Every finding on record at Odyssey Healthcare Holding Company

Upon patient record review, 7 of 19 (Patient #1,#2,#3,#7,#9,#11,#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 1:The medical record contained nursing documentation upon admission of oxygen in use as needed, problem and goals identified in plan of care with no interventions. Corrected on site Patient 2:The medical record contained nursing documentation of 5 falls within 6 weeks. The patients medication profile includes use of Eliquis daily. There was no evidence of problem, goals or interventions related to anticoagulation therapy included in the plan of care. Corrected on site. Patient 3:The plan of care contained problem, goals and interventions for the spiritual care counselor. No services are currently being provided directly by the spiritual care counselor. Corrected on site. Patient 7:The medical record contained active problem, goals and interventions for the medical social worker. No services are currently being provided directly by the medical social worker. Corrected on site. Patient 9:The patient was admitted with a diagnosis of cancer and identified problem of altered skin integrity, altered respiratory status and altered comfort. There are no active goals and interventions for these problems included in the plan of care. Corrected on site. Patient 11:The plan of care contained spiritual care problem of coping with no goals and interventions included in the plan of care. Corrected on site Patient 13:The medical record contained medical social worker documentation of interventions regarding family request for Respite stay for patient in July. No problem statement, goals or interventions included in the plan of care. Corrected on site.

Upon patient record review, 1 of 19 (Patient #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 medications and treatments. Patient 9: The medical record contained nursing documentation that patient was receiving Oxygen via mask on 5/24/23. Oxygen therapy orders for nasal cannula with no evidence that oxygen is being delivered via mask.

Upon patient record review, 10 of 19 (Patient #1,#2,#3,#5,#6,#7,#9,#12,#13,#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 1:The medical record contained nursing documentation upon admission identifying use of walker. There is no evidence of walker included in the plan of care. Corrected on site. Patient 2:The medical record contained nursing documentation upon admission identifying use of overbed table. There is no evidence that the overbed table is included in the plan of care. Corrected on site. Patient 3:The medical record contained nursing documentation on 4/18/23 identifying use of wheelchair and fall mat. There is no evidence that the wheelchair and fall mat are included in the plan of care. Corrected on site. Patient 5:The medical record contained nursing documentation upon admission identifying use of overbed table. There is no evidence that the overbed table is included in the plan of care. Corrected on site. Patient 6:The medical record contained nursing documentation upon admission identifying use of hospital bed and specialty mattress. There is no evidence that hospital bed or specialty mattress are included in the plan of care. Corrected on site. Patient 7:The medical record contained nursing documentation upon admission identifying use of wheelchair, fall mat and shower chair. There is no evidence of wheelchair, fall mat and shower chair included in the plan of care. Corrected on site. Patient 9:The medical record contained nursing documentation on 5/6/23 identifying use of bedside commode. There is no evidence of bedside commode included in the plan of care. Corrected on site. Patient 12:The medical record contained nursing documentation upon admission identifying use of walker. There is no evidence of walker included in the plan of care. Corrected on site. Patient 13:The medical record contained nursing documentation upon admission identifying use of wheelchair and shower chair. There is no evidence of wheelchair or shower chair included in the plan of care. Corrected on site. Patient 14:The medical record contained nursing documentation upon admission identifying use of hospital bed and wheelchair. There is no evidence of hospital bed or wheelchair included in the plan of care. Corrected on site.

Upon client record review, 2 of 19 (Patient #5,#9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5:The plan of care contained a massage therapy frequency of 1 visit weekly. No evidence of visit completed the week of 5/28/23 and missed visit not addressed. Late order entry and corrected on site. Patient 9:The plan of care contained a massage therapy frequency of 1 visit weekly. No evidence of visit completed the week of 5/28/23 and missed visit not addressed. Late order entry and corrected on site.

Upon patient record review, 1 of 19 (Patient #14) 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 14:The medical record contained aide care plan assignment with tasks for external catheter care and empty drainage bag. The patient does not have catheter. Corrected on site.

Upon patient client record review, 1 of 19 (Patient #1) 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 1: The medical record contained nursing documentation stating the catheter balloon was inflated with 30cc. The catheterization order stated that the balloon was to be inflated with 10cc. The agency confirmed that order for 10cc was followed and that the documentation of 30cc's was in error. Corrected on site.