was observed for competency with obtaining the required vital signs. Corrected on site.

Upon patient record review, 2 of 19 (Patient #5,#6) did not have evidence in the patient record that hospice aide assignments and duties are specific to patient needs: Patient #5: During record review the aide plan of care did not address assist to transfer needs. Documentation in the record indicates use of hoyer lift. Corrected on site. Patient #6: The aide plan of care did not address instruction for fall risk. Documentation in the record indicated the patient did have a fall on 5/7/24. Corrected on site.

Upon patient record review, in 5 of 19 records (Patients #3,#4,#10,#12,#14) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #3: The Plan of care indicates the Aide visit frequency as 3 times a week. Only 2 in person visits are documented for week of 6/2/24. On the week of 6/9/24 there is only 1 in person visit and 1 missed visit documented. Corrected on site. Patient #4: The Plan of Care indicates aide visit 3 times a week. On the week of 6/9/24 only 2 in person visits are documented. Corrected on site Patient #10: The Plan of Care indicates Aide frequency as 2 times a week. On the week of 5/26/24 only 1 in person visit is documented. Corrected on site. Patient #12: the Plan of Care indicated aide frequency is 3 times a week. There are no aide visits documented for the week of 5/5/24 or week of 6/2/24. On week of 6/9/24 there is 1 in person visit documented and 1 missed visit documented. On week of 6/16/24 there are only 2 visits documented. Corrected on site. Patient #14: The Plan of Care indicates the aide visit frequency was increased to 2 times a week on 5/19/24. On the week of 5/26/24 there is only 1 missed visit documented.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The agency had a volunteer utilization rate of 2.54% for 2023.

Upon patient client record review, 1 of 19 (Patient #12) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #12: The record indicated that the patient elected to receive the addendum. There was no addendum or indication in documentation that the patient received addendum.

Upon patient client record review, 1 of 19 (Patient #12) did not have evidence that each patient record contains Advance Directives. Patient #12: The record indicates that patient has a living will and POA. There was no evidence of these documents found in chart.

Upon patient client record review, 3 of 19 (Patient #1,#4,#6) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1: The medication profile was missing acknowledgement of education on purpose, side effects, and interactions for all current medication. This was marked as "no" on all of the individual medications. There was a generalized attestation statement present at bottom of the medication profile stating all meds were reviewed. This made the documentation very unclear as to which documentation was correct. Patient #4: The medication profile indicated a "no" for education acknowledgement on atropine, clonazepam, lorazepam, and omeprazole. There was a generalized attestation statement present at bottom of the medication profile stating all meds were reviewed. This made the documentation very unclear as to which documentation was correct. Patient #6: The medical record contained documentation by the chaplain stating spiritual care visits would continue. After agency investigation, it was discovered the patient declined spiritual care and the data was entered in error. Corrected on site with coordination note by the chaplain.

Upon client record review, 1 of 19 (Patient #5) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #5: The skilled nurse visit frequency in the plan of care indicates visits are ordered 2 times a week. On the week of 5/5/24 only 1 visit is documented in the medical record. Corrected on site.

Upon patient record review, 1 of 19 (Patient #1) did not have evidence that the hospice provided the following information: • Hospice election form • Physician certification and recertification of the terminal illness specific to each patient Patent#1: Upon review of records at the SNF there was no evidence of signed CTI and no election of benefit was noted in the hospice chart at the facility.