Every finding on record at Odyssey Healthcare Operating A, LP

Upon patient record review 2 of 27 (Patient #16,19) 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 16: Patient admitted on 03/01/2025. Chaplain services were declined at that time. There is no evidence that the RN or the SW completed this part of the comprehensive assessment at the time of survey. Mini spiritual assessment completed on day 3rd of the survey. Patient 19: Patient admitted on 01/15/2025. Chaplain services were declined. There is no evidence that the RN or the SW completed this part of the assessment. No evidence that the assessment has been completed at the time of survey. Mini spiritual assessment completed on day 3rd of the survey.

Upon patient record review, 2 of 27 (Patient #11,19) 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 11: No evidence that a comprehensive assessment was completed every 15 days between 05/26/2025 and 06/12/2025. 17 days between assessments. Patient 19: No evidence that a comprehensive assessment was completed every 15 days between 07/2/2025 and 07/18/2025. 16 days between assessments.

Upon patient record review, 1 of 27 (Patient #16) 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 16: The clinical documentation indicated that the patient developed a wound on 05/22/2025. No evidence that the wounds were measured for the weeks of May 26, 2025 and June 9, 2025. Wound was de-activated on 06/17/2025.

Upon patient record review, 1 of 27 (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: The medical record indicated that the patient has an active diagnosis of Depression and currently take 2 medications for depression daily (Lexapro and Bupropion). There was no evidence of problems, goals, and interventions related to risk for depression included in the plan of care. COS- order written to add depression to the active plan of care during survey.

Upon patient record review, 1 of 27 (Patient #16) 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. during survey. Patient 16: The current supply list included wound care supplies. The clinical documentation indicated that the wound was inactivated on June 17,2025. COS- Updated active supply list during survey.

Upon client record review, 2 of 27 (Patient #18,20) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #18: No evidence of MSW contribution for IDGs that occurred on 04/01/25, 04/15/25, 04/29/25, 05/13/25, and 06/06/25. The MSW documented that "SW plans to see the patient before next IDG". No patient specific information added to the basic psychosocial template. Patient #20: No evidence that the RN contributed to IDG for the initial IDG that occurred on 12/24/2024, and the following 3 IDGs that occurred on 01/07/2025, 01/21/2025, and 02/04/2025. RN signed those IDGs as being completed however Gentiva's basic RN template within the body of the note was left blank with no patient specific information added. No evidence of MSW contribution for IDGs that occurred on 03/04/2025, 03/18/2025, and 04/01/2025. The MSW documented that "SW plans to see the patient before next IDG". No patient specific information added to the basic psychosocial template.

Upon patient record review, 3 of 27 (Patient #13,15,16) 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 13: The medical record indicated that patient requested to end chaplain services on 03/19/2024. Problems, interventions, and goals related to spiritual care remain on the current the plan of care - new benefit period started on 06/22/2025. Also the current level of care listed on the active POC has the patient as respite care status. The medical record indicates that patient is currently receiving routine home care. No evidence that the patient received respite care since the time of admission, 10/31/2023. COS- new order written to remove the spiritual care plan and update the patient's current level of care during survey. Patient 15: The medical record indicated that patient requested to end social worker services on 04/30/2025. Problems, interventions, and goals related to social services for companionship remain on the current the plan of care - new benefit period started on 06/08/2025. COS-new order written to remove social services from the plan of care during survey. Patient 16: The medical record indicated that the patient had a wound that was inactivated on June 17, 2025. Active wound care orders remain on the current plan of care. COS-new order written to remove wound care orders during survey.

Upon client record review, 1 of 27 (Patient #7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 7: Clinical documentation indicated that the SW completed a PRN visit on 06/26/2025. No evidence that an order was received for a PRN visit.

Upon patient record review 1 of 27 (Patient #11) did not have evidence 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 11: No evidence that an RN completed a supervisory visit every 14 days between the following dates- 3/21/2025 and 4/30/2025 (40 days between visits), 04/30/2025 and 05/15/2025 (15 days between visits), and 05/15/2025 and 06/16/2025 (32 days between visits).

Upon patient record review 1 of 16 (Patient #11) 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 #11: Admitted 6/23/22. There was not evidence of a completed spiritual assessment until 7/29/22.

Upon patient record review, 7 of 16 (Patients #2,#4,#5,#9,#14,#15,#16) 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 record indicated Medrol Dose pack, 4mg tablets, take po per pharmacy instructions. There was not evidence of specific instructions. Patient #4: The record indicated Novalog u-100 insulin Sub Q per instructions. There was not evidence of specific instructions. Corrected on site Patient #5: The record indicated an order for Clear Lax 17 GM powder every pm. There was not evidence of a diluent. Corrected on site. Patient #9: The medication profile contained Low dose Aspirin 81 mg po daily in duplicate. Dates were 3/3/22 and 8/4/22. Corrected on site. Patient #14: The record indicated Tylenol 300/Codeine 30, 1 tablet q6h prn and Tylenol 325mg 2 tabs q6h mild pain. There was not evidence of a maximum allowance per 24h period. Patient #15: The record indicated Tylenol 325 mg, 2 tabs 3x/day and Tylenol 325 mg 2 tabs, q4h prn pain. There was not evidence of a maximum allowance per 24h period. Patient #16: The record indicated Novolin R Flexpen 100u/ml Sub-Q, 1 hour before meals, sliding scale. There was not specific instructions for the sliding scale

Upon patient record review, 1 of 16 (Patient #5) 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 #5: The patient was admitted with a diagnosis of Parkinson's Disease. There was not evidence that the care plan included goals and interventions related to the patient's neurological disease. Corrected on site.

Upon patient record review, 6 of 16 (Patients #2,#4,#5,#14,#15,#16) 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 indicated an order for Medrol Dose pack, 4mg tablets, take po per pharmacy instructions. There was not evidence of specific instructions. Patient #4: The record indicated an order for Novalog u-100 insulin Sub Q per instructions. There was not evidence of specific instructions. Corrected on site. Patient #5: The record indicated an order for Clear Lax 17 GM powder every pm. There was not evidence of a diluent. Corrected on site. Patient #14: The record indicated Tylenol 300/Codeine30, 1 tablet q6h prn and Tylenol 325mg 2 tabs q6h mild pain. There was not evidence of a maximum allowance per 24h period. Patient #15: The record indicated Tylenol 325 mg, 2 tabs 3x/day and Tylenol 325 mg 2 tabs, q4h prn pain. There was not evidence of a maximum allowance per 24h period. Patient #16: The record indicated Novolin R Flexpen 100u/ml Sub-Q, 1 hour before meals, sliding scale. There was not specific instructions for the sliding scale.

Upon client record review, 1 of 10 applicable (Patient #6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6: The record indicated a phone visit by the RN on 7/8/22. There was not evidence that telehealth was a part of the plan of care. Corrected on site.

Upon patient record review, 1 of 15 applicable (Patient #14) did not have evidence in the patient record that hospice aide assignments and duties are: • Written patient care instructions, including precautions, for a hospice aide that are prepared by a Registered Nurse who Patient #14: The medication profile included that the patient was on Eliquis 2.5mg po BID. There was not evidence that bleeding precautions were a part of the aide plan of care.

Upon patient record review 3 of 15 applicable (Patients #1,#5,#12) did not have evidence of 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, 3w12, 1w1. For the week of 7/10/22-7/16/22, the record indicated only 2 visits were conducted (7/13/22 and 7/15/22). Corrected on site Patient #5: The aide visit frequency was 3x/week. For the week of 7/3/22-7/9/22, the record indicated only 2 visits (7/5/22, 7/6/22). Corrected on site. Patient #12: The aide plan of care indicated for the task of shave to be performed weekly. The record documentation by the aide from 7/1/22 to current that shave was performed at every visit (Aide visit frequency was 3x/week).

Upon client record review, 3 of 6 applicable (Patients #3,#5,#15) 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 #3: The visit frequency for the skilled nurse was 2x/week. The record indicated that only 1 visit was made each week from admission to current. Patient #5: The skilled nurse visit frequency was 2x/week. For the weeks of 7/3/22-7/9/22 and 7/17/22-7/23/22, the record indicated only 1 visit each of these weeks. Corrected on site. Patient #15: The record indicated that the skilled nurse conducted video visits on 1/21/22 and 2/3/22. There was not evidence that telehealth was included in the plan of care.