Every finding on record at Kindful Hospice Sapulpa Tulsa, LLC

Based on record review and interview, the hospice failed to ensure the Emergency Preparedness communication plan included updated required information for the hospice staff for all patients, staff and volunteers. --- Findings: A review of administrative records showed documentation that the Emergency Preparedness communication plan did not include current staff contact information for the hospice. On 08/14/24 at 12:30 p.m., Staff A stated the Emergency Preparedness communication plan did not include updated contact information of current staff for the hospice.

Based on record review and interview, the hospice failed to ensure emergency preparedness disaster declaration, table-top exercises, drills, community drills or plan activation events were conducted for calendar years 2022, 2023 and 01/01/24 to 08/13/24 for all patients, volunteers, and employees. --- Findings: A review of administrative records related to emergency preparedness showed no documentation of emergency preparedness disaster declaration, table-top exercises, drills, community drills or plan activation events for calendar years 2022, 2023 and 01/01/24 to 08/13/24 On 08/14/24 at 12:30 p.m., Staff A stated: The agency had no emergency preparedness disaster declaration, table-top exercises, drills, community drills or plan activation events for calendar years 2022, 2023 and 01/01/24 to 08/13/24.

Based on record review and interview, the hospice failed to ensure completion of an initial assessments/plan of care no later than five calendar days after the election of hospice benefits for one (Patient #3) of 19 patients. --- Findings: Patient #3 A review of the clinical record showed an election of the hospice benefit on 04/12/24 with current POC from 07/14/24 to 09/14/24. Documentation showed no MSW initial psychosocial assessment within five days of the initial comprehensive assessment (election of benefits) and development of the POC. Documentation showed no patient or caregiver refusal of assessment and showed no communications or notifications to the physician. On 08/14/24 at 12:40 p.m., Staff B stated the psychosocial component of the initial POC was not completed within the first five days after the election of the hospice benefit for patient #3.

Based on record review and interview, the hospice failed to ensure development of a bereavement POC for two (Patients #4 and 10) of 19 patients. --- Findings: Patient #4 A review of the clinical record showed an initial bereavement assessment dated 04/02/24 with IDG updates on 06/27/24, 07/10/24, 07/25/24 and 08/08/24. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. On 08/14/24 at 12:52 p.m., Staff B stated patient #4 had no bereavement POC. Patient #10 A review of the clinical record showed an initial bereavement assessment dated 05/02/24 with IDG updates on 06/27/24, 07/10/24, 07/25/24 and 08/08/24. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. On 08/14/24 at 1:02 p.m., Staff B stated patient #10 had no bereavement POC.

Based on record review and interview, the hospice failed to ensure: 1. Social work services were provided in accordance with the plan of care for two (Patients #1 and #4) of 19 patients; 2. SN performed wound site care consistent with the physician order for one (Patient #3) of 19 patients; and 3. Aide visits were provided in accordance with the plan of care for five (Patients #7, 8, 9, 12 and 14) of 19 patients. --- Findings: Patient #1 A review of a POC dated 06/30/24 to 08/28/24 with IDG updates on 07/25/24 and 08/08/24 showed documentation of an MSW visit frequency of three times a month, then two times a month. Documentation showed during the month of 07/01/24 to 07/31/24 MSW visits were conducted on 07/01/24 and on 07/15/24 (three visits ordered, two visits scheduled and/or conducted). Documentation showed no communications between the IDG and showed no changes in the ordered MSW visit frequencies. On 08/14/24 at 12:40 p.m., Staff B stated MSW visits were not provided in accordance with the POC for patient #1. Patient #3 A review of a POC dated 07/17/24 to 09/14/24 with an IDG updates on 07/10/24 and 07/25/24 showed documentation for SN to conduct wound site care: cleanse site with normal saline, place crushed Flagyl (an antibiotic) in the wound site and cover with island dressing each SN visit. Documentation showed during SN visits dated 07/24/24, 07/30/24 and on 08/05/24 wound care was completed as follows: cleansed wound site with Dakins solution, placed crushed Flagyl (an antibiotic) in the wound site and covered with an island dressing. Documentation showed no communications or changes in orders for the wound site care. On 08/14/24 at 12:50 p.m., Staff B stated wound site care performed on 07/24/24, 07/30/24 and on 08/05/24 were not in accordance with the POC (wound site care orders) for patient #3. Patient #4 A review of a POC dated 07/01/24 to 09/28/24 with IDG updates on 07/10/24 and 07/25/24 showed documentation of an MSW visit frequency of three times a month for one month, then two times a month for two months. Documentation showed during the month of 07/01/24 to 07/31/24 MSW visits were conducted on 07/02/24 and on 07/15/24 (three visits ordered, two visits scheduled and/or conducted). Documentation showed no communications between the IDG and showed no changes in the ordered MSW visit frequencies. On 08/14/24 at 12:52 p.m., Staff B stated MSW visits were not provided in accordance with the POC for patient #4. Patient #7 A review of a POC dated 06/10/24 to 09/07/24 with IDG updates on 06/27/24, 07/10/24, 07/25/24 and 08/08/24 showed documentation of an aide visit frequency of four times a week for one week, then six times a week for 12 weeks. Documentation showed during the week of 06/23/24 to 06/29/24 on 06/24/24 two aide visits were conducted; on 06/26/24 (one aide visit was conducted, two aide visits ordered), on 06/27/24 (one aide visit was conducted, two aide visits ordered). Documentation showed no communications between the IDG and showed no changes in the ordered aide visit frequencies. On 08/14/24 at 12:55 p.m., Staff B stated aide visits were not provided in accordance with the POC for patient #7. Patient #8 A review of a POC dated 06/26/24 to 09/23/24 with IDG updates on 06/27/24, 07/10/24, 07/25/24 and 08/08/24 showed documentation of an aide visit frequency of four times a week for one week, ten times a week for 12 weeks, then two times a week for one week. Documentation showed on 07/01/24 an order to discontinue 2nd daily home aide visits. Documentation showed during the week of 06/30/24 to 07/06/24, aide visits were conducted on: 07/01/24, 07/02/24, 07/03/24 and on 07/05/24 (four aide visits were conducted, five aide visits ordered), and during the week of 07/14/24 to 07/20/24, aide visits were conducted on: 07/15/24, 07/16/24, 07/17/24 and on 07/19/24 (four aide visits were conducted, five aide visits ordered). Documentation showed no communications between the IDG and showed no changes in the ordered aide visit frequencies. On 08/14/24 at 12:57 p.m., Staff B stated aide visits were not provided in accordance with the POC for patient #8 Patient #9 A review of a POC dated 07/17/24 to 09/14/24 with IDG updates on 06/27/24, 07/10/24, 07/25/24 and 08/08/24 showed documentation of an aide visit frequency of three times a week for one week, then five times a week for eight weeks. Documentation showed on 07/17/24 an order to change the aide visit frequency to five times a week for one week, then eight times a week for eight weeks. Documentation showed during the week of 07/21/24 to 07/27/24, aide visits were conducted on: 07/22/24, 07/23/24, 07/24/24 (x2 visits), 07/25/24 and on 07/26/24 (X2 visits) (seven aide visits were conducted, eight aide visits ordered), and during the week of 08/04/24 to 08/10/24, aide visits were conducted on: 08/05/24 (X2 visits), 08/06/24, 08/07/24 (X2 visits), 08/08/24 and on 08/09/24 (seven aide visits were conducted, eight aide visits ordered). Documentation showed no communications between the IDG and showed no changes in the ordered aide visit frequencies. On 08/14/24 at 1:00 p.m., Staff B stated aide visits were not provided in accordance with the POC for patient #9 Patient #12 A review of a POC dated 05/16/24 to 08/13/24 with IDG updates on 06/27/24, 07/10/24, 07/25/24 and 08/08/24 showed documentation of an aide visit frequency of two times a week for one week, six times a week for 12 weeks, then two times a week for one week. Documentation showed on 06/26/24 an order to change the aide visit frequency to eight times a week for one week, 10 times a week for six weeks, then four times a week for one week. Documentation showed during the week of 05/16/24 to 05/18/24, aide visits were conducted on 05/17/24 (one visit conducted, two visits ordered). During the week of 06/23/24 to 06/29/24, aide visits were conducted on: 06/24/24 (X2 visits), 06/26/24 (X2 visits), 06/27/24 (X2 visits) and on 06/28/24 (X2 visits) (eight visits conducted, 10 visits ordered). During the week of 07/14/24 to 07/20/24 aide visits were conducted on: 07/15/24, 07/16/24, 07/17/24 and on 07/19/24 (four aide visits were conducted, five aide visits ordered). Documentation showed no communications between the IDG and showed no changes in the ordered aide visit frequencies. On 08/14/24 at 1:06 p.m., Staff B stated aide visits were not provided in accordance with the POC for patient #12. Patient #14 A review of a POC dated 06/08/24 to 09/05/24 with IDG updates on 06/27/24, 07/10/24, 07/25/24 and 08/08/24 showed documentation of an aide visit frequency of four times a week for 13 weeks. Documentation showed during the week of 06/23/24 to 06/29/24, aide visits were conducted on 06/25/24 and on 06/27/24 (two visits conducted, four visits ordered). During the week of 06/30/24 to 07/06/24, aide visits were conducted on: 07/02/24 (X2 visits) (two visits conducted, four visits ordered). Documentation showed no communications between the IDG and showed no changes in the ordered aide visit frequencies. On 08/14/24 at 1:09 p.m., Staff B stated aide visits were not provided in accordance with the POC for patient #14

Based on record review and interview, the hospice failed to ensure the plans of care included a hospice diagnosis for eight (Patients #1, 2, 3, 4, 5, 9, 10 and #13) of 19 patients. --- Findings: Patient #1 A recertification plan of care dated 06/30/24 to 08/20/24 and IDG updates to the POC on 06/27/24, 07/10/24, 07/25/24 and on 08/08/24 documented no hospice diagnosis. Patient #2 A recertification plan of care dated 06/25/24 to 08/23/24 and IDG updates to the POC on 06/27/24, 07/10/24, 07/25/24 and on 08/08/24 documented no hospice diagnosis. Patient #3 A recertification plan of care dated 07/17/24 to 09/14/24 and IDG updates to the POC on 06/27/24, 07/10/24, 07/25/24 and on 08/08/24 documented no hospice diagnosis. Patient #4 A recertification plan of care dated 07/01/24 to 09/28/24 and IDG updates to the POC on 06/27/24, 07/10/24, 07/25/24 and on 08/08/24 documented no hospice diagnosis. Patient #5 A recertification plan of care dated 07/03/24 to 08/31/24 and IDG updates to the POC on 06/27/24, 07/10/24, 07/25/24 and on 08/08/24 documented no hospice diagnosis. Patient #9 A recertification plan of care dated 07/17/24 to 09/14/24 and IDG updates to the POC on 06/27/24, 07/10/24, 07/25/24 and on 08/08/24 documented no hospice diagnosis. Patient #10 A recertification plan of care dated 07/30/24 to 10/27/24 and IDG updates to the POC on 06/27/24, 07/10/24, 07/25/24 and on 08/08/24 documented no hospice diagnosis. Patient #13 A recertification plan of care dated 07/12/24 to 09/09/24 and IDG updates to the POC on 06/27/24, 07/10/24, 07/25/24 and on 08/08/24 documented no hospice diagnosis. On 08/14/24 at 12:40 p.m. to 1:08 p.m., Staff B stated the POCs for patients #1, 2, 3, 4, 5, 9, 10 and #13 did not include hospice diagnoses.

Based on record review and interview, the hospice failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients, volunteers, and employees. --- Findings: A review of QAPI Program for calendar years 2022 and 2023; and 01/01/24 to 08/13/24 showed no QAPI program data collection sources or analysis/reporting of collected data or reporting activities for calendar year 2022, 07/01/23 to 12/31/23 and 01/01/24 to 06/30/24. Additional requests for administrative records yielded no results. On 08/14/24 at 12:00 p.m., Staff A stated the hospice had no administrative records which showed data collection sources, analysis/reporting of collected data or activities that showed improved quality of patient care for calendar year 2022, 07/01/23 to 12/31/23 and 01/01/24 to 06/30/24.

Based on record review and interview, the hospice failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities for all patients, volunteers, and employees. --- Findings: A review of administrative records showed no governing body oversite of the ongoing QAPI program which identified the hospice that included data collection, analysis and reporting activities for the hospice for calendar year 2022, 07/01/23 to 12/31/23 and 01/01/24 to 06/30/24. Additional requests for administrative records yielded no results. On 08/14/24 at 12:00 p.m., Staff A stated the hospice had no documentation which showed governing body oversite of QAPI program activities which showed review and approval of data collection, analysis, implementation and follow up of QAPI activities for calendar year 2022, 07/01/23 to 12/31/23 and 01/01/24 to 06/30/24.

Based on record review and interview, the hospice failed to ensure its infection control program surveillance monitoring and reporting was included in QAPI program activities for calendar year 2022, 07/01/23 to 12/31/23 and 01/01/24 to 06/30/24 for all patients, volunteers, and employees. --- Findings: Administrative records showed no infection control program surveillance data was included in QAPI program activities for calendar year 2022, 07/01/23 to 12/31/23 and 01/01/24 to 06/30/24. On 08/14/24 at 12:30 p.m., Staff A stated there was no infection control program surveillance data included in QAPI program activities for calendar year 2022, 07/01/23 to 12/31/23 and 01/01/24 to 06/30/24.

Based on record review and interview, the hospice failed to review and update a hospice aide care plan prior to the provision of aide services for seven (Patients #5, 9, 10, 11, 13, 16 and #17) of 19 patients. --- Findings: Patient #5 A recertification plan of care dated 07/03/24 to 08/31/24 and IDG updates to the POC on 06/27/24, 07/10/24, 07/25/24 and on 08/08/24 showed documentation of an aide visit frequency of four times a week for one week, then six times a week for eight weeks. Documentation showed a hospice aide care plan dated 11/29/23 with an aide frequency of four week two, then six week eleven. Documentation showed no aide care plan (aide assignment) review and update since 11/29/23 by the IDG. Patient #9 A recertification plan of care dated 07/17/24 to 09/14/24 and IDG updates to the POC on 06/27/24, 07/10/24, 07/25/24 and on 08/08/24 showed documentation of an aide visit frequency of three times a week for one weeks, then five times a week for eight weeks. Documentation showed a hospice aide care plan dated effective 11/29/23 with an aide frequency of four week one, then six week six. Documentation showed no aide care plan (aide assignment) review and update since 11/29/23 by the IDG. Patient #10 A recertification plan of care dated 07/30/24 to 10/27/24 and IDG updates to the POC on 06/27/24, 07/10/24, 07/25/24 and on 08/08/24 showed documentation of an aide visit frequency of six times a week for one week, then eight times a week for 12 weeks. Documentation showed a hospice aide care plan dated effective 05/01/24 with an aide frequency of two week one, six week 12, then two week one. Documentation showed no aide care plan (aide assignment) review and update since 05/01/24 by the IDG. Patient #13 A recertification plan of care dated 07/12/24 to 09/09/24 and IDG updates to the POC on 06/27/24, 07/10/24, 07/25/24 and on 08/08/24 showed documentation of an aide visit frequency of two times a week for one week, six times a week for eight weeks then two times a week for one week. Documentation showed a hospice aide care plan dated effective 01/14/24 with an aide frequency of four week one, six week two, three week five, then two week one. Documentation showed no aide care plan (aide assignment) review and update since 01/14/24 by the IDG. Patient #16 A recertification plan of care dated 07/28/23 to 09/25/23 and IDG updates to the POC on 08/03/23, 08/17/23 and on 08/31/23 showed documentation of an aide visit frequency of two times a week for eight weeks. Documentation showed a hospice aide care plan dated effective 11/30/22 with an aide frequency of three times a week for four weeks. Documentation showed no aide care plan (aide assignment) review and update since 11/30/22 by the IDG. Patient #17 A recertification plan of care dated 05/05/24 to 08/02/24 and IDG updates to the POC on 05/16/24, 05/30/24 and on 06/13/24 showed documentation of an aide visit frequency of two times a week for 13 weeks. Documentation showed a hospice aide care plan dated effective 02/05/24 with an aide frequency of three times a week for four weeks. Documentation showed no aide care plan (aide assignment) review and update since 02/05/24 by the IDG. On 08/14/24 at 12:55 p.m. to 1:08 p.m., Staff B stated the clinical records for patients #5, 9, 10, 11, 13, 16 and #17 showed no review and update of the aide care plans (aide assignment) at time of recertification.

Based on record review and interview, the hospice failed to ensure personnel records were maintained with required annual employee performance evaluations and annual continuing education hours for three (Volunteer #1, 2 and #3) of three volunteers and five employees. --- Findings: Volunteer 1 A review of personnel records showed no annual performance evaluation and no annual continuing education for the 06/06/22 to 08/14/24 employment period. Volunteer 2 A review of personnel records showed no annual performance evaluation and no annual continuing education for the 06/28/22 to 08/14/24 employment period. Volunteer 3 A review of personnel records showed no annual performance evaluation and no annual continuing education for the 11/09/22 to 08/14/24 employment period. On 08/14/24 at 12:00 p.m., Staff C stated the personnel records were provided in their entirety and did not contain all the required information for Volunteers 1, 2 and 3.

Based on record review and interview, the hospice failed to ensure completion of the initial bereavement risk assessment no later than 5 calendar days after the election of hospice care for five (Patients #3, 5, 9, 10 and 11) of 11 patients. Findings: Patient #3 A review of the clinical record showed an election of the hospice benefit on 10/29/21 with no completion of the initial bereavement risk assessment from 10/29/21 to 01/26/22 (90 days after election of the hospice benefit) with no documentation of patient or caregiver refusal of visits. Patient #5 A review of the clinical record showed an election of the hospice benefit on 10/26/21 with no completion of the initial bereavement risk assessment from 10/26/21 to 01/23/22 (90 days after election of the hospice benefit) with no documentation of patient or caregiver refusal of visits. Patient #9 A review of the clinical record showed an election of the hospice benefit on 12/22/21 with no completion of the initial bereavement risk assessment from 12/22/21 to 03/21/22 (90 days after election of the hospice benefit) with no documentation of patient or caregiver refusal of visits. Patient #10 A review of the clinical record showed an election of the hospice benefit on 03/09/22 with no completion of the initial bereavement risk assessment from 03/09/22 to 03/22/22 (12 days after election of the hospice benefit) with no documentation of patient or caregiver refusal of visits. Patient #11 A review of the clinical record showed an election of the hospice benefit on 03/10/22 with no completion of the initial bereavement risk assessment from 03/10/22 to 03/22/22 (11 days after election of the hospice benefit) with no documentation of patient or caregiver refusal of visits. On 03/22/22 at 12:40 pm, Staff A stated the initial bereavement risk assessments were not completed within the first five days after the election of the hospice benefit for Patients #3, 5, 9, 10 and 11.

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 eight (Patient #1, 2, 3, 4, 6, 7, 9 and 10) of eleven patients reviewed. Findings: Patient #1 A review of the plan of care dated 11/24/21 to 02/21/22 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 plan of care dated 12/21/21 to 02/18/22 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 10/29/21 to 01/26/22 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 #4 A plan of care dated 01/13/22 to 03/013/22 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 #6 A plan of care dated 01/25/22 to 03/25/22 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 plan of care dated 11/22/21 to 02/19/22 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 #9 A plan of care dated 12/22/21 to 03/21/22 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 #10 A plan of care dated 03/09/22 to 06/06/22 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. On 03/22/22 at 1:20 pm, Staff A stated the plans of care for Patients #1, 2, 3, 4, 6, 7, 9 and 10 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 quality indicator data was used in the design of the QAPI program for all 133 current patients and any new patients admitted to the hospice. A review of QAPI records showed no use of quality indicator data in the QAPI program documentation for 2020 and 2021. On 03/22/22 at 1:30 pm, Staff A stated the QAPI program did not include the use of quality indicator data.

Based on record review and interview, the hospice failed to ensure the hospice aide notified the supervising nurse of missed visits for one (Patient #6) of 11 patients. Findings: Patient #6 A review of the plan of care dated 01/25/22 to 03/25/22 showed a hospice aide frequency of three visits per week. A review of the hospice aide visit notes showed: 1) missed visit notes dated 02/02/22 and 02/04/22 for the week of 01/30/22 to 02/05/22 (two of three attempted visits) showed no notification to the supervising nurse that the visits were not completed. 2) a missed visit note dated 02/23/22 for the week of 02/20/22 to 02/26/22 (one of three attempted visits) showed no notification to the supervising nurse that the visit was not completed. On 02/22/22 at 12:25 pm, Staff A stated there was no documentation of the hospice aide notifying the supervising nurse of missed visits.