Every finding on record at Odyssey Healthcare of Augusta, LLC

Upon patient record review 3 of 19 (Patient #5, 7, 11) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 5: The patient was admitted on 3/28/22, the psychosocial assessment was completed on 5/30/23. Patient 7: The patient was admitted on 4/18/23, the psychosocial assessment was completed on 6/3/23. Patient 11: The patient was admitted on 3/26/23, the spiritual care assessment was completed on 4/5/23.

Upon patient record review 3 of 19 (Patient #9, 11, 19) 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 9: The patient was admitted on 6/25/23, there is no evidence in the patient record of a psychosocial assessment or a spiritual care assessment within 5 days or to date. Patient 11: The patient was admitted on 3/26/23, there is no evidence in the patient record of a psychosocial assessment within 5 days or to date. Patient 19: The patient was admitted on 2/20/23, there is no evidence in the patient record of a psychosocial assessment within 5 days or until patients death.

Upon patient record review, 6 of 19 (Patient #1, 5, 7, 13, 14, 18) 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 1: The medication profile includes oxygen for 2-5L PRN for shortness of breath. The nursing note for 6/26/23 indicates the patient is receiving 6.5L of oxygen on high flow nasal cannula. (Corrected on site.) Patient 5: The medication profile includes Septra DS 1 pill twice a day PO x 10 days which was initiated on 5/2/23 and should have been discontinued on 5/12/23. (Corrected on site.) Patient 7: The patient record on admission on 4/18/23, indicates that the patient uses oxygen 3.5L/min via NC continuously, this is not included in the medication profile. The patient admission record indicates that the patient uses insulin for the management of Type II diabetes mellitus, the medication profile does not include insulin. (Corrected on site.) Patient 13: The medication profile includes Metronidazole 1% topical gel, apply 1inch topically every other day to wound, the application site is not indicated. (Corrected on site.) Patient 14: The medication profile includes Diclofenac 1% topical gel apply to affected area 3 times a day as needed for arthritic stiffness, there is no application site indicated. (Corrected on site.) Patient 18: The medication profile includes Miralax Powder 17 grams oral powder daily as needed for constipation, it does not include the instructions to mix with a diluent.

Upon patient record review, 3 of 19 (Patient #1, 9, 11) 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 1: The patient was admitted on 7/16/19, the bereavement risk assessment was completed on 10/6/21. Patient 9: The patient was admitted on 6/25/23, there is no evidence in the patient record of a bereavement assessment within 5 days or to date. (Corrected on site.) Patient 11: The patient was admitted on 3/26/23, the bereavement risk assessment was completed on 4/5/23.

Upon patient record review, 1 of 19 (Patient #14) 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 14: The record indicates a call through triage on 7/4/23 at 11:12 CST from the primary caregiver reporting that the pt "c/o burning sensation when she urinates and foul smelling urine." An on call visit was advised and forwarded to the on call nurse. There is no documentation in the record that a visit was made or that a subsequent visit has been made since that time. (Documentation added and completed on site.)

Upon patient record review, 6 of 19 (Patient #1, 3, 4, 7, 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 1: The patient was admitted on 7/16/19 with a diagnosis of Alzheimer's disease and a history of multiple seizures. The patient is prescribed Keppra 500mg BID for the management of seizures, the plan of care does not include a problem statement with interventions and goals for the neurological conditions or management. There is evidence in the patient records that the patient required the use of PRN oxygen starting on 2/28/22 there is no problem statement with intervention and goals for the management of shortness of breath. (Added to the current plan of care.) Patient 3: The patient was admitted on 6/26/22, the records indicate that the patient has Type II diabetes mellitus and uses Lispro and Levemir for the management of diabetes, the plan of care does not include a problem statement with interventions or goals for the management of the diabetes. The patient record indicates the patient has nutritional deficits and Megestrol (an appetite stimulant) has been prescribed, there is no problem statement with interventions and goals for the nutritional management. The patient record indicates that the patient has epilepsy and uses Keppra for the management of symptoms, the plan of care does not include a neurological problem statement with interventions and goals. (Added to the current plan of care.) Patient 4: The patient was admitted on 12/16/22 with a diagnosis of subarachnoid hemorrhage with memory loss and history of seizures, the patient takes phenytoin for the management of his seizures, the plan of care does not include a problem statement with interventions or goals for the patients neurological conditions. (Added to the current plan of care.) Patient 7: The patients medication profile includes the use of Clopidogrel 75mg daily, the plan of care does not include a problem statement with interventions and goals for the anticoagulation therapy. (Added to current plan of care.) Patient 9: The patient has a history of chronic atrial fibrillation and the medication profile includes Eliquis, there is no problem statement with interventions or goals for the risk for bleeding or the management of the patient with heart condition. The patient has severe shortness of breath, and a history of multiple falls, he attempts to transfers himself to a bedside commode and to his couch independently, as documented by the nurse on 6/29/23 and 7/3/23. The plan of care does not include a problem statement with interventions or goals for safety, (Added to current plan of care.) Patient 10: The patient was admitted on 6/7/23 with noted nutritional deficiencies aeb: 20 lb weight loss and is prescribed Megestrol 40mg PO daily, the plan of care does not include a problem statement with interventions and goals for the nutritional management. (Corrected on site.)

Upon patient record review, 6 of 19 (Patient #1, 5, 7, 13, 14, 18) 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: Orders on 2/28/22 for oxygen are written for 2-5L PRN for shortness of breath. Evidence in the patient record indicates the patient is receiving Oxygen 6.5L high flow nasal cannula. (Corrected on site.) Patient 5: Orders initiated on 5/2/23 for Septra DS 1 pill twice a day x 10 days, have not been discontinued. (Corrected on site.) Patient 7: The patient record upon admit on 4/18/23 indicates that the patient uses oxygen 3.5L/min via NC continuously, there is no order in the patient record for the use of oxygen. The patient admission assessment indicates that the patient uses insulin for the management of diabetes, there are no orders for the use of insulin in the patient record. (Corrected on site.) Patient 13: The medication orders on 6/21/23 for Metronidazole 1% topical gel, apply 1inch topically every other day to wound, the application site is not indicated. (Corrected on site.) Patient 14: The medication orders on 1/18/23 for Diclofenac 1% topical gel apply to affected area 3 times a day as needed for arthritic stiffness, there is no application site indicated. (Corrected on site.) Patient 18: The medication orders on 1/30/23 for Miralax Powder 17 grams oral powder daily as needed for constipation, does not include the instructions to mix with a diluent.

Upon patient record review, 3 of 19 (Patient #8, 9, 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 equipment and supply needs. Patient 8: The patient was admitted on 5/20/21, the documentation indicates that the patient uses a walker for ambulation, this is also reported again in recent nursing documentation on 6/22/23, the walker is not included in the plan of care. (Corrected on site.) Patient 9: The patient was admitted on 6/25/23 and requires the use of oxygen 6-10L, he uses a bedside commode, has an electric "hospital bed", oxygen concentrator and an over the bed table. These items are not listed in the patients plan of care. (Corrected on site.) Patient10: The patient was admitted on 6/7/23, the admission assessment indicates that the patient requires "assistive devices" for ambulation and requires an electric bed. These items are not included in the plan of care. (Corrected on site.)

Upon client record review, 2 of 19 (Patient #6, 11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 6: The plan of care indicates the SN frequency is 1x week, there is no evidence of a visit the week of 5/28/23. Patient 11: On 3/27/23 an order was entered for the patient to receive SW visit for evaluating VA (Veterans Administration) services for the patient. There is no evidence in the patient record of a visit for this order.

Upon patient record review, 1 of 19 (Patient #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 17: The patient passed away on 1/10/23, the bereavement plan of care includes bereavement letters to be mailed Q1 month, 3 month, 6 month, 9 month, 12 month and 13 month. There is no evidence in the patient record that a 1 month letter was sent.

Upon client record review, 1 of 19 (Patient #15) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient 15: The patient record doses not include a discharge summary. The patient received a PRN nursing visit on 4/15/23 due to lethargy and not eating well, there is no evidence in the record of any additional documentation regarding the discharge of the patient from hospice services. (Corrected on site.)

Upon patient record review, 1 of 19 (Patient #4) did not have evidence that the hospice provided the following information: • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient Patient 4: During the review of the facility record during the home visit, it was noted that the hospice has not provided the Hospice Election form or the physician certification of terminal illness to the nursing facility where the patient resides. (Corrected on site.)