Every finding on record at Odyssey Healthcare Holding Company

Upon patient record review 1 of 19 (Patient #13) 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 13 admitted 9/25/24, initial spiritual assessment completed on 10/3/24.

Upon patient record review 1 of 19 (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 no evidence of an initial spiritual assessment.

Upon patient record review, 3 of 19 (Patient #1, 2, 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: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1 nursing visit 10/21/24 documents oxygen in use no evidence of oxygen on the medication profile. Patient 2 nursing visit on 5/8/24 documents oxygen in use at 2LPM, no evidence of oxygen on medication profile. Patient 5 oxygen on medication profile, no evidence of a route.

Upon patient record review, 3 of 19 (Patient #2, 10, 12) 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 admitted 5/8/24, initial bereavement risk assessment completed on 5/15/24. Patient 10 admitted 10/10/23 and initial bereavement risk assessment completed on 12/19/23. Patient 12 admitted on 6/14/24 and initial bereavement risk assessment completed on 6/23/24.

Upon patient record review, 5 of 19 (Patient #3, 7, 8, 10, 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 3 on Eliquis, no evidence of bleeding precautions. Patient 7 on aspirin, no evidence of bleeding precautions. Patient 8 with dysphasia and recurrent aspiration, no evidence of aspiration precautions. Patient 10 on aspirin, no evidence of bleeding precautions. Patient 13 on aspirin and Keppra, no evidence of bleeding or seizure precautions.

Upon patient record review, 1 of 19 (Patient #2) 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 order 5/8/24 for SW and SC 1prn, no routine frequency.

Upon patient record review, 4 of 19 (Patient #1, 2, 4, 5) 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 RN visit 10/21/24 documents oxygen in use, no evidence of an order for oxygen. Patient 2 nursing visit on 5/8/24 documents oxygen in use at 2LPM, no evidence of an order for oxygen. Patient 4 nursing visit on 10/28/24 documented patient uses BIPAP 4-6hrs/night, no evidence of an order for BIPAP. Patient 5 order for oxygen, no evidence of a route.

Upon patient record review, 3 of 19 (Patient #2, 5, 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 2 nursing visit 10/16/24 documented hospital bed, low air low mattress, and OBT, no evidence of an order for these. Patient 5 nursing visit 8/19/24 documents the use of a cane, no evidence of a DME order for the cane. Patient 10 RN visits document use of hospital bed and OBT, no evidence of a DME order for these.

Upon patient record review, 2 of 19 (Patient #6, 12) 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 order on 8/1/24 for oxygen 2-4LPM, no evidence of a care plan to address respiratory or oxygen/safety. Patient 12 SC discontinued 7/31/24 and MSW discontinued on 8/21/24, both have active current care plans.

Upon patient record review, 3 of 19 (Patient #3, 4, 7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3 order 10/15/24 for SN 1w13 and 4prn. Nursing visits completed on 10/15/24 and 10/16/24. Patient 4 initial plan of care ordered opioid count every nursing visit. Patient taking Morphine concentrate, Hydrocodone, and Morphine ER tablets. No evidence all 3 were counted on each nursing visit from 9/26/24 to 10/28/24. Patient 7 order on 7/9/24 for SW effective 7/7/24 of 1m1, 2m2 and 3 prn, MSW visits completed on 7/9/24 and 7/23/24. Order on 7/9/24 for SC effective 7/7/24 of 1m3 and 2prn, SC visits completed on 7/9/24 and 7/30/24.

Upon patient record review, 4 of 19 (Patient #1, 2, 8, 13) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • 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 bleeding precautions on main care plan and patient is a fall risk, no evidence of bleeding or fall precautions on the aide care plan. Patient 2 aide care plan included transfer chair/bed, bed/chair every visit prn. Aide care plan did not include aspiration, fall, or oxygen precautions. Patient 8 with dysphasia and recurrent aspiration, no evidence of aspiration precautions on the aide care plan. Patient 13 on Keppra no evidence of seizure precautions on the aide care plan.

Upon patient record review 2 of 19 (Patient #4, 10) 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 4 aide care plan included change linen weekly on the 1st visit of the week. Aide visits on 10/22/24 and 10/25/24 both document linen changed. Patient 10 aide care plan includes shave every visit. Aide visit on 10/22/24 documented shave not needed this visit.

Upon client record review, 1 of 19 (Patient #2) did not have documented evidence that the written policies and procedures for managing controlled drugs was provided and discussed.

Upon client record review, 1 of 19 (Patient #2) 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 2 5/8/24 order for SW 1prn, order on 5/13/24 for SW effective 5/17/24 1m3 and 2prn. SW routine visit completed on 5/13/24 without an order.

Upon patient record review, 1 of 13 (Patient #6) 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 Order dated 11/5/21 includes clean incision site with soap and water and apply gauze qd. The last wound measurement and documentation was on 11/16/21. 11/23/21 nursing note states no wound measurements needed. Upon interview with DPCS wound was healed and plan of care was not updated. Orders to discontinue wound care/observation corrected while surveyor on site

Upon patient record review, 2 of 13 (Patient #3, #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 11/11/21 plan of care included SN 5week1, 1 wk12. There was evidence of only 3 visits made week one with no evidence of any missed visit entry. Patient #3 The 10/13/21 plan of care included acceptable pain level of 5/10 and to report changes to MD. SN visit notes dated 10/13-11/23 indicate pain at 7 and did not include evidence that the MD was notified. Patient denied wanting med changes however no evidence of report to MD as ordered.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #2 During home visit observed SN remove equipment box from bag and place on counter top. Removed thermometer and after performing task placed directly on the counter top. Placed BP cuff thermometer and stethoscope back into the box without cleaning then closed box and wiped box down and placed back into nursing bag.

Upon patient record review 2 of 12 applicable (Patient #10, 11) did not have evidence 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 #10 The 4/2/21 plan of care included HA 2wk12. There was no evidence of HA visits completed week one. Patient #11 The aide did not complete tasks of shower or dressing as assigned on 11/18/21.

Upon patient record review, 1 of 13 (Patient #3) 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 #3 The volunteer coordinator signature on the 11/26/21 note is not legible and does not match signature on file.