Carter Healthcare Hospice of East Oklahoma, LLC

“Based on record review and interview, the hospice failed to ensure imminence of death was assessed during the comprehensive assessment for six (Patients #1, 5, 6, 9, 10 and 13) of 14 patients. Patient #1 A review of the Initial Comprehensive Assessment dated 11/20/24 showed no assessment of imminence of death. Patient #5 A review of the Initial Comprehensive Assessment dated 01/07/25 showed no assessment of imminence of death. Patient #6 A review of the Initial Comprehensive Assessment dated 12/31/24 showed no assessment of imminence of death. Patient #9 A review of the Initial Comprehensive Assessment dated 01/20/25 showed no assessment of imminence of death. Patient #10 A review of the Initial Comprehensive Assessment dated 03/12/25 showed no assessment of imminence of death. Patient #13 A review of the Initial Comprehensive Assessment dated 12/09/24 showed no assessment of imminence of death. On 03/18/25 at 1:07 pm., Staff A stated the imminence of death was not assessed on the Initial Comprehensive Assessment for Patients #1, 5, 6, 9, 10 and 13.”

“Based on record review and interview, the hospice failed to ensure supervisory visits were completed every 14 days for six (Patient #1, 2, 3, 4, 5 and 8) of 14 patients. Patient #1 A review of the plan of care dated 11/20/24 to 01/18/25 and plan of care updates dated 12/04/24, 12/18/24, 01/02/25 and 01/15/25 showed a hospice aide frequency of two visits per week for one week and three visits per week for eight weeks. A review of the clinical record showed the following: Hospice aide visits were conducted 12/02/24, 12/04/24 and 12/06/24 for the week of 12/01/24 to 12/01/24. Hospice aide visits were conducted 12/10/24, 12/11/24 and 12/13/24 for the week of 12/08/24 to 12/14/24. Hospice aide visits were conducted 12/26/24, 12/18/24 and 12/20/20 for the week of 12/15/24 to 12/21/24. A review of supervisory visits showed supervisory aide visits were performed on 12/02/24 and 12/17/24 (15 days between supervisory aide visits). Patient #2 A review of the plan of care dated 11/28/24 to 01/26/25 and plan of care updates dated 12/04/24, 12/18/24, 01/02/25 and 01/15/25 showed a hospice aide frequency of three visits per week for eight weeks. A review of the clinical record showed the following: Hospice aide visits were conducted 12/30/24, 01/02/25 and 01/03/25 for the week of 12/29/24 to 01/04/25. Hospice aide visits were conducted 01/06/25, 01/08/25 and 01/10/25 (a missed visit) for the week of 01/05/25 to 01/11/25. Hospice aide visits were conducted 01/13/25, 01/15/25 and 01/17/25 for the week of 01/12/25 to 01/18/25. A review of supervisory visits showed supervisory aide visits were performed on 12/30/24 and 01/15/25 (16 days between supervisory aide visits). Patient #3 A review of the plan of care dated 12/20/24 to 03/19/25 and plan of care updates dated 01/02/25, 01/15/25, 01/29/25 and 02/12/2504/24 showed a hospice aide frequency of two visits per week for 12 weeks. A review of the clinical record showed the following: Hospice aide visits were conducted 12/30/24 (a missed visit) and 01/02/25 for the week of 12/29/24 to 01/04/25. Hospice aide visits were conducted 01/07/25 and 01/09/25 for the week of 01/05/25 to 01/11/25. Hospice aide visits were conducted 01/14/25 (a missed visit) and 01/16/25 for the week of 01/12/25 to 01/18/25. A review of supervisory visits showed supervisory aide visits were performed on 01/01/25 and 01/17/25 (16 days between supervisory aide visits). Patient #4 A review of the plan of care dated 11/25/24 to 02/22/25 and plan of care updates dated 12/04/24, 12/18/24, 01/02/25 and 01/15/25 showed a hospice aide frequency of two visits per week for 13 weeks. A review of the clinical record showed the following: Hospice aide visits were conducted 12/31/24 and 01/02/25 for the week of 12/29/24 to 01/04/25. Hospice aide visits were conducted 01/07/25 and 01/09/25 for the week of 01/05/25 to 01/11/25. Hospice aide visits were conducted 01/14/25 and 01/16/25 for the week of 01/12/25 to 01/18/25. A review of supervisory visits showed supervisory aide visits were performed on 01/01/25 and 01/17/25 (16 days between supervisory aide visits). Patient #5 A review of the plan of care dated 01/07/25 to 04/06/25 and plan of care updates dated 01/15/25, 01/29/25, 02/12/25 and 02/26/25 showed a hospice aide frequency of two visits per week for 13 weeks. A review of the clinical record showed the following: Hospice aide visits were conducted 01/28/25 and 01/30/25 for the week of 01/26/25 to 02/01/25. Hospice aide visits were conducted 02/04/25 and 01/06/25 for the week of 02/02/25 to 02/08/25. Hospice aide visits were conducted 02/11/25 and 02/13/25 for the week of 02/09/25 to 02/15/25. A review of supervisory visits showed supervisory aide visits were performed on 01/30/25 and 02/14/25 (15 days between supervisory aide visits). Patient #8 A review of the plan of care dated 12/17/24 to 02/14/25 and plan of care updates dated 12/18/24, 01/02/25, 01/15/25, 01/27/25 and 02/12/25 showed a hospice aide frequency of two visits per week for one week and three visits per week for eight weeks. A review of the clinical record showed the following: Hospice aide visits were conducted 12/23/24, 12/25/24 (a missed visit) and 12/27/24 for the week of 12/22/24 to 12/28/24. Hospice aide visits were conducted 12/30/24, 01/01/25 and 01/02/25 for the week of 12/29/24 to 01/04/25. Hospice aide visits were conducted 01/06/25, 01/08/25 and 01/10/25 (a missed visit) for the week of 01/05/25 to 01/11/25. A review of supervisory visits showed supervisory aide visits were performed on 12/27/24 and 01/14/25 (28 days between supervisory aide visits). On 03/18/25 at 1:40 pm., Staff A stated supervisory aide visits were not conducted within 14 days for Patients #1, 2, 3, 4, 5 and 8.”