Angel Hands Hospice of Texoma

“Based on record review and interview, the agency failed to follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), for 8 (#1, #2, #3, #5, #10, #11, #12, #13) of 14 patient plans of care reviewed. This failure resulted in the patients not receiving care according to an individualized plan of care. Findings:Record review of Patient #1’s medical record revealed admission to the hospice agency on 3/15/2024. The updated plans of care dated 3/4/2025, 3/19/2025, 4/3/2025, and 4/17/2025 all document the social worker frequency of 1 time a month. No social worker visits are found in the medical record for 4/1/2025 to 4/30/2025. There are no missed visits during this time.Record review of Patient #2’s medical record revealed admission to the hospice agency on 4/23/2024. The updated plan of care dated 1/15/2025 documents the social worker frequencies of 1 time a month. No social worker visits are found in the medical record for 3/1/2025 to 3/31/2025. There are no missed visits during this time.Record review of Patient #3’s medical record revealed admission to the hospice agency on 5/9/2024. The plans of care dated 5/9/2024, 5/23/2024, and 6/6/2024 do not document the aide frequencies. There are no physician orders to specify aide services. The aide care plan dated 5/9/2024 does not specify a frequency for aide visits. Aide visits five times a week are found in the medical record for 5/13/24 to 6/20/24.Record review of Patient #5’s medical record revealed admission to the hospice agency on 8/14/2024. The updated plan of care dated 8/23/2024 document the aide frequencies of 3 times a week. Only one aide visit was found in the medical record for dated 8/21/24.Record review of Patient #10’s medical record revealed admission to the hospice agency on 1/27/2025. The plan of care dated 1/27/2025 documented the aide frequencies of 5 times a week. The plan of care dated 2/7/2025 documented the aide frequencies of 3 times a week effective 1/27/25. From 2/10/25 to 3/8/25 only two (2) aide visits per week are found in the medical record and no aide visit was located after 3/10/25. Record review of Patient #11’s medical record revealed admission to the hospice agency on 1/22/2025. The plan of care dated 2/7/2025 documented the aide frequency of 3 times a week. Only one aide visit dated 2/5/2025 was found in the medical record.Record review of Patient #12’s medical record revealed admission to the hospice agency on 3/7/2025. The initial plan of care dated 3/7/2025 does not document aide frequencies. There are no physician orders to specify aide services. The aide care plan dated 3/10/25 does not specify a frequency for aide visits. The aide visited three times a week between 3/9/2025 and 3/22/2025.Record review of Patient #13’s medical record revealed admission to the hospice agency on 3/13/2025. The initial plan of care dated 3/13/2025 does not document aide frequencies. There are no physician orders to specify aide services. The aide care plan dated 3/13/25 does not specify a frequency for aide visits. The aide visited five times the week of 3/16/2025 and 3/22/2025.In an interview 5/27/2025 at 1:45 pm, the surveyor asked the Administrator and the Alternate Administrator/ DON what the process was for updating the plan of care. The Administrator stated, “if the nurses write an order, it does not go to the plan of care. The nurses have to update the frequencies on the plan of care.” When asked who was responsible for updating the plan of care the Administrator stated, “each discipline is responsible for updating the plan of care.”On 5/27/2025at 2:48pm the surveyor spoke with SW B. When asked what the process was for updating the plan of care SW B stated, “I just go into the medical record depending on if there is a new need to be addressed and I add it there and then we also discuss it in IDG.” When asked how often SW B updated the frequency SW B said, “it depends on if they [patient/ family] want to continue on the regular monthly visits of if they [patient/ family] want to do PRN [as needed] visits.” Surveyor asked what the outcome could be if the plan of care is not followed. SW B responded, “then a service won’t be rendered.” Surveyor asked where it would be documented if SW B could not make a visit. SW B stated, “it’s either documented under a service coordination and there’s also a tab for a missed visit.” When asked who was responsible for ensuring the plan of care was followed SW B stated, “the entire team.”In an interview 5/27/2025 at 3:07 pm, the surveyor asked RN B to explain the process for updating the plan of care. RN B stated, “basically we [team] put in any updates any changes that have occurred in the last few weeks and then we put our signatures.” The surveyor asked how the frequencies were done and RN B said, “the frequencies should be included in the plan of care. We [team] do all that at the beginning on admission and then we [team] make any changes that we [team] need as we [team] go.” The surveyor asked how an aide would know what they needed to do. RN B responded, “we [nurses] do the initial plan of care where we always make one [aide care plan] regardless of whether the patient wants an aide or not we still do a plan of care as if they [aides] were going to perform duties just in case, they [the patient] ever does need assistance it’s [plan of care] already set up. Then we adjust it as we go depending on what the decline is or what the patient needs.” When asked how the aide knows how often to go or if they [aide] has a patient RN B stated, “we usually communicate through teams.” Surveyor asked if there would be any reason for them not to follow the plan of care. RN B stated, “if the patient refuses something. We [nurses] aske them [aides] to document it and the notify the nurse.” When asked who was responsible for updating the plan of care RN B stated, “usually the case manager.” Surveyor asked who was responsible for ensuring the plan of care was followed. RN B stated, “I usually follow up with all my visits.” Surveyor asked RN B if there was any reason why the plan of care would not be followed or updated. RN B responded, “I mean at that point it would be pretty much negligent like you’re not doing your job.”On 5/27/2025 at 3:21 pm surveyor spoke with RN C. When asked about the process for updating the plan of care and frequencies RN C stated, “every two weeks we make our notes and sign those. I was under the impression that we’re [disciplines] supposed to do it [frequencies] for the last two weeks, so she [DON] told me I was doing it wrong.” When asked if there would be any reason not to follow the plan of care RN C stated, “no ma’am.” When asked what the possible outcome to the patient could be if the plan of care is not followed RN C stated, “hospital, safety issues, death.” Surveyor asked who was responsible for ensuring that the plan of care is followed, and RN C responded, “that would be the whole team.”During an interview 5/27/2025 at 3:31 pm when asked about the process for updating the plan of care SW A stated, “that is something that I am not quite sure of.” When asked if there would be any reason for the plan of care not to be followed RN C stated, “no.” The surveyor asked how the patient could be affected if the plan of care was not followed. RN C responded, “[you’re] not going to have success. There won’t be any resolution.”During the exit conference on 5/27/2025 with the Administrator, DON, and office manager at 4:15 pm, the surveyor asked if there was any reason not to follow the plan of care. The DON stated, “no.” The surveyor asked who was responsible for the plan of care and the Administrator stated, “everybody. Really the IDG establishes a plan of care along with all the disciplines.” When asked what the outcome for the patient could be if the plan of care is not followed. The DON stated, “depending on which one. Like an aide visit doesn’t occur well they [patient] just don’t get showered that day. But the nursing visit is not caught early enough if the patient has an infection the infection could get worse it [infection] could get septic and premature death.” The Administrator stated, “quality of care would be diminished.” The surveyor asked who was responsible for ensuring the plan of care was followed. The Administrator responded, “all of us.” The surveyor asked what the policy was regarding the plan of care. The DON stated, “[plan of care] have to be updated every 15 days. If there’s a change in the level of care, we update it. We update it [POC] anytime there’s a change. Maybe we [team] should be updating it [POC] if there’s a frequency change even with the aides.”The agency had a policy [PC.30] titled; “Plan of Care Process” dated 09/01/24. The policy read in parts: “…Purpose: To ensure that the care provided is in accordance with the written Plan of Care (POC), appropriately planned, and delivered in a timely manner to meet the patient’s and family’s specific needs. Policy: I. All hospice care and service furnished to patients and their families will follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient’s needs…”The agency had a policy [PC.110] titled; “Coordination of Care” dated 09/01/24. The policy read in parts: “…Policy: I. The Hospice will develop and maintain a system of communication and integration, in accordance with the Hospice’s own policies and procedures to: A. Ensure that the Interdisciplinary Group/ Team (IDG/IDT) maintains responsibility for directing, coordinating, and supervising the care and services provided. B. Ensure that the care and services provided in accordance with the Plan of Care (POC)…””