Every finding on record at Odyssey Healthcare Operating A, LP

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: No evidence that any discipline completed a psychosocial comprehensive assessment.

Upon patient record review, 2 of 19 (Patient #4,7) 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 4: Patient has two PRN medications listed to take daily PRN for constipation. Dulcolax 10mg suppository PRN daily and MiraLax 17 grams oral powder PRN daily. No evidence that instructions were provided as to which medications should be given first. Patient 7: Patient has two PRN medications listed to take twice daily PRN for constipation. Patient has Senna plus 8.6 twice daily PRN and Milk of Magnesium 400mg/5ml PRN twice daily. No evidence that instructions were given as to which medication should be given first.

Upon patient record review, 4 of 19 (Patient #7,9,10,11) 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 7: No evidence that bereavement risk assessment was completed within 5 days of election. Completed on 07/06/2023, patient admitted on 06/16/2023. Patient 9: No evidence that bereavement risk assessment was completed within 5 days of election. Completed on 07/06/2023, patient admitted on 06/08/2023. Patient 10: No evidence that bereavement risk assessment was completed within 5 days of election. Completed on 06/07/2023, patient admitted on 06/01/2023. Patient 11: No evidence that bereavement risk assessment was completed within 5 days of election. Completed on 07/20/2023, patient admitted on 07/12/2023.

Upon patient record review, 1 of 19 (Patient #3) 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 3: Patient admitted with seizures as a related diagnosis. Currently taking Keppra 500mg twice daily and Depakote 500mg 3 times a day for seizures. No evidence of safety or risk for seizures on the current care plan. Corrected during survey.

Upon patient record review, 2 of 19 (Patient #4,7) 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 4: Patient has two PRN medications listed to take daily for constipation. Dulcolax 10mg supp PRN daily and Miralax 17 grams oral powder PRN daily. No evidence that instructions were provided as to which medications should be given first. Patient 7: Patient has two PRN medications listed to take twice daily for constipation. Patient has Senna plus 8.6 twice daily PRN and Milk of Magnesium 400mg/5ml PRN twice daily. No evidence that instructions were given as to which medication should be given first.

Upon patient record review, 1 of 19 (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: Wound care supplies on current plan of care. No evidence that patient ever had an active wound.

Upon client record review, 2 of 19 (Patient #1,11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: Volunteer referral entered on 06/01/2023. VC entered a note on 06/05 stating that the caregiver would like to meet on 06/09/2023 to complete the volunteer assessment. No evidence that the volunteer assessment was completed. VC added a communication note on 07/24/2023 stating that he had reached out to the caregiver but the patient was not in the mood for visitors and she would follow up when he was feeling better. Patient 11: Initial Plan of care has "Volunteer to assess". No evidence that volunteer assessment was ever completed. Family accepted volunteer services during admit assessment. Declined on recert order. No evidence that an order was entered to discontinue.

Upon patient record review, 1 of 19 (Patient #1) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • 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 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 1:Plan of care has aide visit frequency as twice a week. At least one visit has been declined weekly between the dates of 08/27/2023-09/23/2023 and 10/01-11/2/2023. No evidence that revisions to the plan of care was made or that communication was had with the patient about changing aide frequency. Orders written during survey.

Upon patient client record review, 1 of 19 (Patient #9) 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: Missed visit note dated for -8/30/2023 mostly blank. Visit date, MD name, and RN CM name listed on note. No evidence that any of the remaining questions were answered or documentation as to the reason for missing the visit. Discipline scheduled to provide visit, reason visit was not made, or efforts made to avoid missed visits.