Every finding on record at Odyssey Healthcare Operating A, LP

Upon patient record review 3 of 14 records (Patient #1,#3,#4) 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 #1: The patient was admitted on 11/8/23. The record indicated that the spiritual assessment was completed on 11/15/23, which is greater than the 5 day requirement. Patient #3: The patient was admitted on 9/20/23. The record indicated that the spiritual assessment was completed on 9/28/23. Patient #4: The patient was admitted on 9/12/23. The record indicated that the spiritual assessment was completed on 9/19/23.

Upon patient record review 2 of 14 records (Patient #9,#10) 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. Patient #9,#10: There was not evidence of a spiritual assessment

Upon patient record review, 6 of 14 records (Patient #2,#3,#4,#7,#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 #2: The medication profile contained oxygen 2-3L/min prn shortness of breath. There was not evidence of a route. Corrected on site. Patient #3: The medication profile contained Acetaminophen 325 mg, 650mg q4h prn pain or fever over 100, and Hydrocodone 7.5-Acetaminophen 325, 1 tab 3x/day prn pain. There was not evidence of a maximum allowable dose per 24 hours. Corrected on site. Patient #4: The medication profile contained Nystatin 100,000u topical ointment, 1 application 3x/day, betamethasone topical, 2x daily per instructions, and Lamisil 1% topical cream, 1 application 2x/day. There was not evidence of a specific location for any of these creams/ointments. Corrected on site. Patient #7: The medication profile contained oxygen 2L/min. There was not evidence of a route. Corrected on site. Patient #9: The medication profile contained oxygen 4L/min continuously. There was not evidence of a route. Corrected on site. Patient #10: The initial skilled nurse assessment indicated that the patient had a bowel regimen and was on Miralax. There was not evidence of Miralax in the medication profile.

Upon patient record review, 1 of 14 records (Patient #5) did not have evidence in the patient record that the hospice has developed an individualized written plan of care 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 #5: The patient was admitted with a terminal diagnosis of COPD. There was not evidence that the care plan reflected patient/family goals and interventions based on the patient's respiratory problems. Corrected on site.

Upon patient record review, 6 of 14 records (Patient #2,#3,#4,#7,#9,#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 medications and treatments. Patient #2: The record contained an order for oxygen 2-3L/min prn shortness of breath. There was not evidence of a route. Corrected on site. Patient #3: The record contained orders for Acetaminophen 325 mg, 650mg q4h prn pain or fever over 100, and Hydrocodine7.5-Acetaminophen 325, 1 tab 3x/day prn pain. There was not evidence of a maximum allowable dose per 24 hours. Corrected on site. Patient #4: The record contained orders for Nystatin 100,000u topical ointment, 1 application 3x/day, betamethasone topical, 2x daily per instructions, and Lamisil 1% topical cream, 1 application 2x/day. There was not evidence of a specific location for any of these creams/ointments. Corrected on site. Patient #7: The record contained an order for oxygen 2L/min. There was not evidence of a route. Corrected on site. Patient #9: The record contained an order for oxygen 4L/min continuously. There was not evidence of a route. Corrected on site. Patient #10: The initial skilled nurse assessment indicated that the patient had a bowel regimen and was on Miralax. There was not evidence of an order for Miralax.

Upon patient record review, 1 of 14 records (Patient #8) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and notes the patient's progress towards outcome/goals from the plan of care. Patient #8: The record indicated that the patient had a respite stay from 1/1/24-1/5/24. There was not evidence that the care plan was revised to reflect respite or facility coordination.

Upon client record review, 3 of 14 records (Patient #4,#8,#10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4: The social work visit frequency was 2x/month effective 12/11/23. The record indicated no visits in December and only 1 in January (as of survey). In addition, the skilled nurse visit frequency was 2x/week. For the week of 12/24/23-12/30/23, the record indicated only 1 visit. Patient #8: The skilled nurse visit frequency was 2x/week. For the week of 1/7/24-1/13/24, the record indicated only 1 visit on 1/12/24. Corrected on site. Patient #10: The skilled nurse visit frequency was 2x/week. For the week of 12/24/23-12/30/23, the record indicated only 1 visit.

Upon patient record review 7 of 14 records (Patient #1,#2,#3,#5,#6,#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 #1: The aide visit frequency was 1w1, 2w12. The patient was admitted on 11/8/23. The record indicated only 1 visit for the week of 11/12/23-11/18/23 And no visits for the week of 1/14/23-1/20/23. Corrected on site. Patient #2: The aide visit frequency was 2w13. The record indicated only 1 visit/missed visit documentation for the week of 1/14/23-1/20/23. Corrected on site. Patient #3: The aide visit frequency was 2x/week. The record indicated only 1 visit/missed visit documentation for the week of 1/14/23-1/20/23. Corrected on site. Patient #5: The aide visit frequency was 2x/week. There was not evidence of visits for the week of 1/14/24-1/20/24. Corrected on site. Patient #6,#7: The aide visit frequency was 2x/week. For the week of 1/14/24-1/20/24, the record indicated only 1 missed visit document dated 1/16/24. Corrected on site. Patient #8: The aide visit frequency was 3x/week. For the weeks of 12/24/23-12/30/23 and 12/31/23-1/6/24, the record indicated only 2 visits each of these weeks. Also, there was also not evidence of visits between 1/14/24-1/20/24. Corrected on site.

Upon patient record review 3 of 14 records (Patient #4,#5,#6) did not have evidence of 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 #4: The record indicated an aide supervisory visit on 12/28/23. The next documented aide supervisory visit was 1/2/24, which is longer than the 14 day requirement. Patient #5: The record indicated an aide supervisory visit on 12/18/23. The next documented aide supervisory visit was 1/8/24. Patient #6: The record indicated an aide supervisory visit on 12/20/23. The next documented aide supervisory visit was 1/10/24.

Upon patient record review, 1 of 14 records (Patient #10) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #10: The plan of care and the IDT indicated the patient's hospice diagnosis to be Type II diabetes with diabetic peripheral angiopathy without gangrene. The physician narrative stated '80 year old on hospice services for BPH, CVA, HTN, Hyperlipidemia, and Type II diabetes.' There was not evidence that the medical director determined the terminal diagnosis. It could not be determined which diagnosis was the primary hospice terminal diagnosis. Corrected on site.

Upon patient client record review, 1 of 14 records (Patient #4) 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. Patient #4: The record indicated that the patient was a full code. The social work narrative in the IDT documentation stated that the patient was not a full code. This was a conflict of information. Corrected on site.

Upon client record review, 1 of 14 records (Patient #5) 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 #5: The visit frequency for the skilled nurse was 2x/week. For the week of 1/14/24-1/20/24, the record indicated only 1 missed visit document on 1/17/24. Corrected on site.

Upon client record review, 1 of 14 records (Patient #5) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #5: The record indicated an order dated 12/14/23 for wound care to the patient's right elbow to cleanse with wound cleanser or sterile water. Apply Hydrofera Blue to the wound bed. Cover with silicone adhesive bandage daily and prn. There was not evidence of of which provider was to perform the wound care. The wound care orders were updated on 1/8/24, but still did not indicate which provider was to perform the wound care. Corrected on site.