Every finding on record at Odyssey Healthcare of South Texas, LLC

Upon patient record review 2 of 19 (Patient #2, # 11) 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 #2 and 11, No evidence that a spiritual assessment had been completed.

Upon patient record review, 3 of 19 (Patient #1, #9, and #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 • Duplicate drug therapy Patient #1 the medication profile revealed two different antibiotics; Azithromycin for an URI which was started 10/12/23, and Cefuroxime which was started on 9/12/23, both did not include a stop date or indication for usage. It further revealed 2 medications for constipation, Senna and Bisacodyl suppositories, no indications were listed which to use first or under what condition to admission the other. The senna and Bisacodyl were corrected on site. Lastly the medication profile did not include a topical pain relieving gel that the daughter stated she used on the patient's right shoulder on 9/24/23. Patient #9 and 10 The medication profile revealed 2 medications for constipation, Senna and Bisacodyl suppositories, no indications were listed which to use first or under what condition to administer the other. This was corrected on site

Upon patient record review, 1 of 19 (Patient #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 • 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 #6 The initial POC included a frequency of PRN for both the SW and spiritual care provider.

Upon patient record review, 3 of 19 (Patient #1, #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 orders for two different antibiotics; Azithromycin for an URI which was started 10/12/23, and Cefuroxime which was started on 9/12/23, both orders failed to reveal a stop date or indication for usage. It further revealed 2 medications for constipation, Senna and Bisacodyl suppositories, no indications were listed with instruction when to use either. Antibiotics, Senna and Bisacodyl were corrected on site. No evidence of an order for a pain relieving gel that the daughter stated she used on the patient's right shoulder on 9/24/23. The record revealed the patient had an indwelling urinary catheter, however no orders for the size, insertion technique, or how to provide care of it were found. -corrected on site Patient #9 and 10 The orders for 2 medications for constipation, Senna and Bisacodyl suppositories, no indications were listed which to use first or under what condition to administer the other. This was corrected on site.

Upon client record review, 1 of 19 (Patient #11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #11, The clinical record revealed a RN frequency of twice a week, however during the week of 9/3/23 the RN only visited once.

Upon patient record review, 1 of 19 (Patient #9) did not have evidence in the patient record that hospice aide assignments and duties are: • 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 Patient #9 was a safety risk with a history of 10-15 recent falls. The aide care plan showed no evidence of a fall risk. corrected on site

Upon patient client record review, 1 of 19 (Patient #16) did not evidence that each patient record contains physician orders. Patient #16 No evidence of an order to discharge the patient (who moved out of the service area), from the medical director.

Upon patient client record review, 1 of 19 (Patient #5) 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 #5, the clinical record revealed that home health aide services had been declined by the pt. and family. However, the RN completed supervisory visits on the following dates:10/2/23, 10/9/23, and 10/18/23.

Upon client record review, 1 of 19 (Patient #16) did not have evidence that the discharge summary includes all required information. Patient #16 no evidence of a summary of the patient's stay, including treatments, symptoms and pain management.

Upon personnel record review, 1 of 13 (Personnel #6) did not have evidence all Physical Therapy Services are provided by a qualified licensed Physical Therapist (PT) in accordance with the state's Physical Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #6 no employee file provided for a PT.

Upon personnel record review, 1 of 13 (Personnel #6) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel #6 no employee file provided for a PT.