Every finding on record at Odyssey Healthcare Holding Company

Upon patient record review, 7 of 19 (Patients #4,#6,#7,#8,#11,#12,#14) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 4: Upon observation during home visit medication reconciliation, the facility medication profile did not contain scheduled docusate that was on the hospice medication profile. Patient 6: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen instructions on the medication profile. Corrected on site. Patient 7: The medication profile contained oxygen with a delivery method of a BIPAP in error. Patient had a nasal cannula for administration. Corrected on site. Patient 8,12,14: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen instructions on the medication profile, however an order for oxygen was present. Corrected on site. Patient 11: The medication profile contained Miralax oral powder with no instructions to mix with a diluent. Corrected on site.

Upon patient record review, 2 of 19 (Patients #8,#9) 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 8: There was no evidence of sacral wound measurements from admission 9/6/24 thru 11/11/24 as required per agency policy for weekly measurements. Patient 9: There was no evidence of wound measurements to left heel, ankle, and dorsum since admission 9/18/24 as required per agency policy for weekly measurements.

Upon patient record review, 4 of 19 (Patients #8,#9,#12,#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 8: The medical record contained nursing documentation upon admission identifying patient use of oxygen and history of heart failure exacerbation causing hospitalization. There was no evidence of problems, goals, and interventions related to cardiac and respiratory dysfunction included in the plan of care. Corrected on site. Patient 9: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of problems, goals, and interventions related to respiratory dysfunction included in the plan of care. Corrected on site. Patient 12: The patient is on hospice services with a brain tumor. There was no evidence of problems, goals, and interventions related to neurological dysfunction included in the plan of care. Corrected on site. Patient 13: The medical record contained nursing documentation upon admission identifying patient issue with orthopnea. There was no evidence of problems, goals, and interventions related to respiratory dysfunction included in the plan of care. Corrected on site.

Upon patient record review, 3 of 19 (Patients #6,#7,#11) 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 6: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen rate, frequency, and delivery method. Corrected on site. Patient 7: The medical record contained an order for oxygen with a delivery method of a BIPAP in error. Patient had a nasal cannula for administration. Corrected on site. Patient 11: The medical record contained an order for Miralax oral powder with no instructions to mix with a diluent. Corrected on site.

Upon patient record review, 4 of 19 (Patients #1,#4,#7,#10) 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 equipment and supply needs. Patient 1: The medical record contained nursing documentation upon recertification assessment 9/10/24 identifying patient use of a walker, wheelchair, shower chair, and commode. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 4: The medical record contained nursing documentation upon recertification assessment 9/26/24 identifying patient use of a hospital bed, low air loss mattress, and over bed table. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 7: The medical record contained nursing documentation upon recertification assessment 9/30/24 identifying patient use of a walker. There was no evidence of an order for the walker included in the plan of care. Corrected on site. Patient 10: The medical record contained nursing documentation identifying patient use of a bed, wheelchair, oxygen equipment, and nebulizer. There was no evidence of an order for the bed, wheelchair, oxygen equipment, and nebulizer. Corrected on site.

Upon patient record review, 3 of 19 (Patients #6,#10,#13) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 6: The medical record contained nursing documentation upon recertification assessment 6/10/24 and 10/7/24 identifying patient issue with dysphagia requiring pureed diet and thickened fluids for aspiration prevention. There was no evidence the plan of care was updated to included problems, goals, and interventions related to dysphagia. Corrected on site. Patient 10: The medical record contained nursing documentation upon recertification assessment 10/15/24 identifying patient issue with increased dysphagia. There was no evidence the plan of care was updated to included problems, goals, and interventions related to dysphagia. Corrected on site. Patient 13: The medical record contained nursing documentation 9/24/24 identifying patient had a fall with right wrist fracture. There was no evidence the plan of care was updated to include problems, goals, and interventions related to fall safety. Corrected on site.

Upon patient record review, 2 of 19 (Patients #1,#3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: The medical record contained an order for nursing visits twice weekly. There was no evidence of a second visit completed the week of 9/29/24. Corrected on site with late data entry of reason for missed visit. Patient 3: The medical record contained an order for nursing visits twice weekly. There was no evidence of a second visit completed the week of 10/27/24. Corrected on site with late data entry of reason for missed visit.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient 13: The medical record contained nursing documentation 9/24/24 identifying patient had a fall with right wrist fracture. There was no evidence of an investigation and plan of correction to prevent similar events. Corrected on site with late entry of fall details.

Upon patient record review, 3 of 19 (Patients #15,#16,#17) 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 15: There was no evidence of the tasked 6 month phone call completed after death. Patient 16: There was no evidence of tasked phone calls completed at 48-72 hours, 4-6 weeks, and 6 months after death. Patient 17: There was no evidence of the tasked 6 month phone call completed after death.

Upon patient record review 7 of 19 (Patients #1,#3,#4,#10,#11,#12,#14) 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: The medical record contained an order for aide visits five times weekly. There was no evidence of a fifth visit completed the week of 10/13/24. Corrected on site with documentation of reason for missed visit. Patient 3: The medical record contained an order for aide visits three times weekly. There was one visit documented for the week of 10/27/24. Corrected on site with documentation of reason for missed visits. Patient 4: The medical record contained an order for aide visits three times weekly. There was no evidence of third visits completed the weeks of 9/29/24 and 11/3/24. Corrected on site with documentation of reason for missed visits. Patient 10: The medical record contained an order for aide visits five times weekly. There were three visits completed the week of 9/22/24 and 4 visits completed the week of 10/13/24. Corrected on site with documentation of reason for missed visits. Patient 11: The medical record contained an order for aide visits three times weekly. There was no evidence of a third visit completed the week of 10/6/24. Corrected on site with documentation of reason for missed visit. Patient 12: The medical record contained an order for aide visits two week one then three visits weekly effective 10/13/24. There was no evidence of a second visit completed the week of 10/13/24 and a third visit the week of 10/20/24. Corrected on site with documentation of reason for missed visits. Patient 14: The medical record contained an order for aide visits five times weekly. There was no evidence of a fifth visit completed the weeks of 10/13/24 and 10/20/24. Corrected on site with documentation of reason for missed visits.

Upon patient record review 1 of 19 (Patient #12) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 12: The patient started receiving aide services 10/18/24. There was no evidence of an aide supervisory visit.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The agency had a volunteer utilization rate of 2.85% in 2023.

Upon personnel record review, 1 of 16 (Personnel #5) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation.

Upon patient record review, 1 of 19 (Patient #18) did not evidence that each patient record contains physician orders. Patient 18: There was no evidence of an order to discharge due to extended prognosis.

Upon patient record review, 1 of 19 (Patient #1) 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 1: The medical record contained missed visit documentation 10/8/24 and 10/10/24 that did not explain attempts made for rescheduling or reason for missed visits as required per communication note template.

Upon patient record review 1 of 16 records (Patient #1) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 1: The medical record contained initial psychosocial and spiritual assessments by the social worker and spiritual care provider completed 11/23/21. Patient admitted to hospice services 11-17-21.

Upon patient record review, 6 of 16 records (Patients #3,#4,#8,#13,#14,#16) 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. Patient 3: The medication profile did not contain ordered oxygen per identified use in nursing documentation 10-2-21. Corrected on site. Patient 4: The medication profile did not contain ordered oxygen per equipment and supply list included on the plan of care. Corrected on site. Patient 8: The medication profile contained Glycolax powder without instructions for diluent. Patient 13: The medication profile did not contain ordered oxygen per identified use in nursing documentation 2-11-21. Patient 14: The medication profile included oxygen with no instructions for a delivery method. Patient 16: The medication profile included oxygen with no instructions for a delivery method.

Upon patient record review, 3 of 16 records (Patient #1,#4,#9) 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 1: The medical record contained an initial bereavement assessment dated 11-26-21 with admission date of 11-17-21. Patient 4: The medical record contained an initial bereavement assessment dated 8-12-21 with admission date of 8-6-21. Patient 9: The medical record contained an initial bereavement assessment dated 10-12-21 with admission date of 9-30-21.

Upon patient record review, 5 of 16 records (Patients #6,#8,#9,#11,#14) 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 6: The patient was on services for heart failure and the medical record contained nursing documentation upon admission identifying issues with dysphagia and dyspnea. There was no evidence of problems, goals, or intervention related to respiratory disfunction, cardiac function, and dysphagia included in the plan of care. Corrected on site. Patient 8: The medical record contained nursing documentation upon admission identifying dysphagia and oxygen use on 11-22-21. There was no evidence of problems, goals, and interventions related to dysphagia or respiratory function or oxygen use included in the plan of care. Patient 9: The medical record contained nursing documentation upon admission identifying issue with pain and oxygen ordered 11-17-21. There was no evidence of problems, goals, and interventions related to respiratory function or oxygen use and pain included in the plan of care. Patient 11: The medical record contained nursing documentation identifying decreased respiratory function 12-7-21 and oxygen identified on the medication profile. There was no evidence of problems, goals, and interventions related to respiratory function or oxygen use included in the plan of care. Patient 14: The medication profile contained identified problems of impaired skin integrity and incontinence on the plan of care. There was no evidence of goals and interventions identified with the problems. The nursing documentation identified issues with dyspnea and incontinence. There was no evidence of problems, goals, and interventions related to incontinence and respiratory function included in the plan of care.

Upon patient record review, 10 of 16 records (Patients #1,#3,#4,#7,#8,#9,#11,#12,#14,#15) 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 equipment and supply needs. Patient 1: The medical record contained nursing documentation 11-28-21 identifying use of hospital bed and side rails. There was no evidence of bed and rails included in the plan of care. Corrected on site. Patient 3: The medical record contained nursing documentation upon admission identifying use of walker and oxygen dated 10-2-21. There was no evidence of oxygen concentrator and walker included in the plan of care. Corrected on site. Patient 4: The medical record contained nursing documentation upon admission identifying use of hospital bed, side rails, oxygen, and wheelchair. There was no evidence of bed, rails, oxygen concentrator and wheelchair included in the plan of care. Corrected on site. Patient 7: The medical record contained nursing documentation 12-7-21 identifying patient use of oxygen. There was no evidence of an oxygen concentrator included in the plan of care. Patient 8: The medical record contained nursing documentation 11-4-21-21 identifying patient use of hospital bed, side rails, and wheelchair, and 11-22-21 identifying oxygen. There was no evidence of bed, rails, wheelchair, and oxygen concentrator included in the plan of care. Patient 9: The medical record contained nursing documentation 11-17-21 identifying receipt of oxygen order. There was no evidence of oxygen concentrator included in the plan of care. Patient 11: Upon observation during home visit, patient was in possession of nebulizer, oxygen concentrator, hospital bed, side rails, and overbed table. There was no evidence of oxygen concentrator, bed, rails, and table included in the plan of care. Patient 12: The medical record contained nursing documentation 4-26-21 identifying patient use of hospital bed and side rails. There was no evidence of bed and rails included in the plan of care. Patient 14: The medication profile identified use of oxygen and nebulizer treatments and nursing documentation 9-16-21 identified use of walker. There was no evidence of oxygen concentrator, nebulizer, and walker included in the plan of care. Patient 15: The medical record contained nursing documentation 11-1-21 identifying use of bedside commode. There was no evidence of the commode included in the plan of care.

Upon patient record review, 3 of 13 applicable (Patient #1,#12,#13) did not have evidence in the patient record that hospice aide assignments and duties are: • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 1: The medical record contained aide care plan assignment with tasks for both bed bath and shower to be given every visit. Patients 12 and 13: The medical records contained aide care plan assignment including task to shampoo every visit as needed.

Upon patient record review 1 of 13 applicable (Patient #3) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the interdisciplinary group and included in the plan of care Patient 3: The medical record contained aide frequency ordered at twice weekly for the week of 10-5-21 and five times weekly the weeks of 10-31-21 and 11-7-21. There was no evidence of aide visits the week of 10-5-21 and only four visits the weeks of 10-31-21 and 11-7-21.

Upon patient client record review, 1 of 16 (Patient # 2) 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 2: Profile diagnosis and CTI documentation of diagnosis did not match. Primary diagnosis of colon ca identified in documentation and CTI. Patient profile listed lung cancer as primary diagnosis.