Every finding on record at Odyssey Healthcare Operating A, LP

Upon patient record review 1 of 19 (Patient #3) 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 3: No evidence that the spiritual assessment was completed within 5 days of admission. The patient was admitted on 5/2/25. The spiritual care assessment was completed on 5/8/25.

Upon patient record review, 1 of 19 (Patient #10) 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 10: No evidence that a RN comprehensive assessment was completed every 15 days between 07/18/2025 and 08/12/2025. 25 days between assessments.

Upon patient record review, 2 of 19 (Patient #7,9) 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 7: The medical record indicated that the patient has a history of depression. Currently takes Lexapro daily for depression. No evidence of problems, goals, and interventions related to risk for depression included in the plan of care. COS - plan of care updated to include depression during survey. Patient 9: The medical record indicated that the patient has a history of depression. Currently takes Lexapro daily for depression. No evidence of problems, goals, and interventions related to risk for depression included in the plan of care. COS - plan of care updated to include depression during survey.

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 indicated that the patient was admitted with a foley catheter. Foley catheter removed on 02/21/2025. Foley catheter supplies remained active on the current plan of care that started on 07/29/2025.

Upon patient record review, 1 of 19 (Patient #3) 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 3: The medical record indicated that patient requested to end social services on 08/14/2025, after refusing visits for the months of June, July, and August 2025. Problems, interventions, and goals related to MSW remain on the current the plan of care. COS - new order written to remove the social services plan from the plan of care during survey.

Upon patient record review, 1 of 19 (Patient #1) 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 RN documentation on 05/01/25 indicated that the patient acquired a skin tear on the elbow and that the nurse changed the bandage during the visit. No evidence that an order was received that contained specific wound care orders for the skin tear.

Upon observation and home visit 1 of 4 (Patient #2), there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #2: During the home visit, the hospice aide placed her electronic tablet onto the counter in the patients room without a barrier of any sort.

Upon observation, there was no evidence in QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the hospice's Quality Assessment and Performance Improvement program. Patient 1: Medical record indicated that the patient had a UTI in June 2025. No evidence that a surveillance report was completed at the time of survey.

Upon patient record review 1 of 19 (Patient #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 5: No evidence that a registered nurse made an aide supervisory visit every 14 days between 08/19/25- 09/11/25 (23 days).

Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Nursing services • Medical social services • Physician services • Counseling services, including spiritual counseling, dietary counseling and bereavement counseling • Hospice aide, volunteer, homemaker services • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care • Medical supplies (including drugs and biologicals) and medical appliance Patient #10: Medical record indicated that the LPN had edited an intervention in the respiratory chapter of the plan of care.

Upon patient record review 3 of 13 records (Patient #4,#8,#12) 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 patient was admitted on 8/25/22. The record indicated that the spiritual assessment was not completed until 9/6/22. Patient #8: The patient was admitted on 5/28/21. The record indicated that the spiritual assessment was not completed until 6/1/22. Patient #12: The patient was admitted on 4/1/22. The record indicated that the spiritual assessment was not completed until 4/7/22.

Upon patient record review, 8 of 13 records (Patient #2,#5,#6,#7,#8,#10,#12,#13) 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 #2: The medication profile included Lorazepam 2 mg/ml. 0.25ml prn hourly anxiety, without evidence of a limit. Corrected on site. Patient #5: The medication profile contained oxygen in duplicate. One was oxygen 2L/min prn for SOB/CHF and the second one was Oxygen 1-3L/min via nasal cannula as needed for SOB or low pulse ox with written parameters. Corrected on site. Patient #6: The medication profile contained Miralax 17 GM powder daily prn constipation. There was not evidence of a diluent. Corrected on site. Patient #7:The record indicated Oxygen 2L/min prn for SOB. There was not evidence of a route. Corrected on site. Patient #8: The medication profile contained Acetaminophen 325mg, 2 caps 2 times daily prn mild pain or fever without evidence of a parameter for the fever. Corrected on site. Patient #10: The medication profile contained Tylenol 325mg, 2 caps q6h prn mild pain or fever without evidence of a parameter for the fever. Corrected on site. Patient #12: The medication profile contained Acetaminophen 500mg, 2 tabs q6h prn mild pain or fever without evidence of a parameter for the fever. In addition, Oxygen 2L/min prn SOB without evidence of a route. Patient #13: The record indicated an order for Acetaminophen 500mg, 2 tabs q6h prn mild pain or fever without evidence of a parameter for the fever.

Upon patient record review, 2 of 13 records (Patient #1,#6) did not have evidence in the patient record that the hospice has developed an individualized written plan of care that reflects 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 patient was admitted with a diagnosis of Parkinson's Disease. The social work assessment note indicated that she was confused and had hallucinations, with cognitive impairment. Notations in the record indicated that the patient had a shuffling gait, and functional decline. She required assistive devices to ambulate, and required assistance with bathing, dressing, grooming and toileting. She also had tremors. There was not evidence that the hospice has developed an individualized written plan of care that reflected patient/family goals and interventions related to the patient's neurological problems. Corrected on site. Patient #6: The patient was admitted with a diagnosis of ALS. He had difficulty with ambulation prior to admission. He was weak, total care for all ADL's, had difficulty swallowing secretions and was having increased paralysis of his hands. There was not evidence that the hospice has developed an individualized written plan of care that reflected patient/family goals and interventions related to the patient's neurological problems. Corrected on site.

Upon patient record review, 8 of 13 records (Patient #2,#3,#6,#7,#8,#10,#12,#13) 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 record indicated Lorazepam 2 mg/ml. 0.25ml prn hourly anxiety, without evidence of a limit. Corrected on site. Patient #3: The record indicated an order dated 8/22/22 for volunteer services for companionship. There was not evidence of a frequency. Corrected on site. Patient #6: The record indicated an order for contained Miralax 17 GM powder daily prn constipation. There was not evidence of a diluent. Corrected on site. Patient #7:The record indicated an order for Oxygen 2L/min prn for SOB. There was not evidence of a route. Corrected on site. Patient #8: The record indicated an order for Acetaminophen 325mg, 2 caps 2 times daily prn mild pain or fever without evidence of a parameter for the fever. Corrected on site. Patient #10: The record contained an order for Tylenol 325mg, 2 caps q6h prn mild pain or fever without evidence of a parameter for the fever. Corrected on site. Patient #12: The record indicated an order for Acetaminophen 500mg, 2 tabs q6h prn mild pain or fever without evidence of a parameter for the fever. In addition, Oxygen 2L/min prn SOB without evidence of a route. Patient #13: The record indicated an order for Acetaminophen 500mg, 2 tabs q6h prn mild pain or fever without evidence of a parameter for the fever.

Upon client record review, 4 of 12 applicable records (Patient #3,#5,#6,#7) 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 record indicated that the volunteer conducted visits on 7/23/22, 8/4/22, and 9/8/22 without evidence of a specified frequency for the volunteer. Patient #5: The visit frequency for the spiritual care counselor was for an evaluation , then 1m1, 2m2, 1m1 and 2 prn. The record indicated that an evaluation was conducted on 8/15/22 and subsequent visits on 9/1/22, 9/15/22, and 9/29/22. In addition the volunteer visit frequency was ordered at 1-2x/month for companionship, dated 8/23/22. There was not evidence of visits. Patient #6: The visit frequency for the social worker was dated 7/15/22 effective 7/1/22 3m1, 6m2 4 prn. The patient was admitted on 7/1/22. For the month of August, the record indicated that the social worker conducted visits on 8/1/22, 8/8/22, 8/15/22, 8/22/22, and 8/29/22. For the month of September, visits were conducted on 9/6/22, 9/12/22, 9/20/22, and 9/27/22. In addition, the admission order for the spiritual care counselor was for an evaluation. There was not evidence of a visit for an evaluation by the spiritual care counselor or missed visit documentation. Also, the record indicated an order dated 8/16/22 to start volunteers for companionship 2x/month. There was not evidence of visits. Patient #7: The visit frequency for the social worker for the benefit period of 7/27/22-9/24/22 was 2 every 2m2, 2m1 and 1 prn. Visits were conducted by the social worker on 7/29/22, (evaluation) and subsequently on 8/16/22 and 9/8/22. In addition, the spiritual care counselor visit frequency was 4m2 and 1 prn effective 8/1/22. The record indicated that visits were conducted in August on 8/1/22, 8/4/22, and 8/17/22. Visits were also conducted in September on 9/7/22 and 9/19/22. Also, volunteers were ordered to start 8/1/22 at 3x/mon. There was not evidence of visits.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #8: The RN was observed providing care and an assessment while going in and out of her bag to retrieve equipment without removing gloves and/or sanitizing her hands between entering the bag. Policy #6-013 indicated to remove supplies from the bag and place on a clean, dry surface or on a surface barrier. Do not re-enter the bag with gloves. Remove and perform hand hygiene and then re-enter bag.

Upon patient record review, 2 of 13 records (Patient #2,#5) did not have evidence in the patient record that hospice aide assignments and duties include the tasks to be provided and the frequency of those tasks. Patient #2: The aide plan of care dated 7/13/22 and 9/22/22 indicated to provide hair care weekly and at every visit (Aide frequency was 2x/week). Corrected on site. Patient #5: The record indicated that the patient was deaf. There was not evidence that this was included on the aide plan of care. Corrected on site.

Upon patient record review 2 of 13 records (Patient #5,#6) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #5: The aide plan of care dated 8/11/22 and 8/29/22 indicated to provide for a shampoo weekly. The aide documentation indicated that this task was performed at all visits. Patient #6: The aide plan of care dated 8/10/22 indicated to provide a shampoo and a shave weekly. The record indicated from the date of 8/29/22 to current that these tasks were provided at every visit (The aide visit frequency was 3x/week).

Upon patient record review, 1 of 13 records (Patient #5) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. Patient #5: There was not evidence of a narrative statement and there was not evidence that the physician had signed the certification. Corrected on site.

Upon patient client record review, 1 of 13 records (Patient #2) did not have evidence that each patient record contains a signed election statement in accordance with 418.24. Patient #2: The record indicated that the patient/representative requested the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” on 8/8/22 (After the patient was admitted). The record indicated that the document was furnished on 8/12/22.

Based on review of clinical records, review of policy and procedure and staff interview the hospice failed to ensure Hospice Aide (HA) services were provided in accordance with the plan of care for 1 of 3 patients reviewed, (Patient 3). This practice provided the opportunity for patients to not receive care as outlined in the plan of care and as ordered by the interdisciplinary group. Sample size was 3 and hospice census was 84. Findings are: A. Review of the policy and procedure titled The Plan of Care, dated August 2021, revealed the care provided to the patient will be in accordance with the plan of care. The same policy revealed in the event the ordered visit frequency is not met, the following should occur: 1. If unable to reschedule within the ordered time frame, a missed visit coordination note was to be completed. 2. If the missed visit is a hospice aide visit, the hospice aide must immediately notify the Registered Nurse (RN) case manager. B. Review of Patient 3's clinical record revealed: 1. A plan of care, dated 4/16/2021, for the patient to receive the services of a HA 1 time per week for 13 weeks. 2. IDG meeting form dated 6/30/21, with order for HA visits 1 time per week. 3. IDG meeting form dated 7/14/21, with order for HA visits 1 time per week. 4. There was no documentation in the clinical record the patient received a visit by a HA the weeks of 6/27/21 through 7/3/21, 7/4/21 through 7/10/21, 7/11/21 through 7/17/21, and/or 7/18/21 through 7/24/21. C. The hospice Administrator on 9/30/21 at 4:35 PM during interview confirmed Patient 3 did not receive visits of a HA, as outlined in the patient's plan of care, the week of 6/27/21 through 7/3/21, 7/4/21 through 7/10/21, 7/11/21 through 7/17/21, and/or 7/18/21 through 7/24/21 as outlined in the patient's plans of care. D. The hospice Administrator and the Business Officer Manager during interview on 10/1/21 at 11:25 AM, confirmed there was no documentation in Patient 3's clinical record of missed visit coordination notes or documentation the HA notified the RN case Manager when a missed visit occurred.