Carter Healthcare Hospice of Central Oklahoma, LLC

“Based on record review and interview, the hospice failed to ensure medical social work completion of the initial psychosocial assessment no later than 5 calendar days after the election of hospice care for three (Patients #7, 12 and #14) of 15 patients. Findings: Patient #7A review of the clinical record showed an election of the hospice benefit on 03/04/26 with no completion of an initial psychosocial assessment from 03/04/26 to 03/18/26 (14 days after election of the hospice benefit). The clinical record showed a MSW missed visit on 03/13/26 (nine days after the election of the hospice benefit) and showed no other attempts to complete the initial psychosocial assessment until 03/18/26. Patient #12A review of the clinical record showed an election of the hospice benefit on 02/14/25 with no completion of an initial psychosocial assessment from 02/14/25 to 04/10/25 (55 days after election of the hospice benefit). The clinical record showed no MSW missed visits, no other attempts to complete the initial psychosocial assessment until 04/10/25 and showed no change in orders. Patient #14A review of the clinical record showed an election of the hospice benefit on 12/19/25 with no completion of an initial psychosocial assessment from 12/19/25 to 01/04/26 (16 days after election of the hospice benefit) and no patient or caregiver refusal of medical social work visits or change in orders. On 05/14/26 at 10:42 a.m. to 11:05 a.m., Staff A stated the initial psychosocial assessments were late for patients #7, 12 and #14.”

“Based on record review and interview, the hospice failed to ensure plans of care were fully developed to include SN interventions and goals related to the hospice diagnoses for seven (Patients 2, 3, 4, 5, 10, 11 and #13) of 15 patients. Findings: Patient #2A review of a POC dated 04/17/26 to 07/15/26 with IDG updates on 04/22/26 and on 05/06/26 showed no SN interventions and goals that addressed the hospice diagnoses of colon and lung cancer and showed no communication between the IDG to update the POC. On 05/14/26 at 10:25 a.m., Staff A stated the POC did not have interventions or goals for colon or lung cancer. Patient #3A review of a POC dated 04/22/26 to 07/22/26 with IDG updates on 04/22/26 and on 05/06/26 showed no SN interventions and goals that addressed the hospice diagnoses of Alzheimer’s disease and chronic kidney disease and showed no communication between the IDG to update the POC. On 05/14/26 at 10:31 a.m., Staff A stated the POC did not have interventions or goals for Alzheimer’s disease or chronic kidney disease. Patient #4A review of a POC dated 04/09/26 to 07/07/26 with IDG updates on 04/22/26 and on 05/06/26 showed no SN interventions and goals that addressed the hospice diagnoses of Alzheimer’s disease and cerebrovascular disease and showed no communication between the IDG to update the POC. On 05/14/26 at 10:35 a.m., Staff A stated the POC did not have interventions or goals for Alzheimer’s disease and cerebrovascular disease. Patient #5A review of a POC dated 04/15/26 to 07/13/26 with IDG updates on 04/22/26 and on 05/06/26 showed no SN interventions and goals that addressed the hospice diagnosis of pancreatic cancer and showed no communication between the IDG to update the POC. On 05/14/26 at 10:40 a.m., Staff A stated the POC did not have interventions or goals for pancreatic cancer. Patient #10A review of a POC dated 01/07/26 to 04/06/26 with IDG updates on 01/14/26 and on 01/28/26 showed no SN interventions and goals that addressed the hospice diagnosis of lung cancer and showed no communication between the IDG to update the POC. On 05/14/26 at 10:50 a.m., Staff A stated the POC did not have interventions or goals for lung cancer. Patient #11A review of a POC dated 03/31/26 to 06/28/26 with IDG updates on 04/08/26 and on 04/22/26 showed no SN interventions and goals that addressed the hospice diagnosis of congestive heart failure and showed no communication between the IDG to update the POC. On 05/14/26 at 10:52 a.m., Staff A stated the POC did not have interventions or goals for congestive heart failure. Patient #13A review of a POC dated 11/23/25 to 02/20/26 with IDG updates on 12/02/25, 12/16/25 and on 12/30/25 showed no SN interventions and goals that addressed the hospice diagnosis of cardiovascular disease and showed no communication between the IDG to update the POC. On 05/14/26 at 11:00 a.m., Staff A stated the POC did not have interventions or goals for cardiovascular disease.”

“Based on record review and interview, the hospice failed to ensure the POCs were fully developed to include service discipline visit frequencies for four (Patients #4, 5, 8 and #9) of 15 patients. Findings: Patient #4A review of the POC dated 04/09/26 to 07/07/26 with IDG plan of care updates dated 04/22/26 and 05/06/26 showed no SN visit frequencies and IDG communication notes showed no changes in the physician orders. Patient #5A review of the POC dated 04/15/26 to 07/13/26 with IDG plan of care updates dated 04/22/26 and 05/06/26 showed no SN or volunteer coordinator visit frequencies and IDG communication notes showed no changes in the physician orders. Patient #8A review of the POC dated 04/01/26 to 06/29/26 with IDG plan of care updates on 04/08/26 showed no SN visit frequency from 04/01/26 to 04/21/26 and showed no changes in the physician orders until 04/22/26. Patient #9A review of the POC dated 04/11/25 to 04/17/25 with no IDG plan of care update showed no SN visit frequency. The clinical record showed a physician’s order dated 01/26/26 for a SN visit frequency effective 04/11/25 of daily SN visits. On 05/14/26 at 10:35 a.m. to 10:45 a.m., Staff A stated the POCs for patients #4, 5 and #8 did not include discipline visit frequencies. At 10:50 a.m., Staff A stated the POC for patient #9 did not include a SN discipline visit frequency until a correction order was entered on 01/07/26.”

“Based on record review and interview, the hospice failed to ensure an increase in hospice aide visit frequency was communicated and addressed by the IDG for one (Patient #13) of 15 patients. Findings: Patient #13A review of a POC dated 11/23/25 to 02/20/26 with IDG updates on 12/02/25 and on 12/16/25 showed an aide visit frequency of one time per week. The clinical record showed from 11/30/25 to 12/27/25 two hospice aide visits were conducted per week. The IDG communication notes showed no increase in the hospice aide visits and no change in the physician orders until the IDG meeting on 12/30/25. On 05/14/26 at 11:00 a.m., Staff A stated the IDG did not address the increase in hospice aide visits until 12/30/25.”

“Based on record review and interview, the hospice failed to ensure service discipline frequencies were provided in accordance with the POCs for five (Patients #1, 7, 8, 10 and #12) of 15 patients. Findings: Patient #1A review of the plan of care dated 02/25/26 to 04/25/26 ordered SN visits at a frequency of two times a week and hospice aide visits at three times a week. During the week of 02/25/26 to 02/28/26 showed a SN visit was conducted on 02/25/26 (two visits ordered, one visit conducted); and hospice aide visits were conducted on 02/25/26 and 02/27/26 (three visits ordered, two visits conducted). The clinical record showed no patient or family refusal of visits and no changes in the ordered frequencies. Patient #7A review of the plan of care dated 03/04/26 to 06/01/26 with IDG POC updates on 03/11/26, 03/25/26,04/08/26, 04/22/26 and on 05/06/26 ordered SN visits at a frequency of two to three times a week and hospice aide visits at two to four times a week. During the week of 03/04/26 to 03/07/26 showed no aide visits were conducted (two to three visits ordered, no visit conducted).During the week of 03/08/26 to 03/14/26 showed a SN visit conducted on 03/12/26 (two to three visits ordered, one visit conducted).During the week of 03/15/26 to 03/21/26 showed a SN visit conducted on 03/17/26 (two to three visits ordered, one visit conducted).During the week of 03/22/26 to 03/28/26 showed a SN visit conducted on 03/26/26 (two to three visits ordered, one visit conducted).During the week of 04/05/26 to 04/11/26 showed a SN visit conducted on 04/09/26 (two to three visits ordered, one visit conducted).During the week of 04/12/26 to 04/18/26 showed a SN visit conducted on 04/18/26 (two to three visits ordered, one visit conducted).During the week of 04/19/26 to 04/25/26 showed a SN visit conducted on 04/25/26 (two to three visits ordered, one visit conducted).During the week of 05/03/26 to 05/09/26 showed a SN visit conducted on 05/07/26 (two to three visits ordered, one visit conducted). The clinical record showed no patient or family refusal of visits and no changes in the ordered frequencies. Patient #8A review of the plan of care dated 04/01/26 to 06/29/26 with IDG POC updates on 04/08/26, 04/22/26 and on 05/06/26 ordered SN visits at a frequency of two to three times a week. During the week of 04/19/26 to 04/25/26 showed a SN visit was conducted on 04/21/26 (two to three visits ordered, one visit conducted). The clinical record showed no patient or family refusal of visits and no changes in the ordered frequencies. Patient #10A review of the plan of care dated 01/07/26 to 04/06/26 with IDG POC update on 01/14/26 ordered hospice aide visits two times a week. The clinical record showed no hospice aide visits were conducted between 01/14/26 and the patient’s death on 01/30/26 (six visits ordered, no visits conducted) and showed no patient or family refusal of visits and no changes in the ordered frequency. Patient #12A review of the plan of care dated 12/11/25 to 02/08/26 with IDG POC update on 12/17/26, 12/31/26, 01/14/26 and on 01/28/26 ordered chaplain visits one time a month and MSW visits one time a month. The clinical record showed no chaplain or MSW visits were conducted between 12/11/26 and the patient’s revocation from hospice services on 01/30/26 (two visits ordered, no visits conducted) and showed no patient or family refusal of visits and no changes in the ordered frequencies. On 05/14/26 at 10:25 a.m. to 10:55 a.m., Staff A stated the visit frequencies were not followed as ordered for patients #1, 7, 8, 10 and #12.”

“Based on record review and interview, the agency failed to ensure implementation and review of hospice aide care plans for three (Patients #1, 10 and #12) of 15 patients. Findings: Patient #1A review of a POC dated 02/25/26 to 04/25/26 and IDG updates to the POC on 03/11/26, 03/25/26, 04/08/26 and 04/22/26 ordered hospice aide visits at a frequency of three visits every week. The clinical record showed no review and update to the hospice aide care plan since 10/28/25. Patient #10A review of a POC dated 01/07/26 to 04/06/26 and IDG updates to the POC on 01/14/26, 01/28/26 and 02/11/26 ordered hospice aide visits at a frequency of two visits every week. The clinical record showed no hospice aide care plan was implemented. On 05/14/26 at 10:50 a.m., Staff A stated the clinical records showed no hospice aide care plan. Patient #12A review of a POC dated 12/11/25 to 02/08/26 and IDG updates to the POC on 12/11/25, 12/30/25, 01/14/26 and 01/28/26 ordered hospice aide visit of one time per quarter. The clinical record showed no review and update to the hospice aide care plan since 08/15/25. On 05/14/26 at 10:25 a.m. to 11:00 a.m., Staff A stated the clinical records showed no review and update to the hospice aide care plans in each certification period for patients #1 and #12.”

“Based on record review and interview, the hospice failed to ensure aide supervisory visits were completed every 14 days for one (Patient #1) of 15 patients. Findings: Patient #1A review of a POC dated 02/25/26 to 04/25/26 and IDG updates to the POC on 03/11/26, 03/25/26, 04/08/26 and 04/22/26 ordered hospice aide visits at a frequency of three visits every week with aide visits conducted on 03/04/26, 03/06/26, 03/09/26, 03/10/26, 03/13/26 and on 03/18/26. The clinical record showed supervisory visits were conducted on 03/03/26 and on 03/19/26 (16 days between supervisory visits). On 05/14/26 at 10:25 a.m., Staff A stated supervisory aide visits were not completed every 14 days.”

“Based on record review and interview, the agency failed to ensure completion of visit notes for two (Patients #3 and #5) of 15 patients. Findings: Patient #3 A review of the clinical record showed SN visits conducted on 05/05/26 and 05/08/26 were designated as ‘not started’ in the electronic medical record and showed no communication or coordination note entries for a delay in the documentation of the visits. On 05/14/26 at 10:31 a.m., Staff A stated the SN visit notes for visits on 05/01/26 and on 05/08/26 were not completed. Patient #5 A review of the clinical record showed a volunteer coordinator visit conducted on 05/01/26 was designated as ‘not started’ in the electronic medical record and showed no communication or coordination note entries for a delay in the documentation of the visit. On 05/14/26 at 10:40 a.m., Staff A stated the volunteer coordinator note was not completed.”

“Based on record review and interview, the hospice failed to ensure a required background check was completed for one (Staff D) of five employees 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. Staff DA review of the personnel record showed no background check through OKSCREEN for employment that began 11/04/24. On 05/13/26 at 2:30 p.m., Staff B stated Staff D had no background check through the OKScreen database.”