Every finding on record at Odyssey Healthcare Operating A, LP

Upon patient record review, 7 of 19 (Patients #4,#5,#8,#11,#12,#13,#14) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 4: The medication profile contained an active amoxicillin order 4/26/25 with no defined length of treatment. Corrected on site. Patient 5: The medical record contained an order for oxygen equipment and supplies, and the plan of care contained problems, goals, and interventions related to oxygen safety. There was no evidence of an oxygen rate, frequency and delivery included on the medication profile. Corrected on site. Patient 8: The medication profile contained duplicative furosemide listings with different doses of 20mg and 40mg twice daily. There was no evidence of instructions the doses were to be taken together for a total of 60mg twice daily. Corrected on site. During patient interview upon home visit, the patient stated that she takes 25mg labetolol rather than the 100mg listed on the med profile, Lactulose PRN rather than scheduled twice daily, and had not taken Lyrica for two weeks. Patient 11: The medical record contained nursing documentation upon recertification assessment 3/29/25 identifying patient use of oxygen. There was no evidence of an oxygen rate, frequency and delivery method included on the medication profile. Corrected on site. Patient 12: The medication profile contained duplicative seroquel listings with different doses of 25mg and 50mg at bedtime. There was no evidence of instructions the doses were to be taken together for a total of 75mg. Corrected on site. Patient 13: The medication profile contained an active macrobid order 5/4/25 with no defined length of treatment. Corrected on site. Patient 14: Upon interview with the patient's caregiver during home visit, administration and availability of metamucil, vitamin D, and multivitamins were denied that were current on the medication profile.

Upon patient record review, 1 of 19 (Patient #2) 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 2: There was no evidence of a comprehensive physical assessment completed by an RN from 4/19/25-5/8/25.

Upon patient record review, 4 of 19 (Patients #6,#11,#12,#13) 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 6: The plan of care contained problems, goals, and interventions related to oxygen safety. After agency investigation, the plan of care was incorrect and the patient did not have oxygen. Corrected on site. Patient 11: The medical record contained nursing documentation since admission identifying patient issue with dysphagia and recurrent aspiration. There was no evidence of problems, goals, and interventions related to dysphagia included in the plan of care. Corrected on site. Patient 12: The medical record indication patient was on services for Lewy Body dementia. There was no evidence of problems, goals, and interventions related to neurological dysfunction included in the plan of care. Corrected on site. Patient 13: The medical record contained nursing documentation since admission identifying patient is a high risk of falls, and the medication profile indicates patient is on Eliquis and is treated for seizures. There is no evidence of problems, goals, and interventions related to fall safety, bleeding precautions, and seizure precautions included in the plan of care. Corrected on site.

Upon patient record review, 8 of 19 (Patients #4,#5,#6,#8,#10,#11,#12,#13,#14) 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 4: The medical record contained nursing documentation since admission identifying the patient receives tube feedings for nutritional needs. There was no evidence of an order for formula type, rate or amount and frequency. The record also contained an order for amoxicillin 4/26/25 without a defined length of treatment. Corrected on site. Patient 5: The medical record contained an order for oxygen equipment and supplies, and the plan of care contained problems, goals, and interventions related to oxygen safety. There was no evidence of an order for the oxygen rate, frequency and delivery method. Corrected on site. Patient 8: The medical record contained duplicative orders for furosemide with different doses of 20mg and 40mg twice daily. There was no evidence of instructions the doses were to be taken together for a total of 60mg twice daily. Corrected on site. During patient interview upon home visit, the patient stated that she takes 25mg labetolol rather than the 100mg listed on the med profile, Lactulose PRN rather than scheduled twice daily, and had not taken Lyrica for two weeks. There was no evidence of order changes for these medications documented by hospice. Patient 10: Upon home visit to the facility, the treatment orders identified patient is receiving physical and occupational therapy. There was no evidence hospice had orders for therapy. Patient 11: The medical record contained nursing documentation upon recertification assessment 3/29/25 identifying patient use of oxygen. There was no evidence of an order for the oxygen rate, frequency and delivery method. Corrected on site. Patient 12: The medical record contained duplicative orders for seroquel with different doses of 25mg and 50 mg at bedtime. There was no evidence of instructions the doses were to be taken together for a total of 75mg. Corrected on site. The record also contained nursing documentation since 4/17/25 identifying patient use of a CPAP. There was no evidence of an order for CPAP parameters. Corrected on site. Patient 13: The medical record contained an order 5/4/25 for macrobid without a defined length of treatment. Corrected on site. Patient 14: Upon interview with the patient's caregiver during home visit, administration and availability of metamucil, vitamin D, and multivitamins were denied. There was no evidence of order changes for these medications documented by hospice.

Upon patient record review, 9 of 19 (Patients #3,#4,#5,#6,#7,#10,#11,#12,#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 3: The medical record contained a prescription for albuterol nebulizers. There was no evidence of an order for the nebulizer included in the plan of care. Corrected on site. Patient 4: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, bedrails, over bed table, commode, Hoyer lift, and wheelchair. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 5: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair. There was no evidence of an order for the wheelchair included in the plan of care. Corrected on site. Patient 6: The medical record contained nursing documentation upon admission identifying patient use of a low air loss mattress, shower bench, and wheelchair. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 7: The medical record contained nursing documentation upon recertification assessment 3/5/25 identifying patient use of oxygen, hospital bed, and bedrails. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 10: The medical record contained nursing documentation 4/3/25 identifying patient use of a bed alarm. There was no evidence of an order for the alarm included in the plan of care. Corrected on site. Patient 11: The medical record contained a prescription for duonebs and nursing documentation 3/29/25 identifying patient use of a specialty mattress. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 12: The medical record contained nursing documentation identifying patient use of bedrails since admission, and a CPAP since 4/17/25. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 13: The medical record contained nursing documentation upon admission identifying patient use of a trapeze and low air loss mattress. There was no evidence of orders for the DME included in the plan of care. Corrected on site.

Upon patient record review, 1 of 19 (Patient #1) 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: The current plan of care was not updated to reflect patient's DNR status, both full code and POLST were listed as active code status. Corrected on site.

Upon patient record review, 2 of 19 (Patients #5,#13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5: The medical record contained an order for spiritual care to complete an evaluation and upon a mini spiritual assessment 5/2/25, patient and family were receptive to receive a spiritual care visit. Nursing documentation identified the patient was imminent at time of chart review 5/14/25 and there was no evidence of follow up from the chaplain regarding arranging a spiritual care visit. Patient 13: The medical record contained an order for nursing visits three times weekly. There was no evidence of a third visit the week of 5/4/25.

Upon patient record review, 3 of 19 (Patients #15,#16,#17) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Patient 15: There was no evidence of bereavement care plan tasks including memorial service invitations sent to both of the bereaved, and no evidence of a holiday letter, 3, 6, and 9 month letters sent to the daughter. Patient 16,17:There was no evidence of bereavement care plan tasks including memorial service invitations sent to the bereaved.

Upon patient record review 1 of 19 (Patient #13) 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 13: The medical record contained aide documentation 5/7/25 identifying completion of nail care and shaving. There was no evidence of these tasks assigned on the aide care plan.

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's volunteer utilization rate was 1.3% for 2024.

Upon patient record review, 2 of 19 (Patients #9,#18) 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 9: The medical record contained missed nursing visit documentation 3/20/25 and 4/11/25, however there were completed nursing visits on those dates. Patient 18: The date of plan to discharge on the NOMNC is not legible.

Upon patient record review, 1 of 19 (Patient #10) did not have evidence that the hospice assumes responsibility for professional management of the resident's hospice services in accordance with the hospice plan of care. The hospice is responsible for providing all hospice services including: • Ongoing assessment, care planning, monitoring, coordination and provision of care by the Hospice IDG • Consultation about the patient's care with facility staff • Coordination by the hospice RN for the implementation of the plan of care for the patient Patient 10: Upon home visit to the facility, the treatment orders identified patient is receiving physical and occupational therapy. There was no evidence the hospice involvement with determination of therapy oversight and coordination of care.

Upon patient record review 1 of 13 records (Patient #8) 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 8: There is no evidence of a spiritual assessment completed as part of the comprehensive assessment after admission.

Upon patient record review, 1 of 13 records (Patient #4) 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: There was no evidence of a bereavement assessment completed as part of the comprehensive assessment after admission 3/3/22.

Upon patient record review, 2 of 13 records (Patients #2,#7) 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 contains nursing documentation upon admission identifying patient use of trilogy. There is no evidence of a treatment order identifying parameters for trilogy use. Corrected on site with late order entry. Patient 7: The medical record contains nursing documentation 5/19/22 identifying patient being treated for a UTI with macrobid antibiotic. There is no evidence of an order for the medication. Corrected on site with late order entry.

Upon patient record review, 1 of 13 records (Patient #2) 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 2: The medication profile identifies use of nebulized medications including budesonide and duonebs. There is no evidence of a nebulizer included as DME on the plan of care. Corrected on site.

Upon client record review, 1 of 10 applicable records (Patient #9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 9: The medical record contains nursing documentation 6/2/22 identifying nurse performed wound care. There is no evidence of an order for wound care until 6/6/22.

Upon client record review, 1 of 3 applicable records (Patient #11) 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 11: The medical record contains an order 2/4/22 to increase nursing frequency to daily. There is no evidence of nursing visits completed 2/10/22, 2/12/22 and 2/13/22.

Upon client record review, 1 of 3 applicable records (Patient #11) 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 11: The medical record contained an order for wound care 2/9/22 for patient residing in nursing home. There was no evidence of identification which provider was responsible for performing the wound care.