Every finding on record at Odyssey Healthcare Operating A, LP

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: Patient admitted on 05/15/2020. Bereavement risk assessment completed on 08/11/2020.

Upon client record review, 4 of 19 (Patient #7,11,12,13) 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 7: 4 active wounds identified on the record. Orders from 06/05/2023 indicate that wound care dressings should be changed 3 times a week, 2 to be completed by SNF nurse and one to be completed by the hospice nurse. No evidence that the hospice nurse was changing the dressing once weekly as ordered. All dressing changes between 07/17/2023-08/15/2023 and 06/05/2023-07/11/2023 being performed by SNF nurse. Nurse documented on 08/14/2023 that the patient refused dressing change by hospice nurse, no mention of patient's refusal at any other visit that the dressing change was not performed. Patient 11: Volunteer services started 03/03/2023 at 2 times a month. Patient seen 3 times a month for the month of March, April, May, and June by the volunteer. Clarification orders entered during survey. Patient 12: Volunteer services started 03/03/2023 at 3 times a month. Patient seen twice in March and five times in April. No missed visit notes entered for the month of March. No order written to increase visits for the month of April. Clarification orders entered during survey. Patient 13: Volunteer services declined at the time of admit. Volunteer services started 08/04/2023 at twice a month. No order entered to start Volunteer services. Order entered during survey.