Every finding on record at Hospice of Northeast Oklahoma, LLC

Based on record review and interview, the hospice failed to ensure volunteers provided services that equaled 5% of the total patient care hours of all paid hospice employees for 2024. --- Findings:A review of volunteer records and hours showed the hospice volunteers provided services that equaled 3.05% of the total patient care hours of all paid hospice employees for 2024. On 05/29/24 at 1:20 pm, Staff B stated the hospice volunteer services did not provide 5% of the total patient care hours of all paid hospice employees for 2024.

Based on record review and interview, the hospice failed to ensure it provided the most recent plan of care to a skilled nursing facility for two (Patients #6 and 8) of 14 patients. --- FindingsPatient #6A review of the hospice clinical record for skilled nursing facility #1 showed the most recent hospice plan of care dated 03/02/25 to 04/30/25 (no current hospice plan of care).On 05/29/25 at 10:30 am., skilled nursing facility staff #1 stated the last plan of care in the hospice clinical record ended on 04/30/25 and no current hospice plan of care was accessible to the facility staff.Patient #8A review of the hospice clinical record for skilled nursing facility #2 showed no hospice plan of care.On 05/29/25 at 10:45 am., skilled nursing facility staff #1 stated there was no hospice plan of care available to the facility staff.On 05/29/25 at 12:20 pm., Staff B stated the hospice was not aware the current plan of care for Patients #6 and 8 were not provided to each facility.

Based on record review and interview, the agency failed to ensure required background checks were completed by the surveyed hospice for three (Staff D, G and H) of five employees. --- Staff DA 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 D.Staff GA 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 G.Staff HA 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.On 05/29/25 at 12:30 pm, Staff B stated the OKSCREEN for Staff D, G and H were not completed by the surveyed hospice.

Based on record review and interview, the hospice failed to ensure hospice aide services were provided in accordance with the plan of care frequency for one (Patient #3) of 11 patients. Findings: Patient #3 A review of the plan of care dated 11/19/21 to 02/16/22 and plan of care updates dated 12/02/21, 12/15/21 and 12/30/21 ordered hospice aide visits at a frequency of four visits per week for 12 weeks. A review of the electronic medical record showed the following: Hospice aide visits made on 11/30/21 and 12/02/21 for the week of 11/28/21 to 12/04/21 (two of four completed visits); Hospice aide visits made on 12/06/21 and 12/09/21 for the week of 12/05/21 to 12/11/21 (two of four completed visits); Hospice aide visits made on 12/13/21 and 12/16/21 for the week of 12/12/21 to 12/18/21 (two of four completed visits); and Hospice aide visits made on 12/20/21 and 12/23/21 for the week of 12/19/21 to 12/25/21 (two of four completed visits). On 06/07/22 at 11:30 am, Staff B stated the hospice aide frequency was not followed as ordered for Patient #3.

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 ten (Patients #1, 2, 3, 5, 6, 7, 8, 9, 10 and 11) of eleven patients reviewed. Findings: Patient #1 A review of the plan of care dated 05/16/22 to 08/013/22 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 review of the plan of care dated 02/18/22 to 04/18/22 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 11/19/21 to 02/16/22 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 #5 A plan of care dated 09/19/21 to 11/17/21 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 #6 A plan of care dated 03/22/22 to 06/19/22 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 #7 A review of the plan of care dated 10/14/21 to 12/05/21 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 review of the plan of care dated 08/10/21 to 10/08/21 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 #9 A plan of care dated 02/09/21 to 05/09/21 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 12/14/20 to 03/13/21 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 #11 A plan of care dated 09/03/21 to 12/01/21 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 06/07/22 at 11:05 am, Staff B stated the plans of care for Patients #1, 2, 3, 5, 6, 7, 8, 9, 10 and 11 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 skilled nursing services met the needs of the patient for the management of wounds for two (Patients #8 and 10) of 11 patients. Findings: Patient #8 A plan of care dated 08/10/21 to 10/08/21 documented a skilled nurse frequency of one visit per week for one week and two visits per week for nine weeks. A review of the electronic medical record showed the following: A skilled nurse assessment dated 08/12/21 (one of one assessments) during the week of 08/10/21 to 08/14/21 documented the presence of a wound to the right iliac crest with no assessment of the wounds provided. Skilled nurse assessments dated 08/16/21 and 08/19/21 (two of two assessments) during the week of 08/15/21 to 08/21/21 documented the presence of a wound to the right iliac crest with no assessment of the wounds provided. Patient #10 A review of the plan of care dated 12/14/20 to 03/13/21 showed a skilled nurse frequency of two visits per week for 13 weeks. A review of the electronic medical record showed the following: Skilled nurse assessments dated 12/15/20 and 12/18/20 for the week of 12/14/20 to 12/19/20 (two of two assessments) documented the presence of a wound to the left lower back and right lower back and no assessment of the wound/wounds. A skilled nurse assessment dated 12/22/20 for the week of 12/20/20 to 12/26/20 (one of one assessments) documented the presence of a wound to the left lower back and right lower back and no assessment of the wound/wounds. On 06/07/22 at 12:00 pm, Staff B stated skilled nurse assessments for Patients #8 and 10 failed to document wound assessments.