Heartland Hospice (Mcalester)

“Upon patient record review, 2 of 19 (Patient #2,3) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #2 No evidence of Miralax listed on the patient medication profile, however caregiver stated that patient is receiving Miralax every am. Patient #3 Had continuous oxygen flowing at 3LPM continuous during home visit, the current order written upon start care (8.15.24) states 2/LPM. Upon chart review it was noted the RN documentation dated 3.21.25 stated patient was at 3 LPM nasal cannula”

“Upon patient record review, 1 of 19 (Patient #3) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #3 No evidence that the bereavement risk was completed within the 5 calendar days of the hospice election date. Patient was admitted 8.15.24. On 10.3.24, the medical record shows a note that states there are no bereavement contacts. On 10.15.24, a bereavement risk assessment was completed.”

“Upon patient record review, 1 of 19 (Patient# 3) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #3 Record indicated that the patient developed a new stage II wound on 1.20.25. Wound care orders remained active through 3.21.25. There was no evidence that wounds were measured weekly since the time the wound was added to the plan of care. Gentiva policy states wounds must be assessed and documented weekly”

“Upon patient record review, 4 of 19 (Patient #1, #3, #5, #13) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: The medical record indicates patient taking Senna prn and scheduled colace daily for constipation. No evidence that constipation was added to the current plan of care. No evidence of problems, interventions or goals added to address constipation. Patient #3: The medical record showed evidence that diabetes is listed as an active diagnosis. Patient’s medication list includes insulin and an oral diabetic agent. There was no evidence of problems, interventions and goals listed on the active plan of care related to diabetes. Patient #5: The medical record indicated patient taking depakote and seroquel to manage behaviors. There was no evidence of behavior management on the current plan of care. No evidence of problems, interventions or goals added to address behaviors Patient #13: The medical record indicated the patient has a gastrostomy tube placed for medication administration and parenteral feedings. No evidence that aspiration precaution problems, interventions or goals were added to the patients plan of care”

“Upon patient record review, 2 of 19 (Patient #2,3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2 During the home visit, the caregiver mentioned the patient was receiving Miralax daily for constipation. There was no evidence of an order for Miralax. Patient #3 The medical record indicated that the patient had a foley catheter since the time of admission, this was reflected in both nursing documentation and physician documentation. There was no evidence of an order to include catheter size, maintenance, type of catheter or change frequency.”

“Upon patient record review, 2 of 19 (Patient #17, 18) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #17, 18 The chart did not show evidence of 3, 6, 9, 12 month letters that were sent to the appropriate bereaved.”

“Upon patient record review 2 of 19 (Patient #1,6) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1 Plan of care has aide frequency ordered at 3 times per week, for the week of 3.17.25 there was no evidence that the patient received 3 visits. The medical record showed evidence that one visit occurred on 03/19/2025. Missed visit entered by the aide on 03/17/2025 stated that the visit was missed due to the aide having car problems. No evidence that this visit was missed at the request of the patient or caregiver and no evidence that an order was received to change the frequency for that week. Patient #6 Initial plan of care has aide frequency ordered for 4 times per week; the medical record showed documentation that only 2 aide visits were completed per week from start of care to current with 2 aides completed each visits. No evidence of missed visit notes were entered throughout.”

“Upon patient record review, 3 of 19 (Patient #3, #5, #7) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #3 The medical record indicated that the aide entered a missed visit note on 3.14.25 and 3.21.25 that were not complete. No evidence that a reason was stated as to why the visit was missed. Patient #5 During record review, the CTI dated 12.24.24 had a physician narrative with multiple grammatical errors “lower ext edam whit” and “needs to be masintane donhospice” There was no evidence that a correction was made Patient #7 The medical record indicated that the aide entered missed visit notes on 3.19.25 and 3.23.25 that were not complete. No evidence that a reason was stated as to why the visit was missed.”