Every finding on record at Odyssey Healthcare Holding Company

Upon patient record review, 1 of 5 records (Patient #2) 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 #2: The medication profile contained Lidocaine 4%, 1 patch q24h. There was not evidence of instructions to remove the patch after 12h and/or to leave off for 12h.

Upon patient record review, 5 of 5 records (Patient #1,#2,#3,#4,#5) did not have evidence the plan of care 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 #1,#2,#3,#4,#5: The initial visit frequency for the social worker and the spiritual care counselor was 1 prn.

Upon patient record review, 1 of 5 records (Patient #2) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2: The record contained an order for Lidocaine 4%, 1 patch q24h. There was not evidence of instructions to remove the patch after 12h and/or to leave off for 12h.

Upon patient record review, 2 of 5 records (Patient #2,5) 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. Patient #2: The record contained a physician change form dated 2/13/25, without evidence of whom the new physician would be. The area to document the name of the physician was blank. Patient #5: The care plan included goals and interventions for facility coordination, however the patient was home and not in a facility.

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. No record of exercises or events were documented in 2023.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 3: The election form identified that the patient/responsible party chose a community physician as an attending. The medical record contained an order to change the attending to a different physician without evidence of patient/responsible party choice.

Upon patient record review 2 of 14 (Patients #2,#9) 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 2: There was no evidence of a comprehensive spiritual assessment. Corrected on site. Patient 9: There was no evidence of a comprehensive spiritual assessment. Corrected on site.

Upon patient record review, 4 of 14 (Patients #1,#2,#3,#8) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 1: Upon observation during the home visit, the facility and hospice profiles did not match. The facility profile contained acetaminophen PRN every 8 hours and hospice every 6 hours, a bisacodyl suppository day 3 of no BM and hospice day 4, loperamide 2 capsules at onset of diarrhea, then 1 tablet with each episode of diarrhea, maximum 6 capsules every 24 hours and hospice instructions to notify hospice prior to administration. The hospice medication profile also contained polyethylene glycol oral powder with no instructions to mix with a diluent. Corrected on site. Patient 2: Upon observation during the home visit, the facility and hospice profiles did not match. The facility profile contained melatonin 1 tablet at bedtime and hospice 2 tabs, and duoneb twice daily and hospice three times daily. The facility profile also contained medications not listed on the hospice profile including losartan, cough drops, an albuterol inhaler, docusate sodium, and senna. In addition, the hospice profile contained Miralax oral powder with no instructions to mix with a diluent. Corrected on site. Patient 3: The medication profile contained Miralax oral powder with no instructions to mix with a diluent. Corrected on site. Patient 8: Upon patient interview during medication reconciliation, the prescription bottle for pregabalin had instructions to take twice daily, verified by patient's wife. The hospice medication profile indicated frequency of once daily. Corrected on site.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 2 of 14 (Patient #5, 9) 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 5: No measurements and assessments for right shin since 12/31- order and policy for weekly by hospice nurse Patient 9: RN documentation 11/26/24 identifying discussion with patient and wife regarding facility placement needed. There was no evidence of follow up by the RN until order for SW eval 1/13/25.

Upon patient record review, 4 of 14 (Patients #7,#8,#9,#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 7: The medical record contained nursing documentation since admission identifying patient is a high risk for skin impairment. There was no evidence of problems, goals, and interventions related to the risk of skin impairment included in the plan of care. Corrected on site. Patient 8: The medical record contained nursing documentation since admission identifying patient is insulin dependent. There was no evidence of problems, goals, and interventions related to endocrine dysfunction included in the plan of care. Corrected on site. Patient 9: The medical record contained nursing documentation since admission identifying patient is a high risk for falls and insulin dependent. There was no evidence of problems, goals, and interventions related to fall safety and endocrine dysfunction included in the plan of care. Corrected on site. Patient 10: The medical record contained nursing documentation since admission identifying patient is a high risk for falls and skin impairment. There was no evidence of problems, goals, and interventions related to fall safety and the risk of skin impairment included in the plan of care. Corrected on site.

Upon patient record review, 4 of 14 (Patients #1,#2,#3,#7) 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 1,2,3: The medical record contained orders for polyethylene glycol/Miralax oral powder with no instructions to mix with a diluent. Corrected on site. Patient 7: The medical record contained nursing documentation since admission identifying the patient has a suprapubic catheter. There was no evidence of an order for catheter type, size, and change frequency. Corrected on site.

Upon patient record review, 4 of 14 (Patients #1,#2,#3,#9) 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 1: The medical record contained nursing documentation 12/16/24 identifying patient use of a hospital bed, low air loss mattress, and shower chair; and 12/30/24 identifying use of mechanical lifts. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 2: The medication profile contained a duoneb prescription. There was no evidence of an order for the nebulizer included in the plan of care. Corrected on site. Patient 3: The medical record contained nursing documentation 1/2/25 identifying the nurse ordered a Broda chair to be delivered from the DME supplier. There was no evidence of an order for the chair included in the plan of care. Corrected on site. Patient 9: The medical record contained nursing documentation 11/26/24 identifying patient use of a walker. There was no evidence of an order for the walker included in the plan of care. Corrected on site.

Upon patient record review, 3 of 14 (Patients #3,#4,#5) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient 3, 4, 5: The election form identified the patients/responsible parties chose community physicians as attendings. There was no evidence on ongoing collaboration with the attending physicians no less then every 15 days.

Upon patient record review, 4 of 14 (Patients #1,#6,#9,#14) 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 1: The medical record contained nursing documentation identifying the patient had a seizure reported 12/30/24. There was no evidence of problems, goals, and interventions related to seizure precautions added to the plan of care. Corrected on site. Patient 6: The medical record contained nursing documentation identifying the patient had a seizure reported 11/11/24. There was no evidence of problems, goals, and interventions related to seizure precautions added to the plan of care. Corrected on site. Patient 9: The medical record contained nursing documentation 11/26/24 identifying discussion with patient and wife regarding facility placement needed. There was no evidence of problems, goals, and interventions related to the need for facility placement added to the plan of care. Patient 14: The medical record contained documentation of the patient discharge due to extended prognosis 12/12/24. There was no evidence of problems, goals, and interventions related to the plan to discharge the patient added to the plan of care.

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 9: The medical record contained nursing documentation 11/26/24 identifying patient had a fall the week prior to visit. There was no evidence the agency investigated the incident and developed a plan to prevent similar events from occurring.

Upon patient record review, 2 of 14 (Patients #11,#12) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. • Ensuring that bereavement services reflect the needs of the bereaved. Patient 11: The medical record identified a bereaved person as high risk 6/8/24. The bereavement care plan contained tasks with no evidence of completion including a phone call within 2-4 weeks, 1 and 3 month letters, offering support group, holiday letter, and offering monthly contact unless declined or status reduced to low risk. Patient 12: The medical record identified a bereaved person as moderate risk 5/27/24. The bereavement care plan contained tasks with no evidence of completion including sending a holiday letter, offering support group, and offering monthly contact unless declined or status reduced to low risk.

Upon personnel record review, 1 of 14 (Personnel #5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: ·Reading and recording temperature, pulse, and respiration Personnel 5: There was no evidence the aide was observed obtaining temperature, pulse and respirations.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence in the patient record that hospice aide assignments and duties are specific to the patient's needs. Patient 1: The aide care plan contained a bath type of shower with instructions to provide bed bath, and no transfer instructions to use an EZ stand. Corrected on site.

Upon patient record review 1 of 14 (Patient #9) 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 9: The order for aide frequency was twice weekly upon initial POC. There was no evidence of aide visits completed the first benefit period 9/19/24-12/17/24.

Upon patient record review 1 of 14 (Patient #6) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 6: The medical record contained evidence of only one aide supervisory visit documented 11/18/24.

Upon contract review, 1 of 6 (Premere Rehab contract) did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. The contract for OT/ST was restricted to only telehealth visits.

Upon patient record review, 1 of 14 (Patient #9) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 9: The patient elected to receive the Notification of Hospice Non-Covered Items upon admission 9/19/24. There was no evidence the form was provided.

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 contained an order for catheter flushes 1/8/25 that does not indicate facility or hospice responsibility.

Upon patient record review, 1 of 14 (Patient #2) did not have evidence that the hospice provided the following information: • Physician certification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient Patient 2: Upon observation during the home visit, the facility did not have the certification of terminal illness and a list of team members involved with hospice care.

Upon personnel record review, 1 of 14 (Personnel #11) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at renewal or in accordance with specific state practice act requirements. Personnel 11: There was no evidence of a current DEA registry in the personnel file.

Upon personnel record review, 1 of 14 (Personnel #12) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel 12: There was no evidence of a criminal background check in the personnel file.

Upon personnel record review, 1 of 14 (Personnel #8) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel 8: There was no evidence of a criminal background check in the personnel file.

Upon patient record review, 1 of 13 records (Patient #1) 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. Patient #1: The patient was admitted on 11/10/21. The record indicated that the bereavement assessment was completed on 11/17/21 which is greater than the 5 day requirement.

Upon patient record review, 2 of 13 records (Patient #11,#13) did not have evidence the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. (This deficiency was found only on 2 discharged records) Patient #11: The record indicated an order dated 12/20/21, Change frequency from 1 to 2 times within 30 days. There was not evidence of a discipline. Patient #13: The record indicated an order dated 9/27/21, Change frequency to 2 visits within 30 days. There was not evidence of a discipline.

Upon client record review, 2 of 11 applicable records (Patient #2, 7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: The visit frequency for the skilled nurse was 1x/week effective 1/17/22. The last documented skilled nurse visit was dated 1/17/22. Patient #7: The record indicated a telehealth visit was conducted by the skilled nurse on 1/14/22. There was not evidence that telehealth was included in the plan of care.

Upon patient record review, 1 of 12 applicable records (Patient #9) 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 #9: The record indicated that the patient was on Eliquis 5mg 2x daily. There was not evidence that bleeding precautions were a part of the plan of care. Corrected on site.

Upon patient record review 2 of 12 applicable records (Patient #3,#9) 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 Patient #3: The aide visit frequency dated 12/30/21 was 2x/week. The record indicated 1 missed visit note on 1/4/22. There was not evidence of a visit or missed visit documentation from this date until 1/13/22 when the plan of care revealed the aide services were discontinued. Patient #9: The aide visit frequency was ordered on admission (1/13/22) for 1x/week. There was not evidence of an aide visit until 1/28/22

Upon patient record review, 1 of 13 records (Patient #13) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course, and includes the dates of the certification period. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness The EOB indicated that the start of care was 8/2/21. The initial certification of terminal illness listed the certification period as 8/3/21-10/1/21. (This was found only on a discharge record and the agency did not bill for this patient)

Upon patient record review, 1 of 6 applicable records (Patient #13) did not have evidence that before the recertification period for each patient, and includes the dates of the certification period. 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. The EOB indicated that the start of care was 8/2/21. The initial certification of terminal illness listed the certification period as 8/3/21-10/1/21, which was incorrect. The recertification of terminal illness followed the dates indicating the next cert period began on 10/2/21. This was found only on the discharge record review and the agency did not bill for this patient.

Upon patient client record review, 8 of 13 records (Patient #1,#2,#3,#4,#8,#9,#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. There was not evidence of credentials on the electronic signature of a clinician. It was not able to be determined the discipline of this clinician.

Upon personnel record review, 8 of 13 records (Personnel #4,#5,#6,#7,#10,#11,#12,#13) did not have evidence of criminal background checks being obtained in accordance with state requirements. Records did not contain evidence that a search whereby Minnesota abides by the Serve America Act Federal law (H.R. 1388, Sec. 1614) requiring organizations whose employees work with vulnerable individuals (children, the elderly or disabled) to complete a background check on those employees, including state and federal criminal history check and a search of the predatory offender database.  Appropriate permissions must be provided by the employee. There was not evidence that the criminal background check included a state and federal criminal check.