Carter Healthcare Hospice of Northeast Oklahoma LLC

“Based on record review and interview, the agency failed to ensure that the social worker completed the psychosocial within five days of the initial comprehensive assessment for one (Pt #4) of 14 patients. Findings: Pt #4A review of the clinical record showed an initial comprehensive assessment performed 03/06/26 and showed no psychosocial assessment was completed. A missed visit note was completed by the social worker dated 03/13/26 that showed the patient refused social work services (seven days after the initial comprehensive assessment). On 08/18/26 at 1:51 p.m., Staff B stated no psychosocial assessment was completed, and the patient refusal was not documented until seven days after the initial comprehensive assessment.”

“Based on record review and interview, the hospice failed to ensure: 1. Wound measurements were completed for one (Pt #2) of 14 patients.2. Wound care was completed as ordered for one (Pt #2) of 14 patients. Findings: Pt #2A review of a plan of care period dated 07/16/26 to 09/15/26 showed an order dated 07/28/26 that read, “Hospice SN/family/caregiver to perform wound care to right buttock stage II pressure ulcer wound with skilled nursing visits. Measurements and picture to be taken weekly as patient allows. Wound care as follows: Cleanse wound with NS and pat dry with 4x4 gauze, apply 4x4 duoderm or like hydrocolloid dressing twice weekly and as needed for soilage. Wound care performed as patient/caregiver allows...” A review of the clinical record showed wound measurements were obtained 07/28/26. A review of nurses’ notes showed:1. A nurse’s note dated 07/30/26 showed no wound care performed by the nurse or caregiver, no patient refusal, and no change in orders.2. A nurse’s note dated 08/04/26 showed no wound care performed by the nurse or caregiver, no wound measurements obtained, no patient refusal, and no change in orders.3. A nurse’s note dated 08/06/26 showed no wound care performed by the nurse or caregiver, no patient refusal, and no change in orders.4. A nurse’s note dated 08/11/26 showed no wound care performed by the nurse or caregiver, no wound measurements obtained, no patient refusal, and no change in orders. On 08/18/26 at 1:38 p.m., Staff B stated: 1. Wound care was not completed as ordered.2. Wound measurements were not obtained.”

“Based on record review and interview, the hospice failed to ensure:1. Wound care orders were included in the plan of care for one (Pt #13) of 14 patients.2. Foley catheter orders were included in the plan of care for one (Pt #13) of 14 patients. Findings: Pt #13 A review of a plan of care dated 02/03/26 to 02/06/26 showed an initial nursing assessment completed 02/03/26 that showed a Stage 2 open pressure ulcer to the coccyx the nurse applied triad paste. A review of the clinical record showed a physician’s order dated 02/03/26 for the SN to insert a 16 Fr 30 ml Foley catheter 1 time monthly and 2 prn visits for malfunction, leaking or removal. The plan of care did not contain interventions or treatments for the pressure ulcer or interventions for a foley catheter. On 08/18/26 at 1:38 p.m., Staff B stated the plan of care did not contain: 1. Interventions or treatment of the pressure ulcer.2. Interventions for the foley catheter.”

“Based on record review and interview, the hospice failed to ensure the plan of care included all services necessary for the palliation and management of their terminal hospice diagnosis for two (Pt # 7 and 13) of 14 patients. Findings: Pt #7A review of a plan of care dated 08/07/26 to 10/05/26 showed no interventions and goals for the hospice diagnosis of Alzheimer’s disease. Pt #13A review of a plan of care dated 02/03/26 to 02/06/26 showed no interventions and goals for the hospice diagnosis of malignant neoplasm of pancreas. On 08/18/26 at 1:57 p.m., Staff B stated the plan of care did not include goals or interventions for the hospice diagnoses for Pt # 3 and 7.”

“Based on record review and interview, the hospice failed to maintain evidence that its QAPI program showed measurable improvement in indicators related to improved palliative outcomes and hospice services. This failed practice had the potential to place 12 current patients and any new patient admitted to the hospice at risk of poorly identified outcome measures related to symptom control. (See L561) Based on record review and interview, the hospice failed to analyze quality indicators. This failed practice had the potential to place 12 current patients and any new patient admitted to the hospice at risk for repeated hospice mishaps due to failure of the hospice to self-identify problem areas. (See L562) Based on record review and interview, the hospice failed to maintain evidence of the use of quality indicator data in their QAPI program. This failed practice had the potential to negatively affect patient care due to hospice failure to collect and correct areas of deficient practices for all 12 current patients and any new patient admitted to the hospice. (See L563) Based on a record review and interview, the hospice failed to implement and maintain an effective QAPI Program and failed to ensure performance improvements were tracked to ensure that improvements were sustained. This failed practice had the potential to place 12 current patients and any new patient admitted to the hospice at risk for repeated unidentified areas of poor care and symptom management. (See L570) Based on a record review and interview, the governing body failed to ensure a QAPI program was maintained and evaluated annually. This failed practice had the potential to place all patients on service for the calendar years of 2022 and 2023 at risk for poor outcomes due to the lack oversight and governing body involvement. (See L574) .”

“Based on record review and interview, the hospice failed to ensure completion of the initial bereavement assessment no later than 5 calendar days after the election of hospice care for one (Patient #1) of 14 patients. A review of the clinical record showed an election of the hospice benefit on 01/26/24 with no completion of the initial bereavement assessment from 01/26/24 to 04/10/24 (43 days after the election of the hospice benefit) with no documentation of patient or caregiver refusal of the initial bereavement risk assessment. On 04/10/24 at 3:00 pm., Staff B stated the initial bereavement assessment was not completed for Patient #1.”

“Based on record review and interview, the hospice failed to ensure imminence of death was assessed during the comprehensive assessment for four (Patients #1, 2, 3 and 7) of 14 patients. Patient #1 A review of the Initial Assessment dated 01/26/24 showed no assessment of imminence of death. Patient #2 A review of the Initial Assessment dated 02/05/24 showed no assessment of imminence of death. Patient #3 A review of the Initial Assessment dated 01/31/24 showed no assessment of imminence of death. Patient #7 A review of the Initial Assessment dated 01/10/24 showed no assessment of imminence of death. On 04/10/24 at 3:05 pm., Staff B stated imminence of death was not assessed on the comprehensive assessment for Patients #1, 2, 3 and 7.”

“Based on record review and interview, the hospice failed to ensure an individualized plan of care was fully developed to include all services necessary for the palliation and management of the terminal illness for nineteen (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14) of 14 patients reviewed. Patient #1 A plan of care dated 01/26/24 to 04/24/24 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. Patient #2 A review of the plan of care dated 02/05/24 to 05/04/24 documented a primary diagnosis of chronic obstructive pulmonary disease 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 01/31/24 to 04/29/24 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. Patient #4 A plan of care dated 03/18/24 to 06/15/24 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 #5 A plan of care dated 02/05/24 to 04/04/24 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. Patient #6 A plan of care dated 03/26/24 to 06/23/24 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 #7 A plan of care dated 01/10/24 to 04/08/24 documented a primary diagnosis of dementia and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #8 A plan of care dated 01/14/24 to 03/13/24 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 01/07/24 to 03/06/24 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 #10 A plan of care dated 02/26/24 to 05/25/24 documented a primary diagnosis of dementia 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 02/10/24 to 05/09/24 documented a primary diagnosis of chronic obstructive pulmonary disease and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #12 A plan of care dated 01/22/24 to 04/20/24 documented a primary diagnosis of hypertensive heart and chronic kidney disease with heart failure and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #13 A plan of care dated 12/13/24 to 03/11/24 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 #14 A plan of care dated 11/16/23 to 02/13/24 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 04/10/24 at 2:45 pm, Staff B stated the plans of care for Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14 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 to include the frequency of services provided in the plan of care for five (Patients #1, 2, 3, 5 and 7) of 14 patients. Patient #1 A review of the plan of care dated 01/26/24 to 04/24/24 showed no skilled nurse frequencies from 01/26/24 to 03/14/24. Skilled nurse visits were performed on 01/26/24, 02/06/24, 02/14/24, 02/19/24, 02/27/24 and 03/06/24. Patient #2 A review of the plan of care dated 02/05/24 to 05/04/24 showed no skilled nurse or hospice aide frequencies from 02/05/24 to 03/20/24. Skilled nurse visits were performed on 02/05/24, 02/06/24, 02/12/24, 02/19/24, 02/26/24, 03/06/24, 03/11/24, 03/14/24 and 03/19/24. Hospice aide visits were performed on 02/08/24, 02/09/24, 02/12/24, 02/14/24, 02/21/24, 02/28/24, 03/06/24, 03/13/24 and 03/15/24. Patient #3 A review of the plan of care dated 01/31/24 to 04/29/24 showed no skilled nurse or hospice aide frequencies from 01/31/24 to 03/20/24. Skilled nurse visits were performed on 01/31/24, 02/01/24, 02/15/24, 02/20/24, 02/29/24, 03/05/24 and 03/15/24. Hospice aide visits were performed on02/06/24, 02/14/24, 02/21/24, 02/28/24, 03/07/24 and 03/13/24. Patient #5 A review of the plan of care dated 02/05/24 to 05/04/24 showed no skilled nurse or hospice aide frequencies from 02/05/24 to 03/20/24. Skilled nurse visits were performed on 02/05/24, 02/06/24, 02/12/24, 02/20/24, 02/27/24, 03/04/24, 03/12/24, 03/14/24 and 03/19/24. Hospice aide visits were performed on 02/09/24, 02/13/24, 02/20/24, 02/23/24, 02/27/24, 02/29/24, 03/05/24, 03/08/24 and 03/12/24. Patient #7 A review of the plan of care dated 01/10/24 to 04/08/24 showed no skilled nurse from 01/10/24 to 03/20/24. Skilled nurse visits were performed on 01/10/24, 01/11/24, 01/16/24, 01/25/24, 02/02/24, 0208/24, 02/10/24, 02/16/24, 02/22/24, 02/28/24 and 03/05/24. On 04/10/24 at 3:10 pm., Staff B stated the plan of care failed to contain frequencies for skilled nurse visits and hospice aide visits for Patients #1, 2, 3, 5 and 7.”

“Based on record review and interview, the hospice failed to maintain evidence that its QAPI program showed measurable improvement in indicators related to improved palliative outcomes and hospice services. This failed practice had the potential to place 12 current patients and any new patient admitted to the hospice at risk of poorly identified outcome measures related to symptom control. A review of administrative records showed no evidence of measurable improvements in indicators related to improved palliative outcomes and hospice services for 2023, from 01/01/23 to 08/01/23 and 10/01/23 to 02/01/24. On 04/10/24 at 2:45 pm, Staff B stated there was no documentation showing measurable improvement in indicators related to palliative outcomes and hospice services for 2023 and from 01/01/23 to 08/01/23 and from 10/01/23 to 02/01/24.”

“Based on record review and interview, the hospice failed to analyze quality indicators. This failed practice had the potential to place 12 current patients and any new patient admitted to the hospice at risk for repeated hospice mishaps due to failure of the hospice to self-identify problem areas. A review of administrative records showed no analysis of quality indicators for 2022, from 01/01/23 to 08/01/23 and 10/01/23 to 02/01/24. On 04/10/24 at 2:45 pm, Staff B stated the QAPI for 2022, from 01/01/23 to 08/01/23 and 10/01/23 to 02/01/24 did not contain an analysis of quality indicators.”

“Based on record review and interview, the hospice failed to maintain evidence of the use of quality indicator data in the QAPI program. This failed practice had the potential to negatively affect patient care due to hospice failure to collect and correct areas of deficient practices for all 12 current patients and any new patient admitted to the hospice. A review of administrative records showed no use of quality indicator data in their QAPI program for 2022, from 01/01/23 to 08/01/23 and from 10/01/23 to 02/01/24. On 04/10/24 at 2:45 pm, Staff B stated the QAPI program did not include the use of quality indicator data for 2022, from 01/01/23 to 08/01/23 and from 10/01/23 to 02/01/24.”

“Based on a record review and interview, the hospice failed to implement and maintain an effective QAPI Program and failed to ensure performance improvements were tracked to ensure that improvements were sustained. This failed practice had the potential to place 12 current patients and any new patient admitted to the hospice at risk for repeated unidentified areas of poor care and symptom management. A review of administrative records showed no implemented changes designed to measure and track performance or that improvements were sustained for 2022, from 01/01/23 to 08/01/23 and from 10/01/23 to 02/01/24. The hospice failed to ensure the QAPI Program mandated actions aimed at performance improvement, measured success after implementation and tracked performance to ensure that improvements were sustained. On 04/10/24 at 3:45 pm, Staff B stated the QAPI program did not contain documentation of measurement and tracking of performance improvement projects being sustained in 2022, from 01/01/23 to 08/01/23 and from 10/01/23 to 02/01/24.”

“Based on a record review and interview, the governing body failed to ensure a QAPI program was maintained and evaluated annually. This failed practice had the potential to place all 12 patients on service at risk for poor outcomes due to the lack oversight and governing body involvement. A review of administrative records showed no governing body review of the surveyed hospice QAPI program for calendar years of 2022 and 2023. On 04/10/24 at 2:45 pm, staff B stated the governing body minutes did not show review of the surveyed hospice QAPI for the hospice in 2022 and 2023.”

“Based on record review and interview, the hospice failed to ensure governing body oversight of ongoing operations of the patient care delivery systems for calendar years 2022 and 2023 effecting all 12 patients and all current staff. A review of administrative records showed no governing body oversight of ongoing operations of the patient care delivery systems specific to the hospice in the calendar years of 2022 and 2023. On 04/10/24 at 1:55 p.m., Staff B stated there was no documentation which showed evidence of governing body oversight of ongoing operations of the patient care delivery systems specific to the surveyed hospice in calendar years 2022 and 2023.”

“Based on record review and interview, the hospice failed to the ensure plans of care was coordinated with the long-term care facility for one (Patients #7) of 14 patients reviewed. Patient #7 A review of the plan of care dated 01/10/24 to 04/08/24 showed a primary diagnosis of dementia and documented no patient specific interventions to be provided by the nursing home or the hospice for the palliation and management of the terminal illness, no frequency of skilled nurse or hospice aide visits and no medications. On 04/09/24 at 2:50 pm., nursing home staff A stated there were no other plans of care developed by the hospice for the patient present in the facility. On 04/10/24 at 2:40 pm, Staff B stated the plan of care for Patient #7 did not outline the patient specific interventions to be to be provided by the nursing home or the hospice for the palliation and management of the terminal illness, skilled nurse and hospice aide frequencies and no medications.”