Every finding on record at Odyssey Healthcare of Savannah, LLC

Upon patient record review 1 of 19 records (Patient #13) 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 #13: The patient was admitted on 6/26/23. The record indicated that the spiritual assessment was completed on 7/12/23.

Upon patient record review, 3 of 19 records (Patient #1,#11,#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 #1: The certification of terminal illness indicated that the patient was using oxygen at 4L/min via nasal cannula. Nurse documentation indicated that the patient was using oxygen at 2L/min. There was not evidence that oxygen was on the medication profile. Corrected on site. Patient #11: The record indicated for Miralax 17GM daily prn constipation, Senna 8.6, 1 tab twice daily as needed constipation, Enema 19 GM-7 Gm/118 ml, 1 bottle daily prn until BM achieved constipation, Glycerine rectal supp, use 1 rectally q3 days as needed constipation. There was not evidence of which drug to use first or under what conditions to use the first one followed by the second, third and fourth. Corrected on site. Patient #13: The record indicated for Benadryl 25 mg tabs, take 3 tabs 3x/day as needed for itching, and Hydroxyzine HCl 25 mg, 1 tab TID pruritis. There was not evidence of which drug to use first or under what conditions to use the first one followed by the second. Corrected on site.

Upon patient record review, 3 of 19 records (Patient #4,#8,#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 #4: The patient was admitted on 5/18/23. The record indicated that the bereavement assessment was completed on 5/30/23 which is greater than the 5 day requirement. Patient #8: The patient was admitted on 5/4/23. The record indicated that the bereavement assessment was completed on 5/11/23. Patient #11: The record indicated that a bereavement assessment was conducted only on a paid caregiver. The patient's daughter signed her consents and legal paperwork, and both the daughter and a grand-daughter were involved in the care of the patient. There was not evidence that a bereavement assessment was conducted on either of these family members.

Upon patient record review, 2 of 19 records (Patient #4,#9) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #4: The record revealed that the RN conducted a visit and performed an assessment on 7/8/23. The next RN visit with an assessment was conducted on 7/26/23 which is greater than the required 15 days. Patient #9: The record revealed that the RN conducted a visit and performed an assessment on 6/13/23. The next RN visit with an assessment was conducted on 6/29/23 which is greater than the required 15 days. Also an RN visit with an assessment was conducted on 7/21/23. There was not evidence of an RN visit or assessment until 8/8/23.

Upon patient record review, 1 of 19 records (Patient #2) did not have evidence that a Registered Nurse ensured continuous assessment of the patient and family's needs and coordinated 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 #2: A triage note dated 7/28/23 indicated a call from the caregiver that a nurse was supposed to visit today and didn't and she was expecting a social worker visit and did not get one. Triage indicated that the caregiver requested a nurse visit. The call was escalated. There was not evidence of a call, a visit or any communication until a visit occurred on 8/1/23

Upon patient record review, 1 of 19 records (Patient #4) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient that reflects 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 #4: The patient was admitted with a diagnosis of hypertensive heart failure. Has edema and paroxysmal atrial fibrillation. There was not evidence of goals and interventions related to her cardiac problems. Corrected on site.

Upon patient record review, 3 of 19 records (Patient #1,#4,#6) 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 Patient #1: The visit frequency for the social worker and the spiritual care counselor was 1 prn, dated 6/2/23 on the initial plan of care. Patient #4: The visit frequency for the social worker and the spiritual care counselor was 1 prn, dated 5/18/23 on the initial plan of care. Patient #6: The visit frequency for the social worker and the spiritual care counselor was 1 prn, dated 7/12/23 on the initial plan of care.

Upon patient record review, 3 of 19 records (Patient #1,#11,#13) did not have evidence the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: The certification of terminal illness indicated that the patient was using oxygen at 4L/min via nasal cannula. Nurse documentation indicated that the patient was using oxygen at 2L/min. There was not evidence of an order for oxygen. Corrected on site. Patient #11: The record indicated for Miralax 17GM daily prn constipation, Senna 8.6, 1 tab twice daily as needed constipation, Enema 19 GM-7 Gm/118 ml, 1 bottle daily prn until BM achieved constipation, Glycerine rectal supp, use 1 rectally q3 days as needed constipation. There was not evidence of which drug to use first or under what conditions to use the first one followed by the second, third and fourth. Corrected on site. Patient #13: The record indicated for Benadryl 25 mg tabs, take 3 tabs 3x/day as needed for itching, and Hydroxyzine HCl 25 mg, 1 tab TID pruritis. There was not evidence of which drug to use first or under what conditions to use the first one followed by the second. Corrected on site.

Upon patient record review, 1 of 19 records (Patient #1) did not have evidence the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1: The plan of care indicated 'none' for equipment. Nurse documentation indicated that the patient had a hospital bed and oxygen. Corrected on site.

Upon client record review, 2 of 19 records (Patient #3,#5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: The visit frequency for the spiritual care counselor was for an evaluation then 2m2. The record indicated an evaluation was conducted on 5/23/23, and subsequent routine visits were conducted on 6/21/23, 7/14/23, and 7/21/23. Patient #5: The visit frequency for the social worker for the benefit period beginning on 6/21/23, was 2 every 2m2, 1m2. The record indicated that the social worker conducted visits on 7/3/23, 7/25/23, and 8/3/23. Corrected on site. In addition, the visit frequency for the spiritual care counselor for the benefit period of 5/27/23-7/25/23 was for an evaluation. There was not evidence of a visit or missed visit documentation.

Upon patient record review 3 of 19 records (Patient #4,#7,#8) 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 Patient #4: The aide visit frequency was 2w12. The record indicated only 1 visit for the week of 7/2/23-7/8/23 Corrected on site. Patient #7: The aide visit frequency dated 7/24/23 was 3w12. The record indicated that the aide conducted only 2 visits each week. Patient #8: The aide visit frequency was 2w12. The record indicated only 1 visit for the week of 7/2/23-7/8/23 Corrected on site.

Upon patient record review 1 of 19 records (Patient #1) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #1: The record indicted the first aide visit was 6/8/23. There was not evidence that an aide supervisory visit was conducted until 7/10/23.

Upon personnel record review, 1 of 12 (Personnel #10) did not have evidence in the hospice aide personnel file that a registered nurse made an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. The supervising nurse must assess an aide's ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include all required content. Personnel #10: The aide competency dated 6/23/23 did not contain evidence that any of these tasks were performed with a patient or pseudo-patient. There was not evidence of initials by the supervising nurse in the area to indicate completion. (The record did contain a full completed competency with return demonstration, upon hire, dated 6/23/22)

Upon patient client record review, 2 of 19 records (Patient #6,#9,) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #6,#9: The election statement indicated that the patient/representative wished to receive the Patient Notification of Hospice Non-Covered Items, Services, and Drugs. There was not evidence that this was furnished.

Upon client record review, 2 of 19 records (Patient #4,#8) 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 #4: The visit frequency for the spiritual care counselor was for an evaluation, then 1m1,4m1,5m1. Documentation revealed that the evaluation was conducted on 5/22/23, followed by routine visits on 6/5/23, 6/19/23, 6/26/23, 7/3/23, 7/14/23, 7/17/23, and 7/25/23. Patient #8: The spiritual care visit frequency was for an evaluation then 1m1, 3m1, 2m2. The record indicated that an evaluation was conducted on 5/5/23 and subsequent visits were conducted on 5/18/23, 6/2/23, 6/26/23 and 7/13/23. Corrected on site.