Every finding on record at Odyssey Healthcare Holding Company

Upon patient record review, 1 of 23 (Patient #8) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 8: The medical record contained an election form identifying the patient did not choose to have an attending physician to oversee their hospice care. The patient profile in the medical record indicated the attending physician was a community physician that rounds at the facility. There was also evidence of a signed CTI and plan of care as well as additional orders received from the community physician. Corrected on site with agency obtaining change of physician document signed by the patient for clarification of preferred ongoing involvement.

Upon patient record review, 1 of 23 (Patient #9) 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 9: The medical record contained nursing documentation upon recertification visit 6/13/23 identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. Corrected on site.

Upon patient record review, 1 of 23 (Patient #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 10: The medical record contained an order 6/15/23 stating wound care per facility staff wound nurse and 4 wounds assessed and measured on that date. There was no evidence of additional assessments completed by the hospice nurses.

Upon patient record review, 7 of 23 (Patients #3,#4,#7,#9,#15,#16,#18) 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: The medical record contained nursing documentation 6/20/23 identifying patient receives dialysis and had skin impairments requiring ointment application. The medication profile identifying patient is insulin dependent with sliding scale dosage for administration. There was no evidence of problems, goals, and interventions related to dialysis, endocrine and skin impairments included in the plan of care. Corrected on site. Patient 4: The medication profile identified patient is insulin dependent with instructions for administration with blood glucose parameters. There was no evidence of problems, goals, and interventions related to endocrine dysfunction and monitoring included in the plan of care. Corrected on site. Patient 7: The medical record contained bereavement visits to the patient completed 6/9/23 and 6/28/23. There was no evidence of problems, goals, and interventions related to bereavement included in the plan of care. Corrected on site. Patient 9: The medical record contained an active aide care plan. There was no evidence of the patient receiving aide services. Corrected on site. Patient 15: The medical record contained nursing documentation upon admission identifying patient has dysphagia and was recently hospitalized due to aspiration. There was no evidence of problems, goals, and interventions related to dysphagia. Corrected on site. Patient 16: The plan of care contained active problems, goals, and interventions related to social work care. There was no evidence of the patient receiving social work visits. Corrected on site. Patient 18: The medical record contained an active aide care plan. There was no evidence of the patient receiving aide services. Corrected on site.

Upon patient record review, 2 of 23 (Patients #9,#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 9: The medical record contained nursing documentation upon recertification visit 6/13/23 identifying patient use of oxygen. There was no evidence of an order for oxygen. Corrected on site. Patient 10: The medical record contained an order 6/15/23 stating wound care per facility staff wound nurse. There was no evidence of information on the order identifying wound locations, treatment, and frequency.

Upon patient record review, 4 of 23 (Patients #3,#9,#11,#12) 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 3: The medical record contained nursing documentation 6/20/23 identifying patient use for a mechanical lift for transfers. There was no evidence of the lift included as DME in the plan of care. Corrected on site. Patient 9: The medical record contained nursing documentation upon recertification visit 6/13/23 identifying patient use of oxygen and a walker. There was no evidence of the oxygen and walker included as DME in the plan of care. Corrected on site. Patient 11: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair. There was no evidence of the wheelchair included as DME in the plan of care. Corrected on site. Patient 12: The plan of care identified patient had oxygen equipment. Upon investigation, the agency confirmed patient was not on oxygen and DME was listed in error. Corrected on site.

Upon client record review, 2 of 23 (Patients #10,#15) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 10: The medical record contained an ordered nursing visit frequency for once weekly. There was evidence of 3 scheduled visits completed the week of 6/11/23. The record also contained an order for an extra nursing visit 6/22/23. There was no evidence of a visit completed per order for 6/22/23. Patient 15: The medical record contained an ordered nursing frequency of 3 visits the week of 6/25/23. There was no evidence of a third visit documented.

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 16: The medical record contained nursing documentation 7/21/23 identifying patient had 2 falls within the last week. There was no evidence of an incident report to investigate the falls. Corrected on site.

Upon patient record review, 2 of 23 (Patient #3, 17) did not have evidence in the patient record that hospice aide assignments and duties indicate what tasks are to be done by the Aide and the frequency of these tasks. Patient 3: The medical record contained nursing documentation 6/20/23 identifying patient use for a mechanical lift for transfers. There was no evidence of instructions for lift to transfer included on the aide care plan. Corrected on site. Patient 17: The medical record contained nursing documentation upon admission identifying patient use of a walker for ambulation. There was no evidence of instructions for use of the walker included on the aide care plan. Corrected on site.