Every finding on record at Odyssey Healthcare Holding Company

Upon patient record review, 3 of 19 (Patient 4, 11, 13) 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 • Actual or potential drug interactions • Duplicate drug therapy Patient 4: Facility current medication has Milk of Magnesia order in facility for daily use, hospice medication profile lists to administer medication every 3 days. The hospice medication profile contained Norco to be administered orally in error, patient requires medication via peg tube. Corrected on site. Patient 11: Facility current medication profile did not contain Levison, morphine, robafen, timolol maleate eye drops. Facility current medication profile has Senna S as scheduled 1 tab daily, the hospice medication profile has Senna S as 1 tab twice a day as needed. Patient 13: Facility current medication profile has iron sulfate, glucagon, loratadine, Tylenol, vitamin D3, that are not on hospice current medication profile. Facility also has Zofran every 8 hours profiled, hospice has Zofran on medication profile as every 6 hours as needed. Facility has losartan 25 mg daily profiled, the hospice has losartan 50mg daily on medication profile. Hospice has Ativan and vitamin B12 injection on medication profile which are not on the current facility profile.

Upon patient record review, 1 of 19 (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 was admitted on 1/07/25 with bereavement risk assessment being performed on 01/15/25.

Upon patient record review, 1 of 19 (Patient 10) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • Information on the patient's progress toward desired outcomes • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 10: There is no documentation of patient progress towards massage therapy goals nor any communication identified with the IDG team.

Upon patient record review, 3 of 19 (Patients #5,#6,#13) 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. Per company policy, wound care measurements are to be taken weekly. Patient 5: There is no documentation of sacral wound measurements from 2/12/25 to 3/6/25. Agency policy requires once weekly assessments and measurements. Patient 6: There is no documentation of coccyx wound measurements in the month of February and additional gap in documentation with no measurements of the coccyx wound charted between dates 3/12/25-3/28/25. Agency policy requires once weekly assessments and measurements. Patient 13: There is not consistent documentation of weekly wound care measurements for the coccyx wound and the right buttock wound, the only two measurements charted are on dates 02/24/25 and 03/19/25 since 01/01/2025. Agency policy requires once weekly assessments and measurements.

Upon patient record review, 4 of 19 (Patient 3,4,8,10) 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: Nursing documentation upon admission charts patient has history of seizures, there are no problems, goals, or interventions related to seizures documented.-Corrected on site. Patient 4: Nursing documentation upon admission charts patient has history of seizures, there are no problems, goals, or interventions related to seizures documented.-Corrected on site. Patient 8: Upon admission, patient identified as high risk for falls in the medical record, there are no problems, goals, or interventions related to falls.-Corrected on site. Patient 10: Upon admission, patient identified as a fall risk, there are no problems, goals, or interventions related to falls. Also, admission note states patient with diabetes and rates 4 on New York Heart Association scale, but there are no related endocrine or cardiac problems, goals, or interventions listed.-Corrected on site.

Upon patient record review, 1 of 19 (Patient 5) 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 Patient 5: Massage Therapy frequency did not contain routinely scheduled visits, only 9 PRN visits.-Corrected on site.

Upon patient record review, 3 of 19 (Patient 1, 4, 13) 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: No orders in the medical record for settings on Luisa oxygen concentrator.-Corrected on site. Patient 4: The medical record contained an order for Norco with oral administration in error, patient requires medication via peg tube. The record also contained nursing documentation since admission identifying the patient has an indwelling catheter. There was no evidence of an order for the catheter type, size, change frequency, or maintenance. No orders for feeding tube flushes with medication administration.-Corrected on site. Patient 13: There are no orders in the medical record for catheter size, frequency of change, or maintenance since admission.-Corrected on site. In addition, no evidence of wound orders are written for wound on coccyx and right buttock. Corrected on site.

Upon patient record review, 4 of 19 (Patient 6, 7, 10, 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 equipment and supply needs. Patient 6: Nurse visit on 3/12/25 identifying a lift is in use, there is no order for lift and is not reflected in the Plan of care.-Corrected on site. Patient 7: Nurse visit on 2/26/25 which identifies catheter supplies, hospital bed, over the bed table, transfer bench, walker, oxygen equipment but are not reflected in the Plan of care, nor are there orders for this medical equipment.-Corrected on site. Patient 10: Nurse visit on 1/17/25 identifies Bedside Commode, there is no order for one and is not reflected in the Plan of care.-Corrected on site. Patient 14: Patient has a lift identified by admitting nurse visit on 2/26/25, there are no orders for lift.-Corrected on site.

Upon patient record review, 3 of 19 (Patient 7,9,10) 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 7: Patient identified as high risk for falls in nurse visit on 2/26/25, Plan of care not updated to reflect change. Corrected on site. Patient 9: Nurse visit on 3/13/25 with a documented diet change to puree with nectar thick liquids, Plan of care was not updated to reflect change.-Corrected on site. Patient 10: There is no documentation in plan of care of patient progress towards massage therapy goals nor any communication identified with the IDG team.

Upon patient record review, 1 of 19 (Patient #17) did not have evidence the hospice offers bereavement counseling that includes: • Ensuring that bereavement services reflect the needs of the bereaved. Patient 17: A bereavement contact was identified with high risk assessment after death, per the bereavement plan of care, this requires phone or in person visit within 2-4 weeks after death and additional monthly contacts, there is no evidence in the chart that reflects any contact made or attempts at contact.

Upon patient record review, 3 of 19 (Patient 4, 5, 6) did not have evidence in the patient record that hospice aide assignments and duties are: • 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 Patient 4: Patient identified as a two person assist, but is not identified as so in the aide care plan.-Corrected on site. Patient 5: No instructions in the aide care plan on how to handle wound dressings during shower.-Corrected on site. Patient 6: No instructions given in aide care for transferring patient to shower with fall precautions in place.-Corrected on site.

Upon patient record review, 2 of 13 records (Patients #1,#9) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 1: The medical record contained an election of benefit form identifying patient declined to choose an attending physician. Multiple orders were received and signed by a community physician including a CTI, POC, wound care, medication orders and plan of care updates. There was no evidence patient elected the community physician as their attending after admission. Patient 9: The medical record contained an election of benefit form identifying patient declined to choose an attending physician. Multiple orders were received and signed by a community physician including a CTI, POC, medication orders and spiritual care frequencies. There was no evidence patient elected the community physician as their attending after admission.

Upon patient record review, 4 of 13 records (Patients #7,#10,#11,#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. 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 7: The medication profile listed two acetaminophen suppository instructions; one for 325 mg every 4 hours as needed and one for 650 mg every 6 hours as needed. The medical record contained a physician order 3-26-22 to discontinue acetaminophen 650 mg suppository. Corrected on site. Patient 10: The medication profile contained oxygen with no delivery method identified. Patient 11: The medication profile contained lidocaine patch with no area defined for administration. Patient 12: The medical record identified use of oxygen concentrator as equipment on the plan of care. There was no evidence of the oxygen listed on the medication profile.

Upon patient record review, 2 of 13 records (Patients #2,#9) 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: The medical record contains an initial bereavement assessment completed 3-21-22. Patient admitted to hospice services 3-11-22. Patient 9: The medical record contains an initial bereavement assessment completed 1-21-22. Patient admitted to hospice services 12-23-21.

Upon patient record review, 1 of 13 records (Patient #12) 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 12: The medical record contained nursing documentation on 3-6-22 identifying wound care completed with a dressing applied to patient coccyx. There was no evidence of problems, goals, and interventions related to skin impairment included on the plan of care.

Upon patient record review, 3 of 13 records (Patients #10,#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 medications and treatments. Patient 10: The medical record contained a physician order for oxygen with no delivery method identified. Patient 11: The medical record contained a physician order for a lidocaine patch daily with no area defined for administration. Patient 12: The medical record identified use of oxygen concentrator as equipment on the plan of care. There was no evidence of a physician order for oxygen.

Upon patient record review, 6 of 13 records (Patients #7,#8,#9,#10,#11,#13) 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 7: The medication profile identified patient use of oxygen as ordered by the physician. There was no evidence of oxygen equipment and supplies included as DME on the plan of care. Corrected on site. Patient 8: The medical record contained nursing documentation 4-17-22 identifying nurse ordered hospital bed for stat delivery. There was no evidence of an order or the bed listed as equipment on the plan of care. Corrected on site. Patient 9: The medication profile identified patient was prescribed medication to be administered via a nebulizer. There was no evidence of an order or the nebulizer listed as equipment on the plan of care. Corrected on site. Patient 10: The medical record contained social worker documentation 8-26-21 identifying nurse to order hospital bed, air mattress, table, and half rails. There was no evidence of an order for the equipment or the equipment listed on the plan of care. Patient 11: The medical record contained nursing documentation 8-14-21 identifying patient had ileostomy cares and monitoring, and 8-23-21 identifying need for drain sponge dressing for bile drain care. There was no evidence of ostomy and dressings listed on the plan of care. Patient 13: The medication list identified patient use of nebulizer and oxygen. The medical record also contained chaplain documentation 12-8-21 identifying patient use of hospital bed. There was no evidence of the nebulizer, oxygen, and bed included as equipment on the plan of care.

Upon client record review, 1 of 13 records (Patient #12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 12: The medical record contained nursing documentation 3-6-22 identifying the nurse completed wound care including applying a dressing to the patient's coccyx. There was no evidence of wound care included in the plan of care.

Upon patient client record review, 1 of 13 (Patient #13) did not evidence that each patient record contains physician orders. Patient #13 The medical record contained documentation the patient discharged to a non-contracted facility and proper notification of the planned discharge occurred. There was no evidence of an order to discharge per agency policy requiring orders for all discharges except death and revocation.

Upon patient client record review, 1 of 13 records (Patient #13) 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 13: The medical record contained an election of benefit form identifying the patient declined to choose an attending physician. A verbal certification of terminal illness was documented as received from a community physician despite declination of an attending.

Upon client record review, 2 of 3 applicable records (Patients #2,#9) 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: The medical record contained an ordered nursing frequency of once weekly. There was no evidence of a visit completed the week of 4-17-22 and no change order or missed visit documentation for explanation of why frequency was not met. Patient 9: The medical record contained an ordered nursing frequency of once weekly. There was no evidence of a visit completed the week of 4-17-22 and no change order or missed visit documentation for explanation of why frequency was not met.