Every finding on record at Mercy Hospital Oklahoma City, Inc.

Based on record review and interview, the hospice failed to ensure completion of initial assessments for plans of care no later than five calendar days after election of hospice benefits for five (Patients # 5, 7, 8, 13 and #18) of 23 patients. --- Findings: Patient #5A review of the clinical record showed an election of the hospice benefit on 04/19/25 with current POC from 07/18/25 to 10/15/25. The clinical record showed a chaplain spiritual assessment dated 04/25/25 (6 days) after the initial comprehensive assessment (election of benefits) and development of the POC. The clinical record showed no patient or caregiver refusal of assessment and showed no communications or notifications to the physician.      On 09/12/25 at 2:28 p.m., Staff B stated the chaplain spiritual assessment component of the initial POC was not completed within the first five days after the election of the hospice benefit. Patient #7A review of the clinical record showed an election of the hospice benefit on 06/22/25 with current POC from 06/22/25 to 09/19/25. The clinical record showed no medical social work assessment after the initial comprehensive assessment (election of benefits) and development of the POC. The clinical record showed no patient or caregiver refusal of assessment and showed no communications or notifications to the physician.      On 09/12/25 at 2:34 p.m., Staff B stated the medical social work assessment component of the initial POC was not completed within the first five days after the election of the hospice benefit. Patient #8A review of the clinical record showed an election of the hospice benefit on 06/19/25 with current POC from 07/17/25 to 10/14/25. The clinical record showed no medical social work assessment after the initial comprehensive assessment (election of benefits) and development of the POC. The clinical record showed no patient or caregiver refusal of assessment and showed no communications or notifications to the physician.      On 09/12/25 at 2:37 p.m., Staff B stated the medical social work assessment component of the initial POC was not completed within the first five days after the election of the hospice benefit. Patient #13A review of the clinical record showed an election of the hospice benefit on 09/02/25 with current POC from 09/02/25 to 10/31/25. The clinical record showed a medical social work assessment dated 09/09/25 (7 days) after the initial comprehensive assessment (election of benefits) and development of the POC. The clinical record showed no patient or caregiver refusal of assessment and showed no communications or notifications to the physician.      On 09/12/25 at 2:59 p.m., Staff B stated the medical social work assessment component of the initial POC was not completed within the first five days after the election of the hospice benefit. Patient #19A review of the clinical record showed an election of the hospice benefit on 05/30/25 with current POC from 08/28/25 to 11/25/25. The clinical record showed no chaplain spiritual assessment after the initial comprehensive assessment (election of benefits) and development of the POC. The clinical record showed no patient or caregiver refusal of assessment and showed no communications or notifications to the physician.      On 09/12/25 at 3:10 p.m., Staff B stated the chaplain spiritual assessment component of the initial POC was not completed within the first five days after the election of the hospice benefit.

Based on record review and interview, the hospice failed to ensure development of a bereavement POC at the time of initial assessment for eight (Patients #2, 4, 7, 12, 16, 18, 22 and #23) of 23 patients. --- Findings: Patient #2A review of the clinical record showed an initial bereavement assessment dated 03/13/24 with IDG updates on 08/20/25 and 09/03/25. The clinical record showed no bereavement POC and no bereavement interventions and goals in the overall POC dated 09/03/25 to 11/01/25. The clinical record showed no patient or caregiver refusal of a bereavement POC since the bereavement assessment dated 03/13/24.  On 09/12/25 at 2:07 p.m., Staff A stated:1.    The patient had no bereavement POC and showed no bereavement interventions and goals in the overall POC.2.    A bereavement POC is put into place at the time of a patient’s death. Patient #4A review of the clinical record showed an initial bereavement assessment dated 06/20/25 with IDG updates on 06/20/25, 07/02/25, 07/16/25, 07/30/25, 08/13/25, and 08/27/25. The clinical record showed no bereavement POC and no bereavement interventions and goals in the overall POC dated 06/19/25 to 09/16/25. The clinical record showed no patient or caregiver refusal of a bereavement POC since the bereavement assessment dated 06/20/25.  On 09/12/25 at 2:21 p.m., Staff A stated:1.    The patient had no bereavement POC and showed no bereavement interventions and goals in the overall POC.2.    A bereavement POC is put into place at the time of a patient’s death. Patient #12A review of the clinical record showed an initial bereavement assessment dated 01/24/25 with IDG updates on 07/23/25, 08/06/25, 08/20/25, and 09/03/25. The clinical record showed no bereavement POC and no bereavement interventions and goals in the overall POC dated 07/23/25 to 09/20/25. The clinical record showed no patient or caregiver refusal of a bereavement POC since the bereavement assessment dated 01/24/25.  On 09/12/25 at 2:54 p.m., Staff A stated:1.    The patient had no bereavement POC and showed no bereavement interventions and goals in the overall POC.2.    A bereavement POC is put into place at the time of a patient’s death. Patient #16A review of the clinical record showed an initial bereavement assessment dated 02/12/24 with IDG updates on 08/06/25, 08/20/25, and 09/03/25. The clinical record showed no bereavement POC and no bereavement interventions and goals in the overall POC dated 08/07/25 to 10/05/25. The clinical record showed no patient or caregiver refusal of a bereavement POC since the bereavement assessment dated 02/12/24.  On 09/12/25 at 3:04 p.m., Staff A stated:1.    The patient had no bereavement POC and showed no bereavement interventions and goals in the overall POC.2.    A bereavement POC is put into place at the time of a patient’s death. Patient #18A review of the clinical record showed no initial bereavement assessment with IDG updates on 08/20/25, and 09/03/25. The clinical record showed no bereavement POC and no bereavement interventions and goals in the overall POC dated 08/28/25 to 11/25/25. The clinical record showed no patient or caregiver refusal of a bereavement POC since the initial comprehensive assessment dated 05/30/25.  On 09/12/25 at 3:10 p.m., Staff A stated:1.    The patient had no bereavement POC and showed no bereavement interventions and goals in the overall POC.2.    A bereavement POC is put into place at the time of a patient’s death. Patient #22A review of the clinical record showed an initial bereavement assessment dated 06/14/23 with IDG updates on 01/29/25, 02/12/25, and 02/26/25. The clinical record showed no bereavement POC and no bereavement interventions and goals in the overall POC dated 02/02/25 to 04/02/25. The clinical record showed no patient or caregiver refusal of a bereavement POC since the initial comprehensive assessment dated 06/14/23.  On 09/12/25 at 3:23 p.m., Staff A stated the patient had no bereavement POC and showed no bereavement interventions and goals in the overall POC at the time of the hospice revocation on 03/30/25. Patient #23A review of the clinical record showed an initial bereavement assessment dated 02/05/25 with IDG updates on 02/12/25, 02/26/25, 03/12/25, 03/26/25, 04/09/25 and 04/23/25. The clinical record showed no bereavement POC and no bereavement interventions and goals in the overall POC dated 02/01/25 to 05/01/25. The clinical record showed no patient or caregiver refusal of a bereavement POC since the initial comprehensive assessment dated 05/01/25.  On 09/12/25 at 3:23 p.m., Staff A stated the patient had no bereavement POC and showed no bereavement interventions and goals in the overall POC at the time of the hospice revocation on 05/01/25.

Based on record review and interview, the hospice failed to ensure POCs included interventions and goals related to hospice aide services for one (Patients #10) of 23 patients. --- Findings: Patient #10A review of the plan of care dated 08/11/25 to 10/09/25 with IDGs dated 08/11/25, 08/13/25, 08/26/25 and 09/10/25 showed no interventions and goals for hospice aide services for visits conducted on 08/18/25, 08/21/25, 08/25/25, 09/04/25 and 09/08/25. On 09/12/25 at 2:45 p.m., Staff A stated the plan of care should have included interventions and goals for hospice aide services.

Based on record review and interview, the hospice failed to ensure POCs included services discipline visit frequencies for 16 (Patients #1, 2, 3, 5, 6, 8, 9, 10, 12, 14, 16, 17, 18, 19, 21 and #22) of 23 patients. --- Findings: Patient #1A review of a POC dated 07/20/25 to 10/17/25 with IDG dated 07/23/25, 08/06/25, 08/20/25 and 09/03/25 showed no visit frequencies for chaplain, MSW and volunteer services. On 09/12/25 at 1:55 p.m., Staff A stated the plan of care did not include visit frequencies for chaplain, MSW and volunteer services. Patient #2A review of a POC dated 09/03/25 to 11/01/25 with IDG dated 08/20/25 and 09/03/25 showed no visit frequencies for chaplain, MSW and volunteer services. On 09/12/25 at 2:07 p.m., Staff A stated the plan of care did not include visit frequencies for chaplain, MSW and volunteer services. Patient #3A review of a POC dated 08/05/25 to 10/06/25 with IDG dated 08/06/25, 08/20/25 and 09/03/25 showed no visit frequencies for chaplain, MSW and volunteer services. On 09/12/25 at 2:13 p.m., Staff A stated the plan of care did not include visit frequencies for chaplain, MSW and volunteer services. Patient #5A review of a POC dated 07/18/25 to 10/15/25 with IDG dated 07/23/25, 08/06/25, 08/20/25 and 09/03/25 showed no visit frequencies for chaplain and volunteer services. On 09/12/25 at 2:28 p.m., Staff A stated the plan of care did not include visit frequencies for chaplain and volunteer services.Patient #6A review of a POC dated 07/29/25 to 10/28/25 with IDG dated 07/23/25, 08/06/25, 08/20/25 and 09/03/25 showed no visit frequencies for MSW services. On 09/12/25 at 2:28 p.m., Staff A stated the plan of care did not include visit frequencies for MSW services.Patient #8A review of a POC dated 07/17/25 to 10/14/25 with IDG dated 07/23/25, 08/06/25, 08/20/25 and 09/03/25 showed no visit frequencies for chaplain and MSW services. On 09/12/25 at 2:37 p.m., Staff A stated the plan of care did not include visit frequencies for chaplain and MSW services.Patient #9A review of a POC dated 08/24/25 to 10/22/25 with IDG dated 08/20/25 and 09/03/25 showed no visit frequencies for chaplain, MSW and volunteer services. On 09/12/25 at 2:41p.m., Staff A stated the plan of care did not include visit frequencies for chaplain, MSW and volunteer services. Patient #10A review of a POC dated 08/11/25 to 10/09/25 with IDG dated 08/20/25 and 09/03/25 showed no visit frequencies for chaplain, MSW and volunteer services. On 09/12/25 at 2:45p.m., Staff A stated the plan of care did not include visit frequencies for chaplain, MSW and volunteer services. Patient #12A review of a POC dated 07/23/25 to 09/20/25 with IDG dated 07/23/25, 08/06/25, 08/20/25 and 09/03/25 showed no visit frequencies for chaplain, MSW and volunteer services. On 09/12/25 at 2:54 p.m., Staff A stated the plan of care did not include visit frequencies for chaplain, MSW and volunteer services.Patient #14A review of a POC dated 08/14/25 to 11/11/25 with IDG dated 08/20/25 and 09/03/25 showed no visit frequencies for hospice aide and MSW services. On 09/12/25 at 3:01p.m., Staff A stated the plan of care did not include visit frequencies for hospice aide and MSW services. Patient #16A review of a POC dated 08/07/25 to 10/05/25 with IDG dated 08/06/25, 08/20/25 and 09/03/25 showed no visit frequencies for chaplain, MSW and volunteer services. On 09/12/25 at 3:04 p.m., Staff A stated the plan of care did not include visit frequencies for chaplain, MSW and volunteer services.Patient #17A review of a POC dated 08/24/25 to 10/22/25 with IDG dated 08/20/25 and 09/03/25 showed no visit frequencies for MSW services. On 09/12/25 at 3:07 p.m., Staff A stated the plan of care did not include visit frequencies for MSW services. Patient #18A review of a POC dated 08/28/25 to 10/25/25 with IDG dated 08/20/25 and 09/03/25 showed no visit frequencies for MSW and volunteer services. On 09/12/25 at 3:07p.m., Staff A stated the plan of care did not include visit frequencies for MSW and volunteer services. Patient #19A review of a POC dated 04/06/25 to 07/04/25 with IDG dated 03/26/25, 04/09/25, 04/23/25, 05/07/25, 05/21/25, 06/04/25 and 06/18/25 showed no visit frequency for hospice aide services. On 09/12/25 at 3:14 p.m., Staff A stated the plan of care did not include a visit frequency for hospice aide services. Patient #21A review of a POC dated 03/27/25 to 06/24/25 with IDG dated 03/26/25, 04/09/25, 04/23/25, 05/07/25, 05/21/25, 06/04/25 and 06/18/25 showed no visit frequency for chaplain services. On 09/12/25 at 3:14 p.m., Staff A stated the plan of care did not include a visit frequency for chaplain services. Patient #22A review of a POC dated 02/02/25 to 04/02/25 with IDG dated 01/29/25, 02/12/25 and 02/26/25 showed no visit frequency for volunteer services. On 09/12/25 at 3:23 p.m., Staff A stated the plan of care did not include a visit frequency for volunteer services.

Based on record review and interview, the hospice failed to ensure:Aide visits were provided in accordance with the plan of care for three (Patients #3, 4 and #5) of 23 patients.SN visits were provided in accordance with the plan of care for two (Patients #4 and #14) of 23 patients.SN to perform weight assessment every month for one (Patient #19) of 23 patients. --- Findings: Patient #3A review of a POC dated 08/05/25 to 10/06/25 with IDG updates on 08/06/25, 08/20/25 and 09/03/25 showed an aide visit frequency of two times a week for one week, then three times a week for three weeks. The clinical record shown during the week of:·      08/05/25 to 08/09/25 aide visits were conducted on 08/06/25 (two visits ordered, one visit conducted). ·      08/17/25 to 08/23/25 aide visits were conducted on 08/18/25 and 08/22/25 (three visits ordered, two visits conducted).  The clinical record showed no communication between the IDG and showed no changes in the ordered aide visit frequency.  On 09/12/25 at 2:13 p.m., Staff A stated aide visits were not conducted as ordered on the plan of care. Patient #4A review of a POC dated 06/19/25 to 09/16/25 with IDG updates on 06/20/25, 07/02/25, 07/16/25, 07/30/25, 08/13/25 and 08/27/25 showed an aide visit frequency of three times a week for three weeks and SN visit frequency of two times a week for four weeks. The clinical record shown during the week of:·      06/19/25 to 06/21/25 no aide visits were conducted (three visits ordered, no visit conducted). ·      06/22/25 to 06/28/25 no aide visits were conducted (three visits ordered, no visits conducted). ·      06/29/25 to 07/05/25 two aide visits were conducted on 06/30/25 and 07/03/25 (three visits ordered, two visits conducted). ·      08/18/25 to 08/24/25 one visit was conducted on 08/18/25 (two visits ordered, one visit conducted). The clinical record showed no communication between the IDG and showed no changes in the ordered aide and SN visit frequencies.  On 09/12/25 at 2:21 p.m., Staff A stated the aide and SN visits were not conducted as ordered on the plan of care. Patient #5A review of a POC dated 07/18/25 to 10/15/25 with IDG updates on 07/09/25, 07/23/25, 08/06/25, 08/20/25 and 09/03/25 showed an aide visit frequency of three times a week for six weeks, two times a week for one week, then three times a week for three weeks. The clinical record shown during the week of:·      08/17/25 to 08/23/25 aide visits were conducted on 08/18/25 (three visits ordered, one visit conducted).  The clinical record showed no communication between the IDG and showed no changes in the ordered aide visit frequency.  On 09/12/25 at 2:28 p.m., Staff A stated aide visits were not conducted as ordered on the plan of care. Patient #14A review of a POC dated 08/14/25 to 11/11/25 with IDG updates on 08/06/25, 08/20/25 and 09/03/25 showed an SN visit frequency of two times a week for one week, then three times a week for four weeks. The clinical record shown during the week of:·      08/13/25 to 08/16/25 SN visits were conducted on 08/14/25 (two visits ordered, one visit conducted).  The clinical record showed no communication between the IDG and showed no changes in the ordered SN visit frequency.  On 09/12/25 at 3:01 p.m., Staff A stated SN visits were not conducted as ordered on the plan of care. Patient #19A review of a POC dated 04/06/25 to 07/14/25 with IDG updates on 03/26/25, 04/09/25, 04/23/25, 05/07/25, 05/21/25, 06/04/25 and 06/18/25 showed orders for SN to perform weight assessment every month. The clinical record shown one weight assessment on 02/20/25 of 230.5 pounds from 02/20/25 to the date of the patient’s death on 06/20/25. The clinical record showed no communication between the IDG and showed no changes in the order for SN to perform weight assessment every month.  On 09/12/25 at 3:14 p.m., Staff A stated SN did not conduct weight assessments as ordered on the plan of care.

Based on record review and interview, the agency failed to ensure care was coordinated between the IDG members and the physician for one (Patient #22) of 23 patients. --- Findings: Patient #22A review of the POC dated 02/02/25 to 04/02/25 and plan of care updates dated 01/29/25, 02/12/25 and 02/26/25 showed the patient was discharged from hospice for benefit revocation for an in-patient hospital stay on 03/30/25.  The clinical record showed:·      An aide visit was conducted on 04/01/25.·      A MSW visit was conducted on 04/08/25.·      A SN visit was conducted on 04/20/25. The clinical record showed no discussion by the IDG and showed no orders for the discipline visits by the aide, MSW or SN.  On 09/12/25 at 3:23 p.m., Staff A stated the hospice team members had no orders to see the patient for services after the revocation date of 03/30/25.

Based on a record review and interview, the hospice failed to ensure certification or completion of alternative training requirements to meet the qualifications of a hospice aide for one (Staff H) of eight employees reviewed. --- Findings: Staff HA review of personnel records showed certification as a home care aide expired on 06/30/25. The personnel record showed no current home health aide certification and showed no completion of alternative training requirements to meet the qualifications of a hospice aide. Additional request for information yielded no results. On 09/12/25 at 3:30 p.m., Staff A stated the personnel record for Staff H showed:1.    The home health aide certification had expired.2.    It did not include documentation of alternative training requirements that met qualifications as a hospice aide.

Based on record review and interview, the hospice failed to ensure on-site aide supervisory visits were completed every 14 days for two (Patients #7 and #9) of 23 patients. --- Findings: Patient #7A review of the plan of care dated 06/22/25 to 09/19/25 showed home health aide visits were conducted on:·      07/07/25·      07/21/25 The clinical record showed no supervisory visits from 06/22/25 to 07/22/25(30 + days between supervisory visits). On 09/12/25 at 2:34 p.m., Staff A stated supervisory aide visits were not conducted every 14 days. Patient #9A review of the plan of care dated 08/24/25 to 10/22/25 showed home health aide visits were conducted on:·      08/29/25·      09/05/25 The clinical record showed no supervisory visits from 08/19/25 to 09/10/25(22 + days between supervisory visits). On 09/12/25 at 2:41 p.m., Staff A stated supervisory aide visits were not conducted every 14 days.

Based on record review and interview, the hospice failed to ensure personnel records were maintained with volunteer acknowledged job descriptions for two (Volunteer #1 and #2) of three volunteer files reviewed. --- Findings: Volunteer 1A review of personnel records showed no signed job description for hospice volunteer role, responsibilities and limitations.  Volunteer 2A review of personnel records showed no signed job description for hospice volunteer role, responsibilities and limitations.Additional request for information yielded no results. On 09/12/25 at 3:30 p.m., Staff A stated personnel records were provided in their entirety and did not contain job descriptions Volunteers #1 and #2.

Based on record review and interview, the agency failed to ensure required background checks were completed for three (Volunteers #1, 2 and #3) of three volunteer files reviewed. --- 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 employees of a home care agency whose employment began after 07/01/14. Volunteer #1A review of the personnel record showed no documentation of a background check through OKSCREEN. Volunteer #2A review of the personnel record showed no documentation of a background check through OKSCREEN. Volunteer #3A review of the personnel record showed no documentation of a background check through OKSCREEN. Additional request for information yielded no results. On 09/12/25 at 3:30 p.m., Staff A stated Volunteers #1, 2 and #3 did not have background checks completed through the OkScreen database.

Based on record review and interview, the hospice failed to ensure an allegation of theft was reported to the state agency for one (Patient #20) of one patient. --- Patient #20 A review of complaints and grievances showed a complaint of theft dated 11/08/22. Documentation showed no notification of theft reported to local authorities, the state agency or nurse aide registry. On 04/20/23 at 12:30 pm, Staff A stated the hospice was unaware of the requirement to report the injury to the State Agency.

Based on record review and interview, the hospice failed to ensure effective pain management was provided for one (Patient #1) of 19 patients. --- Patient #2 A review of the plan care dated 12/26/22 to 02/23/23 with plan of care updates dated 01/04/23, 01/18/23, 02/01/23 and 02/15/23 showed a primary diagnosis of chronic obstructive pulmonary disease and documented a skilled nurse frequency of one visit per week for four weeks. A review of the medical record showed the following: A skilled nurse assessment dated 12/27/22 documented the patient pain as a 5 out of 10 on the classic 1-10 pain scale. The patient's pain goal was documented as 4 on the classic 1-10 pain scale. Documentation showed pain medication was administered (no follow up was conducted for the effectiveness of the pain medication) and no documented physician notification (direct contact or interdisciplinary group documentation) of the elevated pain level. A skilled nurse assessment dated 01/03/23 documented the patient pain as a 5 out of 10 on the classic 1-10 pain scale. The patient's pain goal was documented as 4 on the classic 1-10 pain scale. Documentation showed pain medication was administered (no follow up was conducted for the effectiveness of the pain medication) and no documented physician notification (direct contact or interdisciplinary group documentation) of the elevated pain level. A skilled nurse assessment dated 01/10/23 documented the patient pain as a 6 out of 10 on the classic 1-10 pain scale. The patient's pain goal was documented as 4 on the classic 1-10 pain scale. Documentation showed pain medication was administered (no follow up was conducted for the effectiveness of the pain medication) and no documented physician notification (direct contact or interdisciplinary group documentation) of the elevated pain level. A skilled nurse assessment dated 01/24/23 documented the patient pain as a 5 out of 10 on the classic 1-10 pain scale. The patient's pain goal was documented as 4 on the classic 1-10 pain scale. Documentation showed pain medication was administered (no follow up was conducted for the effectiveness of the pain medication) and no documented physician notification (direct contact or interdisciplinary group documentation) of the elevated pain level. A skilled nurse assessment dated 02/07/23 documented the patient pain as a 6 out of 10 on the classic 1-10 pain scale. The patient's pain goal was documented as 4 on the classic 1-10 pain scale. Documentation showed pain medication was administered (no follow up was conducted for the effectiveness of the pain medication) and no documented physician notification (direct contact or interdisciplinary group documentation) of the elevated pain level. A skilled nurse assessment dated 02/09/23 documented the patient pain as a 6 out of 10 on the classic 1-10 pain scale. The patient's pain goal was documented as 4 on the classic 1-10 pain scale. Documentation showed pain medication was administered (no follow up was conducted for the effectiveness of the pain medication) and no documented physician notification (direct contact or interdisciplinary group documentation) of the elevated pain level. A skilled nurse assessment dated 02/13/23 documented the patient pain as a 5 out of 10 on the classic 1-10 pain scale. The patient's pain goal was documented as 4 on the classic 1-10 pain scale. Documentation showed pain medication was administered (no follow up was conducted for the effectiveness of the pain medication) and no documented physician notification (direct contact or interdisciplinary group documentation) of the elevated pain level. A skilled nurse assessment dated 02/16/23 documented the patient pain as a 6 out of 10 on the classic 1-10 pain scale. The patient's pain goal was documented as 4 on the classic 1-10 pain scale. Documentation showed pain medication was administered (no follow up was conducted for the effectiveness of the pain medication) and no documented physician notification (direct contact or interdisciplinary group documentation) of the elevated pain level. A skilled nurse assessment dated 02/20/23 documented the patient pain as a 5 out of 10 on the classic 1-10 pain scale. The patient's pain goal was documented as 4 on the classic 1-10 pain scale. Documentation showed pain medication was administered (no follow up was conducted for the effectiveness of the pain medication) and no documented physician notification (direct contact or interdisciplinary group documentation) of the elevated pain level. A skilled nurse assessment dated 02/23/23 documented the patient pain as a 6 out of 10 on the classic 1-10 pain scale. The patient's pain goal was documented as 4 on the classic 1-10 pain scale. Documentation showed pain medication was administered (no follow up was conducted for the effectiveness of the pain medication) and no documented physician notification (direct contact or interdisciplinary group documentation) of the elevated pain level. On 04/20/23 at 11:25 am, Staff B stated the pain for Patient #2 was not properly managed to meet the patient's stated goal.

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 (Patients #6) of 19 patients. --- Patient #6 A review of the plan of care dated 03/29/23 to 06/26/23 showed hospice aide visits at a frequency of two visits per week for four weeks. A review of the clinical record showed no hospice aide visits for the weeks of 03/02/23 to 03/08/23 and 03/09/23 to 03/15/23. On 04/20/23 at 10:35 am, Staff A stated the ordered hospice aide frequency for Patient #6 was not met.

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 thirteen (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 18 and 19) of 19 patients reviewed. --- Patient #1 A review of the plan of care dated 12/26/22 to 02/23/23 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 01/01/23 to 03/01/23 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 review of the plan of care dated 02/08/23 to 04/08/23 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 review of the plan of care dated 03/21/23 to 06/18/23 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 review of the plan of care dated 01/17/23 to 03/17/23 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 review of the plan of care dated 03/19/23 to 06/16/23 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 02/07/23 to 04/07/23 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 03/09/23 to 06/06/23 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 review of the plan of care dated 01/11/23 to 04/10/23 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 review of the plan of care dated 01/07/23 to 04/06/23 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 review of the plan of care dated 02/16/23 to 04/16/23 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 #18 A review of the plan of care dated 03/28/23 to 06/25/23 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 #19 A review of the plan of care dated 03/14/23 to 06/11/23 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 04/20/23 at 10:28 am, Staff A stated the plans of care for Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 18 and 19 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 the plan of care was revised to reflect the presence of wounds for one (Patient #16) of 19 patients. --- Patient #16 A plan of care dated 02/07/23 to 05/07/23 with plan of care updates dated 03/29/23 and 04/12/23 showed a skilled nurse frequency of two visits per week for five weeks and documented no presence of wounds or treatments to wounds to be performed. A review of the electronic medical record showed the following: A skilled nurse visit dated 03/29/23 documented the presence of a decubitus ulcer with no documented assessment of the wound. A skilled nurse visit dated 04/03/23 documented the presence of a decubitus ulcer with no documented assessment of the wound. A skilled nurse visit dated 04/07/23 documented the presence of a decubitus ulcer with no documented assessment of the wound. A skilled nurse visit dated 04/10/23 documented the presence of a decubitus ulcer with no documented assessment of the wound. A skilled nurse visit dated 04/16/23 documented the presence of a decubitus ulcer with no documented assessment of the wound. A skilled nurse visit dated 04/17/23 documented the presence of a decubitus ulcer with no documented assessment of the wound. On 04/20/23 at 10:55 am, Staff A stated the hospice failed to update the plan of care to include the presence and care and treatment of a decubitus ulcer.

Based on a record review and interview, the governing body failed to ensure an agency specific Quality Assessment Performance Improvement program was evaluated annually for all 85 patients on hospice services and all agency staff for 2021 and 2022. --- A review of administrative records showed no governing body review of the agency specific Quality Assessment Performance Improvement program for 2021 and 2022. On 04/20/23 at 11:20 am, Staff A stated the governing body minutes did not show review of the agency specific Quality Assessment Performance Improvement program for the hospice in 2021 and 2022.

Based on record review and interview, the hospice failed to ensure governing body oversight of ongoing operations of the patient care delivery systems for calendar years 2021 and 2022 effecting all 85 patients and staff. --- A review of administrative records showed no governing body oversight of ongoing operations of the patient care delivery systems specific to the hospice in the calendar years of 2021 and 2022. On 04/20/23 at 11:45 am, Staff A stated there was no documentation which showed evidence of governing body oversight of ongoing operations of the patient care delivery systems specific to the hospice in calendar years 2021 and 2022.

Based on record review and interview, the hospice failed to ensure wound assessments were coordinated with the long term care facility for one (Patient #16) of 19 patients reviewed. --- Patient #16 A plan of care dated 02/07/23 to 05/07/23 with plan of care updates dated 03/29/23 and 04/12/23 showed a skilled nurse frequency of two visits per week for five weeks. A review of the electronic medical record showed the following: A skilled nurse visit dated 03/29/23 documented the presence of a decubitus ulcer with no documented assessment of the wound. A skilled nurse visit dated 04/03/23 documented the presence of a decubitus ulcer with no documented assessment of the wound. A skilled nurse visit dated 04/07/23 documented the presence of a decubitus ulcer with no documented assessment of the wound. A skilled nurse visit dated 04/10/23 documented the presence of a decubitus ulcer with no documented assessment of the wound. A skilled nurse visit dated 04/16/23 documented the presence of a decubitus ulcer with no documented assessment of the wound. A skilled nurse visit dated 04/17/23 documented the presence of a decubitus ulcer with no documented assessment of the wound. Clinical documentation showed no coordination with the long term care facility regarding the presence or treatment of the wound. On 04/20/23 at 10:55 am, Staff A stated the hospice failed to show coordination with the nursing home regarding wound assessment.