Every finding on record at Odyssey Healthcare Operating A, LP

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. The agency did not provide any emergency plan exercises or events.

Upon patient record review 1 of 19 (Patient #7) 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 7: The initial spiritual assessment was completed 3/4/25 with start of care 2/24/25.

Upon patient record review, 2 of 19 (Patients #4,#9) 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 4: Upon observation during the home visit, the facility medication list has immodium 1 tab as needed instead of instructions to take 2 tabs with first loose stool and then 1 tab with subsequent loose stools; potassium chloride ER 20meq instead of 10meq; and facility list has aspercreme lidocaine that is not on the hospice medication profile. Corrected on site. Patient 9: Upon observation during the home visit, the facility medication list does not have dulcolax suppository that is on the hospice medication profile; and facility list contains milk of magnesia and eye multivitamin that is not on the hospice medication profile. Corrected on site.

Upon patient record review, 1 of 19 (Patient #11) 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 11: The initial bereavement assessment was completed 6/16/24 with a start of care 6/8/24.

Upon patient record review, 1 of 19 (Patient #4) did not have evidence that the hospice follows the individualized plan of care developed in in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire. Patient 4: There was no evidence of collaboration with the attending to develop the plan of care.

Upon patient record review, 2 of 19 (Patients #1,#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 since admission identifying the patient had dysphagia and a risk for aspiration. There was no evidence of problems, goals, and interventions related to dysphagia included in the plan of care. The plan of care identified the patient advanced directives for no mechanical ventilation. The medical record also contained a POLST with code status of DNR that was not reflected on the plan of care. Corrected on site. Patient 6: The plan of care identified patient as DNR, however the medical record had an updated POLST identifying Full Code status. Corrected on site.

Upon patient record review, 1 of 19 (Patient #1) 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 contained nursing documentation upon admission identifying patient use of a hospital bed, over bed table, and walker; and 12/30/24 identifying bedrails. There was no evidence of orders for the DME included in the plan of care. Corrected on site.

Upon patient record review, 4 of 19 (Patients #3,#4,#9,#11) 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 3,4,9,11: There was no evidence of IDG collaboration with the attending physician no less frequently then every 15 days

Upon patient record review, 1 of 19 (Patient #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5: The medical record contained an order for social work visits once monthly. There was no evidence of a visit in February 2025.

Upon patient record review, 3 of 19 (Patients #15,#16,#17) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 15,17: There was no evidence the bereavement care plan tasks of support group offered or resources given, memorial service invitation, and holiday letters sent. Patient 16: There was no evidence the bereavement care plan tasks of 2 week condolence cards, support group offered or resources given, memorial service invitation, and holiday letters sent.

Upon patient record review, 1 of 19 (Patient #3) 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 3: The aide care plan contained bathing task of shower every visit and tub bath every visit. The medical record also contained orders for a Hoyer lift but the aide care plan did not have instructions for transfer assistance needed. Corrected on site.

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's volunteer utilization rate was 0.07% for 2024.

Upon personnel record review, 1 of 15 (Personnel #2) did not have evidence the alternate administrator's personnel record verifies that: • There is a signed job description for this role • The employee has been orientated to this role Personnel 2: There was no evidence of a signed job description as alternate administrator.

Upon personnel record review, 2 of 15 (Personnel #2,#10) 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 role as DPCS and alternate administrator. Personnel 10: There was no evidence of orientation to job role as Volunteer Coordinator.

Upon personnel record review, 1 of 15 (Personnel #11) 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 11: There was no evidence of a skills competency in the personnel file.

Upon patient record review, 1 of 19 (Patient #9) 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 9: The patient representative elected to receive the Notification of Hospice Non-Covered Items upon admission 10/30/24. The addendum was not issued until 11/8/24.

Upon patient record review, 2 of 19 (Patients #2,#9) did not have evidence that each patient record contains Advance Directives. Patient 2,9: The plan of care identified the patient as DNR. There was no documentation to support code status.

Upon patient record review, 1 of 19 (Patient #19) did not evidence that each patient record contains physician orders. Patient 19: There was no evidence of a physician order to discharge the patient due to extended prognosis.

Upon patient record review, 2 of 19 (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 12/30/24 of an aide supervisory note. The patient was not receiving aide services. Patient 8: The medical record contained inaccurate orders for oxygen equipment. After agency investigation, the patient has never needed oxygen.

Upon personnel record review, 1 of 15 (Personnel #7) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at renewal or in accordance with specific state practice act requirements. Personnel 7: There was no evidence of current professional licensure. LCSW expired 2/28/25.

Upon personnel record review, 1 of 15 (Personnel #11) 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 11: There was no evidence of a criminal background check.

Upon patient record review 2 of 11 records (Patients #4,#6) 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: The medical record contained a spiritual assessment 2-17-22. Patient admitted to hospice services 2-2-22. Patient 6: The medical record contained a spiritual assessment 9-17-19. Patient admitted to hospice services 7-17-19.

Upon patient record review 1 of 11 (Patient #11) 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 11: There was no evidence of a spiritual assessment as part of the comprehensive assessment.

Upon patient record review, 2 of 11 records (Patients #6,#9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 6: The medication list contained topical antifungal powder with no defined area for administration. Corrected on site. Patient 9: The medication list contained oxygen with no delivery method. The order identified nasal cannula as delivery method. The medication list also contained levsin scheduled every 6 hours. The order's verbal description stated levsin was to be every 6 hours as needed.

Upon patient record review, 3 of 11 records (Patients #5,#6,#7) 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 5: The medical record contained a bereavement assessment completed 3-16-22. Patient admitted to hospice services 1-4-22. Patient 6: The medical record contained a bereavement assessment completed 11-20-20. Patient admitted to hospice services 7-17-19. Patient 7: The patient admitted to hospice services 1-20-22. There was no evidence of an initial bereavement assessment completed.

Upon patient record review, 4 of 11 records (Patients #3,#4,#5,#8) 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 3-19-22 and 3-24-22 identifying problem of constipation requiring assistance for removal of stool. There was no evidence of problems, goals, and interventions related to altered gastrointestinal system and constipation included on the plan of care. Corrected on site. Patient 4: The plan of care included social work problems of coping, companionship and personal affairs. There was no evidence of goals and interventions related to listed problems included on the plan of care. Corrected on site. Patient 5: The plan of care included chaplain problem of declining status. There was no evidence of goals and interventions related to the problem included on the plan of care. The chaplain also listed problem identifying no further visits were required after admission. There was no evidence of an end date or removal of the problem from the plan of care. Patient 8: The medical record contained nursing documentation upon admission identifying patient diagnosis of dysphagia and J-tube for feeding. There was no evidence of problems, goals, and interventions related to dysphagia and feeding tube.

Upon patient record review, 1 of 11 records (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 medications and treatments. Patient 6: The medical record contained an order for Remedy antifungal topical powder with no defined area for administration. Corrected on site.

Upon patient record review, 5 of 11 records (Patients #3,#7,#8,#9,#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 equipment and supply needs. Patient 3: The medication list included nebulized duoneb. There was no evidence of the nebulizer included as DME on the plan of care. Corrected on site. Patient 7: The medical record contained nursing documentation 2-28-22 identifying patient use of a hospital bed. There was no evidence of the bed included as DME on the plan of care. Patient 8: The medication list contained oxygen. There was no evidence of the oxygen included as DME on the plan of care. Patient 9: The medication list contained oxygen. There was no evidence of the oxygen included as DME on the plan of care. Patient 11: The medical record contained nursing documentation 3-1-22 identifying nurse ordered a hospital bed to be delivered. There was no evidence of the bed included as DME on the plan of care.

Upon patient client record review, 1 of 11 records (Patient #4) did not have evidence that each patient record contains a signed election statement in accordance with 418.24. Patient 4: The medical record contained an election of benefit form electing to receive the notification of non-covered hospice services upon admission 2-2-22. The signature dated on the notification was 2-22-22, outside the allowable time frame of five days.

Upon patient client record review, 1 of 11 (Patient #8) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 8: There was no evidence that certification of terminal illness was received from the attending physician.

Upon client record review, 2 of 3 applicable (Patient #2, #5) 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 2: The plan of care contained social worker visit frequency stating 1Q2M2. The patient was being seen by the social worker once monthly. Corrected on site. Patient 5: The plan of care contained social worker and spiritual care visit frequencies stating 1Q2M2. The patient was being seen by the social worker and chaplain once monthly. Corrected on site.

Upon patient record review, 2 of 3 applicable (Patients #2,#5) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient Patients 2 and 5: Upon home visit reviews, there was no evidence of updated plans of care in the hospice binder at the nursing homes. Each patient binder contained the initial POC with no updated POC.

Upon personnel record review, 1 of 1 applicable file (Personnel #12) 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. The hospice agency was unable to obtain a personnel file for a SLP from the contracted agency.

Upon personnel record review, 1 of 4 applicable personnel files (Personnel #12) 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. The agency was unable to obtain a personnel file for a speech therapist from the contracted company.