Every finding on record at Odyssey Healthcare Holding Company

Upon patient record review, 2 of 19 (Patient #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 medications and treatments. Patient #3: 3/1/23 MD Order for wound care to traumatic wounds 3rd finger and index finger. Order does not specify which hand. Patient #9: 3/27/23 order for wound care to apply Betadine daily to left heel. 4/26/23 order for wound care to apply Betadine to right heel. Staff interview confirms 4/26/23 order should have read left heel. Subsequent orders in record are correct.

Upon patient record review, 1 of 19 (Patient #3) 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 #3: 4/20/23 NP Visit. NP documented visit was made at request of RN/CM following disimpaction and anal tear. NP documented that she educated staff that the preference is to keep stools soft to prevent future rectal tearing. Bowel regimen updated. The anal tear, wound treatment was reported to IDG 5/3/23, but problem list/goals not updated to include constipation or wound.

Upon client record review, 1 of 19 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: 4/20/23 NP Visit. NP documented visit was made at request of RN/CM following disimpaction. No order for disimpaction identified in record. Upon interview, staff confirms there is no order for disimpaction. Record updated.

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 12: RN had set up over bed table with bath towel as clean barrier. She also used linen hamper lid as “dirty” surface to put tools once used on patient. When visit was complete, she took items directly from hamper lid to bag and dropped them directly in canvas tote she was using as nursing bag. There was no separation for clean or dirty. It contained booklets/spiral notebook that was previously placed on patient's bed. Nurse stated that "It’s all dirty" and she will clean it when she gets home and put it in baggy before next patient.

Upon patient record review 2 of 19 (Patient #6, 7) 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 #6: 4/24/23 Aide Care Plan: Bath/shower assigned first visit each week. Bath/shower performed by aide May 8, 11; 15, 18. Patient #7: 3/12/23 Aide Care Plan: Bath/shower assigned first visit each week. Bath/shower performed performed May 10, 12; 17, 19.

Based on record review and interview agency staff failed to ensure patient's rights were upheld in 1 of 1 medical records reviewed of patients needing symptom management, out of a total of 10 medical records reviewed (Patient #1). The agency failed to investigate and resolve a complaint for 3 of 3 complaints reviewed. (Patient #1, #2, and #4). 1. Agency staff failed to provide effective symptom management. See L512. 2. Agency staff failed to investigate and resolve complaints submitted. See L505. The cumulative effects of the systematic failures has the potential to affect all patients receiving services at this Hospice Agency.

Based on record review and interview, the agency staff failed to ensure follow up, corrective action, evaluation, and resolution were completed and documented for complaints according to agency policy and procedure in 3 of 10 patients records reviewed (Patient #1, Patient #2, and #4). Findings include: Review of Policy and Procedure titled "Patient Concerns" dated 2/2021 revealed in part "Procedure 2. The employee: A. Listens to concerns expressed by patients without coercion, discrimination, reprisal or Interruption in service. B. Receiving the concern initiates the "Patient Concern Report." C. Provides information regarding the concerns to the Director of Professional Services/Patient Care Manager in a timely manner but no later than the next business day. 3. Director of Professional Services/Patient Care Manager; A. Reviews all patient concerns. B. Initiates a problem-solving process; 1. Assess with the patient the exact nature of the concern, when necessary. 2. Assess the probable cause of the patient concern. 3. Plan appropriate action. 4. Implement a corrective action plan. 5. Evaluate the implemented corrective action plan to determine if the patient concern has been alleviated. 6. Give "Patient Concern Report" to the Administrator for additional review and signature. 12. Resolution/outcome information is documented on the "Concern Report" and communicated to the complainant within 30 days." On 7/22/2021 Patient #1 was admitted to this hospice with a diagnosis of Amyotrophic Lateral Sclerosis (ALS). Registered Nurse (RN) L obtained current medications and medical supplies being used and documented "RN L would be facilitating order for hospice symptom control medications along with oxygen." Oxygen ordered on 7/22/2021 at 11:59 AM was to be delivered 7/22/2021. Patient #1's Oxygen was delivered 7/25/2021. On 7/26/2021 Complainant A called Heartland Hospice on behalf of Patient #1 spoke with Administrator B. Complainant A relayed the experience, the discomfort and respiratory distress that Patient #1 experienced for three days prior to receipt of the supplemental oxygen. Complainant A asked that this matter be addressed as a Performance Improvement Project, Complainant A wished to know how their system failed and what corrective measures will be taken. Complainant A stated "I/we want to be assured that no other client or family have a similar experience and that Complainant A expected to be informed of the outcome." On 8/6/2021 at 12:05 AM Patient #1 expired. Complainant A and family called every number on the form titled "Heartland Hospice After-Hours Process." RN J was also texted at 1:01 AM; no entity at Heartland Hospice could be contacted. Heartland Hospice in Toledo Ohio was finally reached and contacted RN Patient Care Coordinator (PCC) C, who dispatched the on-call RN to our home at 3:00 AM. Complainant A voiced concerns to RN J. On 8/6/2021 at 2:55 PM Complainant A was contacted by Heartland Hospice Patient Care Manager D. Patient Care Manager D left a message for Complainant A which stated "RN J asked that I follow up on a couple of the concerns that you shared with RN J this morning. Patient Care Manager D left contact numbers and work hours." Complainant A returned Patient Care Manager D's call to 608-381-0760 (verified with Administrator A to be Patient Care Manager D's number), and received Patient Care Managers D's voicemail the following message was left, "I am Complainant A returning your call, I'm the spouse of Patient #1 who died 8/6/2021. You may need to consult your notes about my concerns prior to returning my call. Complainant A gave phone numbers for a return call." As of 11/17/2021 Complainant A has not received a response from the concerns which were communicated on 7/26/2021 to Administrator B, 8/6/2021 to Patient Care Manager D, and 8/6/2021 Registered Nurse PCC C. During an interview with Administrator B on 11/16/2021 at 2:50 PM, when asked about the agency complaint log and if there was documentation regarding complaint for Patient #1, Administrator B replied "I don't see any other complaints documented." When asked about the concerns that were brought to Administrator B's attention on 07/26/2021 and 08/06/2021 regarding Patient #1 and documentation of these concerns, Administrator B replied "I neglected writing up a concern when the wife called." During an interview with Administrator B on 11/16/2021 at 3:00 PM, when reviewed documentation on the "Administrator On-Call Log" dated 08/06/2021 regarding the phone outage affecting patients on 08/06/2021, Administrator B replied "Looks like no further action was taken by Registered Nurse PCC C. I didn't know until today that those numbers hadn't worked. Patient Care Manager D also did not write up a complaint on 08/06/2021." Record review of agency complaint log document "Customer Concern Report" dated 08/03/2021 revealed "Concern: Multiple (5), see attached email." Review of the attached email correspondence dated 08/03/2021 revealed Director Our House G communicated customer concerns regarding Patient #2 and Patient #4. The agency document for these customer concerns was incomplete. The sections "Concern evaluation", "Corrective Action Plan", "Date of Implementation", "Signature of Supervisor", "Evaluation of Action Plan", and "Resolved Date" were left blank and failed to reveal documented follow through and completion by the agency per policy and procedure. During interview with Administrator B on 11/16/2021 at 10:30 AM, when reviewed documentation on the "Customer Concern Report" Administrator B replied "the expectation is the form is to be filled out per our policy."

Based on record review and interview, staff failed to provide timely symptom management in 1 of 1 hospice patients out of a total of 10 records reviewed. (Patient #1). Findings Include: Interview with Administrator B on 11/16/2021 at 3:39 PM. Administrator B verified the policy "Equipment Care & Maintenance" doesn't cover or reference how Durable Medical Equipment (DME) is ordered or documented. Administrator B stated "The expectation is staff is to follow the clinical orientation manual related to DME, Day to Day Management, and Total Oversight by RN Case Manager." Review of document titled "Clinical Orientation Manual" dated 7/2021 revealed under "Total Oversight by RN Case Manager, The RN Case Manager provides total oversight of the patients care plan by: Understanding the ongoing needs and financial resources for DME, supplies, and medications. Every patient receives appropriate DME/Medical supplies timely." On 7/22/2021 Patient #1 was admitted to this hospice with a diagnosis of Amyotrophic Lateral Sclerosis (ALS). Registered Nurse (RN) L obtained current medications and medical supplies being used and documented "RN L would be facilitating order for hospice symptom control medications along with oxygen as Patient #1 was experiencing sudden onset elevated respiratory rate and difficulty lying flat or resting." Oxygen ordered on 7/22/2021 at 11:59 AM was to be delivered 7/22/2021. Follow up from RN L on 7/23/2021, RN L was notified no oxygen had been delivered 7/22/2021. On 7/24/2021 Complainant A phoned Heartland Hospice spoke to RN M. Complainant A reports Patient #1 having the following symptoms of respiratory distress (grayish/pearly pale, abnormally weak, and oxygen saturation level of 72%), Patient #1 has still not received oxygen ordered on 7/22/2021, RN M stated "there's no order for oxygen" Patient #1 oxygen was delivered 7/25/2021 at 10:00 AM after the DME company received an urgent order 7/24/2021. Patient #1 waited 3 days for oxygen. Review of document titled "DME tracker" not dated, revealed Patient #1 had oxygen delivered on 7/25/2021. Interview with Administrator B on 1:09 PM. Administrator B stated "there is no order for oxygen on Patient #1's plan of care or separate order sent to the physician. Definitely should have an order."

Based on record review and interview, the agency failed to ensure plans of care were individualized to meet the needs of the patient containing orders for medical equipment or supplies in 4 of 10 patient records reviewed (Patient # 1, #2, #7, and #10). Findings include: Interview with Administrator A on 11/16/2021 at 3:39 PM. Administrator A verified the policy "Equipment Care & Maintenance" doesn't cover or reference how Durable Medical Equipment (DME) is ordered or documented. Administrator A stated "The expectation is staff is to follow the clinical orientation manual related to DME, Day to Day Management, and Total Oversight by RN (Registered Nurse) Case Manager." Review of document titled "Clinical Orientation Manual" dated 7/2021 revealed under "Day to Day Management, The RN Case Manager provides total oversight of the patients care plan by: DME is ordered and received.". Record review for Patient #1 (start of care 07/22/2021) revealed "RN Hospice Start of Care Visit Note" dated 07/22/2021 revealed under Equipment/Supplies "Indicate equipment/supplies ordered by hospice- Oxygen ." Review of document titled "DME tracker" not dated, revealed Patient #1 had oxygen delivered on 7/25/2021. Record review for Patient #1 IDG (Interdisciplinary Group) plan of care dated 07/22/2021 and IDG meeting date 08/04/2021 revealed no orders on the IDG plan of care for a oxygen. During an interview with Administrator B on 11/16/2021 at 1:09 PM, when asked about orders on the plan of care or record for oxygen, Administrator B replied "No order for oxygen can be found, definitely should have an order." Record review for Patient #2 (start of care 07/24/2021) revealed "RN Hospice Start of Care Visit Note" dated 07/24/2021 revealed under Equipment/Supplies "Indicate equipment/supplies ordered by hospice- N/A (Not Applicable). Mostly bedbound." Review of document titled "DME tracker" not dated, revealed Patient #2 had a hospital bed delivered 08/03/2021. Review of agency "Care Concern Report" dated (08/03/2021) regarding Patient #2, with attached email correspondence revealed "Concern #1: At admission on 07/24/2021, Our House staff asked nurse for a hospital bed. Nurse acknowledged that this would be a good idea, however no follow up action was taken. Facility contacted us today to order the bed. Bed has been ordered and is supposed to arrive by 7:00 PM tonight." Record review for Patient #2 IDG plan of care dated 07/24/2021 and IDG meeting date 07/28/2021 revealed no orders on the IDG plan of care for a hospital bed. During an interview with Administrator B on 11/16/2021 at 2:15 PM, when asked about orders on the plan of care or record for a hospital bed for Patient #2, Administrator B replied "No, I cannot find an order for the bed." Record review for Patient #7 (start of care 11/09/2021) revealed "RN Hospice Start of Care Visit Note" dated 11/09/2021 revealed under Equipment/Supplies "Indicate equipment/supplies ordered by hospice- over bed table, raised toilet seat." Review of document titled "DME tracker" not dated, revealed Patient #7 had bed table/toilet seat delivered on 11/10/2021. Record review for Patient #7 IDG plan of care dated 11/09/2021 revealed no orders on the IDG plan of care for an over bed table and raised toilet seat. During an interview with Administrator B on 11/16/2021 at 3:20 PM, when asked about orders on the plan of care or record for the over bed table and raised toilet seat for Patient #7, Administrator B replied "No orders are in for these." During an interview with Administrator B on 11/16/2021 at 3:20 PM, when asked what the agency's expectation is when there is an identified need for medical equipment upon admission or when there is a need, Administrator B replied "An order should be placed day of right away and should be located on the plan of care." Record review for Patient #10 (start of care 09/24/2021) revealed "RN Hospice Start of Care Visit Note" dated 09/24/2021 revealed under Equipment/Supplies "Indicate equipment/supplies ordered by hospice- no orders." Review of document titled "DME tracker" not dated, revealed Patient #10 had oxygen delivered on 9/24/2021. Record review for Patient #10 IDG plan of care dated 09/24/2021 and IDG meeting date 09/24/2021 revealed no orders on the IDG plan of care for oxygen. During an interview with Administrator B on 11/16/2021 at 3:00 PM, when asked about orders on the plan of care or record for oxygen, Administrator B replied "If it is not listed on the plan of care, there are no orders."

Based on record review and interview agency staff failed to maintain an effective after hours process to ensure core services for nursing were provided based on patient need in 1 of 10 patient records reviewed (Patient #1.) 1. Agency staff failed to dispatch a nurse to provide nursing needs of the patient. See L591. The cumulative effects of the systematic failures has the potential to affect all patients receiving hospice services at this Hospice Agency.

Based on record review and interview, the agency failed to meet the nursing needs of patients and/or family caregivers in 1 of 1 patients requiring on-call nursing services (Patient #1) in a total of 10 patient records reviewed. Findings Include: Review of agency admission booklet titled "Hospice Care Patient Information Handbook" dated 2/2021 revealed "Your Hospice Care Team, Nurses: Registered nurses (RN's) manage and coordinate the care and services that your physician orders for you. An RN is available 24 hours a day, 7 days a week." Review of agency form titled "Heartland Hospice After-Hours Process" dated 4/1/2019 revealed "The regular hours of our office are from 8:00 AM-5:00 PM, Monday-Friday. However we are available by phone and in-person 24 hours a day, 7 days a week. 1. Call our main number at 608-819-0033. 2. Your call will be routed to our answering service, Call Center K. One of their customer service representatives will collect information from you and then call our triage RN. The triage nurse is a nurse who can offer advice and assistance over the phone. 3. The triage RN will call you back, typically within 10 minutes of receiving your information from Call Center K. If he/she is unable to meet your needs over the phone they will then dispatch an on-call RN or member of our psychosocial team to assist your in-person. 4. The on-call RN or Psychosocial team member should call you with an estimate time of arrival. **If at any time you feel we are not responding promptly enough. Please call again. **We are very committed to providing you with an excellent experience. If you ever feel that we have not met your needs you may call our office and ask to speak with the on-call administrator. A member of our leadership team will promptly call you back to address any concerns you may have. **In the event of a phone failure at our office, our Answering Service, Call Center K, can be reached any time at 1-866-784-9604. We are committed to ensuring you get the best care possible, and therefore all city has provided a secondary phone number if for some reason their main line goes down. It is 1-920-406-6855. Let the answering service know that Heartland Hospice-Madison is your hospice provider and they will be able to reach someone to assist you." Review of agency form titled "Emergency Response Manual" dated 11/21 revealed in part "Loss of Utilities Response, An electrical failure may present the following hazards: Phones out of service. Emergency action steps #7. In the even phone service is affected, contact corporate IS. If the agency phone lines are impacted by emergency, and there is not the opportunity to forward lines to the contracted answering service, the following steps will be taken. 1. Administrator or designee will notify corporate office to contact verizon to assist with restoration of services. 2. Emergency call down tree will be activated to notify staff. 3. All current patients and facilities will be notified of alternative numbers to call (Call Center K.) Review of the patient census for 8/6/2021 revealed there were 131 patients on service 8/6/2021. On 8/6/2021 at 12:05 AM, patient #1's family called every number on the "Heartland Hospice After-Hours Process" document, as well as the patient care staff numbers that had been given to the family. There was no response from any of the numbers the family tried calling to report that Patient #1 had expired. None of the numbers provided were in service over a period of several hours. Patient #1's family had to provide post mortem cares for Patient #1, including washing, shaving, and dressing Patient #1's body. During interview on 11/10/2021 at 8:25AM Complainant A stated "We found a Heartland Hospice affiliated number in Toledo Ohio. The Toledo staff member was able to contact Registered Nurse Patient Care Coordinator (PCC) C, who was able to send a Heartland Hospice On-Call RN who arrived at 3:00 AM. Three hours post Patient #1's death." Review of agency call log titled "Home and Hospice on Call Log" dated 8/6/2021 revealed "Madison Hospice Regional Administrator, Registered Nurse PCC C was contacted by Heartland Hospice Toledo Ohio Staff I. Toledo Ohio Staff I notified PCC C of all Madison and Call Center K phone lines were out for approximately 45-60 minutes. Patient #1 had died at 12:05 AM and family had been attempting to call all above phone numbers to report Patient #1's death. PCC C dispatched an On-Call RN to Patient #1's home. PCC C checked and per Toledo Ohio Staff I the phone lines had been down approximately 45-60 minutes. Office line as well as back up line. No further follow up documentation from PCC C was found related to the Heartland Hospice Madison Phone failure." On 11/17/2021 at 9:06 AM, call was placed to Call Center K. Call Center Staff E asked if they had knowledge of a phone outage on 8/6/2021 related to the Heartland Hospice back up phone numbers 1-866-784-9604 and 1-920-406-6855. Staff E stated "It looks like we could of had an outage issue, we did not receive any calls, and it looks like we had and issue." When asking how long the phone lines were down Call Center Staff E stated "I don't know." During an interview with Administrator B on 11/16/2021 at 2:50 PM, when asked about what the process would be when identifying there was a known phone issue that could have affected patients, Administrator B replied "I would call and make sure phone numbers are up and running. Make sure nurses are educating patients. Looks like we (the agency) had an issue and looks like we need a plan C if these two numbers don't work." .