Every finding on record at Odyssey Healthcare Operating A, LP

Upon patient record review, 1 of 19 (Patient #14) 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 14: Miralax 17G PRN as directed written on 07/23/2023. No evidence that a diluent was received or a frequency was provided in directions. Directions list to take if no BM in 3 days.

Upon patient record review, 3 of 19 (Patient #3,9,10) 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 3: Initial bereavement risk assessment late. Admitted on 10/06/2023, assessment completed on 10/18/2023. Patient 9: Initial bereavement risk assessment late. Admitted on 11/18/2023, assessment completed on 01/17/2024. Patient 10: Initial bereavement risk assessment late. Admitted on 05/09/2023, assessment completed on 06/05/2023.

Upon patient record review, 2 of 19 (Patient #1,4) 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 1: Patient identified as a risk for falls upon admit and ongoing via RN assessments. No evidence that risk for falls was added on current plan of care. Patient identified as a risk for aspiration on admission and ongoing via RN assessments. No evidence that risk for aspiration was added to current plan of care. Patient 4: Patient identified as a risk for falls upon admit and ongoing via RN assessments. No evidence that risk for falls was added on current plan of care.

Upon patient record review, 3 of 19 (Patient #1,6,14) 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 1: Patient had a wound on admit that was inactivated on 1/25/2024 on the wound care chapter. No evidence that wound care orders were removed from the plan of care. Wound care orders were active at the time during. Corrected during survey. Patient 6: Patient had a wound on admit that was inactivated on 1/09/2024 on the wound care chapter. No evidence that wound care orders were removed from the plan of care. Wound care orders were active at the time during. Corrected during survey. Patient 14: Miralax 17G PRN as directed written on 07/23/2023. No evidence that a diluent was included or a frequency was provided in directions. Directions list to take if no BM in 3 days.

Upon patient record review, 1 of 19 (Patient #5) 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 5: 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 #2,14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: Plan of care has volunteer frequency as 4 times monthly. No evidence that 4 visits occurred for the month of January. No missed visit note or other documentation present and No evidence of an order to change visits for that month or miss visit communications from the caregiver to refuse the visit. Patient 14: Plan of care has MSW frequency as one time a month. No evidence that a visit occurred for the month of January. No missed visit note or other documentation present and no evidence of an order to change visits for that month or miss visit communications from the caregiver to refuse the visit.

Upon patient record review, 1 of 19 (Patient #9) 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 9: Current plan of care orders has the aide to perform "leg and back massage" at every visit. Aide had not been trained on performing leg and back massages, leg and back massages are not a part of the agencies current competency evaluations.

Upon personnel record review, 1 of 14 (Personnel #2 ) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Personnel 2: No evidence that a signed job description for alternate administrator was obtained. Completed during survey.

Upon patient client record review, 1 of 19 (Patient #11) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 11: Elected to receive a notice of Hospice noncovered items, services, and drugs. No evidence that patient ever received the list of non-covered items.

Upon observation, there was no evidence that when the hospice provides durable medical equipment under contract, then the DMEPOS provider is accredited by a CMS approved accreditation organization.

Upon client record review, 3 of 19 (Patient #8,10,12) 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 8: Plan of care has chaplain frequency as once a month. No evidence that patient received a visit for the month of January. No evidence that an order was written to change frequency for the month of January or a missed visit documentation saying the patient or caregiver refused a visit. Patient 10: 11/01/23 missed visit note SW documented that she was not able to make visit due to being on PTO. No evidence that visit was missed at the request of the patient or the family. SW visit for 01/12 missed due to SW not being able to make visit time. No evidence that visit was missed at the request of the patient or the family. Patient 12: RN Missed visit note dated 1/08 for mostly blank. MD name nor was the 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, efforts made to avoid missed visits, nor was the visit date included.