Every finding on record at Odyssey Healthcare Holding Company

Upon patient record review, 7 of 19 (Patients #2,#3,#4,#6,#7,#8,#10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 2: The medication profile contained polyethylene glycol oral powder with no instructions to mix with a diluent. Corrected on site. Patient 3: Upon observation during the home visit the facility and hospice medication profiles did not match. The facility profile contained magnesium oxide and an albuterol inhaler that both discontinued 10/2/24. Patient 4: The medical record contained nursing documentation upon recertification 9/10/24 identifying patient use of oxygen. There was no evidence of oxygen on the medication profile. Corrected on site. Upon observation during home visit, the facility and hospice medication profiles did not match. The facility profile contained amlodipine that was discontinued by hospice 10/4/24, and did not contain hyoscyamine and lorazepam that was on the hospice profile. Patient 6: The medication profile contained duplicative clonazepam listing for once daily at 2pm dated 5/24/24 and for twice daily at 2pm and bedtime dated 10/8/24. Corrected on site. Patient 7: The medication profile contained a lidocaine topical patch with no area defined for administration. Corrected on site. Patient 8: The medication profile contained atropine with no defined frequency. Corrected on site. Patient 10: The medication profile contained nystatin topical powder and lidocaine patch with no areas defined for administration. Corrected on site.

Upon patient record review, 1 of 19 (Patient #1) 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 1: There was no evidence per agency policy of weekly assessments and measurements of wounds to left thigh and mid chest from 9/5/24 to 9/20/24 and 9/20/24 to 10/2/24.

Upon patient record review, 2 of 19 (Patients #3,#9) 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 upon admission identifying patient issues with difficulty swallowing and coughing after eating. There was no evidence of problems, goals, and interventions related to dysphagia included in the plan of care. Corrected on site. Patient 9: The medical record contained nursing documentation upon admission identifying the patient is a high risk for falls. There was no evidence of problems, goals, and interventions related to fall safety included in the plan of care. Corrected on site.

Upon patient record review, 5 of 19 (Patients #2,#4,#7,#8,#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 2: The medical record contained an order for polyethylene glycol oral powder with no instructions to mix with a diluent. Corrected on site. Patient 4: The medical record contained nursing documentation upon recertification 9/10/24 identifying patient use of oxygen. There was no evidence of an order for oxygen. Corrected on site. Patient 7: The medical record contained an order for a lidocaine topical patch with no area defined for administration. Corrected on site. Patient 8: The medical record contained an order for atropine with no defined frequency. Corrected on site. Patient 10: The medical record contained an order for lidocaine patches with no area defined for administration. Corrected on site.

Upon patient record review, 4 of 19 (Patients #6,#8,#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: The medical record contained nursing documentation upon admission identifying patient use of a nebulizer. There was no evidence of an order for the nebulizer included in the plan of care. Corrected on site. Patient 8: The medical record contained nursing documentation since admission 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. Patient 10: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair. There was no evidence of an order for the wheelchair included in the plan of care. Corrected on site. Patient 14: The medical record contained nursing documentation upon admission identifying patient use of a walker and wheelchair. There was no evidence of orders for the equipment included in the plan of care. Corrected on site.

Upon patient record review, 1 of 19 (Patient #1) 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 of wounds activated 7/22/24 and 9/5/24. There was no evidence of problems, goals, and interventions related to skin impairment updated in the plan of care. Corrected on site.

Upon patient record review, 3 of 19 (Patients #15,#16,#17) 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. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 15: The bereavement care plan contained tasks of sending 6 and 9 month newsletters and support group invitations. There was no evidence the 6 and 9 month tasks were completed. Patients 16,17: The bereavement care plans contained tasks of a 6 month phone call, and 3 and 6 month newsletters and support group invitations. There was no evidence the 3 and 6 month tasks were completed.

Upon patient record review, 1 of 19 (Patient #3) did not have evidence in the patient record that hospice aide assignments and duties are specific to patient needs. Patient 3: The aide care plan did not include instructions for level of transfer assistance needed. Corrected on site.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The agency had a volunteer utilization rate of 3% for 2023.

Upon personnel record review, 1 of 16 (Personnel #5) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy.

Upon personnel record review, 1 of 16 (Personnel #5) did not have evidence that the hospice employees have received orientation on their specific job requirements.

Upon personnel record review, 2 of 16 (Personnel #5,#10) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel 5,10: There was no evidence of an initial skills competency assessment.

Upon contract review, 1 of 5 (Hospice Physician contract) did not have evidence of a contract to fulfill the role of alternate medical director. The contract was for Hospice Physician and did not outline responsibilities to assume obligations of the medical director as needed.

Upon patient record review, 4 of 19 (Patients #3,#7,#10,#14) 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 3,10,14: The medical record contained an election form identifying the Notification of Hospice Non-Covered Items was requested upon admission. There was no evidence the information was provided as requested. Corrected on site. Patient 7: The medical record contained an election form identifying the Notification of Hospice Non-Covered Items was requested upon admission 4/29/24. There was no evidence the information was provided as requested.

Upon patient record review, 1 of 19 (Patient #4) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 4: There was no evidence of attending physician signature on the initial CTI prior to billing. The CTI on file was signed by a NP instead of the attending physician elected by the patient upon admission. Corrected on site with signature obtained. Agency notified compliance to address billing.

Upon patient record review, 1 of 19 (Patient #19) did not evidence that each patient record contains physician orders. Patient 19: There was no evidence of an order to discharge the patient for extended prognosis. Corrected on site with late data entry.

Upon personnel record review, 1 of 16 (Personnel #13) 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 13: There was no evidence of a criminal background check completed.

Upon personnel record review, 1 of 16 (Personnel #5) 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 5: There was no evidence of a background check completed.

Based on record review and interview, the agency staff failed to ensure patient rights were followed at end of life in 1 out of 5 discharged patient records out of a total of 10 patient records reviewed (Patient #1). The agency failed to provide effective pain management and symptom control. See L512.

Based on record review and interview, the agency failed to ensure the patient's right to effective pain management was followed in 1 out of 5 discharged patient medical record reviews out of a total of 10 patient medical records reviewed (Patient #1). Findings include: Review of policy "Components Of The Hospice Care Plan" not dated revealed in part, "The nurse maintains a current medication profile and reviews and reconciles all patient medications, both prescription and non-prescription on an ongoing basis in collaboration with the IDG (Interdisciplinary Group)." The policy further states in part, "On each visit, the nurse reviews the patient's medications..." Review of Patient #1's medical record revealed that Patient #1 was admitted to hospice with primary diagnosis of Kidney Cancer and secondary diagnoses of Alzheimer's Disease (a type of dementia) and peripheral vascular disease. Review of Patient #1's SN (skilled nurse) Visit Note Report dated 12/28/2021 at 9:04 a.m. revealed "Patient actively dying with abnormal respiratory rhythm, periods of apnea, irregular heart rhythm." Pain assessment revealed "Patient unable to verbalize pain. Occasional moan/groan. Total pain score 2; mild pain. As-needed morphine given nearly hourly, some effectiveness. Further review of the Visit Note Report revealed, "Increase PRN (as needed) morphine to 1ml(milliliter) every hour as needed. 1ml = 20mg(milligrams)." The Visit Note Report also revealed, "Was a medication reconciliation completed? YES. Were all ordered medication available? YES. Were any medication refills requested? NO. Has a narcotic count been completed this visit? NO." "Hospice Physician Order" dated 12/28/2021 at 9:04 a.m. revealed "D/C (discontinue) previous morphine order. Start morphine 20mg/ml, give 1.0ml (=20mg) every hour as needed for pain or shortness of breath." This order was directly entered into the electronic medical record instead of IPrescribe (software program that allows the order to go straight to the physician for signature and then immediately to the pharmacy). Review of Coordination Notes Report dated 12/29/2021 at 9:45 a.m. revealed "Call from facility stating they used the Patient's last morphine at 2:00 a.m. and they need more. Prescription put into IPrescribe. Call to physician and made aware of stat (urgent) need. States will sign the script right away. Call to pharmacy and stated they have received the prescription and will fill ASAP (as soon as possible.) " An interview was conducted with Administrator A and Patient Care Manager B on 1/20/2022 at 1:30 p.m. regarding the specifics of this incident. Patient Care Manager B stated that this incident started when the facility called hospice on 12/29/2021 at 9:45 a.m. stating they ran out of morphine at 2:00 a.m. Manager B put in a script (prescription) in IPrescribe system for refill and called the Medical Director who signed it right away. Manager B then contacted the pharmacy and they did receive the script and will refill ASAP (as soon as possible.) Upon further investigation, it was determined that the nurse who initiated the order for the morphine refill on 12/28/2021 did not process the order using the IPrescribe system (software program that allows the order to go straight to the physician for signature and then immediately to the pharmacy.) and instead entered the order into the electronic medical record, which would take at least a day before the physician could sign it and it be sent to pharmacy. When asked how long the hospice has been using the system, Administrator A stated that it had been about 3 years. When asked if the nurse in question had been trained on the system, Administrator A stated that everyone had been trained but that the nurse in question is a PRN (as-needed employee) and works extremely infrequently and forgot to use it. Due to the nurse entering the morphine order into the regular medical record system instead of IPrescribe, the Patient was without pain medication for approximately 12 hours at end of life.

Upon patient record review, 8 of 13 records (Patients #1,#2,#3,#4,#5,#8,#9,#11) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 1-3,5,11: The medication profile contained oxygen with no instructions for a delivery method. Corrected on site for relevant current patients. Patient 4:The medication profile contained polyethylene glycol oral powder with no instructions for a diluent. Corrected on site. Patient 8: The medication profile contained oxygen with no instructions for a delivery method and atropine prn for excess secretions with route listed as ophthalmic instead of sublingual. Corrected on site. Patient 9: The medication profile contained oxygen with no instructions for a delivery method, hydrocortisone cream and lidocaine ointment with no locations identified for administration, and fentanyl patch identified as PRN every 72 hours instead of scheduled. Corrected on site.

Upon patient record review, 1 of 13 records (Patient #4) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component within 5 days. Patient 4: The patient was admitted 10-6-21. The medical record contained documentation that the initial bereavement assessment was completed 10-15-21.

Upon patient record review, 8 of 13 records (Patients #1,#2,#3,#4,#8,#9,#10,#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 1: The medical record contains nursing documentation 8-31-21 identifying patient issue with incontinence of bowel and bladder. There is no evidence of problems, goals, and interventions related to incontinence included in the plan of care. Corrected on site. Patient 2: The medical record contains nursing documentation 9-28-21 identifying patient issue with incontinence of bladder. There is no evidence of problems, goals, and interventions related to incontinence included in the plan of care. The plan of care contained active problem of need for home health aide services and an active aide care plan for benefit period 9-9-21 to current. The medical record contained an order to discontinue aide services 7-21-21. Corrected on site. Patient 3: The medical record contains nursing documentation 7-28-21 identifying patient issue with compromised cardiac function and incontinence of bladder. There is no evidence of problems, goals, and interventions related to cardiac and incontinence included in the plan of care. The plan of care contained active problems of need for home health aide services and spiritual care coordinator. The medical record contained an order to discontinue aide services 9-27-21 and chaplain documented no need for further visits after the initial assessment. Corrected on site. Patient 4: The medical record contains nursing documentation 10-6-21 identifying patient issue with compromised cardiac function. There is no evidence of problems, goals, and interventions related to cardiac included in the plan of care. The plan of care contained active problem of need for spiritual care coordinator. The medical record contained chaplain documented no need for further visits after the initial assessment. Corrected on site. Patient 8: The medical record contains an order 7-12-21 identifying patient issue with swallowing and diet modification to pureed consistency. There is no evidence of problems, goals, and interventions related to dysphagia included in the plan of care. Corrected on site. Patient 9: The medical record contains nursing documentation 10-14-21 identifying patient issue with dysphagia causing patient to eat only soft consistency. There is no evidence of problems, goals, and interventions related to dysphagia included in the plan of care. Corrected on site. Patient 10: The medical record contains nursing documentation 4-13-21 and an order 4-26-21 identifying patient issue coughing with meals and diet modification to pureed consistency. There is no evidence of problems, goals, and interventions related to dysphagia included in the plan of care. Patient 12: The medical record contains nursing documentation 6-9-21 identifying patient issue with dysphagia requiring pureed food consistency and nectar thick liquids. There is no evidence of problems, goals, and interventions related to dysphagia included in the plan of care.

Upon patient record review, 5 of 13 records (Patients #1,#3,#4,#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 1: The medical record contains nursing documentation 8-31-21 identifying patient use of a Hoyer lift and Broda chair, and 10-12-21 identifying patient use of oxygen. There is no evidence of the lift, Broda chair, and oxygen equipment included on the plan of care. Corrected on site. Patient 3: The medical record contains nursing documentation upon admission identifying patient use of a wheelchair. There is no evidence of the wheelchair included on the plan of care. Corrected on site. Patient 4: The medical record contains nursing documentation 10-8-21 identifying patient use of bed rails and an indwelling catheter. There is no evidence of the bed rails and catheter supplies included on the plan of care. Corrected on site. Patient 11: The medical record contains nursing documentation 4-7-21 identifying patient use of a commode and an order for oxygen. There is no evidence of the oxygen equipment and commode included on the plan of care. Patient 13: The medical record contains nursing documentation 4-22-21 identifying patient use of CPAP. There is no evidence of CPAP included on the plan of care.

Upon patient record review, 2 of 13 records (Patient #4,#5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 4: The medical record contained nursing documentation 10-8-21 identifying patient had indwelling catheter. There was no evidence of an order for catheter maintenance included in the medical record or plan of care. Corrected on site. Patient 5: The medical record contained nursing documentation 8-10-21 stating a size 16 Fr coude Foley catheter was inserted. There was no evidence of an order for catheter insertion to include size, type and maintenance in the medical record or plan of care.

Upon observation, there was no evidence in the QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. Patient 5: The medical record contained documentation identifying patient was treated for a UTI 9-19-21. There was no evidence of an infection report to track for QAPI program. Corrected on site.