Lifespring Hospice

“Based on record review and interview, the agency failed to ensure emergency preparedness disaster table-top exercises, drills, community drills or plan activation events were conducted at the agency’s branch operations for calendar years 2024 and 2025 for all patients and employees. Findings: A review of emergency preparedness records showed no emergency preparedness disaster table-top exercises, drills, community drills or plan activation events for the agency’s branch site operations located in Chickasha and Pauls Valley in calendar years 2024 and 2025. On 04/17/25 at 11:00 a.m., Staff B stated Chickasha and Pauls Valley locations did not have exercises, drills, events in 2024 and 2025.”

“Based on record review and interview, the hospice failed to ensure: 1.Medical social work completion of the initial psychosocial assessment no later than five calendar days after the election of hospice care for nine (Patients #3, 4, 5, 6, 8, 9, 10, 12 and #16) of 20 patients. 2.Chaplain completion of the initial spiritual assessment no later than five calendar days after the election of hospice care for six (Patients #4, 5, 6, 10, 12 and#16) of 20 patients. Findings: Patient #3A review of the clinical record showed an election of the hospice benefit on 03/18/26 with no completion of an initial psychosocial assessment from 03/18/26 to 04/16/26 (30 days after election of the hospice benefit) and showed no patient or caregiver refusal of medical social worker services/visits. On 04/17/26 at 12:35 p.m., Staff C stated the initial psychosocial assessment had not been completed within the first five days after election of the hospice benefit. Patient #4A review of the clinical record showed an election of the hospice benefit on 09/10/22 with:1.No completion of an initial psychosocial assessment after election of the hospice benefit and no patient or caregiver refusal of medical social worker services/visits. 2.No completion of an initial spiritual assessment after election of the hospice benefit and no patient or caregiver refusal of medical social worker or chaplain services/visits. A review of a POC dated 02/21/26 to 04/21/26 showed no medical social work and no chaplain services/visits and showed no documentation of patient or caregiver refusal of medical social worker or chaplain services/visits. On 04/17/26 at 12:42 p.m., Staff C stated the initial psychosocial assessment, and spiritual assessments had not been completed within the first five days after election of the hospice benefit. Patient #5A review of the clinical record showed an election of the hospice benefit on 09/10/22 with:1.Completion of an initial psychosocial assessment on 03/06/26 (nine days after election of the hospice benefit) and showed no patient or caregiver refusal of medical social worker services/visits. 2.No completion of an initial spiritual assessment after election of the hospice benefit and showed no patient or caregiver refusal of chaplain services/visits. A review of a POC dated 02/26/26 to 05/26/26 showed no chaplain services/visits and showed no documentation of patient or caregiver refusal of chaplain services/visits. On 04/17/26 at 1:00 p.m., Staff C stated the initial psychosocial assessment was conducted late, and the comprehensive spiritual assessments had not been completed within the first five days after election of the hospice benefit. Patient #6A review of the clinical record showed an election of the hospice benefit on 09/20/24 with:1.No completion of an initial psychosocial assessment by 09/25/24 (five days after election of the hospice benefit) and showed no patient or caregiver refusal of medical social worker services/visits. 2.Completion of an initial spiritual assessment on 10/03/24 (13 days after election of the hospice benefit) and showed no patient or caregiver refusal of chaplain services/visits. On 04/17/26 at 1:05 p.m., Staff C stated the initial psychosocial assessment was not conducted, and the comprehensive spiritual assessments had not been completed within the first five days after election of the hospice benefit. Patient #8A review of the clinical record showed an election of the hospice benefit on 09/13/24 with no completion of an initial psychosocial assessment by 09/18/24 (five days after election of the hospice benefit) and showed no patient or caregiver refusal of medical social worker services/visits. On 04/17/26 at 1:20 p.m., Staff C stated the initial psychosocial assessment was not conducted within the first five days after election of the hospice benefit. Patient #9A review of the clinical record showed an election of the hospice benefit on 04/02/26 with completion of an initial psychosocial assessment on 04/11/26 (nine days after election of the hospice benefit) and showed no patient or caregiver refusal of medical social worker services/visits. On 04/17/26 at 1:25 p.m., Staff C stated the initial psychosocial assessment was not conducted within the first five days after election of the hospice benefit. Patient #10A review of the clinical record showed an election of the hospice benefit on 03/20/26 with:1.No completion of an initial psychosocial assessment by 03/25/26 (five days after election of the hospice benefit) and showed no patient or caregiver refusal of medical social worker services/visits. 2.No completion of an initial spiritual assessment by 03/25/26 (five days after election of the hospice benefit) and showed no patient or caregiver refusal of chaplain services/visits. On 04/17/26 at 1:26 p.m., Staff C stated the initial psychosocial assessment, and the comprehensive spiritual assessments had not been completed within the first five days after election of the hospice benefit.Patient #12A review of the clinical record showed an election of the hospice benefit on 06/11/25 with:1.Completion of an initial psychosocial assessment on 08/27/25 (77 days after election of the hospice benefit) and showed no patient or caregiver refusal of medical social worker services/visits. 2.Completion of an initial spiritual assessment on 06/23/25 (12 days after election of the hospice benefit) and showed no patient or caregiver refusal of chaplain services/visits. On 04/17/26 at 1:32 p.m., Staff C stated the initial psychosocial assessment, and the comprehensive spiritual assessments had not been completed within the first five days after election of the hospice benefit. Patient #16A review of the clinical record showed an election of the hospice benefit on 09/27/24 with:1.No completion of an initial psychosocial assessment by 10/01/24 (five days after election of the hospice benefit) and showed no patient or caregiver refusal of medical social worker services/visits. 2.No completion of an initial spiritual assessment by 10/01/24 (five days after election of the hospice benefit) and showed no patient or caregiver refusal of chaplain services/visits. A review of a POC dated 09/22/25 to 11/20/25 showed no medical social work services/visits and showed no documentation of patient or caregiver refusal of medical social work services/visits. On 04/17/26 at 2:10 p.m., Staff C stated the initial psychosocial assessment, and the comprehensive spiritual assessments had not been completed within the first five days after election of the hospice benefit.”

“Based on record reviews and interviews, the hospice failed to ensure bereavement care plans were initiated or were included as a part of the overall POC after the initial and ongoing bereavement assessments for 20 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 and #20) of 20 patients. Findings: On 04/15/26 at 10:00 a.m., Staff D stated:1.The patients are given a bereavement risk score at the initial spiritual and bereavement assessment and are advised of spiritual and bereavement services provided by the Hospice. If the patient or family requests spiritual or bereavement services, the social worker or chaplain is added to the POC. 2.The bereavement program consists of intermittently timed mail outs and follow up telephone calls which begin after the patient’s death. 3.The Hospice does not maintain a written POC for bereavement until after death and it was not included in the overall POC unless the patient’s family or caregiver was assessed as a high risk for bereavement. Patient #1A review of the clinical record showed an election of the hospice benefit on 12/13/24 with a completion of the initial spiritual/bereavement assessment on 12/16/24. A review of a POC dated 02/06/26 to 04/06/26 and IDG updates to the POC on 02/05/26, 02/19/26, 03/05/26, 03/19/26, 04/02/26 and on 04/15/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC and showed no changes in hospice physician orders. On 04/17/26 at 12:00 p.m., Staff C stated the patient had no bereavement POC or bereavement interventions and goals on the IDG POC. Patient #2A review of the clinical record showed an election of the hospice benefit on 09/11/24 with a completion of the initial spiritual/bereavement assessment on 09/12/24. A review of a POC dated 03/05/26 to 05/03/26 and IDG updates to the POC on 02/09/26, 02/23/26, 03/09/26, 03/23/26 and on 04/06/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC and showed no changes in hospice physician orders. On 04/17/26 at 12:22 p.m., Staff C stated the patient had no bereavement POC or bereavement interventions and goals on the IDG POC. Patient #3A review of the clinical record showed an election of the hospice benefit on 03/18/26 with no conduction of the initial spiritual/bereavement assessment between 03/18/26 and 04/15/26. A review of a POC dated 03/18/26 to 06/15/26 and IDG updates to the POC on 03/19/26, 04/02/26 and on 04/15/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC and showed no changes in hospice physician orders. On 04/17/26 at 12:35 p.m., Staff C stated the patient had no bereavement POC or bereavement interventions and goals on the IDG POC. Patient #4A review of the clinical record showed an election of the hospice benefit on 09/10/22 with no conduction of the initial spiritual/bereavement assessment. A review of a POC dated 02/21/26 to 04/21/26 and IDG updates to the POC on 02/23/26, 03/09/26, 03/23/26 and on 04/06/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC and showed no changes in hospice physician orders. On 04/17/26 at 12:42 p.m., Staff C stated the patient had no bereavement POC or bereavement interventions and goals on the IDG POC. Patient #5A review of the clinical record showed an election of the hospice benefit on 02/26/26 with no conduction of the initial spiritual/bereavement assessment. A review of a POC dated 02/26/26 to 05/26/26 and IDG updates to the POC on 02/23/26, 03/09/26, 03/23/26 and on 04/06/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC and showed no changes in hospice physician orders. On 04/17/26 at 1:00 p.m., Staff C stated the patient had no bereavement POC or bereavement interventions and goals on the IDG POC. Patient #6A review of the clinical record showed an election of the hospice benefit on 09/20/24 with completion of the initial spiritual/bereavement assessment on 10/03/24. A review of a POC dated 03/14/26 to 05/12/26 and IDG updates to the POC on 03/24/26, 04/02/26 and on 04/15/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC and showed no changes in hospice physician orders. On 04/17/26 at 1:05 p.m., Staff C stated the patient had no bereavement POC or bereavement interventions and goals on the IDG POC. Patient #7A review of the clinical record showed an election of the hospice benefit on 01/19/26 with no conduction of the initial spiritual/bereavement assessment. A review of a POC dated 01/19/26 to 04/18/26 and IDG updates to the POC on 01/22/26, 02/05/26, 02/19/26, 03/05/26, 03/19/26, 04/02/26 and on 04/15/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC and showed no changes in hospice physician orders. On 04/17/26 at 1:10 p.m., Staff C stated the patient had no bereavement POC or bereavement interventions and goals on the IDG POC. Patient #8A review of the clinical record showed an election of the hospice benefit on 09/13/24 with completion of the initial spiritual/bereavement assessment on 09/17/24. A review of a POC dated 03/07/26 to 05/05/26 and IDG updates to the POC on 03/19/26, 04/02/26 and on 04/15/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC and showed no changes in hospice physician orders. On 04/17/26 at 1:20 p.m., Staff C stated the patient had no bereavement POC or bereavement interventions and goals on the IDG POC. Patient #9A review of the clinical record showed an election of the hospice benefit on 04/02/26 with conduction of the initial spiritual/bereavement assessment on 04/06/26. A review of a POC dated 04/02/26 to 06/30/26 and IDG updates to the POC on 04/15/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC and showed no changes in hospice physician orders. On 04/17/26 at 1:25 p.m., Staff C stated the patient had no bereavement POC or bereavement interventions and goals on the IDG POC. Patient #10A review of the clinical record showed an election of the hospice benefit on 03/20/26 with no conduction of the initial spiritual/bereavement assessment between 03/20/26 and 04/17/26. A review of a POC dated 03/20/26 to 05/18/26 and IDG updates to the POC on 04/02/26 and on 04/15/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC and showed no changes in hospice physician orders. On 04/17/26 at 1:26 p.m., Staff C stated the patient had no bereavement POC or bereavement interventions and goals on the IDG POC. Patient #11A review of the clinical record showed an election of the hospice benefit on 10/11/23 with no conduction of the initial spiritual/bereavement assessment. A review of a POC dated 03/29/26 to 05/27/26 and IDG updates to the POC on 04/02/26 and on 04/15/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC and showed no changes in hospice physician orders. On 04/17/26 at 1:30 p.m., Staff C stated the patient had no bereavement POC or bereavement interventions and goals on the IDG POC. Patient #12A review of the clinical record showed an election of the hospice benefit on 06/11/25 with conduction of the initial spiritual/bereavement assessment on 06/23/25. A review of a POC dated 04/07/26 to 06/05/26 and IDG updates to the POC on 04/02/26 and on 04/15/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC and showed no changes in hospice physician orders. On 04/17/26 at 1:32 p.m., Staff C stated the patient had no bereavement POC or bereavement interventions and goals on the IDG POC. Patient #13A review of the clinical record showed an election of the hospice benefit on 03/04/25 with no conduction of the initial spiritual/bereavement assessment. A review of a POC dated 02/27/26 to 04/27/26 and IDG updates to the POC on 03/05/26, 03/19/26, 04/02/26 and on 04/15/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC and showed no changes in hospice physician orders. On 04/17/26 at 1:36 p.m., Staff C stated the patient had no bereavement POC or bereavement interventions and goals on the IDG POC. Patient #14A review of the clinical record showed an election of the hospice benefit on 03/04/25 with no conduction of the initial spiritual/bereavement assessment. A review of a POC dated 02/18/26 to 05/18/26 and IDG updates to the POC on 02/19/26, 03/05/26, 03/19/26, 04/02/26 and on 04/15/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC and showed no changes in hospice physician orders. On 04/17/26 at 1:50 p.m., Staff C stated the patient had no bereavement POC or bereavement interventions and goals on the IDG POC. Patient #15A review of the clinical record showed an election of the hospice benefit on 12/12/24 with no conduction of the initial spiritual/bereavement assessment. A review of a POC dated 02/05/26 to 04/05/26 and IDG updates to the POC on 02/19/26, 03/05/26, 03/19/26, 04/02/26 and on 04/15/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC and showed no changes in hospice physician orders. On 04/17/26 at 1:57 p.m., Staff C stated the patient had no bereavement POC or bereavement interventions and goals on the IDG POC. Patient #16A review of the clinical record showed an election of the hospice benefit on 09/27/24 with no conduction of the initial spiritual/bereavement assessment. A review of a POC dated 09/22/25 to 11/20/25 and IDG updates to the POC on 10/02/25, 10/15/25, and on 10/30/25 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC and showed no changes in hospice physician orders. On 04/17/26 at 2:00 p.m., Staff C stated the patient had no bereavement POC or bereavement interventions and goals on the IDG POC. Patient #17A review of the clinical record showed an election of the hospice benefit on 07/01/25 with no conduction of the initial spiritual/bereavement assessment. A review of a POC dated 12/28/25 to 02/25/26 and IDG updates to the POC on 01/08/26 and on 01/22/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC and showed no changes in hospice physician orders. On 04/17/26 at 2:22 p.m., Staff C stated the patient had no bereavement interventions and goals on the IDG POC and no bereavement POC until after death on 01/26/26. Patient #18A review of the clinical record showed an election of the hospice benefit on 02/08/26 with conduction of the initial spiritual/bereavement assessment on 02/16/26. A review of a POC dated 02/08/26 to 05/08/26 and IDG updates to the POC on 02/19/26, 03/05/26, 03/19/26 and on 04/02/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC and showed no changes in hospice physician orders. On 04/17/26 at 2:25 p.m., Staff C stated the patient had no bereavement POC or bereavement interventions and goals on the IDG POC. Patient #19A review of the clinical record showed an election of the hospice benefit on 06/27/23 with date of the initial spiritual/bereavement assessment is unknown (due to data migration from one eMR system to another). The documentation showed the patient revoked benefits and was discharged for outpatient treatment on 11/07/25. A review of a POC dated 10/14/25 to 12/12/25 and IDG updates to the POC on 10/15/25, and on 10/30/25 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC and showed no changes in hospice physician orders. On 04/17/26 at 2:27 p.m., Staff C stated the patient had no bereavement POC or bereavement interventions and goals on the IDG POC. Patient #20A review of the clinical record showed an election of the hospice benefit on 07/10/23 with date of the initial spiritual/bereavement assessment is unknown (due to data migration from one eMR system to another). The patient deceased on 09/24/23. A review of a POC dated 07/23/23 to 12/12/25 and documentation showed no IDG updates to the POC, showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC, and showed no changes in hospice physician orders. On 04/17/26 at 2:35 p.m., Staff C stated the patient had no bereavement POC or bereavement interventions and goals on the IDG POC.”

“Based on record review and interview, the agency failed to ensure care was coordinated between the IDG members and the physician for two (Patients #1 and #2) of 20 patients. Findings: Patient #1A review of a POC dated 02/06/26 to 04/06/26 and IDG updates to the POC on 02/05/26, 02/19/26, 03/05/26, 03/19/26, 04/02/26 and on 04/15/26. A review of the clinical record showed a chaplain visit frequency of one time a month for three months; and a medical social work visit frequency of one time a month for one month, two times a month for one month, then one time a month for one month. The clinical record showed chaplain missed visits on 02/11/26, 03/02/26 and 04/06/26 (three visits ordered, no visits conducted). The clinical record showed medical social work missed visits on 02/06/26,03/02/26, 03/13/26 and on 04/07/26 (four visits ordered, no visits conducted). The clinical record showed no discussion by the IDG about the missed visits and showed no hospice physician orders to change the service disciplines or the disciplines visit frequencies. Patient #2A review of a POC dated 03/05/26 to 05/03/26 and IDG updates to the POC on 02/09/26, 02/23/26, 03/09/26, 03/23/26 and on 04/06/26.A review of the clinical record showed a chaplain visit frequency of one time a month for two. The clinical record showed chaplain missed visits on 03/12/26 (one visit ordered, no visit conducted) and showed no attempts to make up the visit. The clinical record showed no discussion by the IDG about the missed visits and showed no hospice physician orders to change the service disciplines or the disciplines visit frequencies. On 04/17/26 at 12:22 p.m., Staff C stated the IDG team members did not document any discussion about the chaplain missed visit.”

“Based on record reviews and interviews, the agency failed to ensure continued review and update of hospice aide care plans for nine (Patients #1, 2, 4, 8, 13, 15, 16, 17 and 19) of 20 patients. Findings: Patient #1A review of a POC dated 02/06/26 to 04/06/26 and IDG updates to the POC on 02/05/26, 02/19/26, 03/05/26, 03/19/26, 04/02/26 and on 04/15/26 ordered hospice aide visits at a frequency of one time a week for one week, three visits every week for eight weeks, then one time a week for one week. An aide care plan dated 12/10/24 showed no further update to the hospice aide care plan, including frequencies and durations of services since 12/10/24. On 04/17/26 at 12:00 p.m., Staff A stated the aide care plan had not been reviewed and updated at each recertification. Patient #2A review of a POC dated 03/05/26 to 05/03/26 and IDG updates to the POC on 02/09/26, 02/23/26, 03/09/26, 03/23/26 and on 04/06/26 ordered hospice aide visits at a frequency of one time a week for one week, three visits every week for eight weeks. An aide care plan dated 09/12/24 showed no further update to the hospice aide care plan, including frequencies and durations of services since 09/12/24. On 04/17/26 at 12:22 p.m., Staff A stated the aide care plan had not been reviewed and updated at each recertification. Patient #4A review of a POC dated 02/21/26 to 04/21/26 and IDG updates to the POC on 02/23/26, 03/09/26, 03/23/26 and on 04/06/26 ordered hospice aide visits at a frequency of three visits every week for eight weeks and one time a week for one week. An aide care plan dated 07/15/24 showed no further update to the hospice aide care plan, including frequencies and durations of services since 07/15/24. On 04/17/26 at 12:42 p.m., Staff A stated the aide care plan had not been reviewed and updated at each recertification. Patient #8A review of a POC dated 03/07/26 to 05/05/26 and IDG updates to the POC on 03/19/26, 04/02/26 and on 04/15/26 ordered hospice aide visits at a frequency of three visits every week for eight weeks and one time a week for one week. An aide care plan dated 09/15/24 showed no further update to the hospice aide care plan, including frequencies and durations of services since 09/15/24. On 04/17/26 at 1:20 p.m., Staff A stated the aide care plan had not been reviewed and updated at each recertification. Patient #13A review of a POC dated 02/27/26 to 04/27/26 and IDG updates to the POC on 03/05/26, 03/19/26, 04/02/26 and on 04/15/26 ordered hospice aide visits at a frequency of one time a week for one week, three visits every week for eight weeks. An aide care plan dated 03/04/25 showed no further update to the hospice aide care plan, including frequencies and durations of services since 03/04/25. On 04/17/26 at 1:36 p.m., Staff A stated the aide care plan had not been reviewed and updated at each recertification. Patient #15A review of a POC dated 02/05/26 to 04/05/26 and IDG updates to the POC on 02/19/26, 03/05/26, 03/19/26, 04/02/26 and on 04/17/26 ordered hospice aide visits at a frequency of one time a week for one week, three visits every week for eight weeks. An aide care plan dated 12/13/24 showed no further update to the hospice aide care plan, including frequencies and durations of services since 12/13/24. On 04/17/26 at 1:57 p.m., Staff A stated the aide care plan had not been reviewed and updated at each recertification. Patient #16A review of a POC dated 09/22/25 to 11/20/25 and IDG updates to the POC on 10/02/25, 10/15/25, and on 10/30/25 ordered hospice aide visits at a frequency of three times a week for eight weeks, two times a week for one week. An aide care plan dated 09/30/24 showed no further update to the hospice aide care plan, including frequencies and durations of services since 09/30/24. On 04/17/26 at 2:10 p.m., Staff A stated the aide care plan had not been reviewed and updated at each recertification. Patient #17A review of a POC dated 12/28/25 to 02/25/26 and IDG updates to the POC on 01/08/26 and on 01/22/26 ordered hospice aide visits at a frequency of three times a week for eight weeks, two times a week for one week. An aide care plan dated 07/07/25 showed no further update to the hospice aide care plan, including frequencies and durations of services since 07/07/25. On 04/17/26 at 2:22 p.m., Staff A stated the aide care plan had not been reviewed and updated at each recertification. Patient #19A review of a POC dated 10/14/25 to 12/12/25 and IDG updates to the POC on 10/15/25, and on 10/30/25 ordered hospice aide visits at a frequency of two times a week for nine weeks. An aide care plan dated 07/12/24 showed no further update to the hospice aide care plan, including frequencies and durations of services since 07/12/24. On 04/17/26 at 2:27 p.m., Staff A stated the aide care plan had not been reviewed and updated at each recertification.”

“Based on record review and interview, the hospice failed to ensure on-site aide supervisory visits were completed every 14 days for one (Patient #3) of 20 patients. Findings: Patient #3A review of the POC dated 03/18/26 to 06/15/26 showed a home health aide visits frequency of two times a week for twelve weeks, then one time a week for one week. A review of the clinical record showed aide visits were conducted on 03/27/26, 03/30/26, 04/02/26 and 04/09/26. The clinical record showed no supervisory visits from 03/18/26 to 04/10/26(23 days between supervisory visits). On 04/17/26 at 12:35 p.m., Staff C stated the supervisory aide visits were not conducted every 14 days.”

“Based on record review and interview, the hospice failed to ensure volunteer services were a part of the hospice program in calendar years 2024 and 2025 for all patients, caregivers and employees. Findings: A review of hospice program volunteer records showed the hospice program had no volunteer personnel and showed no volunteer recruitment activities in calendar years 2024 and 2025. On 04/15/26 at 10:15 a.m., Staff E stated:1.The hospice had no volunteer personnel.2.The hospice had no records which showed volunteer recruitment activities from 04/03/24 to 04/15/26. At 11:00 a.m., Staff A stated they identified problems with the volunteer program and a performance improvement project was implemented for 2nd quarter of 2026.”

“Based on record review and interview, the hospice failed to ensure volunteer services met hospice program requirements in calendar year 2024 and 2025 for all patients, caregivers, and employees. Findings: A review of volunteer records showed the hospice program had no utilization of volunteer personnel in calendar year 2024 and a utilization of 0.01% in calendar year 2025. On 04/17/26 at 10:15 a.m., Staff E stated:1.She was helping from the corporate office but there had not been a volunteer coordinator at the hospice for some time.2.There were not any volunteers for the hospice in 2024 or 2025. At 11:00 a.m., Staff A stated we identified problems with the volunteer program and a performance improvement project was implemented for 2nd quarter of 2026.”

“Based on record review and interview, the agency failed to ensure governing board appointment of an administrator for the hospice for all patients, families, caregivers and employees. Findings: On 04/14/26 at 12:30 p.m., after arrival at the agency the OSDH surveyor was connected by telephone to Staff D (name withheld) who identified himself as the administrator of the hospice. A review of emergency preparedness records dated 06/27/25 identified an individual (name withheld) differently than Staff D as the administrator for the hospice. A review of governing board meeting minute records for calendar year 2025 showed no appointment of Staff D as the administrator for the hospice. A request for governing board administrative records that showed Staff D was appointed as the administrator for the hospice yielded no results. On 04/16/26 at 2:00 p.m., Staff A stated there were no governing board meeting minutes that showed Staff D was appointed by the governing board. On 04/17/26 at 11:30 a.m., a review of a document titled, Hospice Governing Body Meeting Minute 3rd quarter 2025 showed Staff D was designated as the administrator. Staff A stated the governing board meeting minute record was dated 04/17/26.”

“Based on record review and interview, the agency failed to ensure CMS NPI included two branch sites (McAlester and Sayre locations) for the hospice for all patients and staff. Findings: On 04/13/26, a review of hospice federal provider information showed the hospice was located in Norman, Oklahoma and had branch operation sites in Chickasha, Oklahoma, Pauls Valley, Oklahoma and Shawnee, Oklahoma. On 04/14/26 at 12:00 p.m., the OSDH surveyor arrived at the hospice. On 04/14/26 at 1:30 p.m., an entrance conference was conducted by telephone with Staff A and B. Documentation that identified the branch sites for the hospice was requested. A review of a printed document showed the addresses for the branch sites as Shawnee, Pauls Valley and Chickasha, Oklahoma and handwritten onto the document were the words “drop sites” which identified the cities of McAlester and Sayre, Oklahoma. On 04/14/26 at 3:00 p.m., Staff B stated:1.The hospice had branch sites in Shawnee, Pauls Valley and Chickasha.2.They had drop site locations in McAlester and Sayre which the staff used to drop things off and pick up supplies. On 04/14/26 at 3:30 p.m., Staff E stated:1.The drop site locations were inside of company-related home care agency’s offices (names withheld) in McAlester and Sayre.2.CMS was not informed of the drop site locations and the hospice did not file a request to add the locations as branch sites for the hospice.”

“Based on record review and interview, the hospice failed to ensure an inpatient care contract was in place to meet patient pain management and respite care needs for all patients, caregivers and employees. Findings: On 04/14/26 at 1:30 p.m., a request for general inpatient contract records for calendar years 2024 and 2025 yielded no results. On 04/15/26 At 10:00 a.m., Staff A stated:1.The general inpatient contract lapsed in July of 2025.2.The Hospice did not have a contract for general inpatient care.3.Their practice was to negotiate with a patient’s facility of choice for respite care when it was needed. At 3:00 p.m., a contract titled, Agreement for Inpatient Hospital Care, dated 04/15/26 was reviewed. Staff A stated she was not aware the Hospice did not have a contract for general inpatient care.”