Every finding on record at Seasons Hospice of Muskogee, Inc.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical record review of patients discharged from hospice revealed the agency did not ensure that the discharge summary was sent to the patient's attending physician. CLINICAL RECORD 13: The patient elected the hospice benefit on 12/16/2024 and transferred to another hospice on 08/01/2025. The clinical record lacked evidence of the discharge summary being sent to the patient's attending physician, as evidenced by the documentation in the electronic medical record. On the discharge summary dated 08/01/2025, for the question "Patient attending physician notified" response was entered as no. CLINICAL RECORD 14: The patient elected the hospice benefit on 01/27/2025 and revoked the hospice benefit on 01/31/2025. The clinical record lacked evidence of the discharge summary being sent to the patient's attending physician, as evidenced by the documentation in the electronic medical record. On the discharge summary dated 01/31/2025, for the question, "Patient attending physician notified," response was entered as no. During an interview with the Clinical Director (Personnel Record 4) on 10/22/2025 she stated that she thought the attending physician was being notified at time of discharge but that they would educate the staff and start the process immediately.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by a review of clinical records and interviews. In 4 of 11 (36%) records reviewed the patient needs were identified in the Social Work (SW) assessments and the agency did not ensure each patient had a complete written plan of care. . Clinical Record 5: On the initial assessment (10/03/22) the SW, identified problems in the psychosocial assessment section. It was documented, "Pt doesn't have a funeral home in place. Social Worker (SW) will be talking to (patient's) daughter about that." The order frequency in the plan of care is 1 time a month and 3 PRN. No plan of care was created for this problem, with goals and interventions. Clinical Record 6:On the initial assessment (11/22/22) the SW identified problems in the psychosocial assessment section. It was documented, "Pt does not have a DNR in place. SW asked (the patient's daughter) about a funeral home they will be using. They did not know the name of the funeral home." In the section Plan of Care - Problems, it is noted, "There are no problems to display for this section." No plan of care was created for this problem, with goals and interventions. Clinical Record 8: In the SW communication note dated 11/30/22 she documents in part "SW spoke with Adult Protective Services (APS) over the phone about the patient to see how his visit went last week. (APS) stated that he felt that the patient was not safe being home alone and that he talked to the patient's daughter at the time of the visit." Further down in her note she documented, "(Patient's daughter) was going to take the Pt to her home until she can find 24-hour care for the pt. (Patient's daughter) is wanting information about transferring him to another agency." No evidence existed that POC was updated to identify these problems, goals and interventions. Clinical Record 11: In the SW visit note dated 5/16/22, she noted in part, "SW gave emotional support to the Dtr in law." In the SW visit note dated 06/01/22, she documented in part, "SW was told by an (another) nurse that the caregiver could use some help. SW and the (patient's wife) scheduled a time for SW to come out and help her fill out an application." No evidence existed that POC was updated to identify these problems, goals and interventions. Administrator and Master's Social Worker (MSW), who was this BSW's oversite was interviewed on 12/15/22 and stated she became aware that the social worker hadn't been adding a social worker care plan to the plan of care, last week and had started re-training the BSW on creating plans of care for each patient she makes visits to. The Social Worker was interviewed and she verbalized that she was unaware at this agency that she needed to create social worker care plans for her patients until last week. When she became aware she needed to make care plans she started adding care plans to her patient's records.

It is required that each patient’s individualized written plan of care: reflects patient and family goals; Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments; Includes all services necessary for the palliation and management of the terminal illness, including the following: a) Intervention to manage pain and symptoms; A detailed statement of the scope and frequency of services necessary to meet specific patient and family needs; Measurable outcomes anticipated from implementing and coordinating the plan of care; Drugs and treatment necessary to meet the needs of the patient; Medical supplies and appliances necessary to meet the needs of the patient; Includes the Interdisciplinary Group’s documentation of the patient’s or representative’s level of understanding, involvement, and agreement with the POC; The documentation in the patient’s record is in accordance with the hospice’s policies and procedure. individualized written plan of care reflects patient and family goals, and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records and interviews. In 4 of 11 (36%) records reviewed revealed the agency did not ensure planned interventions based on problems identified in initial and comprehensive assessments were added to the patient's plan of care.. Clinical Record 5: On the initial assessment (10/03/22) the SW, identified problems in the psychosocial assessment section. It was documented, "Pt doesn't have a funeral home in place. Social Worker (SW) will be talking to (patient's) daughter about that." The order frequency in the plan of care is 1 time a month and 3 PRN. No plan of care was created for this problem with problems, goals and interventions in the clinical record. There were needs of the patient and family identified in the social worker's notes, communication notes, and Interdisciplinary Group (IDG) that were not documented as a problem with interventions and goals in the plan of care or plan of care updates. Clinical Record 6: On the initial assessment (11/22/22) the SW identified problems in the psychosocial assessment section. It was documented, "Pt does not have a DNR in place. SW asked (the patient's daughter) about a funeral home they will be using. They did not know the name of the funeral home." In the section Plan of Care - Problems, it is noted, "There are no problems to display for this section." There are no problems, goals, or interventions for the social worker in the clinical record. There were needs of the patient and family identified in the social worker's notes, communication notes, and IDG that were not documented as a problem with interventions and goals in the plan of care or plan of care updates. Clinical Record 8: In the SW communication note dated 11/30/22 she documents in part "SW spoke with Adult Protective Services (APS) over the phone about the patient to see how his visit went last week. (APS) stated that he felt that the patient was not safe being home alone and that he talked to the patient's daughter at the time of the visit." Further down in her note she documented, "(Patient's daughter) was going to take the Pt to her home until she can find 24-hour care for the pt. (Patient's daughter) is wanting information about transferring him to another agency." There is no social worker care plan for these problems, goals, or interventions in the clinical record. There were needs of the patient and family identified in the social worker's notes, communication notes, and IDG that were not documented as a problem with interventions and goals in the plan of care or plan of care updates. Clinical Record 11: In the SW visit note dated 5/16/22, she noted in part, "SW gave emotional support to the Daughter in law." In the BSW visit note dated 06/01/22, she documented in part, "SW was told by an (another) nurse that the caregiver could use some help. SW and the (patient's wife) scheduled a time for SW to come out and help her fill out an application." There is no care plan with problems, goals, and interventions for the social worker in the clinical record. There were needs of the patient and family identified in the social worker's notes, communication notes, and IDG that were not documented as a problem with interventions and goals in the plan of care or plan of care updates. The Administrator and Master's Social Worker (MSW), who this SW's oversite, were interviewed on 12/15/22 and stated she became aware that the social worker hadn't been adding a social worker care plan to the plan of care, last week and had started re-training the BSW on creating plans of care for each patient she makes visits to. Social Worker was interviewed and she verbalized that she was unaware at this agency that she needed to create social worker care plans for her patients until last week. When she became aware she needed to make care plans she started adding care plans to her patient's records.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: The initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided; Signed copies of the notice of patient rights and the hospice election statement; Responses to medications, symptom management, treatments, and services; Outcome measure data elements per regulation; Physician certification and recertification of terminal illness as required; Any advance directives; Copies of inpatient discharge summary, as applicable; Physician orders. This standard was not met as evidenced by a review of clinical records and interviews. In 3 of 3 (100%) records revealed that the agency did not ensure that each patient had orders for a level of care or discharge change. Clinical Record 9: The social worker documented in part in a communication note dated 11/01/22, "Pt starts 5-day respite today (11/1) "... There was no physician orders in the chart for a change in the level of care from routine to respite. Clinical Record 10: The patient was discharged on 09/03/22 when the patient went to the hospital. There was no physician order to discharge the patient. Clinical Record 11: The LPN visit note dated 6/17/22 states in part, "Spoke with (caregiver) she states she is having increased difficulty caring for patient and notified LPN and SW for possible respite." The RN, visit note dated 6/21/22 states in part, "Pt being seen at SNF in (patient's room) its his last day of respite." There were no physician orders found in the chart to change the level of care. The Administrator stated the record lacked evidence of any physician orders for respite care.

It is required that if a patient is discharged from hospice, the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 2 (100%) applicable records reviewed revealed the agency did not ensure that discharge summaries were sent to the attending physician upon discharge from hospice services.. Clinical Record 9:The patient was discharged from services and admitted to the hospital on 11/05/22. There was no evidence in the patient's clinical record that a discharge summary was sent to the attending physician upon discharge from hospice services. Clinical Record 10: The nurse documented in a discharge note on 09/03/22, in part, The patient was discharged from hospice services on 09/03/22 and there was no evidence of a discharge summary being sent to the attending physician. The Administrator and Corporate Compliance Officer were interviewed on 12/15/22 with this finding. Both stated they discovered this problem of not sending discharge summaries to the attending physician at discharge, a couple of weeks ago and have started a Performance Improvement Project (PIP).

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. In 4 of 4 (100%) records reviewed revealed the agency did not ensure that each patient had an integrated plan of care with the skilled nursing facility/nursing facility (SNF/NF).. Clinical Record 2: This patient resided in a nursing facility (NF) and during the record review for benefit period 8, 10/23/22-12/21/22 there was no integrated care plan with the facility found in the records. Clinical Record 9:Licensed Practical Nurse (LPN) noted in her documentation on 10/31/22, "Pt agreed to 5 day respite at Nursing Home with possible long term stay. Pt will start respite care tomorrow 11/1/22." There was no integrated plan of care with the facility found in the chart. Clinical Record 10: The patient was residing in Nursing Facility upon election to hospice on 06/17/22. There is no integrated care plan with the facility found in the chart. Clinical Record 11: The LPN visit note dated 6/17/22 states in part, "Spoke with (caregiver) she states she is having increased difficulty caring for patient and LPN and SW for possible respite." The RN visit note dated 6/21/22 states in part, "Pt being seen at care center on his last day of respite." There are no other communication notes in the chart and no integrated plan of care with Care Center. The Administrator and Corporate Compliance Officer interviewed on 12/15/22, agreed the record lacked evidence of an integrated care plan with the facility.

It is required that The hospice designates a member of each Interdisciplinary Group who is responsible for a patient/resident in a SNF/NF or ICF/IDF. The designated IDG member: Provides overall coordination of care of the patient/resident, working with the facility representative staff; Communicates with facility staff and others providing care for the terminal illness and related conditions; Is responsible to ensure the quality of care for the patient and family. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 11 (9%) records reviewed revealed that the agency did not ensure there was coordination of care with the SNF/NF for the patient's respite stay.. Clinical Record 11: The patient elected hospice on 8/16/21 and passed away on 6/22/22. He previously had been living at home with his wife until he needed more assistance, and the patient was placed on respite on 6/17/22. The RN visit note on 6/21/22 notes in part, "this is the last day of respite." The IDG did not make a notation in the IDG comprehensive meeting updates on dates 6/15/22 or 6/29/22 that the patient was needing respite care or had a respite level of care change or that he had discharged back home. Administrator was interviewed on 12/16/22 and she agreed the record lacked evidence of coordination of care with the facility staff.