Every finding on record at Odyssey Healthcare Holding Company

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. The agency did not have evidence of a table top or full scale emergency drill performed in 2024.

Upon patient record review, 1 of 14 (Patient #10) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient 10: The SN documented on 3/20/25 "Patient pain is a 9/10 states he is taking medications methadone, oxycodone, and testosterone every 14 days and taking 2 Dilaudid. This is not the correct medication orders" (pt was on Fentanyl patch and Diluadid per POC). On 3/26/25 the SN documented "pain still a 8.5/10 patient states pain meds not working". The MD did increase the Dilaudid. The SN called the MD to report the high level of pain or the incorrect usage of the pain medications and pt switched from Dilaudid to Oxycodone per pt request. On 3/28/25 the LPN saw the pt and pt was "upset as he was out of pain meds and wanted to know why the nurse did not bring them". There is evidence the pt was out of pain medication per narcotic count. There was no documentation of diversion or misuse. The LPN contacted the RNCM but there is no evidence the MD was called and medications were refilled or that the MD refused to refill pain medications. The patient ended up going to the hospital 3/29/25 due to uncontrolled pain and discharged from hospice.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 7: The EOB at SOC indicated patient chose an attending. There was no attending listed on the EOB the spot was blank

Upon patient record review 1 of 14 (Patient #3) 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 3: Patient admitted 12/24/24 the SC initial assessment did not get completed until 12/30/24. The Mini spiritual assessment had documentation after each template question of "Neither guardian nor spouse responded at the time of writing". The SC documented family request visit 12/30/24. The SC assessment was later than 5 days.

Upon patient record review 1 of 14 (Patient #5) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 5: The Chaplain documented on 4/4/25 that the family refused a chaplain. The mini spiritual assessment template questions were completed on 4/5/25 and 4/7/25 and all assessment questions answered no. There is no evidence of a spiritual care assessment being completed on this patient by any discipline.

Upon patient record review, 4 of 14 (Patient #1,2,3,5) 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: Patient 1: The medication profile contains a duplicate order for Acetaminophen 325mg 2 tabs every 6 hours PRN. In addition, the facility MAR contains an order for Tylenol 325mg 2 tabs daily. This order is not on the hospice POC. Patient 2: The Hospice POC contains an order for Ativan 0.5mg 1 tab Q4 hours PRN. The facility MAR does not have this order. Patient 3: The facility MAR contains an order for Haloperidol PRN. There is no order on the hospice POC. Patient 5: The medication profile contains an order on 4/8/25 for Hydromorphone 4mg 0.5 tab every 6 hours. The medication profile also contains an order on 4/9/25 for hydromorphone 2mg 1 tab every 6 hours. These are duplicate orders.

Upon patient record review, 4 of 14 (Patient #3,7,9,10) 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 3: The SN identified a wound to the patient's spine on 3/25/25 though did not measure the wound. The SN assessed the spinal wound again on 4/1/25 and did not measure the wound. Per agency policy the wound should be measured when identified and weekly. Patient 7: The patient has wound to the buttocks and forearm that was not measured the week of 4/20/25-4/26/25, per agency policy wounds are to be measured weekly. Patient 9: The SN documented identifying an area of "Small skin breakdown between pt toes" on 4/10/25 and orders received for wound care. The wound was not measured upon identification of the wound. The wound has not been assessed since it was identified on 4/10/25 the SN sees the pt once a week. There is no evidence of a discontinuation of the wound care order. Patient 10: The SN documented on 3/20/25 "Patient pain is a 9/10 states he is taking medications methadone, oxycodone, and testosterone every 14 days and taking 2 Dilaudid. This is not the correct medication orders" (pt was on Fentanyl patch and Diluadid per POC). On 3/26/25 the SN documented "pain still an 8.5/10 patient states pain meds not working". The MD did increase the Dilaudid. The SN called the MD to report the high level of pain or the incorrect usage of the pain medications and pt switched from Dilaudid to Oxycodone per pt request. On 3/28/25 the LPN saw the pt and pt was "upset as he was out of pain meds and wanted to know why the nurse did not bring them". There is evidence the pt was out of pain medication per narcotic count. There was no documentation of diversion or misuse. The LPN contacted the RNCM but there is no evidence the MD was called and medications were refilled or that the MD refused to refill pain medications. The patient ended up going to the hospital 3/29/25 due to uncontrolled pain and discharged from hospice. There was no evidence of continuous assessment of the patient.

Upon patient record review, 2 of 14 (Patient #5,6) 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 5: The MSW documented on 4/7/25 "full code waiting on DNR form signature". There was no care plan added for the needed advance directive. Patient 6: The SN documented 4/7/25 "Pt pain currently a 7/10 it is manageable, discussed use of morphine pump and frequency of visits. Pt has a port and is concerned about infection control. Educated over port access and frequency of care". There were no care plans with goals and interventions for a port, for care or flushing to keep port patent in case of needed use.

Upon patient record review, 4 of 14 (Patient #1,3,5,6) 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: The facility MAR contains an order for Tylenol 325mg 2 tabs daily. This order is not on the hospice POC. Patient 3: The facility MAR contains an order for Haloperidol PRN. There is no order on the hospice POC. Patient 5: The medical record contains an order on 4/8/25 for Hydromorphone 4mg 0.5 tab every 6 hours. The medical record also contains an order on 4/9/25 for hydromorphone 2mg 1 tab every 6 hours. These are duplicate orders. Patient 6: The SN documented 4/7/25 "Pt pain currently a 7/10 it is manageable, discussed use of morphine pump and frequency of visits. Pt has a port and is concerned about infection control. Educated over port access and frequency of care". There were no orders on the POC for a port for care of flushing to keep port patent in case of needed use.

Upon patient record review, 1 of 14 (Patient #8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 8: The current POC contains an order for SN visits twice weekly. The week of 4/20/25-4/26/25 the SN visited on 4/21/25 and there was no second visit made that week. There was no evidence of missed visit documentation or refusal.

Upon patient record review, 2 of 14 (Patient #5,6) 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 5: The MSW documented on 4/7/25 "full code waiting on DNR form signature". MSW documentation on 4/15/25 indicated they are still awaiting a witness for the DNR. There is no evidence the MSW followed up on this psychosocial need as of 4/30/25. Patient 6: On 4/14/25 the SN documented "requested a visit from MSW ASAP". The MSW did not visit until 4/25/25. There was no documentation as to why the MSW didn't visit until 11 days later.

Upon patient record review, 1 of 14 (Patient #6) did not have evidence in the patient record that the hospice has offered and/or provided spiritual counseling in accordance with the patient/family's desires. Patient 6: The SN documented that the patient was requesting a "buddy visit" with the chaplain on 4/10/25. The Chaplain did not visit until 4/18/25. There was no evidence of communication as to why the visit happened over a week later.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 1: The POC contains a problem of high risk for aspiration. The MD documented in CTI 1/26/25 that patient appears to be dysphagic. The aide POC contains a directive for the aide to offer fluids each visit. There was no risk for aspiration added to the aide POC 4/2/25. Corrected on site.

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 provided evidence of their volunteer hours in 2024 as 3.20%. This is less than 5% required.

Upon personnel record review, 3 of 14 (Personnel #2,4,12) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel 2,4,12 The personnel did not have competencies in their employee file.

Upon patient record review, 3 of 14 (Patient #1,4,9) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient 1: The CTI 4/9/25 did not contain a narrative by the medical director. Patient 4: The CTI 3/17/25 does not contain a narrative by the medical director. Patient 9: The CTI 3/31/25 does not contain a narrative by the medical director.

Upon patient record review, 3 of 14 (Patient #7,9,10) did not have evidence that each patient record contains: Patient 7: The EOB at SOC indicated patient chose an attending. There was no attending listed on the EOB the spot was blank. Patient 9: The patient consents indicate patient requested a copy of the Patient Notification of Hospice Non-Covered Items, Services, and Drugs. There is no evidence this addendum was given to the patient and would have been due by 1/11/25. Patient 10: The patient consents indicated patient requested a copy of the Patient Notification of Hospice Non-Covered Items, Services, and Drugs. There is no evidence this addendum was given to the patient and would have been due by 3/23/25.

Upon patient record review, 5 of 14 (Patient #1,2,4,6,8) did not have evidence that each patient record contains Advance Directives. Patient 1: The POC contains an order that patient is a DNR. There was no copy of a DNR in the medical record. Patient 2: The POC contains an order that patient is a DNR. There was no copy of a DNR in the medical record. Corrected on site. Patient 4: The MSW documented on 4/28/25 "patient has a out of hospital DNR". There was no copy of a DNR in the medical record. Patient 6: The medical record contains advance directives that state patient is a DNR. There is no copy of the DNR in the record. Patient 8: The medical record contains advance directives that state patient is a DNR. There is no copy of the DNR in the record.

Upon patient record review, 4 of 14 (Patient #1,2,4,8) 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 SN documented on 4/25/25 "GSON" and "PCGR". These are not approved abbreviations. Patient 2: The MSW documented on 4/18/25 "pt ambulates with a 4WW". On 4/14/25 the SN documented "NOP injury". These are not approved abbreviations. Patient 4: The SN documented on 4/28/25 "BTP". This is not an approved abbreviation. Patient 8: The RN documented performing supervisory visits on an LPN 4/7/25,4/14/25,4/17/25. There is no evidence an LPN seeing this patient.

Upon patient record review, 2 of 14 (Patient #4,7) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 4: The POC 2/14/25 contains an order for Chaplain effective 2/14/25 once a month for 2 months. The Chaplain saw the patient on 2/13/25 which was in the last certification period. There was not a visit for February after the 2/14/25 date. There was no evidence of missed visit documentation or refusal. Patient 7: The SN documented performing wound care on 4/23/25 "wound cleansed with wound cleanser, pat dry, applied xeroform, ABD pad and wrapped with kerlix. This order was not received until 4/24/25. On 4/23/25 the SN documented wound to gluteal area "wound cleansed with NS, pat dry, applied barrier cream". There was no evidence of an order for this wound care. The SN documented wound care to the left forearm "cleansed with NS, pat dry, applied barrier cream.". The order for this wound was to cleanse wound with TESR wound spray and cover with opti foam. The SN did not follow the POC.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 7: The medical record contains an order for wound care to bilateral anterior shins though does not state who is to perform the wound care.

Upon patient record review, 1 of 13 (Patient #2) 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 #2 - Patient admitted 06/22/2021 no evidence of an initial bereavement assessment completed within 5 days.

Upon patient record review, 2 of 13 (Patient #2, 9) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #2 - POC dated 04/18/2022 included a Vol frequency 9 PRN Patient #9 - POC dated 03/01/2022 included a Vol frequency 1 wk 1, 6 PRN.

Upon patient record review, 2 of 13 (Patient #1, 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 medications and treatments. Patient #1 - Senna plus 86mg-50mg 1 tablet as needed for bowels - did not include use modifier. Patient #10 - POC dated 04/28/2022 contained weekly PICC line and cap changes - did not include procedure details.

Upon patient record review 2 of 11 applicable (Patient #5, 8) 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 #5 - Aide care plan to change bed linens 1 x week - aide changed 2 x week - weeks 3, 4 and 5. Patient #8 - Aide care plan to change bed linens 1 x week - aide changed 2 x week - weeks 2, 3, 4, 5, 6 and 7.

Upon patient record review, 2 of 13 (Patient #10, 12) 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 #10 - SN incomplete documentation related to PICC line care - SN visit 05/03/2022, 05/10/2022 and 05/17/2022 dressing and caps changed - did not document details of procedure. SN visit 05/17/2022 no documentation of PICC line site, 05/10/2022 and 05/17/2022 no documentation of arm circumference. Patient #12 - SN visit note 03/22/2022 and 03/29/2022 documentation that Foley catheter size as 18-10cc but was a 16F 10cc.

Upon patient record review, 1 of 13 (Patient #5) did not have evidence that if a drug order is verbal or given via an electronic transmission, it is given to a Registered Nurse, Nurse Practitioner, pharmacist, physician or other licensed individuals as designated by state regulations. The person receiving the order records and signs it immediately and has the prescribing person sign it in accordance with state and federal regulations. Patient #5 - SN visit note 03/02/2022 and 03/09/2022 NP documented to hold lisinopril due to low B/P but no order written to hold medication. The medication was not given during this time.