Every finding on record at Odyssey Healthcare Operating A, LP

Upon patient record review, 3 of 14 (Patients #2,#8,#9) 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 2,9: There was no evidence hospice provided information to the patient or responsible party regarding policies on advance directives. Patient 8: The receipt of policies on advance directives was signed and dated 5/2/25. Patient admitted to hospice 3/3/25.

Upon patient record review, 4 of 14 (Patients #2,#8,#9,#10) 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. Patient 2: There was no evidence the hospice obtained the patient's or responsible party's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Corrected on site with receipt of Patient's Rights and Responsibilities signed and dated 7/17/25/25. Patient admitted 2/13/25. Patient 9,10: There was no evidence the hospice obtained the patient's or responsible party's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient 8: The receipt of Patient's Rights and Responsibilities was signed and dated 5/2/25. Patient admitted to hospice 3/3/25.

Upon patient record review, 3 of 14 (Patients #2,#8,#9) did not have evidence of the appropriate documentation for release of confidential information. Patient 2: There was no evidence the agency received documentation for release of confidential information. Corrected on site with form signed 7/16/25. Patient admitted 2/13/25. Patient 8: The receipt of authorization to release confidential information was signed and dated 5/2/25. Patient admitted to hospice 3/3/25. Patient 9: There was no evidence the agency received documentation for release of confidential information.

Upon patient record review 1 of 14 (Patient #1) 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 1: The initial spiritual assessment was completed 1/20/25 with start of care 11/18/24.

Upon patient record review 1 of 14 (Patient #6) 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 6: There was no evidence of a spiritual assessment.

Upon patient record review, 3 of 14 (Patients #2,#6,#8) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 2: During home visit medication reconciliation, the board and care facility had an order for scheduled spironolactone that was not on the hospice medication profile. The hospice also had scheduled bupropion, vitamin B12, isosorbide mononitrate and tamsulosin; and as needed loperamide and ondansetron that were not being administered by the facility. Patient 6: During home visit medication reconciliation, the patient had a bottle of Haldol to be administered as needed. There was no evidence of Haldol on the medication profile. Patient 8: The medication profile contained pregabalin listed twice with same dose and frequency. The medical record also contained nursing documentation identifying patient use of oxygen since admission. There was no evidence of oxygen on the medication profile. Corrected on site with removal of one pregabalin listing and addition of oxygen to medication profile.

Upon patient record review, 3 of 14 (Patients #1,#3,#10) 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 1: The medical record contained nursing documentation identifying patient wound on left buttock since at least 5/23/25. There was no evidence of wound measurements from 5/23/25 to 6/24/25. Agency policy requires weekly wound assessments and measurements. Patient 3: There was no evidence of coccyx wound measurements since 7/1/25. Agency policy requires weekly wound assessments and measurements. Patient 10: The medical record contained orders for right heel wound care since 6/26/25. There was no evidence of wound assessments and measurements. Agency policy requires weekly wound assessments and measurements.

Upon patient record review, 4 of 14 (Patients #2,#5,#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 medications and treatments. Patient 2: The medical record contained an order 6/13/25 that only stated Foley. There were no instructions to insert catheter or identify size, change frequency, or maintenance of the catheter. Corrected on site with clarification order that the patient does not have a catheter. Upon home visit medication reconciliation, the board and care facility contained an order for scheduled spironolactone that was being administered. There was no evidence of hospice having an order for spironolactone. Patient 5: The medical record contained an order 7/10/25 that only stated continue to monitor. There were no instructions to identify what was being monitored. Corrected on site with clarification order to monitor right neck and chin wounds. Patient 6: During home visit medication reconciliation, the patient had a bottle of Haldol to be administered as needed. There was no evidence of an order for Haldol in the medical record. Patient 8: The medical record also contained nursing documentation identifying patient use of oxygen since admission. There was no evidence of an order for oxygen. Corrected on site with order received.

Upon patient record review, 1 of 14 (Patient #6) 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 6/4/25 identifying patient use of a walker for ambulation. There was no evidence of an order for the walker included in the plan of care. Corrected on site with order received.

Upon patient record review, 1 of 14 (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 medical record contained a POLST identifying patient is DNR code status signed 1/6/24. There was no evidence the plan of care was updated to identify the patient as DNR.

Upon client record review, 5 of 14 (Patients #1,#2,#3,#5,#10) 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 an order for spiritual care visits once monthly. There was no evidence of visits completed in May and June. Patient 2: The medical record contained volunteer visits 6/4/25, 6/13/25, 6/18/25, and 6/26/25. There was no evidence of an order or care planning for volunteer visits. Patient 3: The medical record contained orders since 7/1/25 for coccyx wound care to be completed by hospice nurse every visit. There was no evidence of wound care completed since 7/1/25 with visits made 7/2/25, 7/8/25, and 7/10/25. Patient 5: The medical record contained an order for nursing visits twice weekly. There was no evidence of a second visit completed the week of 7/6/25. Missed frequency for week of 7/6/25 was corrected on site with coordination note entered to explain missed visit on 7/8/25. Patient 10: The medical record contained an order for volunteer visits weekly. There was no evidence of visits completed the weeks of 6/29/25 and 7/6/25. Corrected on site with clarification order entered that patient requested discontinuation of volunteer visits 6/29/25.

Upon patient record review, 1 of 14 (Patient #8) did not have evidence in the patient record that hospice aide assignments and duties are specific to the patient needs. Patient 8: The medical record contained nursing documentation 6/1/25 and 6/24/25 identifying patient as a max assist for transfers. The aide care plan did not include instructions for assistance with transfers and contained a task for showering the patient. Corrected on site with instructions for transfer assist added to aide care plan.

Upon patient record review 2 of 14 (Patients #6,#10) 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 6: The medical record contained aide visits once weekly. There was no evidence of supervision by the RN from 5/28/25 to 6/18/25. Patient 10: The medical record contained aide visits three times weekly. There was no evidence of supervision by the RN from 6/19/25 to 7/10/25.

Upon patient client record review, 4 of 14 (Patients #2,#8,#9,#10) 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 2,9,10: There was no evidence the hospice obtained the patient's or responsible party's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient 8: The receipt of Patient's Rights and Responsibilities was signed and dated 5/2/25. Patient admitted to hospice 3/3/25.

Upon patient client record review, 3 of 14 (Patients #8,#10,#11) did not have evidence that each patient record contains Advance Directives. Patients 8,10,11: The plan of care identified the patient as DNR. There was no supporting evidence such as a POLST or living will to indicate this was an advance directive chosen by the patient or responsible party.

Upon patient client record review, 2 of 14 (Patients #1,#8) 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 1: The medical record contained nursing documentation upon recertification assessment 5/2/25 identifying patient use of a low air loss mattress. After agency investigation, the patient was found to not have a mattress and the documentation was in error. Corrected on site with clarification note entered into the record. Patient 8: The medical record contained nursing documentation 5/23/25 identifying patient use of a walker for ambulation. After agency investigation, the patient was found to not have a walker and the documentation was in error. Corrected on site with clarification note entered into the record.

Upon client record review, 3 of 14 (Patients #2,#8,#9) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient 2: There was no evidence the patient receiving information on managing controlled drugs. The patient has had a morphine order since 2/14/25. Corrected on site with form completed to show evidence policies provided. Patient 8: There was no evidence the patient receiving information on managing controlled drugs. The patient has had a morphine order since 3/11/25. Patient 9: There was no evidence the patient receiving information on managing controlled drugs. The patient has had a morphine order since 6/4/25 and Ativan order since 5/8/25.

Upon personnel record review, 2 of 15 (Personnel #13,#15) did not have evidence the hospice obtained a criminal background check results on all contracted individuals who have direct patient care and access to patient records.

Upon personnel record review, 1 of 15 (Personnel #5) 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.

Upon patient record review, 5 of 13 (Patients #1,#3,#8,#9,#12) 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 medical record contains nursing documentation 7/24/22 identifying children's Robitussin ordered was unavailable and MD authorized substitution for Robitussin DM. The medication profile contained the children's Robitussin, not the DM. Corrected on site. Patient 3: The medication profile contains a lidocaine topical patch with no area defined for administration. Corrected on site. Patient 8: The medication profile contains oxygen with no defined delivery method. Corrected on site. Patient 9: The medication profile contains duplicative listings of fleet enemas, miralax, and senna. Instructions for enemas and senna are identical and the difference for miralax is 7/20/22 contained instructions for a diluent and 7/21/22 does not. Corrected on site. Patient 12: The medication profile contained calmoseptine topical ointment with no area defined for administration.

Upon patient record review, 2 of 13 (Patients #7,#13) 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: The medical record contains an initial bereavement assessment completed 7/14/22 with patient admission date of 7/4/22. Patient 13: There was no evidence of a bereavement assessment. Patient was on service 2/9/22-7/5/22.

Upon patient record review, 4 of 13 (Patients #1,#2,#5,#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 contains nursing documentation upon admission identifying patient issues with severe pain and gastrointestinal bleed. There was no evidence of problems, goals, and interventions related to pain or gastrointestinal dysfunction included on the plan of care. Patient 2: The medical record contains nursing documentation upon admission identifying patient issues with dysphagia, cardiac, and neurological dysfunction. There was no evidence of problems, goals, and interventions related to dysphagia, cardiac, and neurological dysfunction included on the plan of care. Patient 5: The medical record contains nursing documentation upon admission identifying patient had a wound to coccyx and healing documented 6/13/22. There was no evidence of problems, goals, and interventions related to risk for skin impairment or history of care plan for skin impairment. There was also no evidence of the care plan reflecting the need for home health aide services. Corrected on site. Patient 6: The medical record contains nursing documentation upon admission identifying patient issue with dysphagia and recent aspiration pneumonia leading to admission. There was no evidence of problems, goals, and interventions related to dysphagia included on the plan of care.

Upon patient record review, 6 of 13 (Patients #1,#3,#4,#8,#9,#12) 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 contains nursing documentation 7/24/22 identifying children's Robitussin ordered was unavailable and MD authorized substitution for Robitussin DM. There was no evidence of an order for the Robitussin DM. Corrected on site. Patient 3: The medical record contains an order for a lidocaine topical patch with no area defined for administration. Corrected on site. Patient 4: The medical record contained an order to insert a 18Fr Foley catheter 5/18/22. The order did not contain instructions for balloon size and maintenance. Patient 8: The medical record contains an order for oxygen with no defined delivery method. Corrected on site. Patient 9: The medical record contains an order for miralax with no instructions for a diluent. Corrected on site. Patient 12: The medical record contained an order for calmoseptine topical ointment with no defined area for administration.

Upon patient record review, 4 of 13 (Patients #1,#9,#11,#12) 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 1: The medical record contains nursing documentation upon admission identifying patient use of commode. There was no evidence of the commode included as DME on the plan of care. Corrected on site. Patient 9: The medical record contains nursing documentation upon admission identifying patient use of walker, There was no evidence of the walker included as DME on the plan of care. Corrected on site. Patient 11: The medical record contains nursing documentation upon admission identifying patient use of walker. There was no evidence of the walker included as DME on the plan of care. Patient 12: The medical record contains nursing documentation 5/4/22 identifying patient use of a hoyer lift for transfers. There was no evidence of the lift included as DME on the plan of care.

Upon client record review, 4 of 13 (Patients #1,#2,#4,#8) 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 an order for the social worker once the first week of service. Social worker documentation stated patient requested for call the following week to schedule. There was no evidence of further communication with the patient or any social work visits completed. Patient 2: The medical record contained an order for nursing frequency of once weekly. There was no evidence of a visit completed the week of 6/12/22. Patient 4: The medical record contained nursing documentation 5/10/22 and 5/20/22 identifying the nurses removed the foley catheters. There was no evidence of orders to remove the catheters. Patient 8: The medical record contained an ordered nursing frequency of once weekly. There was no evidence of a visit completed the week of 7/24/22 at time of chart review 8/3/22. Corrected on site with late entry of visit documented 8/4/22.

Upon patient record review, 2 of 10 applicable (Patients #1,#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 1: The aide care plan contains task to change linens if patient requests. Corrected on site. Patient 2: The medical record contained an order for two aides to be required for completion of each aide visit. There was no evidence of the need for second aide included in instruction on the aide care plan. Corrected on site.

Upon patient record review 6 of 10 applicable (Patients #1,#2,#3,#4,#6,#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 1: The medical record contains an ordered aide frequency of three times weekly until 7/8/22 and frequency was reduced to two times weekly. There was no evidence of any aide visits completed the week of 6/23/22 and one missed visit but no completed visits the week of 7/10/22. Patient 2: The medical record contains an ordered aide frequency of twice weekly. There was no evidence of a second visit completed the week of 7/10/22. Patient 3: The medical record contains an ordered aide frequency from start of care 5/9/22 as one time week one, then twice weekly. There was no evidence of any visits completed until 6/20/22. After leadership investigation, patient was refusing aide visits initially and care plan was not updated to reflected refusal and change frequency. Corrected on site with late entry order. Patient 4: The medical record contains an ordered aide frequency from start of care 5/9/22 as one time week one, then twice weekly. There was no evidence of second visits completed the weeks of 7/10/22 and 7/17/22. Patient 6: The medical record contains an ordered aide frequency of twice weekly. There was no evidence of a second visit completed the week of 6/19/22. Patient 13: The medical record contained an ordered aide frequency of twice weekly. There was no evidence of a second visit completed the week of 5/22/22.

Upon patient client record review, 1 of 13 (Patient #5) 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 5: The medical record contains an election of benefit form and consents signed by a patient representative. There was no evidence of a defined relationship to the patient documented on the forms. The date of election was also left blank on the election of benefit form, however the date forms signed reflected the start of care date.

Upon patient client record review, 1 of 13 (Patient #12) did not evidence that each patient record contains physician orders. Patient 12: There was no evidence of an order to discharge patient due to extended prognosis as required by agency discharge policy.

Upon patient client record review, 1 of 13 (Patient #2) 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 2: The medical record contains nursing documentation upon admission identifying nurse received an order approving crushing medication. There is no evidence of instructions for crushing on the medication profile or an order to crush medication. After leadership investigation, it was confirmed that admission documentation was in error and patient is able to swallow medication without issue. Corrected on site with late order clarification.