Every finding on record at Odyssey Healthcare Holding Company

Upon patient record review, 3 of 19 (Patient #1, #3, #4) 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 #1: Dextromethorphan-guaifenesin was on the medication profile. The SNF had Guaifenesin for the patient. In addition, Oxymetazoline Nasal Spray is on the medication profile. The SNF did not have the medication Patient #3: Dextromethorphan-guaifenesin was on the medication profile. The SNF had Guaifenesin for the patient. In addition, Ondansetron is on the agency medication profile. The SNF does not have the medication. Patient #4: Mupirocin Ointment is in the patients home for his arm. It's not on the medication profile. Cephalexin 500 mg is in the patients home and not on the medication profile. Hydrocodone-Acetaminophen and Ondansetron is on the med profile and not in the patients home..

Upon patient record review, 2 of 19 (Patient #2,#5) 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. Patients #2,#5: There was not evidence of a bereavement assessment completed within the 5 days.

Upon patient record review, 1 of 19 (Patient #4) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient #4: During the home visit it was noted that the patient had medications in multiples places in his home, several still in the pharmacy bags. He was unclear about what he was taking and when. The record did not contain evidence that the plan of care includes teaching the patient how to manage and organize his medications.

Upon patient record review, 1 of 19 (Patient #4) 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 #4: Cephalexin 500 mg is in the patients home and there is no evidence of an order for cephalexin.

Upon observation, 1 of 4 visits, (Patient #8) there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #8: During the bed bath, the aide washed the upper body and then completed peri-care. She then continued with the patients bath without changing the dirty water in her basin.

Based on staff interviews, staff training record review, and agency policy review, it was determined that the agency failed to orient one of five sampled staff members regarding patient rights, specifically the right to be free from physical abuse of any kind by agency employees. --- The findings include: In a sample of five agency employee records for abuse prevention and reporting training, it was revealed that one employee, Employee A, hired on 9/22/22, had not received training in the prevention and reporting of abuse. In an interview and record review with the Office Manager on 10/10/22 at 11:45 am, she was asked if Employee A had received training in the prevention and reporting of abuse, as outlined in the agency policy. The policy includes the following: "Abuse or Neglect (Alleged or Suspected) Reporting Reasonable Suspicion of a Crime" (dated 2/22) Purpose: To provide guidelines to staff members in identifying victims of alleged or suspected physical, sexual, emotional, or financial abuse and to establish a notification process to the appropriate local and state authorities. Procedure: All staff receive training on-hire for identifying and reporting victims of alleged or suspected abuse or neglect." The office manager stated Employee A had not received this training at hire or during orientation and provided an email from the Agency's Learning Services which stated "No, Abuse training is not required for new hires anymore, so it was not auto assigned to Employee A. It's only required annually and will be assigned to all direct care staff on 1/1/23." The Office Manager was asked if Employee A had been caring for patients since her hire date of 9/22/22. She stated, "Yes, she has been orienting in the field with other staff and caring for clients."

Upon patient record review, 4 of 16 (Patient #1, #6, #7, #12) 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 #1: Medication profile listed Juven powder daily per peg tube and Miralax powder daily per peg tube. No diluent listed for either medication. Patient #6: Medication profile listed Nystantin 100,000u/gm powder topically as needed 2 times daily to affected area. No location specified. Patient #7: Medication profile listed Miralax 17g powder po prn daily for constipation. No diluent listed. Patient #12: Medication profile contained two identical entries for Lisinopril 10mg po daily. Corrected on site.

Upon patient record review, 5 of 16 (Patient #1, #6, #7, #12, #14) 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 #1: Medication profile listed Juven powder daily per peg tube and Miralax powder daily per peg tube. No diluent listed for either medication. Patient #6: Medication profile listed Nystantin 100,000u/gm powder topically as needed 2 times daily to affected area. No location specified. Patient #7: Medication profile listed Miralax 17g powder po prn daily for constipation. No diluent listed. Patient #12: Medication profile listed Lisinopril 10mg po daily twice. Corrected on site. Patient #14: Wound care ordered on 9/27/2021. No location noted. Wound care ordered for Stage 1 on 9/28/2021. No location noted.

Upon patient record review, 2 of 16 (Patient #1, Patient #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: Initial plan of care listed "none" for DME. Record indicates patient utilizes oxygen and tube feeding. Patient #15: Initial plan of care listed "none" for DME. Record indicated patient resided in a SNF and utilized DME.

Upon client record review, 1 of 16 (Patient #11) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #11: IDG met and reviewed the patient on 8/24/2021 and 9/9/2021. This was greater than 15 calendar days between meetings.

Upon client record review, 4 of 11 applicable (Patient #2, #3, #6, #12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: On 10/8/2021 an order was written for SCC 1 time within 3 days. No evidence to support this frequency was met. Patient #3: SN frequency was ordered 2 week 1 then 1 week 13 effective 9/3/2021. Unable to locate any visits performed by SN week of 9/12/2021. In addition, SCC was ordered 1 visit within every 30 days effective 9/8/2021. Visits performed on 9/8/2021, 9/15/2021 and 10/26/2021. The visit on 10/26/21 was greater than 30 days from the previous visit. Patient #6: SW frequency was ordered 1 time within every 30 days. Visits performed on 8/18/2021, 10/2/2021 and 10/21/2021. The visit on 10/2/2021 was more than 30 days from the previous visit. Patient #12: SN frequency ordered 2 week 2, 1 week 10 effective 10/17/2021. Only one SN visit note week of 10/17/2021 and week of 10/24/2021.

Upon home visit observation, 1 of 4 patients (Patient #1) there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1: Aide observed using patients personal cloth hand towel to dry hands.

Upon patient record review, 1 of 16 (Patient #6) did not have evidence that Social work services are based on the patient's psychosocial assessment and the patient/family's needs and acceptance of these services. Patient #6: Patient was noted to be a full code and no funeral arrangements upon start of care. No evidence in the social worker visits on 8/18/2021, 10/1/2021 and 10/21/2021 that any end of life planning or discussions occurred.

Upon patient record review, 1 of 11 applicable (Patient #3) did not have evidence in the patient record that hospice aide assignments and duties are ordered by the IDG and included in the plan of care. Patient #3: Aide care plan contains orders to provide a complete bed bath at every visit and a partial bed bath weekly. It is unclear as to which one is to be performed by the aide.

Upon patient record review 6 of 11 applicable (Patient #5, #7, #8, #10, #12, #13) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #5: Aide care plan contains orders to provide shampoo one time weekly. It was noted that the aide documented providing shampoo at all visits from 10/6/2021 - 11/1/2021 (10/6, 10/8, 10/11, 10/14, 10/21, 10/25, 10/26, 10/28 and 11/1). Patient #7: Aide ordered 2 week 1, 3 week 1, 2 week 11. Only 1 visit performed the week of 9/21/2021 (first week of care). No evidence of a second visit or missed visit documentation. Patient #8: Aide ordered 2 week 8, 1 week 1 effective 9/18/2021. An order to discontinue aide visits effective 9/24/2021. No evidence to support any visits were performed prior to services being discontinued. Patient #10: Aide ordered 3 week 12 effective 9/19/2021. Only 2 visits performed week of 9/19/2021. No evidence to support a 3rd visits was performed. Patient #12: Aide care plan ordered weights weekly. Aide obtained weights on 10/12/2021, 10/14/2021, 10/19/2021 and 10/20/2021. No other weights documented. Patient #13: Aide ordered 2 week 1, 3 week 11, 4 week 1 effective 9/13/2021. Only 2 visits performed week of 10/10/2021. No evidence to support a third visit performed that week.

Upon patient client record review, 1 of 16 (Patient #2) did not have evidence that all entries are legible, clear, complete. Patient #2: An order dated 10/13/2021 was written to change SC frequency to 1 time within every 30 days effective 12/5/2021. (A date which has not yet occurred)

Upon client record review, 1 of 5 applicable (Patient #10) did not have evidence that services were provided in accordance with the plan of care for patients residing in a SNF. Patient #10: SCC frequency order effective 9/20/2021 for 1 visit within every 3 days. Order to correct SCC frequency to 1 visit within every 30 days effective 10/3/2021. No evidence to support original frequency was met prior to 10/3/2021.