Hospice By Loving Care

“Based on record review and interview, the hospice failed to ensure volunteers were available for office activities and home visits for all patients, their families, and staff. This failed practice contributed to lost support for the operation of the hospice programs, patients, their families, and staff. (See L0644)Based on record review and interview, the hospice failed to ensure volunteers had been identified for what position they would occupy for seven (Volunteer #1, 2, 3, 4, 5, 6, and 7) of seven volunteers. This failed practice placed all patients and their families at risk of:1. Not matching skills to needs.2. Not enhancing patient and family support.3. Not providing respite for caregivers.4. Not ensuring training and readiness. (See L0646) Based on record review and interview, the hospice failed to ensure volunteers provided services that equaled 5% of the total patient care hours of all paid hospice employees for 2024 and 2025 for all patients and staff. This failed practice placed all patients and families at risk for their need for companionship, emotional support, practical assistance, and respite for being caregivers unmet. (See L0647)”

“Based on record review and interview, the hospice failed to ensure the plan of care included the frequency of a foley catheter change for one (Pt #11) of nineteen patients. Findings: Pt #11A plan of care dated 04/25/26 to 06/23/26 was not updated with the standing order dated 08/28/25 that read in part “Insert foley catheter, changing once a month and prn equipment malfunction or obstruction.” The nurses’ notes dated 04/27/26, 04/30/26, 05/04/26, 05/07/26, and 05/11/26 showed the patient had a foley catheter that was last changed on 03/27/26. The nurses note dated 05/14/26 showed the catheter was changed and nurses’ notes through the end of the patient’s benefit period 06/23/26 did not show the catheter was changed again. On 06/24/26 at 12:55 p.m., Staff B stated the catheter was not changed every 30 days.”

“Based on record review and interview, the hospice failed to ensure volunteers were available for office activities and home visits for all patients, their families, and staff. This failed practice contributed to lost support for the operation of the hospice programs, patients, their families, and staff. Findings: A review of the volunteer list showed seven volunteers. No documentation showed the volunteers had provided any administrative assistance or home visit activity for patient and family support. On 06/24/26 at 8:35 a.m., Staff C stated:1. The volunteers did not want to go into homes.2. The volunteers have not provided any office work.”

“Based on record review and interview, the hospice failed to ensure volunteers had been identified for what position they would occupy for seven (Volunteer #1, 2, 3, 4, 5, 6, and 7) of seven volunteers. This failed practice placed all patients and their families at risk of:1. Not matching skills to needs.2. Not enhancing patient and family support.3. Not providing respite for caregivers.4. Not ensuring training and readiness. Findings: A review of the volunteer list did not show a designation of what position each volunteer would have. On 06/24/26 at 8:35 a.m., Staff C stated the volunteers do not have assigned positions. The volunteers have not provided work in the office or in the patient’s homes.”

“Based on record review and interview, the hospice failed to ensure volunteers provided services that equaled 5% of the total patient care hours of all paid hospice employees for 2024 and 2025 for all patients and staff. This failed practice placed all patients and families at risk for their need for companionship, emotional support, practical assistance, and respite for being caregivers unmet. Findings: A request for volunteer records and hours for Calendar Year 2024 and 2025 yielded no results. On 06/24/26 at 8:35 a.m., Staff C stated cost savings for 2024 and 2025 is 0%.”

“Based on record review and interview, the hospice failed to ensure discharge summaries were completed for two (Pt #4 and 5) of three patients who had revoked services. Findings: Pt #4A review of the plan of care showed a certification period of 02/24/26 to 05/24/26 with a hospice revocation dated 05/03/26. The record did not show a discharge summary. Pt #5A review of the plan of care showed a certification period of 01/22/26 to 03/27/26 with a hospice revocation dated 03/27/26. The record did not show a discharge summary. On 06/24/26 at 12:43 p.m., Staff B stated a Pt #4 and 5 did not have discharge summaries completed.”

“Based on record review and interview, the hospice failed to ensure OKSCREEN background checks were completed for eight (Staff F, G, H, I, J, K, L, and M) of eight employees reviewed. Findings:A review of the “Long Term Care Act” documented requirements for hospices to acquire and maintain an OKSCREEN background check on all employees with access to patients and patient records and whose employment began after 06/01/14.Staff F, G, H, I, J, K, L, and M A review of the personnel record showed no background checks through OKSCREEN. On 06/24/26 at 09:20am, Staff C stated OKSCREEN background checks for Staff F, G, H, I, J, K, L, and M were not for the hospice.”

“Based on record review and interview, the hospice failed to ensure completion of an initial plan of care no later than 5 calendar days after the election of hospice benefits for one (Patient #18) of 19 patients. Findings: Patient #18 A review of the clinical record showed an election of the hospice benefit on 10/24/23 with no completion of the initial POC from 10/24/23 to 11/07/23 date of the first IDG (14 days after election of the hospice benefit). Documentation showed no communications or notifications to the physician prior to the 11/07/23 IDG. On 04/03/24 at 2:49 p.m., Staff A stated the initial POC was not completed within the first five days after the election of the hospice benefit for patient #18.”

“Based on record review and interview, the hospice failed to ensure the IDG updated the plans of care to include scope and discipline frequencies prior to the recertification periods for nine (Patients #1, 2, 3, 5, 6, 7, 8, 12 and 16) of 19 patients. Findings: Patient #1 A review of the plan of care for the certification period 02/01/24 to 03/31/24 showed the POC was updated on 02/13/24 (12 days after the beginning of the certification period). IDG updates dated 01/16/24, 01/30/24 and on 02/06/24 showed no documentation of anticipated service scope and discipline frequencies for the recertification period of 02/01/24 to 03/31/24. Documentation showed no IDG communications and no physician notifications related to recertification scope of hospice services and discipline frequencies prior to the end of the POC ending on 01/31/24. Patient #2 A review of the plan of care for the certification period 02/21/24 to 04/20/24 showed the POC was updated on 02/27/24 (6 days after the beginning of the certification period). IDG updates dated 01/30/24 and on 02/13/24 showed no documentation of anticipated service scope and discipline frequencies for the recertification period of 02/21/24 to 04/20/24. Documentation showed no IDG communications and no physician notifications related to recertification scope of hospice services and discipline frequencies prior to the end of the POC ending on 02/20/24. Patient #3 A review of the plan of care for the certification period 03/07/24 to 05/05/24 showed the POC was updated on 03/12/24 (5 days after the beginning of the certification period). IDG updates dated 02/13/24 and on 02/27/24 showed no documentation of anticipated service scope and discipline frequencies for the recertification period of 03/07/24 to 05/05/24. Documentation showed no IDG communications and no physician notifications related to recertification scope of hospice services and discipline frequencies prior to the end of the POC ending on 03/06/24. Patient #5 A review of the plan of care for the certification period 03/06/24 to 05/04/24 showed the POC was updated on 03/12/24 (6 days after the beginning of the certification period). IDG updates dated 02/13/24 and on 02/27/24 showed no documentation of anticipated service scope and discipline frequencies for the recertification period of 03/06/24 to 05/04/24. Documentation showed no IDG communications and no physician notifications related to recertification scope of hospice services and discipline frequencies prior to the end of the POC ending on 03/05/24. Patient #6 A review of the plan of care for the certification period 03/21/24 to 05/19/24 showed the POC was updated on 03/26/24 (5 days after the beginning of the certification period). IDG updates dated 02/27/24 and on 03/12/24 showed no documentation of anticipated service scope and discipline frequencies for the recertification period of 03/21/24 to 05/19/24. Documentation showed no IDG communications and no physician notifications related to recertification scope of hospice services and discipline frequencies prior to the end of the POC ending on 03/20/24. Patient #7 A review of the plan of care for the certification period 03/05/24 to 05/03/24 showed the POC was updated on 03/12/24 (7 days after the beginning of the certification period). IDG updates dated 02/13/24 and on 02/27/24 showed no documentation of anticipated service scope and discipline frequencies for the recertification period of 03/05/24 to 05/03/24. Documentation showed no IDG communications and no physician notifications related to recertification scope of hospice services and discipline frequencies prior to the end of the POC ending on 03/04/24. Patient #8 A review of the plan of care for the certification period 01/17/24 to 04/15/24 showed the POC was updated on 01/26/24 (9 days after the beginning of the certification period). IDG updates dated 01/09/24 and on 01/23/24 showed no documentation of anticipated service scope and discipline frequencies for the recertification period of 01/17/24 to 04/15/24. Documentation showed no IDG communications and no physician notifications related to recertification scope of hospice services and discipline frequencies prior to the end of the POC ending on 01/16/24. Patient #12 A review of the plan of care for the certification period 03/05/24 to 05/03/24 showed the POC was updated on 03/12/24 (7 days after the beginning of the certification period). IDG updates dated 02/13/24 and on 02/27/24 showed no documentation of anticipated service scope and discipline frequencies for the recertification period of 03/05/24 to 05/03/24. Documentation showed no IDG communications and no physician notifications related to recertification scope of hospice services and discipline frequencies prior to the end of the POC ending on 03/04/24. Patient #16 A review of the plan of care for the certification period 12/21/23 to 02/19/24 showed the POC was updated on 12/29/24 (8 days after the beginning of the certification period). IDG updates dated 12/14/23 and on 12/26/23 showed no documentation of anticipated service scope and discipline frequencies for the recertification period of 12/21/23 to 02/19/24. Documentation showed no IDG communications and no physician notifications related to recertification scope of hospice services and discipline frequencies prior to the end of the POC ending on 12/20/23. On 04/03/24 at 2:49 p.m. to 3:15 p.m., Staff A stated the plans of care for patients #1, 2, 3, 5, 6, 7, 8, 12 and 16 were not updated and implemented by the IDG prior to the beginning of the patients recertification periods.”

“Based on record review and interview, the hospice failed to ensure patient refusal of social work services was communicated and addressed by the IDG for one (Patient #7) of 19 patients. Findings: Patient #7 A review of a POC dated 03/05/24 to 05/04/24 documented a MSW visit frequency of one time a month with IDG meetings to update the POC on 02/27/24, 03/12/24, and on 03/26/24. Documentation showed patient refusal of MSW visits on 02/23/24 and on 03/28/24. Documentation showed no attempts to reschedule the visits or follow up with the patient and showed no IDG team meeting discussions of patient refusal of MSW visits and no changes in MSW visit frequency. On 04/03/24 at 3:00 p.m., Staff A stated patient refusal of spiritual MSW visits should have been discussed during the IDG team meetings and the MSW visit frequency should have been addressed. Findings: Patient #7 A review of a POC dated 03/05/24 to 05/04/24 documented a MSW visit frequency of one time a month with IDG meetings to update the POC on 02/27/24, 03/12/24, and on 03/26/24. Documentation showed patient refusal of MSW visits on 02/23/24 and on 03/28/24. Documentation showed no attempts to reschedule the visits or follow up with the patient and showed no IDG team meeting discussions of patient refusal of MSW visits and no changes in MSW visit frequency. On 04/03/24 at 3:00 p.m., Staff A stated patient refusal of spiritual MSW visits should have been discussed during the IDG team meetings and the MSW visit frequency should have been addressed.”

“Based on record review and interview, the hospice failed to ensure an initial spiritual assessment was conducted by the Chaplain for one (Patient #19) of 19 patients. Findings: Patient #19 A review of the clinical record showed an election of the hospice benefit on 09/19/23 with no completion of the spiritual assessment prior to the patients death on 10/06/23 (17 days after the initial comprehensive assessment). Documentation showed no declined chaplain visits and no changes in orders. On 04/03/24 at 2:55 p.m., Staff A stated the Chaplain had not conducted the initial spiritual assessment for patient #19 within the five day timeframe required to complete the initial comprehensive assessment.”

“Based on record review and interview, the hospice failed to ensure documentation of physician certificate of terminal illness for subsequent certification periods for one (Patient #4) of 19 patients. Findings: Patient #4 A review of the clinical record showed a plan of care dated 02/27/24 to 04/26/24. Documentation showed a certificate of terminal illness dated 12/26/23. Documentation showed no certificate of terminal illness for subsequent certification period of 02/27/24 to 04/26/24. On 04/03/24 at 3:05 p.m., Staff A stated patient #4 had no certificate of terminal illness or related physician statement of imminence of death for subsequent certification period of 02/27/24 to 04/26/24.”