Every finding on record at Stillwater Medical Center Authority

Based on record review and interview, the agency failed to ensure personnel records included orientation to hospice philosophy for two (Staff I and J) of 7 personnel records. --- Findings. Staff IA review of the personnel record showed no orientation to the hospice philosophy. Staff JA review of the personnel record showed no orientation to the hospice philosophy.On 06/12/26 at 10:49 a.m., Staff A stated the personnel files for Staff I and J had no orientation to the hospice philosophy.

Based on record review and interview, the hospice failed to ensure development and implementation of a bereavement POC for 19 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 14, 15, 16, 17, 18 and 19) of 19 patients. --- Findings: Patient #1 A review of the clinical record showed an initial bereavement assessment dated 05/08/23. Documentation showed no spiritual assessment and no bereavement POC. Documentation showed no patient or caregiver refusal of a spiritual assessment or bereavement POC and showed no change in orders. Patient #2 A review of the clinical record showed an initial spiritual assessment on 07/21/23 and a bereavement assessment dated 07/24/23. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #3 A review of the clinical record showed a bereavement assessment dated 02/08/23 and an initial spiritual assessment on 03/31/23 (52 days after the SOC). Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of an initial spiritual assessment or bereavement POC and showed no change in orders. Patient #4 A review of the clinical record showed a bereavement assessment dated 04/26/23 and an initial spiritual assessment on 06/21/23 (58 days after the SOC). Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of an initial spiritual assessment or bereavement POC and showed no change in orders. Patient #5 A review of the clinical record showed an initial spiritual assessment and a bereavement assessment dated 08/11/23. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #6 A review of the clinical record showed a bereavement assessment dated 06/30/23 and an initial spiritual assessment on 07/03/23. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #7 A review of the clinical record showed an initial spiritual assessment and a bereavement assessment dated 08/11/23. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #8 A review of the clinical record showed an initial spiritual assessment and a bereavement assessment dated 08/09/23. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #9 A review of the clinical record showed a bereavement assessment dated 04/14/23 and an initial spiritual assessment on 06/21/23 (69 days after the SOC). Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of an initial spiritual assessment or bereavement POC and showed no change in orders. Patient #10 A review of the clinical record showed an initial spiritual assessment on 03/23/23 and a bereavement assessment dated 03/24/23. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #11 A review of the clinical record showed a bereavement assessment dated 12/13/22 and showed no initial spiritual assessment. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of an initial spiritual assessment or bereavement POC and showed no change in orders. Patient #12 A review of the clinical record showed a bereavement assessment dated 01/24/23 and an initial spiritual assessment on 06/21/23 (148 days after the SOC). Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of an initial spiritual assessment or bereavement POC and showed no change in orders. Patient #13 A review of the clinical record showed an initial spiritual assessment and a bereavement assessment dated 11/30/22. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #14 A review of the clinical record showed a bereavement assessment dated 12/14/22 and an initial spiritual assessment on 03/31/23 (107 days after the SOC). Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of an initial spiritual assessment or bereavement POC and showed no change in orders. Patient #15 A review of the clinical record showed an initial spiritual assessment dated 06/21/23 (62 days after the SOC). Documentation showed no bereavement assessment and no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement assessment or bereavement POC and showed no change in orders. Patient #16 A review of the clinical record showed an initial spiritual assessment dated 05/25/23 (10 days after the SOC). Documentation showed no bereavement assessment and no bereavement POC was developed and implemented prior to the patients death on 06/25/23. Documentation showed no patient or caregiver refusal of a bereavement assessment or bereavement POC prior to the patients death and showed no change in orders. Patient #17 A review of the clinical record showed an initial bereavement assessment dated 04/03/23. Documentation showed no initial spiritual assessment and no bereavement POC was developed and implemented prior to the patients death on 04/10/23. Documentation showed no patient or caregiver refusal of a spiritual assessment or bereavement POC prior to the patients death and showed no change in orders. Patient #18 A review of the clinical record showed an initial bereavement assessment dated 01/19/23. Documentation showed no initial spiritual assessment and no bereavement POC was developed and implemented prior to the patients death on 03/28/23. Documentation showed no patient or caregiver refusal of a spiritual assessment or bereavement POC prior to the patients death and showed no change in orders. Patient #19 A review of the clinical record showed a bereavement assessment dated 03/25/23 and showed non-visit documentation that an initial spiritual assessment was declined on 03/31/23 (7 days after the SOC). Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of an initial spiritual assessment within 5 days of the SOC or bereavement POC and showed no change in orders. On 08/22/23 at 11:20 a.m., Staff A stated for patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 and 19: 1. Had no bereavement POCs; 2. Bereavement POC are established after a patient has deceased and; 3. Patient family members or significant others identified as the bereaved receive standardized bereavement letters, information mail outs and some telephone contacts over a 13 month period from the date the patient has deceased.

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 #15 and 16) of 19 patients and; 2. Chaplain / Bereavement services were provided in accordance with the plan of care for 12 (Patients #1, 3, 4, 9, 11, 12, 14, 15, 16, 17, 18 and 19) of 19 patients. --- Findings: Patient #1 A review of a POC dated 08/07/23 to 10/30/23 showed documentation of a SOC on 05/04/23. Documentation showed no initial spiritual assessment by the chaplain within 5 days of the SOC between 05/04/23 and 05/09/23 (one visit ordered, no visit conducted). Documentation showed no communications between the IDG, showed no changes in the ordered initial spiritual assessment and documented no patient refusal of the initial spiritual assessment until 06/21/23 (48 days after the SOC). Patient #3 A review of a POC dated 08/06/23 to 10/04/23 showed an initial spiritual assessment by the chaplain on 03/31/23 (52 days after the SOC). Documentation showed no initial spiritual assessment by the chaplain within 5 days of the SOC from 02/07/23 to 02/12/23 (one visit ordered, no visit conducted). Documentation showed no communications between the IDG, no patient or caregiver refusal of an initial spiritual assessment and showed no change in orders. Patient #4 A review of a POC dated 07/24/23 to 10/21/23 showed an initial spiritual assessment on 06/21/23 (58 days after the SOC). Documentation showed no initial spiritual assessment by the chaplain within 5 days of the SOC from 04/25/23 to 04/30/23 (one visit ordered, no visit conducted). Documentation showed no communications between the IDG, no patient or caregiver refusal of an initial spiritual assessment and showed no change in orders. Patient #9 A review of a POC dated 07/12/23 to 10/09/23 an initial spiritual assessment on 06/21/23 (69 days after the SOC). Documentation showed no initial spiritual assessment by the chaplain within 5 days of the SOC from 04/13/23 to 04/18/23 (one visit ordered, no visit conducted). Documentation showed no communications between the IDG, no patient or caregiver refusal of an initial spiritual assessment and showed no change in orders. Patient #11 A review of a POC dated 08/06/23 to 10/04/23 showed no initial spiritual assessment. Documentation showed no initial spiritual assessment by the chaplain within 5 days of the SOC from 12/09/22 to 12/24/22 (one visit ordered, no visit conducted). Documentation showed no communications between the IDG, no patient or caregiver refusal of an initial spiritual assessment and showed no change in orders. Patient #12 A review of a POC dated 06/28/23 to 08/26/23 showed an initial spiritual assessment on 06/21/23 (148 days after the SOC). Documentation showed no initial spiritual assessment by the chaplain within 5 days of the SOC from 01/23/23 to 01/28/23 (one visit ordered, no visit conducted). Documentation showed no communications between the IDG, no patient or caregiver refusal of an initial spiritual assessment and showed no change in orders. Patient #14 A review of a POC dated 08/10/23 to 10/08/23 showed an initial spiritual assessment on 03/31/23 (107 days after the SOC). Documentation showed no initial spiritual assessment by the chaplain within 5 days of the SOC from 12/13/22 to 12/18/22 (one visit ordered, no visit conducted). Documentation showed no communications between the IDG, no patient or caregiver refusal of an initial spiritual assessment and showed no change in orders. Patient #15 A review of a POC dated 04/21/23 to 07/19/23 showed an initial spiritual assessment dated 06/21/23 (62 days after the SOC) and showed no initial bereavement assessment / psychosocial assessment by the social worker. Documentation showed no initial spiritual assessment by the chaplain and no initial bereavement assessment / psychosocial assessment by the social worker within 5 days of the SOC from 04/21/23 to 04/26/23 (two visits ordered, no visits conducted). Documentation showed no communications between the IDG, no patient or caregiver refusal of an initial spiritual assessment or initial bereavement assessment / psychosocial assessment and showed no change in orders. Patient #16 A review of a POC dated 05/17/23 to 08/14/23 showed an initial spiritual assessment dated 05/25/23 (10 days after the SOC) and showed no initial bereavement assessment / psychosocial assessment by the social worker. Documentation showed no initial spiritual assessment by the chaplain and no initial bereavement assessment / psychosocial assessment by the social worker within 5 days of the SOC from 05/17/23 to 05/22/23 (two visits ordered, no visits conducted). Documentation showed no communications between the IDG, no patient or caregiver refusal of an initial spiritual assessment or initial bereavement assessment / psychosocial assessment and showed no change in orders. Patient #17 A review of a POC dated 03/31/23 to 06/28/23 showed documentation of a SOC on 03/31/23. Documentation showed no initial spiritual assessment by the chaplain within 5 days of the SOC from 03/31/23 to 04/04/23 (one visit ordered, no visit conducted). Documentation showed no communications between the IDG, showed no patient or caregiver refusal of an initial spiritual assessment and showed no change in orders. Patient #18 A review of a POC dated 01/17/23 to 04/16/23 showed documentation of a SOC on 01/17/23. Documentation showed no initial spiritual assessment by the chaplain within 5 days of the SOC from 01/17/23 to 01/22/23 (one visit ordered, no visit conducted). Documentation showed no communications between the IDG, showed no patient or caregiver refusal of an initial spiritual assessment and showed no change in orders. Patient #19 A review of a POC dated 03/24/23 to 06/21/23 showed documentation of a SOC on 03/24/23. Documentation showed no initial spiritual assessment by the chaplain within 5 days of the SOC from 03/24/23 to 03/29/23 (one visit ordered, no visit conducted). Documentation showed no communications between the IDG, showed non-visit documentation that an initial spiritual assessment was declined on 03/31/23 (7 days after the SOC) and showed no change in orders. On 08/22/23 at 12:05 p.m. to 1:30 p.m., Staff B stated: 1. Social work services were not provided in accordance with the plan of care for patients #15 and 16 and; 2. Chaplain / Bereavement services were not provided in accordance with the plan of care for patients #1, 3, 4, 9, 11, 12, 14, 15, 16, 17, 18 and 19.

Based on record review and interview, the hospice failed to ensure the plans of care were fully developed to include service disciplines and frequencies to meet individualized patient care for three (Patients #6, 7 and 11) of 19 patients. --- Findings: Patient #6 A review of the plan of care dated 06/30/23 to 09/27/23 and plan of care updates dated 07/12/23, 07/26/23 and on 08/09/23 ordered no chaplain visits. Documentation showed no refusal of spiritual services, no IDG communications and showed no changes in the ordered disciplines or frequencies between the start of care date of 06/30/23 and 08/17/23. Patient #7 A review of the plan of care dated 08/10/23 to 11/07/23 and showed no plan of care updates by the IDG. Documentation showed no chaplain visits were ordered. Documentation showed no refusal of spiritual services, IDG communications and showed no changes in the ordered disciplines or frequencies between the start of care date of 08/10/23 and 08/17/23. Patient #11 A review of the plan of care dated 08/06/23 to 10/04/23 and plan of care updates dated 07/26/23 and 08/09/23 ordered no hospice aide visits, SN visits or chaplain visits. Documentation showed no refusal of services, no IDG communications and showed no changes in the ordered disciplines or frequencies between the certification date of 08/06/23 and 08/19/23. On 08/22/23 at 12:35 p.m. to 1:00 p.m., Staff A stated the plans of care for patients #6, 7 and 11 were not fully developed to include service disciplines and frequencies to meet the patients individualized care needs.

Based on record review and interview, the hospice failed to ensure IDG meetings to update and revise individualized patient care plans were conducted every 15 days for one (Patient #18) of 19 patients. --- Findings: Patient #18 A review of the clinical record showed a start of care date of 01/17/23, a plan of care dated 01/17/23 to 04/16/23 documented a primary diagnosis of chronic obstructive pulmonary disease. Documentation showed an IDG meeting on 01/25/23, 02/08/23, 02/22/23 and on 03/08/23. Documentation showed no other IDG meeting documentation and no coordination of care communications with the physician related to hospice services from 03/08/23 and the patients date of death on 03/28/23 (20 days). On 08/22/23 at 1:40 p.m., Staff A stated patient #18 should have had IDG meetings to update and revise the individualized care plan every 15 days from 03/08/23 and should have shown documentation of coordination of care communications with the physician related to ongoing hospice services and the patients date of death on 03/28/23.

Based on record review and interview, the agency failed to ensure continued review and update of a home hospice aide care plan for eight (Patients #2, 5, 9, 10, 11, 13, 14 and 16) of 19 patients. --- Findings: Patient #2 A review of the plan of care dated 07/21/23 to 08/19/23 and plan of care updates dated 07/26/23 and 08/09/23 ordered hospice aide visits one to two times a week for four weeks. Documentation showed no update to the hospice aide care plan for 07/21/23 to 08/19/23. Patient #5 A review of the plan of care dated 08/10/23 to 11/07/23 and showed no plan of care updates ordered hospice aide visits two times a week for 12 weeks. Documentation showed no hospice aide care plan for 08/10/23 to 11/07/23. Patient #9 A review of a POC dated 07/12/23 to 10/09/23 and plan of care updates dated 07/12/23, 07/26/23 and on 08/09/23 ordered hospice aide visits one to two times a week for 12 weeks. Documentation showed no update to the hospice aide care plan for 07/12/23 to 10/09/23. Patient #10 A review of a POC dated 06/19/23 to 09/16/23 and plan of care updates dated 06/14/23, 06/28/23, 07/12/23, 07/26/23 and on 08/09/23 ordered hospice aide visits one time a week for 13 weeks. Documentation showed no update to the hospice aide care plan for 06/19/23 to 09/16/23. Patient #11 A review of the plan of care dated 08/06/23 to 10/04/23 and plan of care updates dated 07/26/23 and 08/09/23 ordered no hospice aide visits. Documentation showed hospice aide visits were conducted on 08/08/23, 08/12/23, 08/16/23 and on 08/16/23 (no visits ordered, four visits conducted). Documentation showed no update to the hospice aide care plan for 08/06/23 to 10/04/23. Patient #13 A review of the plan of care dated 07/27/23 to 09/24/23 and plan of care updates dated 07/26/23 and on 08/09/23 ordered hospice aide visits two times in five days, two times in five days, then three times a week for seven weeks. Documentation showed no update to the hospice aide care plan for 07/27/23 to 09/24/23. Patient #14 A review of the plan of care dated 08/10/23 to 10/09/23 and plan of care updates dated 08/09/23 ordered hospice aide visits one time a week for one week then, two times a week for eight weeks. Documentation showed no update to the hospice aide care plan for 08/10/23 to 10/09/23. Patient #16 A review of the plan of care dated 05/17/23 to 08/14/23 and plan of care updates dated 05/31/23, 06/14/23 and 06/28/23 ordered hospice aide visits one time a week for one week then, two times a week for 12 weeks. Documentation showed no update to the hospice aide care plan for05/17/23 to 08/14/23. On 08/22/23 at 12:10 p.m. to 1:25 p.m., Staff A stated the clinical records for patients #2, 5, 9, 10, 11, 13, 14 and 16 showed no updated or current hospice aide care plans for their CHHA service discipline.

Based on record review and interview, the hospice failed to ensure on-site supervisory visits were completed every 14 days for one (Patient #14) of 19 patients. --- Findings: Patient #14 A review of the plan of care dated 08/10/23 to 10/08/23 showed a home health aide visit frequency of one to two visit a week for nine weeks. Documentation showed hospice aide visits were conducted on 08/12/23, 08/16/23 and on 08/19/23. Documentation showed no supervisory visits were made from 07/23/23 to 08/22/23 (29 days between supervisory visits). On 08/22/23 at 1:12 p.m., Staff A stated supervisory aide visits were not conducted every 14 days for patient #14.

Based on record review and interview, the hospice failed to ensure personnel records were maintained with required skill competency evaluations for two (Volunteer 2 and 3, Staff D and F) of three volunteers and five employees. --- Findings: Volunteer 2 A review of personnel records showed no skill competency evaluation for a hospice volunteer. Volunteer 3 A review of personnel records showed no skill competency evaluation for a hospice volunteer. Staff D A review of personnel records showed no skill competency evaluation for hospice aide. Staff F A review of personnel records showed no skill competency evaluation forlicensed practical nurse. On 08/22/23 at 10:50 a.m., Staff A stated personnel records were provided in their entirety and did not contain all required information for Volunteer 2 and 3; and Staff D and F.

Based on record review and interview, the hospice failed to ensure required background checks were completed for one (Staff D) of five employees and one volunteer (Volunteer 1) of 3 volunteers 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 1 A review of the personnel record showed no documentation of a background check through OKSCREEN for employment that began 01/08/18. Staff D A review of the personnel record showed no documentation of a background check through OKSCREEN for employment that began 06/30/17. On 08/22/23 at 10:50 a.m., Staff A stated Volunteer 1 and Staff D had no background check through the OkScreen database.