Every finding on record at Odyssey Healthcare Operating A, LP

Upon patient record review, 1 of 20 (Patient #17) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient 17: The medical record contained nursing documentation 2/21/24 identifying patient had severe vomiting requiring a new order for Compazine suppositories. There was no evidence of follow up for effectiveness with coordination notes and no further visits made prior to the patient's death 2/23/24.

Upon patient record review, 6 of 20 (Patients #1,#3,#5,#8,#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. 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 listings for Humalog, listed with one set dose of 8 units three times daily and one sliding scale dose three times daily. Corrected on site. During the home visit medication reconciliation, the hospice medication profile did not include Benadryl and multivitamin listed on facility MAR; doses for paroxetine was 7.5mg per facility and 10 mg on hospice; and metoprolol was 25mg per facility and 100mg on hospice. Patient 3: The medication profile contained oxygen with no delivery method. Patient 5: The medication profile contained oxygen with no delivery method. Corrected on site. Patient 8: The medication profile contained Cipro listed as an active medication that was started 2/2/24 for 7 days; duplicative levetiracetam; and oxygen no delivery method. Corrected on site. Patient 10: The medical record contained nursing documentation identifying patient use of oxygen. There was no evidence of oxygen included on the medication profile. Corrected on site. Patient 11: The medication profile contained polyethylene glycol oral powder with no instructions to mix with a diluent. Corrected on site.

Upon patient record review, 3 of 20 (Patients #1,#5,#20) 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 1: There was no evidence of a comprehensive physical assessment by an RN from 8/23/24 to current 9/16/24. Patient 5: There was no evidence of a comprehensive physical assessment by an RN from 8/23/24 to current 9/16/24. Patient 20: There was no evidence of a comprehensive physical assessment by an RN from 8/2/24 to 8/18/24.

Upon patient record review, 1 of 20 (Patient #11) 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 11: The medical record contained nursing documentation since admission identifying patient has a pleural drainage system. There was no evidence of problems, goals, and interventions related to the pleural drainage included in the plan of care. Corrected on site.

Upon patient record review, 6 of 20 (Patients #1,#3,#5,#7,#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: During the home visit medication reconciliation, the hospice did not have orders for Benadryl and multivitamin listed on facility MAR. Patient 3: The medical record contained an order for oxygen with no delivery method. Patient 5:The medical record contained an order for oxygen with no delivery method. Corrected on site. Patient 7: The medical record contained an order 8/6/24 stating cleanse with normal saline, pat dry and leave open to air. There was no evidence of a location defined for the wound or abrasion treated. Patient 10: The medical record contained nursing documentation identifying patient use of oxygen. There was no evidence of an order for oxygen. The record also contained an order for Foley placement 9/2/24 with no catheter and balloon size, change frequency, and maintenance included in the order. Corrected on site. Patient 11: The medical record contained an order for polyethylene glycol oral powder with no instructions to mix with a diluent.

Upon patient record review, 5 of 20 (Patients #2,#4,#5,#7,#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 2,4: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed. There was no evidence of an order for the bed included in the plan of care. Corrected on site. Patient 5: The medical record contained nursing documentation upon admission identifying patient use of a commode, over the bed table, oxygen concentrator, walker, and wheelchair. There was no evidence of orders for the equipment included in the plan of care. Corrected on site. Patient 7: The medical record contained nursing documentation upon admission identifying patient use of a cane. There was no evidence of an order for the cane included in the plan of care. Patient 8: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, bedrails, and over the bed table. There was no evidence of orders for the equipment included in the plan of care. Corrected on site.

Upon patient record review, 1 of 20 (Patient #5) 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 5: The plan of care contained active problems, goals, and interventions related to spiritual care to be provided by the spiritual care provider, however spiritual care services were discontinued 8/13/24. Corrected on site.

Upon client record review, 1 of 20 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: The medical record contained an order for social work visits once monthly. There was no evidence of an August visit completed.

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. The QAPI minutes for Quarter 2, 2024 contained evidence threshold rates set were not met for bereavement chart audits, facility file audits, CAHPS return rate, and live discharge rates. There was no evidence of a written plan of correction developed for these issues.

Upon patient record review 3 of 20 (Patients #1,#2,#7) 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 contained an order for aide visits twice weekly. There was no evidence of second visits completed the weeks of 8/11/24, 8/18/24, 8/25/24, and 9/1/24. Patient 2: The medical record contained an order for aide visits twice weekly. There was no evidence of second visits completed the weeks of 8/25/24 and 9/8/24. Patient 7: The medical record contained an order for aide visits twice weekly. There was no evidence of a second visit completed the weeks of 8/4/24.

Upon patient record review 2 of 20 (Patients #1,#5) 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 1: There was no evidence of an aide supervisory visit completed since 8/23/24. Patient 5: There was no evidence of an aide supervisory visit completed since 8/28/24.

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 volunteer utilization rate for 2023 was 0.7%.

Upon patient client record review, 2 of 20 (Patients #1,#6) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient 1,6: The medical records contained an election form identifying the patient representatives elected to receive a Notification of Hospice Non-Covered Items. There was no evidence the forms were received.

Upon patient client record review, 3 of 20 (Patients #1,#6,#8) did not have evidence that each patient record contains Advance Directives. Patients 1,6,8: There was no evidence of Advance Directives to support the patients' DNR status.

Upon patient client record review, 1 of 20 (Patient #19) did not evidence that each patient record contains physician orders. Patient 19: There was no evidence of an order to discharge the patient for extended prognosis.

Upon client record review, 1 of 20 (Patient #20) did not have evidence that the discharge summary includes all required information. Patient 20: There was no evidence of a discharge summary. Patient discharged 8/28/24 due to moving out of the service are per documentation.

Upon client record review, 3 of 20 (Patients #1,#2,#14) 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 1: The medical record contained an order for nursing visits once weekly. There was no evidence of a visit completed the week of 9/8/24. Patient 2: The medical record contained an order for nursing visits twice weekly. There was no evidence of a second visit made week of 9/1/24. Patient 14: The medical record contained an order for social work visits once monthly. There was no evidence of visits made in July or August.

Upon patient record review, 1 of 20 (Patient #1) 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 1: Upon observation during the home visit, there was no evidence the hospice agency provided the required paperwork to the SNF.