Every finding on record at Odyssey Healthcare of Kansas City, LLC

Upon observation, there was no evidence the Emergency Plan communication plan includes: • There was a method for sharing information and medical documentation for patients under the hospice's care, as necessary, with other health care providers to maintain the continuity of care • A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii) • A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4)

Upon patient record review, 3 of 14 (Patient #8, #9, 10) 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 #8: As observed during a home visit the instructions on the Humulin N box said it was to be taken in the AM and the Lorazepam bottle said 1mg po every 2 hours prn. Review of the hospice medication profile said Humulin N 18U SQ daily and Lorazepam 1mg oral every 2 hours. The caregiver who was the grandson also revealed during the visit that the patient was taking Milk of Magnesia prn and High Fiber Liquid 30ml daily at lunch which was not on the hospice medication profile. In addition, the medication profile revealed that Claritin 10mg po daily was a duplicate on the med profile. Corrected on site. Patient #9: As observed during a home visit the facility medication profile revealed orders for Lorazepam 0.5mg every 12h prn and Neurontin 300mg at HS. The hospice medication profile said Lorazepam 1mg every 6h prn and Neurontin 300mg AM. Corrected onsite. The hospice medication profile also had Milk of Magnesia 400mg/5ml 30ml daily and Senna 8.6 1 tablet daily and those medications were not on the facility medication profile. The Senna was corrected onsite. In addition, the medication profile revealed that Bisacodyl was a duplicate on the medication profile. Corrected on site. Patient #10: As observed during a home visit the SNF medication profile said Antifungal (Clotrimazole) External Cream 1% topical apply to right big toe topically daily. There was no evidence that the hospice medication profile contained this medication. There were 9 medications (Abilify, Bisacodyl, Fleets Enema, Omeprazole, Ondansetron, Oxybutynin, Senna, Sertraline, Tums) and oxygen that were on the hospice medication profile but not on the facility medication profile.

Upon patient record review, 1 of 14 (Patient #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 #8: Upon review of the record there is no evidence an initial bereavement risk assessment was completed for the grandson Ryan, who is the primary hands-on caregiver in the home.

Upon patient record review, 1 of 14 (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: Upon review of the record the nurse documented on 8/8/2025 "there is a small abrasion on the right knee" which is not a complete assessment of the new wound. In the 8/14/2025 nurse visit it is documented "abrasion to right knee scabbed" which is not a complete assessment of the wound. There was also no evidence that a dressing change was completed during the visits by the hospice nurse or that a dressing had been in place as per the order.

Upon patient record review, 1 of 14 (Patient #8) 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 #8: Upon review of the record the care plan had wound care interventions and goals but documentation didn't reveal that the patient had any wounds. Corrected on site.

Upon patient record review, 1 of 14 (Patient #2) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #2: Upon review of the record it revealed an order on 6/8/2025 for the SN visit frequency of 2wk2, 1wk1, 4prn. There was a new SN visit frequency order on 6/11/2025 with an additional 8prn visits. Another order was written on 7/7/2025 which included 12 prn visits. The record indicated there were additional prn visit orders without an increase in routine visits.

Upon patient record review, 4 of 14 (Patient #1, #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 medications and treatments. Patient #1: Upon review of the documentation wound care was being provided by the family however the order stated the hospice nurse was to do the wound care. Patient #8: Upon record review there were orders for Humulin N 18U SQ daily and Lorazepam 1mg oral every 2 hours. During the home visit the box for the Humulin N was ordered as every AM and the Lorazepam was 1mg po every 2 hours prn. Corrected onsite. There was no order in the hospice record for Milk of Magnesia and High Fiber Liquid that the patient's caregiver said he was giving the patient. Corrected onsite. Patient #9: Upon record review the orders were Lorazepam 1mg every 6h prn and Neurontin 300mg AM. During the home visit the facility medication profile revealed orders that were different than the hospice orders Lorazepam 0.5mg every 12h prn and Neurontin 300mg at HS. Corrected onsite. Patient #10: Upon review of the SNF medication profile it said Antifungal (Clotrimazole) External Cream 1% topical apply to right big toe topically daily. There was no evidence of an order for the Clotrimazole in the patient's hospice record.

Upon patient record review, 6 of 14 (Patient #1, #3, #4, #5, #6 and #8) 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: Upon review of the record it was documented that the patient had a new wound on right knee on 8/8/2025 but there was no evidence that the care plan was updated with wound interventions and goals. Patient #3: Upon review of the record on 7/18/2025 wound care interventions and goals were still on the care plan even though the documentation revealed the wound healed 7/28/2025. Corrected onsite. Patient #4: Upon review of the documentation revealed that the 7/29/2025 left proximal forearm wound was healed on 8/12/2025, the 8/12/2025 right eyebrow wound was healed on 8/12/2025 and the 6/17/2025 left distal forearm wound was healed on 6/24/2025. There no evidence that the 3 wounds had interventions and goals in the care plan. Patient #5: Upon review of the record it indicated that the patient had a UTI diagnosed on 8/4/2025 but there is no evidence that infection interventions and goals were added to the care plan. Patient #6: Upon review of the record it is documented that the patient was on respite care from 8/13/2025 through 8/17/2025. There is no respite interventions or goals added to the care plan. Patient #8: Upon review of the record there were SW interventions and goals on the care plan even though additional SW services were refused by the patient and family after the evaluation visit. Corrected on site.

Upon patient record review, 4 of 14 (Patient #1, #4, #5, #8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: Upon review of the record the nurse documented on 8/8/2025 "there is a small abrasion on the right knee", there was no evidence that a dressing change was completed during the visits by the hospice nurse or that a dressing had been in place as per the order. Patient #4: Upon review of the record the 7/3/2025 order was to increase SN visits to daily effective 6/29/2025. The record revealed that there were no SN visits made on 6/29/2025, 7/1/2025 and 7/2/2025. The record indicated that the SC did an evaluation on 6/19/2025 with a subsequent visit frequency effective 7/7/2025 2every2m2, 1m1, 2prn. No evidence that the SC followed the visit frequency and record revealed visits on 7/7/2025, 7/24/25 and 8/6/2025. Patient #5: Upon review of the record it indicated that the SC did the evaluation on 6/23/2025 with a visit frequency effective 6/19/2025 2every2m2, 2m1, 1m1, 3prn. There is no evidence in the record that the SC followed the ordered visit frequency due to making visits on 7/9/2025, 7/31/2025 and 8/14/2025. Patient #8: Upon review of the record there was an order on 7/9/2025 for a "PT eval for passive and active ROM. Restorative program." There is no evidence that the PT eval had been completed.

Upon patient record review 1 of 14 (Patient #7) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #7: Upon review of the record the daughter's initial bereavement assessment was completed and scored high. There is no evidence in the record of follow-up bereavement support to the daughter.

Upon observation, and record review, 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 #1: Upon record review it was documented the patient had a fall on 8/8/2025. There is no evidence in the record that a fall incident report was completed. Patient #4: Upon record review it is documented the patient had a fall on 7/21/2025 and 8/13/2025. There is no evidence in the record that a fall incident report was completed.

Upon observed home visit, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #9: The SW did not use hand sanitizer during the observation visit.

Upon patient record review 1 of 14 (Patient #5) 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 #5: Upon review of the record the aide care plan said the patient was to be shaved the 2nd visit of each week. The documentation revealed that the aide shaved the patient on the 1st visit of the week on the following dates: 6/24/2025, 7/8/2025, 7/15/2025, 7/22/2025, 7/28/2025, 8/12/2025 and 8/19/2025.

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 2024 QAPI annual report upon review revealed that the 2024 utilization of volunteers was 2.29% which does need meet the required 5%.

Upon patient client record review, 1 of 14 (Patient #6) 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 #6: Upon review of the record the nurse documented on 6 visits (7/21/2025, 7/25/2025, 7/28/2025, 8/1/2025, 8/4/2025 and 8/8/2025) "Wound care performed per Dr. orders" instead of the specific wound care that was completed during the visit by the nurse.

Upon patient record review, 1 of 14 (Patient #10) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice's 24-hour on-call system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient Patient #10: Upon review of the SNF clinical record there was no evidence of the names and contact information for hospice personnel involved in hospice care of the patient.

Upon patient record review 2 of 13 records (Patients #8,#13) did not have evidence in the patient record that the comprehensive assessment identifies the 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. Patients #8,#13: There was not evidence of a spiritual assessment.

Upon patient record review, 7 of 13 records (Patients #6,#7,#8,#9,#10,#12,#13) 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 #6: The medication profile indicated for Hydrocodone 10/Acetaminophen 325, 1 tab 4x daily and Acetaminophen 325mg, 2 tabs q6h prn pain or fever with no maximum allowance in a 24h period, and no parameter for fever. Corrected on site. Patient #7: The medication profile indicated for Acetaminophen 325mg, 2 caps q4h prn for breakthrough pain and acetaminophen 650mg rectal supp q6h as needed for fever over 100 with no maximum allowance per 24 hour period. Corrected on site. Patient #8: The record indicated orders for Acetaminophen rectal supp 650mg, 1 q6h prn fever, and Acetaminophen ER 650mg (straight order) q8h with no maximum allowance in a 24h period, and no parameter for fever. Corrected on site. Patient #9: The medication profile indicated Acetaminophen supp 325mg, 1 q6h prn fever and Acetaminophen 325mg, 2 tabs 3x daily (straight order) with no maximum allowance in a 24h period, and no parameter for fever. In addition, the medication profile indicated Polyethylene Glycol 17 Gm oral powder daily without evidence of a diluent. Corrected on site. Patient #10: The medication profile indicated Acetaminophen 500mg, 2 tabs daily and Acetaminophen rectal supp 650mg, 1 q6h prn pain or fever with no maximum allowance in a 24h period, and no parameter for fever. Corrected on site. Patient #12: The record indicated oxygen 2-4L/min continuous without evidence of a route. Patient #13: The medication profile indicated for Acetaminophen 650 rectal supp q4h prn pain or fever and Hydrocodone5/Acetaminophen 325, 1-2 tabs every 6h as needed for pain, and Percocet5/325, 1-2 tabs q4h prn pain with no maximum allowance for Acetaminophen in a 24h period, and no parameter for fever. In addition, Polyethylene Glycol 17 Gm oral powder daily without evidence of a diluent. Also, oxygen 2-4L/min as needed without evidence of a route.

Upon patient record review, 3 of 13 records (Patients #1,#6,#10) 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 4/12/22. The record indicated that the bereavement assessment was completed on 5/4/22. Patients #6,#10: There was not evidence of a bereavement assessment.

Upon patient record review, 1 of 13 records (Patient #10) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs Patient #10: The record indicated the visit frequency for the skilled nurse as 2w8 and 12 prn. Corrected on site.

Upon patient record review, 7 of 13 records (Patients #6,#7,#8,#9,#10,#12,#13) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #6: The record indicated orders for Hydrocodone 10/Acetaminophen 325, 1 tab 4x daily and Acetaminophen 325mg, 2 tabs q6h prn pain or fever with no maximum allowance in a 24h period, and no parameter for fever. Corrected on site. Patient #7: The record indicated orders for Acetaminophen 325mg, 2 caps q4h prn for breakthrough pain and acetaminophen 650mg rectal supp q6h as needed for fever over 100 with no maximum allowance per 24 hour period. Corrected on site. Patient #8: The record indicated orders for Acetaminophen rectal supp 650mg, 1 q6h prn fever, and Acetaminophen ER 650mg (straight order) q8h with no maximum allowance in a 24h period, and no parameter for fever. Corrected on site. Patient #9: The record indicated orders for Acetaminophen supp 325mg, 1 q6h prn fever and Acetaminophen 325mg, 2 tabs 3x daily (straight order) with no maximum allowance in a 24h period, and no parameter for fever. In addition, there was an order for Polyethylene Glycol 17 Gm oral powder daily without evidence of a diluent. Corrected on site. Patient #10: The record indicated orders for Acetaminophen 500mg, 2 tabs daily and Acetaminophen rectal supp 650mg, 1 q6h prn pain or fever with no maximum allowance in a 24h period, and no parameter for fever. Corrected on site. Patient #12: The record indicated an order for wound care dated 3/17/22 to clean the wound with wound cleanser, dry with sterile gauze, place optifoam or border dressing. Change once weekly and prn. Facility will provide care when hospice is not present. There was not evidence of a location of the wound. In addition, the record indicated oxygen 2-4L/min continuous without evidence of a route. Patient #13: The record indicated orders for Acetaminophen 650 rectal supp q4h prn pain or fever and Hydrocodone5/Acetaminophen 325, 1-2 tabs every 6h as needed for pain, and Percocet5/325, 1-2 tabs q4h prn pain with no maximum allowance for Acetaminophen in a 24h period, and no parameter for fever. In addition, there was an order for Polyethylene Glycol 17 Gm oral powder daily without evidence of a diluent. Also, oxygen 2-4L/min as needed without evidence of a route.

Upon client record review, 3 of 5 applicable records (Patients #2,#4,#7) 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 visit frequency for the social worker for the benefit period beginning 7/8/22 was 2m2 and 2 prn. The record indicated only 1 visit conducted on 8/22/22. Patient #4: The visit frequency for the social worker was 2m2, 1m1. The record indicated that the social worker visited only on 8/19/22. Patient #7: The visit frequency for the social worker was for an evaluation then 2m2, 1m1 and 3 prn. The record indicated that the evaluation was conducted on 7/11/22 and a subsequent visit on 8/17/22. In addition, the visit frequency for the spiritual care counselor was for an evaluation then 2m2, 1m2 and 3 prn. The record indicated that the evaluation was conducted on 7/12/22 and subsequent visits on 8/2/22, and 9/1/22.

Upon patient record review, 1 of 12 applicable records (Patient #5) did not have evidence in the patient record that hospice aide assignments and duties that are in the plan of care, specifically 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 #5: The aide plan of care dated 8/3/22 indicated to transfer patient from bed to chair and from chair to bed per patient request. Corrected on site.

Upon patient record review 2 of 12 applicable records (Patients #1,#2) did not have evidence of documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #1: The aide visit frequency for the benefit period beginning 7/13/22 was 1w1, 2w12. For the week of 8/28/22-9/3/22, the record indicated only 1 visit on 9/1/22. Patient #2: The aide visit frequency for the benefit period beginning 7/8/22 was 1w1, 3w8, 1w1. For the week of 8/7/22-8/13/22, the record indicated only 2 visits on 8/10/22 and 8/12/22. For the week of 8/21/22-8/27/22, only 1 visit was made on 8/22/22, and for the week of 8/28/22-9/3/22, documentation revealed only 2 missed visits.

Upon client record review, 1 of 13 records (Patient #9) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed.

Upon client record review, 4 of 8 applicable records (Patients #1,#9,#10,#12) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #1: The visit frequency for the social worker for the benefit period beginning on 7/13/22 was 2m2, 1m1 and 2 prn. The record indicated no visit in July and only 1 visit in August on 8/12/22. Patient #9: The visit frequency for the social worker was 2m2 and 2prn. The record indicated only 1 visit on 8/19/22. In addition, the visit frequency for the spiritual care counselor was 2m2, 1m1, and 2 prn. The record indicated that visits were conducted on 8/3/22 and 9/6/22. Patient #10: The visit frequency for the social worker was for an evaluation then 2m2, 1m1. The record indicated that the social worker conducted the evaluation on 7/6/22 and then only 1 visit on 8/1/22. Patient #12: The visit frequency for the social worker was for an evaluation then 1 every 2m2, 1m2 and 3 prn. The record indicated that the only visit was the evaluation on 1/27/22. The social worker visit frequency was discontinued on 3/16/22. In addition, the spiritual care counselor visit frequency was for an evaluation, then 2 every 2m2 and 3 prn. The record indicated that visits were conducted on 2/10/22, 2/23/22, 3/1/22, and 3/21/22.

Upon patient record review, 1 of 1 applicable records (Patient #10) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care. • Names and contact information for hospice personnel involved in hospice care of each patient Corrected on site.