Saint Francis Hospice

“Based on record review and interview, the hospice failed to ensure interventions for the hospice diagnosis were specified in the plan of care for two (Pt #20 and 22) of 27 patients. Findings:Pt #20A review of a POC dated 05/20/26 to 05/27/26 with IDG updates on 05/28/26, 06/11/26, 06/25/26, 07/09/26, 07/26/26 and 08/06/26, showed no interventions to monitor for the hospice diagnosis of heart failure with preserved ejection fraction.Pt #22A review of a POC dated 07/16/26 to 07/29/26 with IDG updates on 07/16/26 and 07/30/26, showed no interventions to monitor for the hospice diagnosis of congestive heart failure.On 08/12/26 at 11:50 a.m, Staff E stated the plans of care for Pt #20 and 22 did not have interventions related to their hospice diagnosis.”

“Based on record review and interview, the hospice failed to ensure the plan of care contained interventions and goals for pain for one (Pt #10) of 27 patients. Findings: Pt #10 A review of a POC dated 08/09/26 to 08/12/26 with no IDG updates showed the Pt had orders for Morphine Concentrate 20 mg/1 ml with no: 1. Acceptable pain level.2. Pt education on Morphine and pain scales.3. When to notify the hospice regarding pain. On 08/12/26 at 11:45 a.m., Staff E stated the plan of care showed no interventions or goals for pain.”

“Based on record review and interview, the hospice failed to ensure nursing staff provided services based on patient needs for two (Pt #1 and 3) of 27 patients. Findings:Pt #1A review of a plan of care dated 12/18/26 to 01/01/26 and a nursing assessment dated 12/30/26 showed a blood pressure of 120/0 and showed no other attempt to obtain the patient’s blood pressure. Pt #3A review of an initial plan of care dated 01/22/26 to 02/04/26 and a nursing assessment dated 01/22/26 showed the patient’s last bowel movement was 01/13/26 with the patient started on Senna (a medication) two daily for constipation. A nursing assessment dated 01/23/26 showed the last bowel movement was 01/13/26 with no further interventions or physician notification. On 08/12/26 at 12:06 p.m., Staff E stated:1. The nurse should have rechecked the BP on Pt #1.2. The nurse did not follow up on the patient not having had a bowel movement in 10 days.”

“Based on record review and interview, the hospice failed to ensure hospice aide visits were provided in accordance with the plan of care for four (Patients #1, 7, 10 and 17) of 23 patients. Patient #1 A review of the plan of care dated 12/05/23 to 03/03/24 and plan of care updates dated 01/04/24 and 01/18/24 showed a hospice aide frequency of two visits per week for one week and three visits per week for 12 weeks. A review of the clinical record showed the following: A hospice aide missed visit dated 01/15/24 documented the reason for the missed visit as bad weather for the week of 01/14/24 to 01/20/24 (two of three completed visits for this week). Documentation showed no attempts to reschedule the missed visit and no change in the ordered frequency. Patient #7 A review of the plan of care dated 02/09/24 to 05/08/24 and plan of care updates dated 02/15/24, 02/29/24, 03/14/24, 03/28/24 and 04/11/24 showed a hospice aide frequency of three visits per week for 12 weeks. A review of the clinical record showed the following: A hospice aide missed visit dated 02/14/24 documented the reason for the missed visit was due to a refusal of bath for the week of 02/11/24 to 02/17/24 (two of three completed visits for this week). Documentation showed no refusal of other services outlined in the plan of care, no attempts to reschedule the missed visit and no change in the ordered frequency. A hospice aide missed visit dated 03/25/24 and 03/29/24 documented the reason for the missed visit was due to a refusal of bath for the week of 03/24/24 to 03/30/24 (one of three completed visits for this week). Documentation showed no refusal of other services outlined in the plan of care, no attempts to reschedule the missed visit and no change in the ordered frequency. A hospice aide missed visit dated 04/05/24 documented the reason for the missed visit was due to a refusal of bath for the week of 03/31/24 to 04/06/24 (two of three completed visits for this week). Documentation showed no refusal of other services outlined in the plan of care, no attempts to reschedule the missed visit and no change in the ordered frequency. Patient #10 A review of the plan of care dated 03/27/24 to 06/24/24 and plan of care updates dated 04/04/24, 04/18/24 and 05/02/24 showed a hospice aide frequency of one visit per week for one week and three visits per week for 12 weeks. A review of the clinical record showed the following: A hospice aide missed visit dated 04/17/24 and 04/19/24 documented the no reason for the missed visit for the week of 04/14/24 to 04/20/24 (one of three completed visits for this week). Documentation showed no refusal of services outlined in the plan of care, no attempts to reschedule the missed visit and no change in the ordered frequency. Patient #17 A review of the plan of care dated 04/23/24 to 06/21/24 and plan of care update dated 04/25/24 showed a hospice aide frequency of two visits per week for one week and three visits per week for 12 weeks. A review of the clinical record showed the following: A hospice aide missed visit dated 04/24/24 documented the reason for the missed visit was due to a refusal of bath for the week of 04/23/24 to 04/24/24 (one of two completed visits for this week). Documentation showed no refusal of other services outlined in the plan of care, no attempts to reschedule the missed visit and no change in the ordered frequency. On 05/02/24 at 3:30 pm., Staff B stated the hospice aide frequencies were not met in accordance with the ordered frequencies in the plan of care for Patients #1,7 and 10. On 05/03/24 at 10:16 am., Staff B stated the hospice aide frequency was not met in accordance with the ordered frequencies in the plan of care for Patient #17.”

“Based on record review and interview, the hospice failed to ensure the plan of care was individualized and fully developed to include all services necessary for the palliation and management of the terminal illness for eleven (Patients #2, 3, 4, 5, 7, 9, 10, 11, 14, 16 and 18) of 23 patients reviewed. Patient #2 A review of the plan of care dated 02/21/24 to 05/21/24 documented a primary diagnosis of adenocarcinoma of left lung and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #3 A plan of care dated 04/24/24 to 07/22/24 documented a primary diagnosis of cerebrovascular disease and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #4 A plan of care dated 02/15/24 to 04/14/24 documented a primary diagnosis of late effect cerebrovascular accident and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #5 A plan of care dated 01/03/24 to 04/01/24 documented a primary diagnosis of Alzheimer’s disease and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #7 A plan of care dated 02/09/24 to 05/08/24 documented a primary diagnosis of senile degeneration of the brain and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #9 A plan of care dated 04/12/23 to 07/10/24 documented a primary diagnosis of cancer of larynx and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #10 A plan of care dated 03/27/24 to 06/24/24 documented a primary diagnosis of acute congestive heart failure and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #11 A plan of care dated 04/10/24 to 07/06/24 documented a primary diagnosis of late effect cerebrovascular accident and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #14 A plan of care dated 01/24/24 to 03/23/24 documented a primary diagnosis of atherosclerosis of native coronary artery and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #16 A plan of care dated 04/20/24 to 07/18/24 documented a primary diagnosis of cancer of the colon and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #18 A plan of care dated 04/12/24 to 07/10/24 documented a primary diagnosis of congestive heart failure and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. On 05/01/24 at 3:18 pm., Staff B stated the plans of care for Patients #2 and 3 failed to be individualized for services necessary for the palliation and management of the terminal illness. On 05/02/24 at 3:20 pm., Staff B stated the plans of care for Patients #4, 5, 7, 9, 10, 11, 14 and 16 failed to be individualized for services necessary for the palliation and management of the terminal illness. On 05/03/24 at 10:36 am., Staff B stated the plans of care for Patients #18 and 19 failed to be individualized for services necessary for the palliation and management of the terminal illness.”

“Based on record review and interview, the agency failed to ensure required background checks were completed by the surveyed hospice for two (Staff H and K) of five employees. A review of 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. Staff H A review of the personnel record showed a background check performed by another agency license number. No background check was performed for the surveyed agency through OKSCREEN for Staff H. Staff K A review of the personnel record showed a background check performed by another agency license number. No background check was performed for the surveyed agency through OKSCREEN for Staff K. On 05/02/24 at 1:30 pm, Staff L stated the OKSCREEN for Staff H and K were not completed by the surveyed hospice.”