Every finding on record at Odyssey Healthcare Operating A, LP

Upon observation, on 2 of 4 home visits (Patient #6, #12) there was not evidence that the patient has the right: • To exercise his or her rights as a patient of the hospice to identify visiting personnel through agency generated photo IDs Patient #6-The Chaplain visiting the patient did not have a name badge. Patient #12-The MSW visiting the patient had an agency name badge; however it did not include a photo ID.

Upon patient record review, 3 of 19 (Patient #4, #8, #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 #4-The medication profile includes the following duplicative orders for medications to be administered for pain without differentiation for administration: Acetaminophen 325mg q6h po prn pain; Acetaminophen 650 mg suppository 1 q6h po prn pain and Morphine 100 mg/5ml (20 mg/ml ) .25 ml q4h prn pain. The profile also does not include the maximal allowable daily dosage of Acetaminophen. (corrected on site) Patient #8-The medication profile includes Zithromax Z-Pak 250 mg 1 tab as directed for bronchitis (frequency is missing). (corrected on site) Patient #12-The medication profile includes Azithromycin 1 gm oral packet. Dosage is listed as "per instructions". Frequency is listed as directed on package. On 12/04/23 Medrol 4mg tablets in a dose pack per instructions was added to the medication profile. Follow instruction on med pack giving tabs as directed for 5 day period. (dosage/instructions were not specified in the profile)

Upon patient record review, 2 of 19 (Patient #1, #11) 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 the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs Patient #1-Orders for Aide services scope and frequency were not included in the plan of care. Patient #11-Effective 11/16/23 the Chaplain frequency is ordered as 2 prn for spiritual support. (prn can not be a stand alone frequency).

Upon patient record review, 4 of 19 (Patient #4, #5, #8, #12) 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 #4-The 11/20/23 plan of care includes the following duplicative orders for medications to be administered for pain without differentiation for administration: Acetaminophen 325mg q6h po prn pain; Acetaminophen 650 mg suppository 1 q6h po prn pain and Morphine 100 mg/5ml (20 mg/ml ) .25 ml q4h prn pain. The plan of care also does not include the maximal allowable daily dosage of Acetaminophen. (corrected on site) Patient #5- The 12/05/23 plan of care includes orders for the nurse to assess the catheter site for s/sx of skin breakdown, infection and patency. The plan of care does not include the specific type of catheter, size, balloon size and frequency of changes. (corrected on site) Patient #8-The plan of care includes Zithromax Z-Pak 250 mg 1 tab as directed for bronchitis (frequency is missing). The patient was admitted on 10/24/23 with a Foley catheter. The plan of care does not include orders for management of the Foley. Patient #12-The 01/10/24 plan of care includes Azithromycin 1 gm oral packet. Dosage is listed as "per instructions". Frequency is listed as directed on package.

Upon patient record review, 5 of 19 (Patient #1, #3, #5, #8, #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-On 12/01/23 the Chaplain is ordered to visit monthly for one month. The chaplain visited twice in December on 12/04/23 and 12/28/23. Patient #3- On 12/23/23 the Chaplain is ordered to visit 2m1 (twice monthly for one month). The Chaplain visited once in December on 12/28/23. Patient #5- On 12/05/23 the Chaplain is ordered to visit 1m3 (once monthly) The Chaplain visited twice in December o 12/07/23 and 12/28/23. On 12/05/23 the Social worker is ordered to visit 1m1(once monthly). The Social Worker visited twice in December on 12/06/23 and 12/27/23. On 12/6/23 the nurse documented changing the patients Foley catheter and the record does not contain orders for catheter changes. Patient #8- On 10/26/23 the Chaplain is ordered to visit 2m2 (twice monthly for two months). The Chaplain visited monthly on 10/26/23 and 11/16/23. On 10/27/23 the Social Worker is ordered to visit 2m2(twice monthly for two months). The Social worker visited monthly on 10/27/23 and 11/30/23. On 10/29/23 the nurse documented removing the patients Foley at the request of the wife. The record does not contain orders to remove the Foley. Patient #11- Effective 12/01/23 the Social worker was ordered to visit 3m1(three times monthly for one month). The Social worker visited three times weekly between 12/01/23 and 12/28/23.

Upon patient record review, 3 of 19 (Patient #1, #3, #13) did not have evidence in the patient record that hospice aide assignments and duties are: • Complete Written patient care instructions for a hospice aide prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 Patient #1- The Aide Care Plan does not include Oxygen Precautions or Aspiration Precautions which were identified safety measures and applicable to the Aide Plan of Care. (corrected on site) Patient #3-The RN assigned the Aide to perform a bed bath and shower on each visit(not specific). The Aide Care Plan does not include Oxygen Precautions, Fall Precautions, or skin breakdown precautions which were identified safety measures and applicable to the Aide Plan of Care. (corrected on site) Patient #13-The Aide Care Plan assigns the Aide to perform a bed bath and shower on each visit(not specific).

Upon patient record review 2 of 19 (Patient #4, #6) did not 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 #4-Between 11/21/23 and 12/26/23 an aide supervisory visit is not on record. Patient #6-Between 11/28/23 and 12/27/23 an aide supervisory visit is not on record.

Upon personnel record review, 1 of 13 (Personnel # 2) did not have evidence the alternate administrator's personnel record includes: • A signed job description for this role Personnel #2-The individual is designated as the Alternate Administrator. The only job description on record is for an RN.

Upon patient record review, 5 of 19 (Patient #1, #3, #4, #8, #13) did not have evidence that each patient record contains Advance Directives. Patient #1, #3, #4, #8, #13-The records indicate the patients have a DNR. A copy of the DNR paperwork is not attached in the record and the records do not contain documentation that a copy was requested. (corrected on site)

Upon patient record review, 3 of 19 (patient #6, #8, #10) did not evidence all entries are accurate, clear and complete. Patient #6- On 12/19/23 the nurse documents the patient is on Oxygen as needed and education was provided on Oxygen safety. Upon interview with patient on home visit 01/10/24 the patient does not have Oxygen. Patient #8-On 10/29/23 the nurse documents administering a suppository. The documentation is not specific for the name and dosage of suppository administered. Patient #10- On 10/28/23, 10/29/23, and 11/13/23 the nurse documents administering Morphine during the visit. The documentation is not specific for the dosage of Morphine administered.

Upon personnel record review, 1 of 13 (Personnel #13) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #13-A professional license was not provided for the contracted SLP who would be available to provide patient care if requested.

Upon personnel record review, 1 of 13 (Personnel #12) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #12-A professional license was not provided for the contracted OT who would be available to provide patient care if requested.

Upon personnel record review, 1 of 13 (Personnel # 11) did not have evidence all Physical Therapy Services are provided by a qualified licensed Physical Therapist (PT) in accordance with the state's Physical Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #11-A professional license was not provided for the contracted PT who would be available to provide patient care if requested.

Upon personnel record review, 3 of 13 (Personnel #11, #12, #13 ) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel #11, #12, #13-Background checks were not provided for the contracted PT/OT/SLP individuals who would be available to provide patient care if requested.