Every finding on record at Heart to Heart Hospice of Southeast Oklahoma, LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #TX.17 "Medication List and Monitoring" (revision date 01/01/2021) read in part, "The Hospice will maintain a current, accurate Medication Profile of all prescription and over-the-counter medications taken by the patient." In 3 of 14 (21%) clinical records reviewed, the agency did not ensure the drug profile included the patient's current medications. Clinical Record 10: The patient elected hospice care on 10/18/2024 with a diagnosis of chronic combined systolic and diastolic heart failure. The nursing visit note dated 11/11/2024 documented, "Oxygen Saturation Characteristics: 96% on Oxygen 2 (liters) L"... "Is the patient using oxygen in the home? Yes." A clinical record review revealed that the hospice medication profile did not document oxygen. Clinical Record 12: The patient elected hospice care on 11/30/2024 with a diagnosis of cerebral aneurysm. The nursing visit note dated 12/01/2024 documented, "Oxygen Saturation Characteristics: 94% on Oxygen 2L." The nursing visit note dated 12/03/2024 documented, "Oxygen Saturation Characteristics: 92% on Oxygen 3L." A clinical record review revealed that the hospice medication profile did not document oxygen. Clinical Record 13: The patient elected hospice care on 11/08/2024 with a diagnosis of nonrheumatic aortic valve stenosis. The initial nursing assessment dated 11/08/2024 documented, "Does the patient utilize oxygen-yes on 5L O2 (oxygen)." The nursing visit note dated 11/09/2024 documented, "Oxygen Saturation Characteristics: 98% on Oxygen 3L." A clinical record review revealed that the hospice medication profile did not document oxygen. During an interview and the joint clinical record review on 12/11/2024, the Area Clinical Manager confirmed that the hospice medication profile did not accurately reflect the medications the facility administered to the patient.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene; [and] use of gloves, mask, eye protection, or face shield depending on anticipated exposure This standard was not met as evidenced by document review, interview, and observation. Agency policy #IC.3 "Hand Hygiene" (revision date: 09/15/2022) read in part, "Staff may use an alcohol-based hand rub for routinely decontaminating hands in the clinical situations below: 4. Before moving from a contaminated body site to a clean body site during patient care." In 1 of 3 (33%) home visits observed, the agency did not ensure that hand hygiene was performed as indicated per the agency's policy. Home Visit 1: The patient elected hospice care on 11/082024 with a diagnosis of neurocognitive disorder with Lewy bodies. During the home visit with the Hospice Aide (HA) [Personnel Record 1) on 12/11/2024, the HA provided pericare to the patient and then cleaned the patient's back and legs. The HA did not perform hand hygiene before moving from a contaminated body site to a clean one during patient care. During an interview on 12/11/2024, the Area Clinical Manager confirmed that the HA should have cleansed hands before moving from a contaminated body site to a clean body site during patient care.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy IPU#1127 (effective date 05/03/2020) read in part, “1. Physician orders are obtained to admit or discharge a patient, transfer care, administer medications, perform diagnostic testing, provide treatments and medical equipment, ensure appropriate nutrition and/or maintain body functions.” In 3 of 10 (30%) clinical records reviewed of patients that received oxygen, the agency did not ensure that the patient’s clinical record included a physician’s order for the oxygen administered. Clinical Record 10: The patient elected hospice care on 10/18/2024 with a diagnosis of chronic combined systolic and diastolic heart failure. The nursing visit note dated 11/11/2024 documented, “Oxygen Saturation Characteristics: 96% on Oxygen 2 (liters) L”... “Is the patient using oxygen in the home? Yes.” A clinical record review revealed no physician’s order for oxygen, including the rate, frequency, and route of oxygen administration. Clinical Record 12: The patient elected hospice care on 11/30/2024 with a diagnosis of cerebral aneurysm. The nursing visit note dated 12/01/2024 documented, “Oxygen Saturation Characteristics: 94% on Oxygen 2L.” The nursing visit note dated 12/03/2024 documented, “Oxygen Saturation Characteristics: 92% on Oxygen 3L.” A clinical record review revealed no physician’s order for oxygen, including the rate, frequency, and route of oxygen administration or the change in the rate of oxygen administration documented on 12/03/2024. Clinical Record 13: Clinical Record 13: The patient elected hospice care on 11/08/2024 with a diagnosis of nonrheumatic aortic valve stenosis. The initial nursing assessment dated 11/08/2024 documented, “Does the patient utilize oxygen-yes on 5L O2 (oxygen).” The nursing visit note dated 11/09/2024 documented, “Oxygen Saturation Characteristics: 98% on Oxygen 3L.” A clinical record review revealed no physician’s order for oxygen, including the rate, frequency, and route of oxygen administration or the change in the rate of oxygen administration documented on 11/11/2024. During an interview and the joint clinical record review on 12/11/2024, the Area Clinical Manager confirmed that the clinical records did not contain physician orders for the oxygen administered to the patient.