Every finding on record at Odyssey Healthcare Operating A, LP

Upon patient record review, 1 of 5 (Patient #4) 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 SN documented on 8/15/25 that the spouse has been using barrier cream once daily. The POC has "barrier cream" listed in the supply items and the nursing goals have "Apply barrier cream" but there is no order for any specific barrier cream on the POC (ie: Calmoseptine, A&D ointment,Zinc). Barrier cream being mentioned by SN being used at each visit. Corrected on site, order added for Remedy Zinc Cream.

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years.

Upon patient record review, 3 of 14 (Patients #3,#5,#8) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patients 3,5,8: There was no evidence the patient or responsible party was provided written information regarding policies on advance directives.

Upon patient record review, 3 of 14 (Patients #3,#5,#8) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patients 3,5,8: There was no evidence the patient or responsible party received a copy of the Patient's Rights and Responsibilities.

Upon patient record review, 1 of 14 (Patient #8) did not have evidence of the appropriate documentation for release of confidential information.

Upon patient record review 1 of 14 (Patient #2) 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 2: The medical record contained an initial spiritual assessment 4/16/25 with start of care 4/7/25.

Upon patient record review, 1 of 14 (Patient #1) 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 1: The medication profile contained two continuous oxygen orders. One for 2 liters per minute continuously overnight and one for 3 liters per minute continuous. There were no instructions to indicate both were current orders or if one was outdated. Corrected on site with new order clarifications and removal of outdated oxygen from medication profile.

Condition of participation: Interdisciplinary group, care planning, and coordination of services

Upon patient record review, 3 of 14 (Patients #1,#2,#6) 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: The medical record contained nursing documentation upon admission identifying patient is a high risk for falls. There was no evidence of problems, goals, and interventions related to fall safety included in the plan of care. Corrected on site with update to plan of care. Patient 2: The medical record contained nursing documentation upon admission identifying the patient is a high risk for falls and has a suprapubic catheter. There was no evidence of problems, goals, and interventions related to fall safety included in the plan of care. The plan of care also included inappropriate interventions for an external catheter. Corrected on site with update to plan of care. Patient 6: The medical record contained nursing documentation upon admission identifying patient use of a condom catheter. There was no evidence of problems, goals, and interventions related to catheter use included in the plan of care. Corrected on site with update to plan of care.

Upon patient record review, 2 of 14 (Patients #1,#9) 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: The medical record contained two orders for continuous oxygen without instructions if one was to be discontinued or if they were both accurate for different times of the day. Corrected on site with order clarification. Patient 9: The medical record contained nursing documentation upon admission identifying patient has a suprapubic catheter. There was no evidence of orders for the catheter type, size, change frequency, and maintenance. Corrected on site with order received.

Upon patient record review, 2 of 14 (Patients #6,#8) 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 6: The medical record contained nursing documentation upon admission identifying patient use of bedrails and a trapeze. 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 6/10/25 identifying patient use of a wheelchair. There was no evidence of an order for the chair included in the plan of care. Corrected on site with order received.

Upon patient record review, 1 of 14 (Patient #7) 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 7: The medical record contained an order 6/9/25 identifying patient need for nectar thick liquids. There was no evidence the plan of care was updated to include problems, goals, and interventions related to the diet modification. Corrected on site with update to plan of care.

Upon client record review, 1 of 14 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: The medical record contained documentation of volunteer visits completed 6/17/25, 6/24/25, and 6/26/25. There was no evidence of orders for volunteers included in the plan of care.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient 7: The medical record contained an order 6/16/25 for an X-ray of the right hip. There was no evidence of follow up on results.

Upon observation, there was no evidence a written plan of correction is developed in response to any QAPI activity that does not meet an acceptable threshold.

Upon observation, there was no evidence the hospice documents what QAPI projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence the hospice provided spiritual counseling in accordance to patient and family desires. Patient 1: The medical record contained documentation by the spiritual care provider 5/29/25, identifying the patient's daughter requested the chaplain to facilitate provision of communion from a Catholic priest regularly. There was no evidence of follow up on this request.

Upon observation, there was no evidence in-service training for Hospice Aides are supervised by a Registered Nurse.

Upon observation, there was no evidence the hospice must maintain a written description of the in-service training provided during the previous 12 months.

Upon patient record review, 1 of 14 (Patient #2) 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 2: The medical record contained nursing documentation starting 6/27/25 identifying patient was unable to assist with a pivot transfer and became assist of 2 for transfers 7/2/25. The aide care plan did not contain any instructions for transfer assistance needed.

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 0.67% for 2024.

Upon personnel record review, 1 of 16 (Personnel #2) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel 2: There was no evidence of orientation to job specific requirements.

Upon personnel record review, 1 of 16 (Personnel #10) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel 10: There was no evidence of skills competency completion.

Upon patient client record review, 4 of 14 (Patient #1,3,5,8) 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 1: The election form identified the patient's responsible party elected to receive the Notification of Hospice Non-Covered Items. There was no evidence information was provided. Patients 3,5,8: There was no evidence the patient or responsible party was provided written information regarding Patient's Rights and Responsibilities.

Upon patient client record review, 6 of 14 (Patients #2,#4,#8,#9,#11,#12) did not have evidence that each patient record contains Advance Directives. Patient 2,8,9,11,12: The plan of care identified the patient as DNR. There was no evidence a living will, POLST or other supporting evidence to indicate patient or responsible party choice of DNR status. Patient 4: The plan of care identified the patient as DNR. There was no evidence a living will, POLST or other supporting evidence to indicate patient or responsible party choice of DNR status. The notification of advance directives form from admission also identified the patient has a POA. There was no evidence of legal POA documentation.

Upon patient client record review, 1 of 14 (Patient #14) did not evidence that each patient record contains physician orders. Patient 14: There was no evidence of an order to discharge the patient for extended prognosis.

Upon client record review, 1 of 14 (Patient #5) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient 5: There was no evidence the patient or responsible party received written policies for managing controlled drugs. Patient is on Haldol and Ativan.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Hospice medication information specific to each patient Patient 7: There was no evidence of CTIs at the facility and no plan of care updates since December 2024.

Upon personnel record review, 1 of 16 (Personnel #7) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel 7: There was no evidence of background check completion.

Upon patient record review 1 of 5 (Patient #4) 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 #4 - SOC 08/25/2022; MSW assessment visit 09/01/2022.

Upon patient record review, 1 of 5 (Patient #5) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component completed within 5 days of the election of hospice. Patient #5 - SOC 08/05/2022 - no evidence of initial bereavement assessment as of 09/02/2022.

Upon patient record review, 1 of 13 records (Patient #4) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient 4: There was no evidence of policies on advance directives having been received.

Upon patient record review, 1 of 13 records (Patient #4) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities.

Upon patient record review, 1 of 13 records (Patient #4) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 4: There was no evidence of an election form and consents showing proof the patient was given the option to choose an attending physician.

Upon patient record review, 1 of 13 records (Patient #4) did not have evidence of the appropriate documentation for release of confidential information.

Upon patient record review, 1 of 13 records (Patient #4) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient 4: There was no evidence on the consents showing proof of services covered under hospice were received.

Upon patient record review, 1 of 13 records (Patient #4) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient 4: There was no evidence showing proof information about the scope of services was received.

Upon patient record review, 7 of 13 records (Patients #1, #4, #5, #8, #9, #10, #11) 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 duplicative norco, duplicative morphines with different doses and frequencies, both PRN, and oxygen with no delivery method. Corrected on site. Patient 4, 5, 8, 10, 11: The medication profile contained atropine with wrong route of ophthalmic instead of sublingual/oral. Patient : The medication profile contained duplicative ibuprofen, and duplicative morphine. Corrected on site. Patient 5: The medication profile contained morphine 20mg/ml stated 0.25ml dose with instructions stating 0.5 mg instead of 5 mg. Corrected on site. Patient 9: The medication profile contained duplicative lorazepam with 0.25 ml q6h prn and 0.5 ml q4h prn both for anxiety and agitation, and oxygen with no delivery method. Corrected on site. Patient 11: The medication profile contained diclofenac gel and lidocaine patch with no areas defined for administration, and oxygen with no delivery method

Upon patient record review, 1 of 13 records (Patients #9) 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 9: There was no evidence of nursing visits the weeks of 5/22/22, 5/29/22, 6/5/22, and 6/26/22- no evidence to demonstrate an update to the comprehensive assessment as required.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 1 of 13 records (Patients #9) 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 9: The medical record also contained a wound care order 5/22/22. There was no evidence wound was assessed per agency policy of once weekly.

Upon patient record review, 2 of 13 records (Patients #3, #9) 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 contained nursing documentation throughout assessments identifying patient risk of aspiration and need for pureed diet. There was no evidence of problems, goals, and interventions related to aspiration risk included on the plan of care. Corrected on site. Patient 9: The medical record contained a wound care order dated 5/22/22. There was no evidence of problems, goals, and interventions related to skin impairment included on the plan of care. Corrected on site.

Upon patient record review, 7 of 13 records (Patients #1, #4, #5, #8, #9, #10, #11) 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: The medical record contained an order for oxygen with no delivery method. Corrected on site. Patient 4, 5, 8, 10, 11: The medical record contained an order for atropine with wrong route of ophthalmic instead of sublingual/oral for excessive secretions. Corrected on site. Patient 5: The medical record contained an order for morphine 20mg/ml stated 0.25ml dose with instructions 0.5 mg instead of 5 mg. Corrected on site. Patient 8: The medical record contained an order oxygen with no delivery method. Corrected on site. Patient 9: The medical record contained an order for oxygen with no delivery method. Corrected on site. Patient 11: The medical record contained an order for diclofenac gel and lidocaine patch with no area defined for administration, and an order for oxygen with no delivery method.

Upon patient record review, 2 of 13 records (Patients #6, #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 equipment and supply needs. Patient 6: Upon observation during home visit, patient use of oxygen, a hospital bed, and bedside table was witnessed. There was no evidence of the oxygen supplies, bed, and table included as DME on the plan of care. Corrected on site. Patient 7: The medical record contained nursing documentation upon admission identifying patient use of wheelchair and social worker documentation 5/22/22 identifying use of hospital bed. There was no evidence of the wheelchair and bed included as DME on the plan of care. Corrected on site.

Upon patient record review, 4 of 13 records (Patients #8, #9, #11, #12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 8: The medical record contained an order for nursing frequency of twice weekly. There was no evidence of nursing visits the weeks of 6/5/22 and 6/12/22. Patient 9: The medical record contained an order for nursing frequency of once weekly. There was no evidence of nursing visits completed the weeks of 5/22/22, 5/29/22, 6/5/22, 6/12/22, and 6/26/22. Patient 11: The medical record contains nursing documentation 12/21/21 identifying oxygen administered at 10 LPM. The order for oxygen had dose of 2 LPM. Patient 12: The medical record contained an order for nursing frequency of once weekly. There was no evidence of visits the weeks of 5/15/22 and 5/22/22.

Upon patient record review 1 of 10 applicable (Patient #10) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the interdisciplinary group Patient 10: The medical record contained an ordered aide frequency of twice weekly. There was no evidence of a second visit completed the week of 7/3/22.

Upon patient record review, 1 of 13 records (Patient #4) 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 4: There was no evidence of a signed election statement or evidence showing receipt of patient rights.

Upon patient record review, 2 of 13 records (Patient #3, #12) 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 3: The medical record contained repetitive nursing documentation 6/1/22, 6/3/22, 6/7/22, 6/10/22, 6/14/22, and 7/8/22 stating patient "able at a cup cake and drink ensure and m8lk during lunch, fefused breakfast, she lo9k thin, chachatic". Patient 12: There was no evidence of an order to discharge as required per discharge policy.

Upon patient record review, 2 of 2 applicable records (Patients #4,#5) 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 4: Upon observation during home visit, there was no evidence of a hospice election form, current medication list, or aide care plan included in the NF chart. Patient 5: Upon observation during home visit, there was no evidence of a hospice aide care plan included in the NF chart.

There was no evidence of vaccination status for the contracted Physical Therapist and Speech Language Pathologist.