Every finding on record at Odyssey Healthcare of Flint, LLC

Upon patient record review, 2 of 5 (Patient #3,4) 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 indicated that the patient started treatment for a UTI on 12/31/2025. There was no evidence of problems, goals, and interventions related UTI or infection included in the current plan of care. Corrected on site, plan of care updated during the survey. Patient 4: The medical record indicated that the patient admitted on treatment for a chronic UTI. Patient is currently prescribed Cipro 250mg daily prophylactically. There was no evidence of problems, goals, and interventions related to the genitourinary chapter, chronic UTI, or infections included in the current plan of care. Corrected on site, plan of care updated during the survey.

Upon client record review, 2 of 5 (Patients #4,#5) did not have evidence that the plan of care included IDG's documentation of the patient's or families level of understanding, involvement and agreement with the plan of care. Patient 4: The medical record contained nursing documentation identifying patient fall 8/30/25 resulting in patient report of soreness to bottom. There was no evidence of family involvement with developing a plan of care related to the fall. Agency completed an internal investigation regarding the incident and completed nursing education to staff 10/28/25. Patient 5: The medical record contained nursing documentation identifying patient fall 10/27/25 resulting in patient report of leg pain, inability to bear weight on left leg, and skin tear with bruising to right arm. There was no evidence of family involvement with developing a plan of care related to the fall.

Upon patient record review, 1 of 5 (Patient #2) 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 a stat order for morphine still current and Miralax oral powder with no instructions to mix with a diluent. Corrected on site with order clarification received and medication profile update.

Upon patient record review, 1 of 5 (Patients #4) did not have evidence in the patient record that as part of the patient-specific comprehensive assessment the hospice may determine the need for a referral and/or further evaluation by other appropriate health professionals. Patient 4: The medical record contained a nursing visit 8/30/25 in response to a fall with reports of some soreness to patient's bottom. There was no evidence of a comprehensive assessment with examination of potentially injured area with report to physician to determine if further evaluation needed. Fall report stated there was no injury however nursing visit 8/31/25 did indicate pain and swelling to right hip resulting from fall 8/30/25 and patient was sent to the emergency room. Agency completed an internal investigation of incident and provided education to nursing staff on 10/28/25.

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

Upon patient record review, 2 of 5 (Patients #4,#5) did not have evidence that the hospice follows the individualized plan of care developed in in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire. Patient 4: The medical record contained nursing documentation identifying patient fall 8/30/25 resulting in patient report of soreness to bottom. There was no evidence of physician notification regarding the fall. Agency completed an internal investigation regarding the incident and completed nursing education to staff 10/28/25. Patient 5: The medical record contained nursing documentation identifying patient fall 10/31/25 resulting in patient sustaining bumps to left side and back of head. There was no evidence of physician notification regarding the fall.

Upon patient record review, 2 of 5 (Patients #4,#5) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient 4: The medical record contained nursing documentation identifying patient fall 8/30/25 resulting in patient report of soreness to bottom. There was no evidence of family education related to the fall. Agency completed an internal investigation regarding the incident and completed nursing education to staff 10/28/25. Patient 5: The medical record contained nursing documentation identifying patient fall 10/27/25 resulting in patient report of leg pain, inability to bear weight on left leg, and skin tear with bruising to right arm. There was no evidence of family education related to the fall.

Upon patient record review, 2 of 5 (Patients #2,#3) 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 2: The medical record contained a prescription for Eliquis. There was no evidence of problems, goals, and interventions related to risk for bleeding included in the plan of care. Corrected on site with plan of care update. Patient 3: The medical record contained a prescription for Plavix. There was no evidence of problems, goals, and interventions related to risk for bleeding included in the plan of care.

Upon patient record review, 1 of 5 (Patient #2) 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 Miralax oral powder with no instructions to mix with a diluent. Corrected on site with order clarification received.

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 5: The medical record contained nursing documentation 10/31/25 identifying patient fall reported that morning. There was no evidence of agency investigation of the incident.

Upon patient record review 1 of 19 (Patient #5) 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 medical record contained a spiritual assessment completed 7/6/23 with a start of care 6/29/23.

Upon patient record review 2 of 19 (Patients #8,#10) 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 8: There was no evidence of a comprehensive spiritual assessment. Patient 10: There was no evidence of a comprehensive spiritual assessment.

Upon patient record review, 4 of 19 (Patients #3,#4,#5,#12) 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 3: The medication profile contained duplicative senna s prn. Corrected on site. Patient 4: The medication profile contained miralax oral powder with no instructions for a diluent. Corrected on site. Patient 5: The medication profile contained miralax oral powder with no instructions for a diluent. Corrected on site. Patient 12: The medical record contained nursing documentation 6/27/23 identifying oxygen was increased to allow up to 3 liters per minute administered. The medication profile stated 2 liters for dose. Corrected on site.

Upon patient record review, 2 of 19 (Patients #1,#8) 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 medical record contained an initial bereavement assessment completed 6/2/23. Patient admitted to hospice 5/26/23. Patient 8: The medical record contained an initial bereavement assessment completed 3/23/22. Patient admitted to hospice 3/15/22.

Upon patient record review, 3 of 19 (Patients #11,#12,#14) 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 11: The medical record indicated the patient was received spiritual care visits. There was no evidence of problems, goals, and interventions related to spiritual care included in the plan of care. Corrected on site. Patient 12: The plan of care included an active problem of altered skin integrity. There was no evidence of goals and interventions related to skin. The medical record also contained nursing documentation upon recertification visit 6/27/23 identifying patient had a PEG tube and indwelling catheter. There was no evidence of problems, goals, and interventions related to the PEG tube or catheter included in the plan of care. Corrected on site. Patient 14: The plan of care included an active problem of altered skin integrity. There was no evidence of goals and interventions related to skin. The medication profile identified patient was an insulin dependent diabetic requiring blood glucose check three times daily and sliding scale administration of insulin with meals. The medical record indicated patient was on hospice for terminal diagnosis of hypertensive heart disease with heart failure. There was no evidence of problems, goals, and interventions related to endocrine and cardiac dysfunction included in the plan of care. Corrected on site.

Upon patient record review, 3 of 19 (Patients #4,#5,#12) 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 4: The medical record contained an order for miralax oral powder with no instructions for a diluent. Corrected on site. Patient 5: The medical record contained an order for miralax oral powder with no instructions for a diluent. Corrected on site. Patient 12: The medical record contained nursing documentation 6/27/23 identifying oxygen was increased to allow up to 3 liters per minute administered. The current oxygen order had not been updated and stated 2 liters for dose. Corrected on site.

Upon patient record review, 9 of 19 (Patients #2,#3,#5,#6,#7,#8,#10,#12,#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 2: The medical record contained nursing documentation upon recertification visit 6/30/23 identifying patient use of a walker. There was no evidence of the walker included as DME in the plan of care. Corrected on site. Patient 3: The medical record contained nursing documentation upon recertification visit 6/29/23 identifying patient use of a wheelchair. There was no evidence of the wheelchair included as DME in the plan of care. Corrected on site. Patient 5: The medical record contained nursing documentation upon admission identifying patient use of a walker, wheelchair, and shower chair. There was no evidence of the walker, wheelchair, and shower chair included as DME in the plan of care. Corrected on site. Patient 6: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, bed rails, over the bed table, commode, and wheelchair. There was no evidence of the bed, rails, table, commode, and wheelchair included as DME in the plan of care. Corrected on site. Patient 7: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, walker, wheelchair, and over the bed table. There was no evidence of the bed, walker, wheelchair, and table included as DME in the plan of care. Corrected on site. Patient 8: The medical record contained nursing documentation upon recertification visit 6/26/23 identifying patient use of a wheelchair. There was no evidence of the wheelchair included as DME in the plan of care. Corrected on site. Patient 10: The medical record contained nursing documentation 6/28/23 identifying patient use of a nebulizer. There was no evidence of the nebulizer included as DME in the plan of care. Corrected on site. Patient 12: The medical record contained nursing documentation upon recertification visit 6/27/23 identifying patient use of a hoyer lift. There was no evidence of the lift included as DME in the plan of care. Corrected on site. Patient 14: The medical record contained nursing documentation upon recertification visit 6/20/23 identifying patient use of oxygen. There was no evidence of the oxygen equipment included as DME in the plan of care. Corrected on site.

Upon client record review, 3 of 19 (Patients #2,#3,#8) 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 medical record contained an ordered nursing frequency of twice week. There was no evidence of a second visit documented for the week of 5/28/23. The record also contained an ordered spiritual care frequency of once monthly. There were two scheduled spiritual care visits documented in June. Patient 3: The medical record contained an ordered nursing frequency of twice week. There was no evidence of a second visit documented for the week of 5/28/23. Patient 8: The medical record contained an ordered nursing frequency of twice week. There was no evidence of a second visit documented for the week of 6/18/23.

Upon patient record review, 1 of 19 (Patient #8) 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 8: The aide care plan contained a task to shave weekly or PRN. Corrected on site.

Based on record review and interview, the hospice failed to receive Medicare approval before providing hospice services at a proposed multiple site location, see (L-656), and failed to ensure the proposed multiple location was part of the hospice and shared administration, supervision, and services with the hospice parent site, see (L-657). Findings include: 1: Failed to receive Medicare approval for multiple location (L-656). 2: Failed to ensure the multiple location shared administration, supervision, and services with the parent site (L-657). The cumulative effect of these systemic problems resulted in the hospice's inability to ensure the provision of quality care in a safe environment and has the potential to adversely affect all patients served.

Based on record review and interview, the hospice failed to receive Medicare approval before providing hospice services at 1 of 1 proposed multiple locations, which resulted in the potential for poor patient outcomes. Findings include: During review of the proposed multi site staff sheet (Attachment #11), it was discovered that the list documented, "*all 3 Flint (Parent site) chaplains helping cover Saginaw until Saginaw hires."[sic]. Further review of the agency's organizational chart (Attachment #8) for the parent site and the proposed multiple site (Saginaw) on 10/28/21, also noted that Chaplain #1 was documented as a chaplain for both sites. The proposed multiple site was noted to be providing hospice Spiritual Counseling services with staff from Kindred Hospice. During a 10/28/21 onsite visit to the proposed branch site, the location of 231594 Southern Care Hospice, 6270 State St., Saginaw, was observed to be present and engaged in providing hospice services independent of the Kindred Hospice parent.

Based on document review and interview, it was determined the hospice failed to ensure all multiple locations shared supervision with the parent site for 1 of 1 proposed multiple locations, which resulted in the potential for poor patient outcomes due to lack of supervision by the parent office. Findings include: *** Policy: Nurse Practitioner (NP) job description, dated 9/2020, "If the NP identifies the need for updates to the plan of care to include additions/changes to the patient's medications and/or treatments/interventions, they will contact Medical Director/Hospice Physician ...." During an interview with the administrator (Adm#1) on 10/28/21 at 10:00 a.m., Adm#1 was asked how the parent site (Kindred-Flint) oversees the proposed multi-site (6270 State St., Saginaw), Adm#1 stated, "Southern Care Hospice (Branch site in Saginaw) is its own entity (It has its own provider number 231594), so it would not have oversight from Kindred Hospice until the transition (to a multiple site)." When asked who orients and supervises the NPs at the branch location, Adm#1 responded, "The orientation is online. I am new in this position, and I would like to have the regional director (RD#1) on a call with us to help answer questions." During a phone interview on 10/28/21 at 11:30 a.m., RD#1 was asked how the parent site (Kindred-Flint) oversees the multi-site (Saginaw), RD#1 stated, "Southern Care Hospice (proposed branch site in Saginaw) is its own entity, so it would not have oversight from Kindred Hospice until it is approved and under the Kindred provider number." When asked how the nurse practitioner (NP) at the branch site is supervised, RD#1 stated, "We normally have an Executive Director at the branch site that oversees that site, but the position is vacant at the moment, so Adm#1 is also the interim Executive Director (ED#1) overseeing the Saginaw location and the NPs. "An organizational chart was provided that documents Adm#1 as the administrator for the Flint site and ED#1 as the Executive Director for the Saginaw site. (ED#1 no longer occupies the Executive Director position in Saginaw). When asked what the involvement of the Medical Director is with the NPs, RD#1 responded, "The NPs work for the agency, not the doctor. They report to the administrator. The NPs only do the Face-to-Face visits and the History and Physical (H&P) visits. They do not prescribe medications or oversee patients. The NPs would call the doctor if they had questions, just like a nurse would." (See NP policy above). During a 10/28/21 onsite visit to the proposed branch site, Southern Care Hospice, 6270 State St., Saginaw, CM#1 was asked about oversite of the branch site and she said Adm#1 is currently overseeing the branch site. When asked when the last time Adm#1 was at the branch site CM#1 responded, "Just a few days ago." It was also observed that Southern Care Hospice 231594 was present at that location and engaged in providing hospice services independent of the Kindred Hospice parent.