Every finding on record at Sooner Hospice, LLC

Based on record review and interview, the hospice failed to ensure completion of the initial spiritual assessment no later than 5 calendar days after the election of hospice care for two (Patients #5 and 14) of 14 patients. --- Findings:Patient #5A review of the clinical record showed an election of the hospice benefit on 05/06/25 with no completion (in person) of the initial bereavement and spiritual assessment from 05/06/25 to 05/21/25 (15 days after the election of the hospice benefit).  A review of the clinical record showed an initial spiritual assessment dated 05/08/25 was completed by telephone.  Documentation showed no patient or caregiver refusal of an in person initial spiritual assessment.Patient #14A review of the clinical record showed an election of the hospice benefit on 01/17/25 with no completion (in person) of the initial bereavement and spiritual assessment from 01/17/25 to 01/31/25 (14 days after the election of the hospice benefit).  A review of the clinical record showed an initial spiritual assessment dated 01/21/25 was completed by telephone.  Documentation showed no patient or caregiver refusal of an in person initial spiritual assessment.On 05/21/25 at 1:15 pm., Staff B stated: the initial comprehensive assessment was to be completed within five days of the election of the hospice benefit and the initial spiritual assessment for Patients #5 and 14 was not completed in person within the first five days of the election of the hospice benefit.  Staff B stated the Chaplain may have not been aware telehealth visits were no longer acceptable.

Based on record review and interview, the hospice failed to ensure1. Chaplain visits were provided in accordance with the plan of care for one (Patient #6) of 14 patients and2. hospice aide visits were provided in accordance with the plan of care for one (Patient #10) of 14 patients. --- Findings:Patient #6A review of the plan of care dated 03/01/25 to 04/29/25 showed a Chaplain frequency of two visits per month for two months.  A review of the clinical record showed the following:A Chaplain visit note dated 03/07/25 showed the visit was completed by telephone.A Chaplain visit note dated 04/11/25 showed the visit was completed by telephone.A Chaplain visit note dated 04/18/25 showed the visit was completed by telephone.A Chaplain visit note dated 04/25/25 showed the visit was completed by telephone.Patient #10A review of the plan of care dated 03/12/25 to 05/10/25 showed a hospice aide frequency of three visits per week for one week and five visits per week for eight weeks.  A review of the clinical record showed the following:Hospice aide visits dated 03/17/25, 03/18/25, 03/20/25 and a hospice aide missed visit note (no reason charted) for the week of 03/16/25 to 03/22/25 (three of five ordered visits completed).  Documentation showed no patient/caregiver refusal of the visits, no attempt to reschedule the missed visit and no physician orders to change the ordered frequency.Hospice aide visits dated 04/07/25, and 04/08/25 for the week of 04/06/25 to 04/12/25 (two of five ordered visits completed).  Documentation showed no patient/caregiver refusal of the visits and no physician orders to change the ordered frequency.Hospice aide visits dated 04/15/25, 04/17/25, 04/18/25 and a hospice aide missed visit note dated 04/16/25 (due to being out on paid time off and their grandfather falling) for the week of 04/13/25 to 04/19/25 (three of five ordered visits completed).  Documentation showed no patient/caregiver refusal of the visits, no attempt to reschedule the missed visit and no physician orders to change the ordered frequency.Hospice aide visits dated 04/28/25, 04/29/25, 05/01/25 and 05/02/25 for the week of 04/27/25 to 05/03/25 (four of five ordered visits completed).  Documentation showed no patient/caregiver refusal of the visits and no physician orders to change the ordered frequency.On 05/21/25 at 1:10 pm., Staff B stated:1. the Chaplain frequency was not followed as ordered for Patient #6 due to the Chaplain not being aware telehealth visits were no longer allowed and2. the hospice aide frequency was not followed as ordered for Patient #10.

Based on record review and interview, the hospice failed to ensure hospice aides reported missed/incomplete visits for one (Patient #10) of 14 patients. --- Findings:Patient #10A review of the plan of care dated 03/12/25 to 05/10/25 showed a hospice aide frequency of three visits per week for one week and five visits per week for eight weeks.  A review of the clinical record showed the following:Hospice aide visits dated 03/17/25, 03/18/25, 03/20/25 and a hospice aide missed visit note (no reason charted) for the week of 03/16/25 to 03/22/25 (three of five ordered visits completed).  Documentation showed no notification to the supervising nurse of the missed or incomplete visits.Hospice aide visits dated 04/07/25, and 04/08/25 for the week of 04/06/25 to 04/12/25 (two of five ordered visits completed).  Documentation showed no notification to the supervising nurse of the incomplete visits.Hospice aide visits dated 04/15/25, 04/17/25, 04/18/25 and a hospice aide missed visit note dated 04/16/25 (due to being out on paid time off and their grandfather falling) for the week of 04/13/25 to 04/19/25 (three of five ordered visits completed).  Documentation showed no notification to the supervising nurse of the missed or incomplete visits.Hospice aide visits dated 04/28/25, 04/29/25, 05/01/25 and 05/02/25 for the week of 04/27/25 to 05/03/25 (four of five ordered visits completed).  Documentation showed no notification to the supervising nurse of the incomplete visits.On 05/21/25 at 1:10 pm., Staff B stated there was no documentation of the hospice aide notifying the supervising nurse of missed or incomplete visits for Patient #10.

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. --- A review of volunteer records and hours showed the hospice volunteers provided services that equaled 0% of the total patient care hours of all paid hospice employees for 2024. On 05/21/25 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 hospice aide services were provided in accordance with the plan of care frequency for one (Patient #5) of 13 patients. Findings: Patient #3 1. A review of the clinical record showed a plan of care dated 03/17/22 to 05/15/22 and plan of care updates dated 03/17/22, 03/31/22, 04/14/22, 04/28/22 and 05/12/22 which showed orders for a hospice aide frequency of one visit per week for one week and then two visits per week for eight weeks. A review of the clinical record showed: a hospice aide visit dated 05/03/22 for the week of 05/01/22 to 05/07/22 (one completed visit). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency. On 06/14/22 at 11:50 am, Staff A stated the ordered hospice aide frequency for Patient #5 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 eleven (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 12 and 13) of 13 patients reviewed. Findings: Patient #1 A review of the plan of care dated 01/25/22 to 04/24/22 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 03/02/22 to 04/30/22 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 03/16/22 to 05/14/22 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 03/17/22 to 05/15/22 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 03/21/22 to 05/19/22 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 04/08/22 to 07/06/21 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 03/09/22 to 05/07/22 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 04/18/22 to 07/16/22 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 #12 A plan of care dated 04/06/22 to 07/04/22 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 #13 A plan of care dated 04/22/22 to 07/20/22 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 06/14/22 at 11:55 am, Staff A stated the plans of care for Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 12 and 13 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 decreased hospice aide services for one (Patient #5) of 13 patients. Findings: Patient #5 A review of the clinical record showed a plan of care dated 03/17/22 to 05/15/22 and plan of care updates dated 03/17/22, 03/31/22, 04/14/22, 04/28/22 and 05/12/22 which showed orders for a hospice aide frequency of one visit per week for one week and then two visits per week for eight weeks. A review of the clinical record showed: a hospice aide visit dated 03/22/22 and a hospice aide missed visit dated 03/24/22 due to patient was "already washed" for the week of 03/20/22 to 03/26/22 (one completed visit); a hospice aide visit dated 04/07/22 and a hospice aide missed visit dated 04/06/22 due to patient was "already bathed" for the week of 04/03/22 to 04/09/22 (one completed visit); a hospice aide visit dated 04/21/22 and a hospice aide missed visit dated 04/20/22 due to patient was ok with a Thursday visit for the week of 04/17/22 to 04/23/22 (one completed visit); a hospice aide visit dated 04/26/22 and a hospice aide missed visit dated 04/28/22 due to "no need for a visit" for the week of 04/24/22 to 04/30/22 (one completed visit); a hospice aide visit dated 05/03/22 for the week of 05/01/22 to 05/07/22 (one completed visit); and a hospice aide visit dated 05/11/22 and a hospice aide missed visit dated 06/13/22 due to "no need for visit" for the week of 05/08/22 to 05/14/22 (one completed visit). Updates to the plan of care showed no coordination by the interdisciplinary group or updates to services provided to the patient to reflect patient needs based on decreased hospice aide services. On 06/14/22 at 11:50 am, Staff A stated the plan of care should have been updated to reflect the decreased hospice aide services provided for Patient #5.