Trinity Hospice

“Based on record review and interview, the hospice failed to ensure contact information for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for all patients and employees. Findings: A review of administrative records showed no contact information for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for the agency. On 08/20/24 at 2:00 p.m., Staff A stated the hospices Emergency Preparedness Plan did not include resource contact information for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials.”

“Based on record review and interview, the hospice failed to ensure emergency preparedness disaster declaration, table-top exercises, drills, community drills or plan activation events were conducted for 05/01/2022 to 12/31/22, calendar year 2023 and 01/01/24 to 08/19/24 for all patients, volunteers, and employees. Findings: A review of administrative records related to emergency preparedness showed no documentation of emergency preparedness disaster declaration, table-top exercises, drills, community drills or plan activation events for 05/01/2022 to 12/31/22, calendar year 2023 and 01/01/24 to 08/19/24. On 08/20/24 at 2:00 p.m., Staff A stated the hospice had no emergency preparedness disaster declaration, table-top exercises, drills, community drills or plan activation events for 05/01/2022 to 12/31/22, calendar year 2023 and 01/01/24 to 08/19/24.”

“Based on record review and interview, the hospice failed to ensure: 1. Initial spiritual assessments were conducted by the Chaplain within the five-day timeframe required to complete the initial comprehensive assessment for two (Patients #5 and #7) of 14 patients. 2. Initial psychosocial assessments were conducted by the MSW within the five-day timeframe required to complete the initial comprehensive assessment for one (Patients #5) of 14 patients. Findings: Patient #5 A review of the clinical record showed an election of the hospice benefit/SOC on 05/16/24. Documentation showed a spiritual assessment was conducted on 05/22/21 (6 days from the date of election) and a psychosocial assessment was conducted on 05/24/21 (8 days from the date of election). Documentation showed no declined chaplain or MSW visits and no changes in orders. On 08/21/24 at 9:38 a.m., Staff A stated the Chaplain and MSW had not conducted the initial spiritual and psychosocial assessments for patient #5 within the five-day timeframe required to complete the initial comprehensive assessment. Patient #7 A review of the clinical record showed an election of the hospice benefit/SOC on 06/11/24. Documentation showed a spiritual assessment was conducted on 06/17/24 (6 days from the date of election). Documentation showed no declined chaplain visits and no changes in orders. On 08/21/24 at 9:42 a.m., Staff A stated the Chaplain had not conducted the initial spiritual assessment for patient #7 within the five-day timeframe required to complete the initial comprehensive assessment.”

“Based on record review and interview, the hospice failed to ensure development of a bereavement POC for 11 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11) of 14 patients. Findings: Patient #1 A review of the clinical record showed an initial bereavement assessment dated 08/09/24 with no IDG update. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #2 A review of the clinical record showed an initial bereavement assessment dated 08/09/24 with no IDG update. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #3 A review of the clinical record showed an initial bereavement assessment dated 04/02/24 with later IDG updates on 06/25/24, 07/10/24, 07/25/24 and 08/07/24. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #4 A review of the clinical record showed an initial bereavement assessment dated 06/21/24 with later IDG updates on 06/25/24, 07/10/24, 07/25/24 and 08/07/24. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #5 A review of the clinical record showed an initial bereavement assessment dated 05/22/24 with IDG updates on 05/29/24, 06/13/24, 06/25/24, 07/10/24, 07/25/24 and 08/07/24. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #6 A review of the clinical record showed an initial bereavement assessment dated 06/07/24 with later IDG updates on 06/25/24, 07/10/24, 07/25/24 and 08/07/24. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #7 A review of the clinical record showed an initial bereavement assessment dated 06/17/24 with later IDG updates on 06/25/24, 07/10/24, 07/25/24 and 08/07/24. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #8 A review of the clinical record showed an initial bereavement assessment dated 06/21/24 with later IDG updates on 06/25/24, 07/10/24, 07/25/24 and 08/07/24. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #9 A review of the clinical record showed an initial bereavement assessment dated 03/01/24 with later IDG updates on 06/25/24, 07/10/24, 07/25/24 and 08/07/24. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #10 A review of the clinical record showed an initial bereavement assessment dated 07/31/24 with IDG updates on 08/07/24. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #11 A review of the clinical record showed a SOC on 05/23/24 and an initial bereavement assessment dated 06/27/24 with IDG updates on 05/24/24, 06/10/24, 06/25/24, 07/10/24, 07/25/24 and 08/07/24. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. On 08/21/24 at 9:27 a.m. to 9:55 a.m., Staff A stated patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11 had no bereavement POCs. On 08/21/24 at 11:52 a.m., Staff H stated Bereavement POCs are developed and put into place after a patient passes away.”

“Based on record review and interview, the hospice failed to ensure: 1. Aide visits were provided in accordance with the plan of care for eight (Patients #1, 2, 3, 4, 5, 6, 7 and 8) of 14 patients; 2. SN visits were provided in accordance with the plan of care for seven (Patients #3, 4, 5, 6, 7, 8 and 10) of 14 patients; 3. Social work services were provided in accordance with the plan of care for one (Patients #9) of 14 patients; 4. Chaplain services were provided in accordance with the plan of care for one (Patients #9) of 14 patients. Findings: Patient #1 A review of a POC dated 08/07/24 to 11/05/24 with IDG updates on 08/08/24 showed documentation of an aide visit frequency of three times a week. Documentation showed during the weeks of: 08/07/24 to 08/10/24 (one aide visit was conducted, three aide visits ordered); 08/11/24 to 08/17/24 (no aide visit was conducted, three aide visits ordered). Documentation showed no communications between the IDG and showed no changes in the ordered aide visit frequencies. On 08/21/24 at 9:27 a.m., Staff A stated aide visits were not provided in accordance with the POC for patient #1. Patient #2 A review of a POC dated 08/07/24 to 11/05/24 with IDG updates on 08/08/24 showed documentation of an aide visit frequency of three times a week. Documentation showed during the weeks of: 08/07/24 to 08/10/24 (one aide visit was conducted, three aide visits ordered); 08/11/24 to 08/17/24 (two aide visits were conducted, three aide visits ordered). Documentation showed no communications between the IDG and showed no changes in the ordered aide visit frequencies. On 08/21/24 at 9:30 a.m., Staff A stated aide visits were not provided in accordance with the POC for patient #2. Patient #3 A review of a POC dated 06/27/24 to 09/24/24 with IDG updates on 05/24/24, 06/10/24, 06/25/24, 07/10/24, 07/25/24 and 08/07/24 showed documentation of an aide visit frequency of three times a week and SN visit frequency of two times a week. Documentation showed during the weeks of: 06/27/24 to 06/29/24 (one aide visit was conducted, three aide visits ordered; ono SN visit was conducted, two SN visits ordered); 07/14/24 to 07/20/24 (two aide visits were conducted, three aide visits ordered); 07/21/24 to 07/27/24 (two aide visits were conducted, three aide visits ordered); 07/28/24 to 08/03/24 one SN visit was conducted, two SN visits ordered); 08/04/24 to 08/10/24 (two aide visits were conducted, three aide visits ordered). Documentation showed no communications between the IDG and showed no changes in the ordered aide or SN visit frequencies. On 08/21/24 at 9:35 a.m., Staff A stated aide and SN visits were not provided in accordance with the POC for patient #3. Patient #4 A review of a POC dated 06/20/24 to 09/18/24 with IDG updates on 06/25/24, 07/10/24, 07/25/24 and 08/07/24 showed documentation of an aide visit frequency of three times a week and SN visit frequency of two times a week. Documentation showed during the weeks of: 06/20/24 to 06/22/24 (one aide visit was conducted, three aide visits ordered); 06/30/24 to 07/06/24 (one SN visit was conducted, two SN visits ordered); 07/28/24 to 08/03/24 (one aide visit was conducted, three aide visits ordered); 08/04/24 to 08/10/24 (one SN visit was conducted, two SN visits ordered). Documentation showed no communications between the IDG and showed no changes in the ordered aide or SN visit frequencies. On 08/21/24 at 9:37 a.m., Staff A stated aide and SN visits were not provided in accordance with the POC for patient #4. Patient #5 A review of a POC dated 05/16/24 to 08/14/24 with IDG updates on 05/24/24, 06/10/24, 06/25/24, 07/10/24, 07/25/24 and 08/07/24 showed documentation of an aide visit frequency of three times a week and SN visit frequency of two times a week. Documentation showed during the weeks of: 05/16/24 to 05/18/24 (one aide visit was conducted, three aide visits ordered); 05/19/24 to 05/25/24 (two aide visits were conducted, three aide visits ordered); 06/09/24 to 06/15/24 (one SN visit was conducted, two SN visits ordered); 06/16/24 to 06/22/24 (one aide visit was conducted, three aide visits ordered); 06/30/24 to 07/06/24 (one aide visit was conducted, three aide visits ordered; one SN visit was conducted, two SN visits ordered); 07/07/24 to 07/13/24 (one aide visit was conducted, three aide visits ordered); 08/04/24 to 08/10/24 (one aide visit was conducted, three aide visits ordered; one SN visit was conducted, two SN visits ordered); 08/11/24 to 08/17/24 (one aide visit was conducted, three aide visits ordered). Documentation showed no communications between the IDG and showed no changes in the ordered aide or SN visit frequencies. On 08/21/24 at 9:38 a.m., Staff A stated aide and SN visits were not provided in accordance with the POC for patient #5. Patient #6 A review of a POC dated 06/06/24 to 09/04/24 with IDG updates on 06/10/24, 06/25/24, 07/10/24, 07/25/24 and 08/07/24 showed documentation of an aide visit frequency of three times a week and SN visit frequency of two times a week. Documentation showed during the weeks of: 06/06/24 to 06/08/24 (no aide visit was conducted, three aide visits ordered); 06/16/24 to 06/22/24 (one aide visit was conducted, three aide visits ordered); 06/30/24 to 07/06/24 (two aide visits were conducted, three aide visits ordered; one SN visit was conducted, two SN visits ordered); 07/07/24 to 07/13/24 (one SN visit was conducted, two SN visits ordered); 08/04/24 to 08/10/24 (one aide visit was conducted, three aide visits ordered); 08/11/24 to 08/17/24 (one aide visit was conducted, three aide visits ordered). Documentation showed no communications between the IDG and showed no changes in the ordered aide or SN visit frequencies. On 08/21/24 at 9:40 a.m., Staff A stated aide and SN visits were not provided in accordance with the POC for patient #6. Patient #7 A review of a POC dated 06/11/24 to 09/09/24 with IDG updates on 06/25/24, 07/10/24, 07/25/24 and 08/07/24 showed documentation of an aide visit frequency of three times a week and SN visit frequency of two times a week. Documentation showed during the weeks of: 06/11/24 to 06/16/24 (one aide visit was conducted, three aide visits ordered); 07/07/24 to 07/13/24 (two aide visits were conducted, three aide visits ordered); 07/21/24 to 07/27/24 (two aide visits were conducted, three aide visits ordered; one SN visit was conducted, two SN visits ordered). Documentation showed no communications between the IDG and showed no changes in the ordered aide or SN visit frequencies. On 08/21/24 at 9:42 a.m., Staff A stated aide and SN visits were not provided in accordance with the POC for patient #7. Patient #8 A review of a POC dated 06/18/24 to 09/16/24 with IDG updates on 06/25/24, 07/10/24, 07/25/24 and 08/07/24 showed documentation of an aide visit frequency of three times a week and SN visit frequency of two times a week. Documentation showed during the weeks of: 06/23/24 to 06/29/24 (one aide visit was conducted, three aide visits ordered); 06/30/24 to 07/06/24 (two aide visits were conducted, three aide visits ordered; one SN visit was conducted, two SN visits ordered); 07/07/24 to 07/13/24 (one aide visit was conducted, two aide visits ordered); 07/14/24 to 07/20/24 (two aide visits were conducted, three aide visits ordered); 08/04/24 to 08/10/24 (two aide visits were conducted, three aide visits ordered); 08/11/24 to 08/17/24 (one SN visit was conducted, two SN visits ordered). Documentation showed no communications between the IDG and showed no changes in the ordered aide or SN visit frequencies. On 08/21/24 at 9:44 a.m., Staff A stated aide and SN visits were not provided in accordance with the POC for patient #8. Patient #9 A review of a POC dated 02/29/24 to 05/29/24 with IDG updates on 03/06/24, 03/20/24, 04/03/24, 04/17/24, 05/01/24, and 05/15/24 showed documentation of an MSW visit frequency of one time a month and Chaplain visit frequency of one time a month. Documentation showed during the months of April and May no MSW or Chaplain visits were conducted (two visits ordered, no visits scheduled and/or conducted). Documentation showed no communications between the IDG and showed no changes in the ordered MSW or Chaplain visit frequencies. On 08/14/24 at 12:40 p.m., Staff B stated MSW and Chaplain visits were not provided in accordance with the POC for patient #9. Patient #10 A review of the clinical record showed a SOC date of 07/24/24. Documentation showed no POC. An IDG update on 08/08/24 showed documentation of an SN visit frequency of two times a week. Documentation showed during the week of 08/04/24 to 08/10/24 (one SN visit was conducted, two SN visits were ordered). Documentation showed no communications between the IDG and showed no changes in the ordered SN visit frequency. On 08/21/24 at 9:52 a.m., Staff A stated SN visits were not provided in accordance with the POC for patient #10.”

“Based on record review and interview, the hospice failed to ensure the plans of care included a hospice diagnosis and a frequency and duration of visits for MSW and Chaplain services for one (Patient #8) of 14 patients. Findings: Patient #8 A recertification plan of care dated 06/18/24 and IDG updates to the POC on 06/27/24, 07/10/24, 07/25/24 and on 08/08/24 documented no hospice diagnosis and no and a frequency and duration of visits for MSW and Chaplain services. On 08/21/24 at 9:44 a.m., Staff A stated the recertification POC had no hospice diagnosis and no and a frequency and duration of visits for MSW and Chaplain services for patient #8.”

“Based on record review and interview, the hospice failed to ensure the IDG: 1. Updated the plans of care the recertification periods for one (Patients #9) of 14 patients and; 2. Developed and initiated a POC after the SOC for one (Patient #10) of 14 patients. Findings: Patient #9 A review of a POC dated 02/29/24 to 05/29/24 with IDG updates on 03/06/24, 03/20/24, 04/03/24, 04/17/24, 05/01/24, 05/15/24 and 05/29/24 showed no documentation of a POC for the subsequent recertification periods starting on 05/30/24. IDG updates dated 06/13/24, 06/25/24, 0710/24, 07/25/24 and on 08/07/24 showed no documentation of anticipated service scope and discipline frequencies for the recertification period of 05/30/24 to 07/29/24 and 07/30/24 to 09/28/24. 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 05/29/24. On 08/21/24 at 9:46 a.m., Staff A stated the recertification plans of care for patients #9 were not updated and implemented by the IDG prior to the beginning of the patients recertification periods after 05/29/24. Patient #10 A review of the clinical record showed a SOC date of 07/24/24. Documentation showed no POC. An IDG update on 08/08/24 showed documentation of an SN visit frequency of two times a week. Documentation showed during the week of 08/04/24 to 08/10/24 (one SN visit was conducted, two SN visits were ordered). Documentation showed no communications between the IDG and showed no changes in the ordered SN visit frequency. On 08/21/24 at 9:52 a.m., Staff A stated the plans of care for patients #10 was not completed and implemented by the IDG within five days of the SOC on 07/24/24.”

“Based on record review and interview, the hospice failed to ensure its QAPI Program showed measurable improvement in indicators related to improved palliative outcomes and hospice services for all patients, employees and volunteers. Findings: Administrative records related to the QAPI program for the hospice were requested. No administrative records related to the QAPI program were provided. On 08/20/24 at 9:30 a.m., Staff A stated the hospice had no administrative records related to the QAPI program for the hospice for calendar years 2022 and 2023. Additional request for administrative records yielded no results. On 08/21/24 at 9:20 a.m., Staff A stated: 1. The hospice had no QAPI program records for calendar years 2022, 2023 and 01/01/24 to 08/20/24; and 2. The hospice was presently auditing patient records as a part of QAPI activities, but the hospice had not conducted a QAPI meeting in 2024.”

“Based on record review and interview, the hospice failed to ensure implementation and evaluation of PIPs for all patients, employees and volunteers. Findings: Administrative records related to the QAPI program for the hospice were requested. No administrative records related to the QAPI program were provided. On 08/20/24 at 9:30 a.m., Staff A stated the hospice had no administrative records related to the QAPI program for the hospice for calendar years 2022 and 2023. Additional request for administrative records yielded no results. On 08/21/24 at 9:20 a.m., Staff A stated: 1. The hospice had no QAPI program records for calendar years 2022, 2023 and 01/01/24 to 08/20/24; and 2. The hospice was presently auditing patient records as a part of QAPI activities, but the hospice had not conducted a QAPI meeting in 2024.”

“Based on record review and interview, the hospice failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities for all patients, volunteers, and employees. Findings: A review of administrative records showed no governing body oversite of an ongoing QAPI program for the hospice for calendar years 2022, 2023 and 01/01/24 to 08/20/24. Additional requests for administrative records yielded no results. On 08/21/24 at 9:20 a.m., Staff A stated the hospice had no documentation which showed governing body oversite of QAPI program activities that included review and approval of data collection, analysis, implementation and follow up of QAPI activities for calendar years 2022, 2023 and 01/01/24 to 08/20/24.”

“Based on record review and interview, the hospice failed to ensure its infection control program surveillance monitoring and reporting was included in QAPI program activities for calendar years 2022, 2023 and 01/01/24 to 08/20/24 for all patients, volunteers, and employees. Findings: Administrative records related to the QAPI program for the hospice were requested. No administrative records related to the QAPI program were provided. On 08/20/24 at 9:30 a.m., Staff A stated the hospice had no administrative records related to the QAPI program for the hospice for calendar years 2022 and 2023. Additional request for administrative records yielded no results. On 08/21/24 at 9:20 a.m., Staff A stated: 1. The hospice had no QAPI program records for calendar years 2022, 2023 and 01/01/24 to 08/20/24; 2. The hospice had not conducted a QAPI meeting in 2024; and The hospice had no infection surveillance data for calendar years 2022, 2023 and 01/01/24 to 08/20/24.”

“Based on record review and interview, the hospice failed to ensure volunteer services were a part of the hospice program for all patients, caregivers, and employees. Findings: A review of administrative records showed no hospice program volunteer activities from 05/12/23 to 08/20/24. On 08/21/24 at 10:35 a.m., a review of a personnel record for Staff I showed a job description as a medical social worker and showed no documentation or job description as the volunteer coordinator for the hospice. At 10:45 a.m., Staff A stated: 1. The hospice had no administrative records which showed volunteer service activities 05/12/23 to 08/20/24 and; 2. The hospice had no volunteer personnel other than the Volunteer Coordinator (identified as Staff I). At 11:05 a.m., Staff I stated: 1. She was the volunteer coordinator for the hospice; and 2. The hospice had no volunteer personnel for administrative or patient/caregiver related activities.”

“Based on observation, record review and interview, the hospice failed to ensure the IDG communicated and coordinated the patients care with the residential care facility for four (Patients #1, 2, 4 and #8) of 14 patients. Findings: Patient #1 A review of the POC dated 08/07/24 to 11/05/24 showed orders for SN two times a week; hospice aide three times a week; medical social work one time a month; and chaplain services one time a month for palliation and management of terminal illness related to dementia. Documentation showed no IDG communications or coordination of care with the residential care facility. Patient #2 A review of the POC dated 08/07/24 to 11/05/24 showed orders for SN two times a week and hospice aide three times a week for palliation and management of terminal illness related to malnutrition. Documentation showed no IDG communications or coordination of care with the residential care facility. Patient #4 A review of the POC dated 06/20/24 to 09/18/24 showed orders for SN two times a week and hospice aide three times a week; medical social work one time a month; and chaplain services one time a month for palliation and management of terminal illness related to Alzheimers disease. Documentation showed no IDG communications or coordination of care with the residential care facility. Patient #8 A review of the POC dated 06/18/24 to 09/16/24 showed orders for SN two times a week and hospice aide three times a week for palliation and management of terminal illness related to Alzheimers disease. Documentation showed no IDG communications or coordination of care with the residential care facility. On 08/20/24 at 4:00 p.m., Residential Care Facility Staff #1 stated: 1. The hospice should leave a written report of any changes in a patient during a visit; 2. The hospice has not provided a POC which documented care services provided to patients #1, 2, 4 and #8; and 3. She did not know what disciplines of care or visit frequency and duration of each service discipline patients #1, 2, 4 and #8 received from the hospice. At 4:15 p.m., a review of the hospice binders (home chart) in the residential care facility for patients #1, 2 and #4 showed no POC or written communication by the IDG as an update to the POC; and patient #8 had no hospice binder (home chart) in the residential care facility. On 08/21/24 at 9:27 a.m. to 9:44 a.m., Staff A stated: 1. Documentation for patients #1, 2, 4 and #8 showed no IDG communications or coordination of care with the residential care facility and; 2. Each patient should have had an updated POC at each certification period and/or when the POC was changed by the IDG.”

“Based on record review and interview, the agency failed to ensure required background checks were completed for six (Staff D, E, F, G, H and I) of six employee files 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 D A review of the personnel record showed no documentation of a background check through OKSCREEN. Staff E A review of the personnel record showed no documentation of a background check through OKSCREEN. Staff F A review of the personnel record showed no documentation of a background check through OKSCREEN. Staff G A review of the personnel record showed no documentation of a background check through OKSCREEN. Staff H A review of the personnel record showed no documentation of a background check through OKSCREEN. Staff I A review of the personnel record showed no documentation of a background check through OKSCREEN. On 08/21/24 at 10:30 a.m., Staff A stated Staff D, E, F, G, H and I had no background check through the OkScreen database.”