Every finding on record at Odyssey Healthcare Operating A, LP

Upon patient record review 1 of 19 (Patient #8) did not have evidence in the patient record that the hospice interdisciplinary group completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 8: The initial comprehensive spiritual assessment was completed 10/3/24 with start of care 9/25/24

Upon patient record review 1 of 19 (Patient #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 11. There was no evidence of a comprehensive spiritual assessment. Corrected on site.

Upon patient record review, 3 of 19 (Patients #2,#3,#6) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 2: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen included on the medication profile. Corrected on site. Patient 3: During observation of home visit, the patient's wife stated they did not have acetaminophen suppositories that were on the medication profile and that the patient takes one tablet of lisinopril daily, not twice daily per medication profile. Corrected on site. Patient 6: During observation of home visit, the facility medication profile did not contain lorazepam and the hospice medication profile did not contain clonidine, levsin, naloxone HCl nasal liquid, and nystatin topical powder that were on the facility medication profile. Corrected on site.

Upon patient record review, 4 of 19 (Patients #2,#3,#4,#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 2: The initial bereavement assessment was completed 9/12/24 with start of care 7/25/24. Patients 3,4: There was no evidence of bereavement assessments. Corrected on site. Patient 10: The initial bereavement assessment was completed 6/7/24 with start of care 5/30/24

Upon patient record review, 3 of 19 (Patients #6,#12,#14) 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 6: During the home visit observation, the facility treatment orders contained wound care orders for a coccyx wound received 10/9/24. There was no evidence of nursing documentation of a coccyx wound. Corrected on site. Patient 12: There was no evidence of wound measurements to the bilateral great toes, left heel, and coccyx wounds since 10/15/24. Agency policy requires weekly assessments and measurements. Corrected on site with measurements and assessment completed 10/29/24. Patient 14: There was no evidence of wound measurements between 9/30/24 and 10/23/24. There was a refusal dated 10/16/24 and patient was unable to tolerate 10/11/24, however agency policy was not followed for documentation with refusal to include reasons provided for refusal, education completed and to whom, and notification of the attending physician as well as report of refusals to medical director and other IDG members.

Upon patient record review, 2 of 19 (Patients #4,#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 4: The patient was on hospice services for a terminal diagnosis of COPD. There was no evidence of problems, goals, and interventions related to respiratory dysfunction included in the plan of care. Corrected on site. Patient 8: The medical record contained nursing documentation identifying patient excoriation to skin folds since admission. There was no evidence of problems, goals, and interventions related to skin impairment included in the plan of care. Corrected on site.

Upon patient record review, 2 of 19 (Patients #2,#6) 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 nursing documentation upon admission identifying patient use of oxygen and 10/4/24 identifying facility wraps patients legs daily to help with edema. There was no evidence of an order for oxygen or edema treatment. Corrected on site. Patient 6: During the home visit observation, the facility treatment orders contained wound care orders for a coccyx wound. There was no evidence of wound care orders in the hospice medical record. Corrected on site.

Upon patient record review, 8 of 19 (Patients #1,#2,#3,#5,#8,#9,#10,#13) 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 1: The medical record contained nursing documentation upon admission identifying patient use of a Hoyer lift for transfers. There was no evidence of an order for the DME included in the plan of care. Corrected on site. Patient 2: The medical record contained nursing documentation upon admission identifying patient use of a trapeze. There was no evidence of an order for the DME included in the plan of care. Corrected on site. Patient 3: The medical record contained nursing documentation upon recertification 9/24/24 identifying patient use of a Hoyer lift and use of a wheelchair since admission. There was no evidence of an order for the DME included in the plan of care. Corrected on site. Patient 5: The medical record contained nursing documentation 9/23/24 identifying patient use of a over the bed table, commode, and wheelchair, and 10/14/24 identifying use of one half side rail. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 8: The medical record contained nursing documentation upon admission identifying patient use of bedrails, chair lift, wheelchair, shower chair, and a raised toilet seat. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 9: The medical record contained nursing documentation upon admission identifying patient use of a cane. There was no evidence of an order for the DME included in the plan of care. Corrected on site. Patient 10: The medical record contained nursing documentation upon admission identifying patient use of a walker. There was no evidence of an order for the DME included in the plan of care. Corrected on site. Patient 13: The medical record contained nursing documentation upon recertification identifying patient use of a commode, and documentation upon admission identifying use of a walker and over bed table. There was no evidence of orders for the DME included in the plan of care. Corrected on site.

Upon patient record review, 2 of 19 (Patients #11,#19) 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 11: There was no evidence the plan of care was updated from full code to DNR status. DNR order was received 10/16/24. Corrected on site. Patient 19: There was no evidence the plan of care was revised to reflect the plan to discharge patient due to extended prognosis.

Upon patient record review, 1 of 19 (Patient #11) did not have evidence in the patient record that hospice aide assignments and duties are specific to the patient's preferences and needs. Patient 11: There was no evidence the aide care plan was updated to reflect the needs of the patient who was documented as preferring bed baths over showers since 10/11/24 which was reported to the RN. Corrected on site.

Upon patient record review 1 of 19 (Patient #1) 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 1: The medical record contained an ordered aide frequency of once weekly. There was no evidence of a visit completed the week of 10/6/24. Corrected on site with late entry documentation of reason for missed visit.

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 agency had a volunteer utilization rate of 0% for 2023.

Upon patient client record review, 2 of 19 (Patients #2,#19) 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 2: The medical record contained inappropriately authenticated documentation 10/4/24 identifying patient is a full code, however patient is DNR per orders and plan of care. Corrected on site with addendum to documentation. Patient 19: The medical record contained inappropriately authenticated documentation regarding the patient's continued eligibility during IDG 10/8/24. The patient was discharged due to extended prognosis 9/26/24.

Upon patient record review, 1 of 19 (Patient #6) 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 6: During observation of home visit, there was no evidence the facility had received a list of hospice personnel involved with care, election form, certification of terminal illness, and current plan of care. The last POC provided was dated 9/28/24. Corrected on site.

Upon patient record review, 7 of 13 records (Patient #1,#3,#6,#7,#9,#10,#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. Patient #1: The medication profile contained Miralax 17 Gm/dose oral powder, 17 Gm daily prn. There was not evidence of a diluent. In addition, the medication profile contained Tylenol Extra Strength, 1 500mg. Take as directed on bottle. Corrected both on site. Patient #3: Nurse documentation indicated that the patient was on oxygen at 2L/min. The care plan listed oxygen and oxygen supplies under DME and the certification of terminal illness read that the patient was dependent on supplemental oxygen via nasal cannula. There was not evidence that oxygen was on the medication profile. In addition, an order dated 11/1/21 indicated to hold Xarelto and ASA for 5 days. There was not evidence that these medications were resumed on the medication profile. Corrected both on site. Patient #6,#7,#13: The medication profile contained Miralax 17 Gm/dose oral powder, 17 Gm daily prn. There was not evidence of a diluent. #6,#7 Corrected on site. Patient #9: The medication profile contained duplicate medication of Hydrocodone5mg-Acetaminophen 325mg tab, 1-2 tabs q6h as needed prn for pain. Corrected on site. Patient #10: The medication profile contained Ketoconazole 2% topical cream-Triamcinolone 0.025% lotion BID prn chronic rash. There was not evidence of a location. Corrected on site.

Upon patient record review, 6 of 13 records (Patient #1,#3,#6,#7,#10,#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 record contained an order for Miralax 17 Gm/dose oral powder, 17 Gm daily prn. There was not evidence of a diluent. In addition, there was an order for Tylenol Extra Strength, 1 500mg. Take as directed on bottle. Corrected both on site. Patient #3: Nurse documentation indicated that the patient was on oxygen at 2L/min. The Care plan listed oxygen and oxygen supplies under DME and the certification of terminal illness read that the patient was dependent on supplemental oxygen via nasal cannula. There was not evidence of an order. Corrected on site. Patient #6,#7,#13: The record contained an order for Miralax 17 Gm/dose oral powder, 17 Gm daily prn. There was not evidence of a diluent. #6,#7 Corrected on site. Patient #10: The record contained an order for Ketoconazole 2% topical cream and Triamcinolone 0.025% lotion BID prn chronic rash. There was not evidence of a location. Corrected on site.

Upon client record review, 1 of 13 records (Patient #2) 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 record contained an order for oxygen continuously at 2L/min via nasal cannula. The nurse visit documentation indicated that the oxygen has not been initiated. Corrected on site.

Upon patient record review 1 of 10 applicable records (Patient #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 #8: The aide visit frequency was 2w8. For the week of 10/24/21-10/30/21, the record indicated only 1 visit on 10/28/21.

Upon observation, there was not evidence that 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 annual report for the percentage of volunteer usage for the year 2019 was 0.35%.