Every finding on record at Professional Home Hospice of Muskogee, Inc.

Based on record review and interview, the hospice failed to ensure a bereavement care plan was initiated or was included as a part of the overall POC after the initial and ongoing spiritual/bereavement assessments for 11 (Patients #2, 3, 5, 6, 7, 8, 9, 10, 11, 12 and #13) of 13 patients. --- Findings: Patient #2 A review of the clinical record showed an election of the hospice benefit on 10/05/23 with a completion of the initial spiritual/bereavement assessment on 10/10/23. A review of a POC dated 04/02/24 to 05/31/24 and IDG updates to the POC on 03/22/24, 04/05/24 and on 04/19/24 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. Patient #3 A review of the clinical record showed an election of the hospice benefit on 10/25/23 with a completion of the initial spiritual/bereavement assessment on 01/10/22. A review of a POC dated 04/22/24 to 04/24/24 and IDG updates to the POC on 04/05/24 and on 04/19/24 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. Patient #5 A review of the clinical record showed an election of the hospice benefit on 10/30/23 with a completion of the initial spiritual/bereavement assessment on 10/30/23. A review of a POC dated 10/30/23 to 01/27/24 and IDG updates to the POC on 11/03/23 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. Patient #6 A review of the clinical record showed an election of the hospice benefit on 12/30/21 with a completion of the initial spiritual/bereavement assessment on 01/03/22. A review of a POC dated 08/27/22 to 10/25/22 and IDG updates to the POC showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. Patient #7 A review of the clinical record showed an election of the hospice benefit on 01/23/24 with a completion of the initial spiritual/bereavement assessment on 01/23/24. A review of a POC dated 03/28/24 to 05/21/24 and IDG updates to the POC on 03/22/24, 04/05/24 and on 04/19/24 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. Patient #8 A review of the clinical record showed an election of the hospice benefit on 10/23/23 with a completion of the initial spiritual/bereavement assessment on 10/23/23. A review of a POC dated 04/20/24 to 06/18/24 and IDG updates to the POC on 04/19/24 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. Patient #9 A review of the clinical record showed an election of the hospice benefit on 09/13/23 with a completion of the initial spiritual/bereavement assessment on 09/13/23. A review of a POC dated 03/11/24 to 05/09/24 and IDG updates to the POC on 03/08/24, 03/22/24, 04/05/24 and on 04/19/24 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. Patient #10 A review of the clinical record showed an election of the hospice benefit on 08/19/23 with a completion of the initial spiritual/bereavement assessment on 08/19/23. A review of a POC dated 03/07/24 to 05/05/24 and IDG updates to the POC on 03/08/24, 03/22/24, 04/05/24 and on 04/19/24 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. Patient #11 A review of the clinical record showed an election of the hospice benefit on 01/10/23 with a completion of the initial spiritual/bereavement assessment on 01/12/23. A review of a POC dated 03/05/24 to 05/03/24 and IDG updates to the POC on 02/23/24, 03/08/24, 03/22/24, 04/05/24 and on 04/19/24 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. Patient #12 A review of the clinical record showed an election of the hospice benefit on 07/20/22 with a completion of the initial spiritual/bereavement assessment on 07/24/22. A review of a POC dated 03/11/24 to 05/08/24 and IDG updates to the POC on 03/08/24, 03/22/24, 04/05/24 and on 04/19/24 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. Patient #13 A review of the clinical record showed an election of the hospice benefit on 02/22/23 with a completion of the initial spiritual/bereavement assessment on 02/28/23. A review of a POC dated 04/17/24 to 06/15/24 and IDG updates to the POC on 04/05/24 and on 04/19/24 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. On 05/01/24 at 10:40 a.m., Staff D stated: all patients are given a bereavement risk score at the time of the initial spiritual/bereavement assessment and are advised of spiritual and bereavement services provided by the hospice and The bereavement program consists of intermittently timed mail outs and follow up telephone calls which begin after the patients death. On 05/01/24 at 10:50 a.m., Staff B stated the Hospice does not maintain a written POC for bereavement; bereavement is not included on the overall POC unless the patients family or caregiver is assessed at a moderate to high risk for bereavement, then social work and/or chaplain services are provided as needed and interventions and/or related goals for each discipline is added to the plan of care.

Based on record review and interview, the hospice failed to ensure the plan of care was developed to include a hospice diagnosis for one (Patient #8) of 13 patients. --- Findings: Patient #8 A plan of care dated 04/20/24 to 06/18/24 and IDG updates to the POC on 04/19/24 documented no hospice diagnosis. On 05/01/24 at 2:02 p.m., Staff B stated the POC did not include a hospice diagnosis or any historical medical diagnoses.

Based on record review and interview, the hospice failed to ensure completion and provision of a discharge summary of care for two (Patients #4 and #6) of 13 patients. --- Findings: Patient #4 A review of the clinical record showed the patient was transferred to residential care facility (Nursing Home) for respite care on 04/21/23 and then was subsequently discharged at the time of death on 05/04/23. Documentation showed no transfer/discharge summary of care was completed or provided to the attending physician or to the to residential care facility (Nursing Home). Patient #6 A review of the clinical record showed the patient was transferred to another hospice agency on 09/07/22. Documentation showed no transfer/discharge summary of care was completed or provided to the attending physician or to the receiving hospice agency. On 05/01/24 at 1:57 p.m., Staff B stated: 1. The hospice did not complete or provide a transfer/discharge summary of care to the attending physician for patients #4 and #6 or; 2. Provide a transfer/discharge summary of care to the to residential care facility (Nursing Home) for patient #4 or to the receiving hospice agency for patients #6.

Based on observation, record review and interview, the hospice failed to ensure the IDG communicated and coordinated the patients care with the residential care facility (Nursing Home) for one (Patient #4) of 13 patients. --- Findings: Patient #4 A review of the POC dated 04/05/23 to 07/03/23 showed orders for SN two times a week for 13 weeks, then one time a week for one week; hospice aide one time a week for one week, then two times a week for 12 weeks; medical social work one time a week for one week; and chaplain services one time a week for one week for palliation and management of terminal illness related to coronary artery disease. Documentation showed no IDG communications or coordination of care with the residential care facility (Nursing Home) at the time of placement for respite care on 04/21/23. On 05/01/24 at 1:55 p.m., Staff B stated documentation for patient #4 showed no IDG communications or coordination of care with the residential care facility (Nursing Home) at the time of placement for respite care.