Every finding on record at Odyssey Healthcare Holding Company

Upon patient record review, 2 of 19 (Patient #1, 19) 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: Nystatin 100,000 units/gm topical powder listed on medication record to be applied twice daily "per instructions". The instructions text box contained the "Nystatin" with no further instruction on location of medication application. Patient 19: Medication record includes Clonidine 0.1mg tablet, 1 by mouth twice daily as needed "for high blood pressure" with no evidence of parameters as to when administration would be indicated. Medication record also lists Hydralazine 50mg 1-2 tablets by mouth three times daily as needed "for hypertension. Max dose 6 tabs daily" with no parameters as to when medication administration would be appropriate and whether 1 or 2 tabs would be indicated.

Upon patient record review, 2 of 19 (Patient #10 & 15) 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 10: Massage therapy frequency order "8 PRN". No evidence of detailed scope and frequency of discipline to meet specific patient needs. Patient 15: MSW frequency on 6/6/23 recert plan of care is 28 PRN. Massage therapy frequency on this POC is 13 PRN. No evidence of detailed scope and frequency for either discipline to meet specific patient needs.

Upon patient record review, 1 of 19 (Patient #19) 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 19: Plan of Care includes Clonidine 0.1mg tablet, 1 by mouth twice daily as needed "for high blood pressure" with no evidence of parameters as to when administration would be indicated. Plan of Care also lists Hydralazine 50mg 1-2 tablets by mouth three times daily as needed "for hypertension. Max dose 6 tabs daily" with no parameters as to when medication administration would be appropriate and whether 1 or 2 tabs would be indicated.

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 the provision of wound care the RN did not doff gloves, cleanse hands, and don clean gloves after removing soiled dressing and before continuing with application of clean dressing to breast wound.

Upon patient client record review, 2 of 19 (Patient # 10 & 11) 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: 3/25/24 aide supervisory visit indicates aide is not present under supervisory section of documentation. The clinician states aide is present in home during visit in the narrative note. Patient 11: Plan of Care indicates presence of urinary catheter with SN visit note on 3/13/24 and 3/20/24 indicating suprapubic catheter in place. SN note dated 3/27/24 indicates GU status as "incontinent with use of briefs/under pads". No evidence of discontinuation of catheter.