Every finding on record at Traditions Hospice of Tulsa, LLC

Observed in Record Review. In 1 of 2 patient records review discharged for extended prognosis, During RRD/C# 2's patient record review it was noted the organization had not ensured RRD/C# 2 was given a Notice of Non-Medicare Coverage (NOMNC) 2 days prior to discharge. For example: review of RRD/C# 2's patient record revealed a NOMNC signed the same day as discharge. This was reviewed, discussed, and validated with the Branch Director. Observed in Record Review. In 1 of 4 patient records review with request for list of non-covered items, During RRHV# 1's patient record review it was noted the organization had not ensured it respected the patient's right to participate in decisions about their care, treatment, or services. For example: review of RRHV# 1's consent for hospice form revealed documentation that RRHV# 1 requested notice of non-coverage items at admission. Review of RRHV# 1's patient record revealed no documentation that RRHV# 1 was provided a list of non-covered items. This was reviewed, discussed, and validated with the Branch Manager and Clinical Team Lead.

Observed in Record Review. In 2 of 6 patient records reviewed, During RRBR#1 and RRNHV# 2's patient records it was noted the organization had not ensured the comprehensive assessment was completed no later than five calendar days after the election of benefit. For example: during RRBR# 1's patient reocrd review it was noted the initial bereavement risk assessment was complete approximately four months after the election of benefit and three months after death. Review of RRNHV# 2's patient record revealed the initial bereavement risk assessment was completed seven days after the election of benefit. This was reviewed, discussed, and validated with the Branch Director and Clinical Team Lead.

Observed in Record Review. In 11 of 14 patient records reviewed, During RRHV# 1, RRHV# 2, RRHV# 4, RRNHV# 1, RRNHV# 2, RRNHV# 3, RRNHV# 4, RRNHV# 5, RRNHV# 6, RRNHV# 7, and RRNHV# 9's patient records review it was noted the organization had not ensured it assessed and reassessed its patients per organization policy “Patient Assessment, s” that included an assessment of skin integrity, barriers and safety hazards in the home environment, and initial bereavement assessment; “Pain and Symptom Management - PC 135” that includes a comprehensive pain or risk for pain assessment at the start of care to include pain severity/intensity, and assessment and impact on usual activities; and “Wound Assessment Standard Operating Procedure” that includes wound measurements weekly. For example: review of RRHV# 1's patient record revealed a discharge summary with documentation RRHV# 1 had a PEG tube in place. Review of RRHV# 1's start of care registered nurse comprehensive assessment revealed no documentation of a PEG tube. Further review of RRHV# 1's record revealed skilled nurse visit notes with documentation that RRHV# 1 had a PEG in the upper right quadrant that was not in use. Further review of RRHV# 1's patient record revealed a stage IV pressure ulcer to the coccyx. Review of the SN visit notes, and wound assessment form revealed documentation that the stage IV pressure ulcer to the coccyx was measured twice since start of care or approximately once every 35 days. Further review of RRHV# 1’s start of care comprehensive assessment revealed documentation under “assessed what relieves/worsen pain” to include “Yes” with no further documentation of the assessment findings. Review of RRHV# 2, RRNHV# 2, RRNHV# 3, RRNHV# 4, RRNHV# 5, RRNHV# 6, RRNHV# 7, and RRNHV# 9’s start of care RN comprehensive assessments revealed a pain assessment with documentation under “Assessing what relieves/worsen pain” to include “Yes”, and “Assessing the effect on function or quality of life” to include “Yes” with no further documentation of the assessment findings. Review of RRHV# 4’s recertification RN comprehensive assessment revealed documentation that a fall safety risk assessment was not completed as “Not appropriate at the time of evaluation”. Review of RRHV# 4’s patient record revealed RRHV# 4 had fallen approximately 24 days prior to the recertification RN comprehensive assessment and was assessed as a fall risk of 8/10. Review of RRNHV# 1’s patient record revealed RRNHV# 1 had a terminal diagnosis of Senile Degeneration of the Brain. Review of RRNHV# 1’s recertification RN Comprehensive assessment revealed a pain assessment that included “Are you uncomfortable because of pain” with documentation “unable to verbalize”. Further review of the pain assessment included “was a detailed pain assessment completed” to include “Yes”. However, there was no documentation of a non-verbal pain assessment. This was reviewed, discussed, and validated with the Branch Director.

Observed in Record Review. In 3 of 14 patient records reviewed, During RRNHV# 3, RRNHV# 6, and RRNHV# 10's patient records review it was noted the organization had not ensured an initial bereavement risk assessment was completed. For example: review of RRNHV# 3’s patient record revealed a start of care date 48 days prior to the surveyor review of the record. Further review of RRNHV# 3’s patient record revealed no documentation of a Bereavement Risk Assessment. Review of RRNHV# 6’s patient record revealed a start of care date approximately 36 days prior to the surveyor review of the record. Further review of RRNHV# 6’s patient record revealed no documentation of a Bereavement Risk Assessment. During RRNHV# 10's patient record review it was noted RRNHV# 10's start of care was approximately 26 days prior to the surveyor review of the record. Further review of RRNHV# 10's patient record revealed no documentation of a Bereavement Risk Assessment. This was reviewed, discussed, and validated with the Branch Director.

Observed in Record Review. In 14 of 14 patient records reviewed, During RRHV# 1, RRHV# 2, RRHV# 3, RRHV# 4 RRNHV# 1, RRNHV# 2, RRNHV# 3, RRNHV# 4, RRNHV# 5, RRNHV# 6, RRNHV# 7, RRNHV# 8, RRNHV# 9, and RRNHV# 10's patient records review it was noted the organization had not ensured the plan of care reflected the patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. For example: review of RRHV# 1's start of care RN comprehensive assessment revealed RRHV# 1 had an indwelling urinary catheter. However, review of RRHV# 1's plan of care and subsequent updates to the plan of care revealed no documentation of an indwelling urinary catheter. In addition, review of RRHV# 1's patient record revealed documentation of a PEG tube in the upper right quadrant and no documentation on the plan of care or subsequent updates to the plan of care regarding a PEG tube. Review of RRNHV# 2's patient record revealed RRNHV# 2 was dependent on a ventilator for breathing. However, review of RRNHV# 2's plan of care and subsequent plans of care revealed no documentation of a ventilator. Review of RRHV# 3's recertification RN comprehensive assessment revealed documentation the RRHV# 3's daughter reported RRHV# 3 was no longer able to have bowel movements on her/his own and needed to use disimpaction for most bowel movements. Review of RRHV# 3's plan of care revealed a diagnosis of constipation. However, further review of the plan of care and updates to the plan of care revealed no goal for constipation. Review of RRHV# 4, RRNHV# 1, RRHV# 2, RRNHV# 3, RRNHV# 4, RRNHV# 5, RRNHV# 6, RRNHV# 7, RRNHV# 8, RRNHV# 9, and RRNHV# 10's plans of care revealed goals with no time frame and/or in appropriate time frames and/or not measurable goals, such as Patient will verbalize/demonstrate a reduction or relief of cardiopulmonary symptoms ; Pain will be managed at a level acceptable for the patient”, “Patient will have decreased fear/anxiety regarding death and dying process”, “Patients safety needs will be met”, “Patient and family will feel relief from spiritual concerns”, and “Patient and family will express increased sense of closure and peacefulness at the end of life”. This was reviewed, discussed, and validated with the Branch Director. .

Observed in Record Review. In 6 of 14 patient records reviewed, During RRHV# 1, RRHV# 2, RRNHV# 2, RRNHV# 3, RRNHV# 5, RRNHV# 10's patient records review it was noted the organization had not ensured the plan of care included all services needed for the palliation and management of the terminal illness and related conditions to include interventions to manage pain and symptoms, a statement of the scope and frequency of the services necessary to meet the patient's and family's needs; and treatments necessary to meet the patient's needs; and medical supplies and appliances necessary to meet the patient's needs. For example: review of RRHV# 1's patient record revealed RRHV# 1 had an indwelling urinary catheter. However, review of RRHV# 1's plan of care and subsequent updates to plan of care revealed no interventions for the indwelling urinary catheter. Review of RRNHV# 2's patient record revealed documentation that RRNHV# 2 was dependent on a ventilator for breathing and using a cough-assists 1-2 times daily. However, review of the plan of care and subsequent updates to the plan of care revealed no documentation of a ventilator or interventions. During RRHV# 2's home observation it was noted RRHV# 2 used a power operated vehicle (POV). However, review of RRHV# 2's plan of care and subsequent updates to the plan of care revealed no documentation of a POV. Review of RRNHV# 3’s plan of care revealed the order for the nurse to set up a medication reminder weekly. Review of the skilled nurse visit notes revealed documentation the nurses were setting up RRNHV# 3’s medication reminder and Levemir 75-unit syringes for twice daily insulin administration. However, review of the plan of care revealed no documentation of weekly insulin set up or any interventions related to diabetes mellitus. Review of RRNHV# 5’s patient record revealed RRNHV# 5 had oxygen at 2l per nasal cannula as needed. Review of RRNHV# 5’s plan of care to include the medication profile revealed no documentation of an order for oxygen. Review of RRNHV# 10’s patient record revealed RRNHV# 10 had continuous oxygen at 3 lpm. Review of RRNHV# 10’s plan of care to include the medication profile revealed no documentation of an order for oxygen. This was reviewed, discussed, and validated with the Branch Director and Clinical Team Lead.

Observed in Record Review. In 1 of 14 patient records reviewed, During RRNHV# 2's patient record review it was noted the organization had not ensured the plan of care included a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. For eample: RRNHV# 2 was dependent ona ventilator and had a respiratory therapist visit once a month and as needed. however, there was no documentation on the plan of care regarding a ventilator or the need for monthly visits from the contracted respiratory therapist

Observed in Record Review. In 1 of 3 bereavement records reviewed, During RRBR# 3's patient record review it was noted the organization had not ensured it provided care, treatment, or services for each patient according to the patient's individual plan of care. For example: RRBR# 3's was assessed as Moderate risk and the bereavement plan of care included a phone calls and home visit. Review of the bereavement record revealed all contacts were by phone with no home visit. Further review of the bereavement record revealed no documentation regarding why a home visit was not conducted. This was reviewed, discussed, and validated with the Branch Director and Clinical Team Lead.

Observed in Patient Home. In 1 of 4 home visits conducted, During RRHV# 1's home observation it was noted the organization had not ensured it implemented infection prevention and control activities as planned. For example: during RRHV# 1's home observation the registered nurse failed to follow the organization policies Hand Hygiene IC.3 that included hand hygiene after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient and after removing gloves, and Bag Technique IC.12 that included hand hygiene prior to entry into the bag. During RRHV# 1's home observation the nurse was observed putting on two pairs of gloves entered the bag multiple times with the same gloves. In addition, the nurse was observed cleaning the vital sign equipment and putting the equipment immediately in to the bag with the same gloves used to clean the equipment. The nurse was observed removing the gloves and left the room prior to performing hand hygiene. This was observed, discussed, and validated with the Clinical Team Lead. Observed in Patient Home. In 1 of 3 home visits conducted with vital sign equipment, During RRHV# 1's home observation it was noted the organization had not ensured it implemented infection prevention and control activities when cleaning and performing disinfection of medical supplies and devices. For example: during RRHV# 1's home observation the registered nurse was observed cleaning the vital sign equipment with a Clorox wipe and putting the equipment immediately into the nurse bag without allowing any wet time/contact time. This was observed, discussed, and validated with the Clinical Team Lead.

Observed in Patient Home. In 7 of 13 patient records reviewed with home health aide, During RRHV# 1, RRHV# 2, RRHV# 3, RRNHV# 4, RRNHV# 5, RRNHV# 8, and RRNHV# 10's patient records review, and RRHV# 3's home observation and patient record review it was noted the organization has not ensured the registered nurse prepared complete written patient care instructions for the home health aide (HHA). For example: during RRHV# 3's home observation two HHA's performed a Hoyer Lift transfer from the bed to the shower chair. In addition, RRHV# 3 had an oxygen concentrator and portable oxygen tanks present in the room. Review of RRHV# 3's HHA written patient care instruction's revealed no documentation of Hoyer Lift for transfers, oxygen or oxygen safety precautions. Review of RRHV# 1's HHA written patient care instructions revealed the task of bed bath. Review of RRHV# 1's patient record revealed RRHV# 1 had a PEG tube in the upper right quadrant. However, review of the HHA written patient care instructions revealed no documentation of a PEG tube. Review of RRHV# 2's patient record revealed oxygen as needed. Review of RRHV# 2's HHA written patient care instructions revealed no documentation of oxygen safety precautions. Review of RRNHV# 4's patient record revealed RRNHV# 4 had a wound on the coccyx with a dressing. Review of RRNHV# 4's HHA written patient care instructions revealed the task of a shower. Further review of the HHA written patient care instructions revealed no documentation of a wound or what to do it the dressing became wet. Review of RRNHV# 5, RRNHV# 8, and RRNHV# 10's patient records revealed the patients were on oxygen. Review of RRNHV# 5, RRNHV# 8, and RRNHV# 10's HHA written patient care instructions revealed no documentation of oxygen or oxygen safety precautions. This was observed, discussed, and validated with the Branch Director and Clinical Team Lead.

Observed in Patient Home. In 1 of 1 home visits conducted with home health aide, During RRHV# 3's home observation it was noted the organization had not ensured the home health aide (HHA) provided services as ordered by the physician in the plan of care. For example: during RRHV# 3's home observation the HHA was observed applying a Zinc paste to RRHV# 3's buttock, applying Athletes foot powder to RRHV# 3's abdomen and under the breasts, and applying Skin Prep to bilateral heels. Review of RRHV# 3's HHA patient written instructions revealed no task/documentation of applying Zinc paste, Athletes food powder, or Skin Prep. This was observed, discussed, and validated with the Clinical Team Lead.

Observed in Record Review. In 1 of 14 patient records reviewed, During RRNHV# 2's patient record review it was noted the organization had not ensured the patient record contained information that reflected the patient's care, treatment, or services. For example: review of RRNHV# 2's patient record revealed RRNHV# 2's start of care was 240 days prior to the surveyor review of the patient record with a terminal diagnosis of ALS. Further review of RRNHV# 2's patient record revealed RRNHV# 2 had a tracheostomy and was dependent on a ventilator for breathing. Review of the skilled nurse visit notes revealed documentation that the ventilator settings were set by the respiratory therapist. However, review of RRNHV# 2's patient record revealed no documentation from a respiratory therapist. This was discussed with the Branch Director that shared the contracted respiratory therapist visits RRNHV# 2 monthly and as needed and validated there was no documentation from the respiratory therapist in RRNHV# 2's patient record. Observed in Patient Home. In 3 of 3 home visits conducted with medication review, During RRHV# 1, RRHV# 2, and RRHV# 4's home observations it was noted the organization had not ensured the patient's record contained information that reflected the patient's care, treatment, or services. For example: during RRHV# 1's medication reconciliation at the Nursing Facility (NF) home observation it was noted the hospice’s medication profile was missing Famotidine 20 mg twice daily started approximately 54 days prior to the home observation. During RRHV# 2's medication reconciliation at the Assisted Living Facility (ALF) home observation it was noted the hospice's medication profile was missing Melatonin 3mg tab at bedtime as needed for insomnia. Further review of the hospice medication profile revealed Levothyroxine 100 mcg daily. However, the ALF medication record revealed Levothyroxine 75 mcg. During RRHV# 4's medication reconciliation at the NF home observation it was noted the hospice’s medication profile was missing Clonidine 0.1mg three times a day as needed for B/P over 165/95. This was observed, reviewed, and validated with the clinicians at the home observations and the Clinical Team Lead and Branch Director.

Observed in Record Review. In 12 of 114 patient records reviewed, During RRHV# 2, RRHV# 3, RRHV# 4, RRNHV# 1, RRNHV# 2, RRNHV# 3, RRNHV# 4, RRNHV# 6, RRNHV# 7, RRNHV# 8, RRNHV# 9, and RRNHV# 10's patient records review it was noted the organization had not ensured all entries into the patient record were appropriately authenticated with currently accepted standards of practice and organization policy Verification of Physician Licensure and Order PC.25 that included The individual receiving the order must record and sign it immediately and have the prescribing person sign it in accordance with state and federal regulations... For example: review of the patients' Medical Director's verbal order Certificate of Terminal Illness (CTI) revealed documentation that the admission registered nurse received the verbal order CTI. However, the signature line Verbal Certificate Taken By was not signed by the admission nurse that took the verbal order, it was signed by the Branch Director or the Clinical Team Lead. This was reviewed, discussed, and validated with the Branch Director and Clinical Team Lead.

Observed in Patient Home. In 2 of 2 home visits conducted in a SNF/NF, During RRHV# 1 and RRHV# 4's home observations it was noted the organization had not ensured it provided the Nursing Facility (NF) with the patient's initial Certification of Terminal Illness (CTI) and recertification CTIs. For example: review of RRHV# 1's hospice binder, nursing facility binder, and interview with NF staff and NF Director of Nursing revealed no documentation of the initial CTI. Review of RRHV# 4's hospice binder revealed no documentation of the initial CTI and the first recertification CTI. This was reviewed, discussed, and validated with the Clinical Team Lead.

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, 12 and 13) of thirteen patients reviewed. Findings: Patient #1 A review of the plan of care dated 02/02/22 to 04/02/22 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 01/24/22 to 03/24/22 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 #3 A plan of care dated 12/31/21 to 02/28/22 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 02/25/22 to 04/25/22 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 02/14/22 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 #6 A plan of care dated 02/09/22 to 05/09/22 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 01/23/22 to 03/23/22 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 #8 A review of the plan of care dated 01/06/22 to 03/06/22 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 02/14/22 to 04/14/22 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 #10 A plan of care dated 04/07/22 to 07/05/22 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 #11 A plan of care dated 03/30/22 to 06/27/22 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 review of the plan of care dated 04/13/22 to 07/11/22 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 review of the plan of care dated 04/04/22 to 07/02/22 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 04/27/22 at 1:00 pm, Staff A, B and C stated the plans of care for Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13 failed to include services necessary for the palliation and management of the terminal illness.