Every finding on record at Hospice of Mcalester, Oklahoma, Inc.

Based on administrative document and emergency preparedness plan review, the agency failed to maintain an emergency preparedness plan that was reviewed and updated at least every 2 years. --- Review of administrative documents and emergency preparedness documents failed to provide evidence the agency had reviewed and/or updated the Emergency Preparedness Plan since 2018. During an interview on 06/05/24 at 11:00 AM, the Interim Executive Director stated the Emergency Preparedness Plan had not been reviewed at least every 2 years as required.

Based on administrative document review and interview, the agency failed to maintain an emergency preparedness plan based on a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach that was reviewed and updated at least every 2 years. --- Review of administrative documents and emergency preparedness documents failed to provide evidence the agency had reviewed and/or updated the Emergency Preparedness Plan facility-based and community-based hazard risk assessment since 2018. During an interview on 06/05/24 at 11:00 AM, the Interim Executive Director stated the Emergency Preparedness Plan facility-based and community-based hazard risk assessment had not been reviewed at least every 2 years as required.

Based on administrative document review and interview, the agency failed to provide evidence of initial training in emergency preparedness policies and procedures to all new hospice employees, emergency preparedness training at least every 2 years or maintain documentation of all emergency preparedness training. --- Review of administrative documents and emergency preparedness documents failed to provide evidence of initial training in emergency preparedness policies and procedures to all new hospice employees, emergency preparedness training at least every 2 years or maintain documentation of all emergency preparedness training since 2018. During an interview on 06/05/24 at 11:00 AM, the Interim Executive Director stated the agency failed to provide training in emergency preparedness policies and procedures at least every 2 years.

Based on administrative record review and interview, the agency failed to conduct exercises to test the emergency plan annually. --- Review of administrative documents and emergency preparedness documents, the agency failed to conduct exercises to test the emergency plan annually since 2021. During an interview on 06/05/24 at 11:00 AM, the Interim Executive Director stated the agency had not conduct exercises to test the emergency plan annually.

Based on administrative document review and interview, the Governing Body failed to ensure is maintained and evaluated annually. --- Based on administrative document and quality assurance and performance improvement (QAPI) document review and interview, the Governing Body failed to ensure an effective QAPI program was maintained and evaluated annually. During an interview on 06/05/24 at 11:00 AM, the Interim Executive Director stated the Governing Body had not evaluated the QAPI program annually.

Based on administrative document review and interview, the agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases an integral part of the hospice's quality assessment and performance improvement program. --- Based on administrative document and QAPI record review, the agency failed to provide evidence of an agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases as part of the agency's QAPI program. During an interview on 06/05/24 at 11:00 AM, the Interim Executive Director and Patient Care Coordinator stated the agency did not have an agency-wide system to monitor infections as part of the QAPI program.

Based on administrative document review and interview, the agency failed to ensure the hospice aide received l2 hours of in-service training during each 12-month period. --- Review of personnel records and educational training documents, the agency failed to provide evidence of 12 hours of Inservice training during a 12- month period for one (#4) of one (#4) hospice aide records reviewed. Inservice documents provided for the hospice aide indicated completion of 5.5 hours in 2022, 2 hours in 2023, 2.5 hours year to date in 2024. During an interview on 06/05/24 at 11:00 AM, the Interim Executive Director stated the hospice aide did not complete 12 hours of inservice annually as required.

Based on administrative document review and interview, the agency failed to document and demonstrate viable and ongoing efforts to recruit and retain volunteers. --- Based on volunteer program document review, the agency failed to provide evidence of ongoing efforts to recruit and retain volunteers. During an interview on 06/05/24 at 11:00 AM, the Interim Executive Director stated the agency had no volunteer recruitment program in place.

Based on administrative document review and interview, the agency failed to provide volunteers for day-to-day administrative and/or direct patient care services in a minimum of 5 percent of the total patient care hours of all paid hospice employees and contract staff. --- Based on administrative document review, the agency failed to provide volunteers for day-to-day administrative and/or direct patient care services. Physician volunteer hours were documented for 2 physicians, but no other core service volunteers were identified. Documentation of Volunteer hours for the years 2023 and 2024 failed to show a minimum of 5% volunteer hours for administrative or direct patient care services. During an interview on 06/05/24 at 11:00 AM, the Interim Executive Director stated the agency did not currently have any volunteers except the 2 physicians.

Based on record review and interview, the hospice failed to ensure the hospice aide notified the supervising nurse of missed visits for three (Patients #4, 5 and 6) of 11 patients. Findings: Patient #4 A review of the plan of care dated 01/06/22 to 03/06/22 and plan of care updates dated 01/20/22, 02/03/22, 02/17/22 and 03/03/22 showed a hospice aide frequency of three visits per week. A review of the hospice aide visit notes showed: 1. hospice aide visit notes dated 01/12/22 and 01/14/22 for the week of 01/09/22 to 01/15/22 (two of three visits completed) showed no notification to the supervising nurse of visits refused or declined by the patient. 2. hospice aide visit notes dated 01/31/22 and 02/02/22 for the week of 01/30/22 to 02/05/22 (two of three visits completed) showed no notification to the supervising nurse of visits refused or declined by the patient. Patient #5 A review of the plan of care dated 01/06/22 to 03/06/22 and plan of care updates dated 01/20/22, 02/03/22, 02/17/22 and 03/03/22 showed a hospice aide frequency of two visits per week. A review of the hospice aide visit notes showed: 1. a hospice aide visit note dated 02/01/22 for the week of 01/30/22 to 02/05/22 (one of two visits completed) showed no notification to the supervising nurse of visits refused or declined by the patient. 2. a hospice aide visit note dated 02/22/22 for the week of 02/20/22 to 02/26/22 (one of two visits completed) showed no notification to the supervising nurse of visits refused or declined by the patient. Patient #6 A review of the plan of care dated 12/19/21 to 02/26/22 and plan of care updates dated 12/23/22, 01/06/22, 01/20/22, 02/03/22 and 02/17/22 showed a hospice aide frequency of three visits per week. A review of the hospice aide visit notes showed: 1. hospice aide visit notes dated 12/20/21 and 12/22/21 for the week of 12/19/21 to 12/25/21 (two of three visits completed) showed no notification to the supervising nurse of visits refused or declined by the patient. 2. hospice aide visit notes dated 12/27/21 and 12/29/21 for the week of 12/26/21 to 01/01/22 (two of three visits completed) showed no notification to the supervising nurse of visits refused or declined by the patient. 3. hospice aide visit notes dated 01/31/22 and 02/02/22 for the week of 01/30/22 to 02/05/22 (two of three visits completed) showed no notification to the supervising nurse of visits refused or declined by the patient. 4. hospice aide visit notes dated 02/14/22 and 02/18/22 for the week of 02/13/22 to 02/19/22 (two of three visits completed) showed no notification to the supervising nurse of visits refused or declined by the patient. On 03/30/22 at 9:25 am, Staff A stated the hospice aides failed to document the visits as missed and there was no documentation of the hospice aide notifying the supervising nurse of missed visits.

Based on record review and interview, the agency failed to ensure required State background checks were completed for five (Staff C, D, E, F and G) of five employees. Findings: The "Long-Term Care Security Act Title 63 of the Oklahoma Statutes" documented requirement for an OKSCREEN national background check with fingerprinting for all hospice employees whose employment began after 06/01/14. Staff C A review of the personnel record showed no OKSCREEN background check for employment that began 03/15/21. Staff D A review of the personnel record showed no OKSCREEN background check for employment that began 12/20/21. Staff E A review of the personnel record showed no OKSCREEN background check for employment that began 02/17/20. Staff F A review of the personnel record showed no OKSCREEN background check for employment that began 11/04/14. Staff G A review of the personnel record showed no OKSCREEN background check for employment that began 08/20/15. On 03/30/22 at 9:00 am, Staff B stated Staff C, D, E, F and G had no OKSCREEN background check in their employee file.