Every finding on record at Odyssey Healthcare Operating A, LP

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities.

Upon patient record review, 3 of 14 (Patients #1,#8,#9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 1: During home visit medication reconciliation, the facility and hospice medication profiles did not match. The facility profile contained haloperidol and Metamucil PRNs that were not on the hospice profile. Corrected on site with orders received and medication profile updated. Patient 8: During home visit medication reconciliation, the facility and hospice medication profiles did not match. The facility medication profile contains bowel protocol of step 1 give 3 oz prune juice if no BM in 2 days, step 2 give Miralax if no BM in 3 days, step 3 bisacodyl suppository if no BM in 8 hours, step 4 fleets enema if no results in 8 hours, step 5 repeat fleets enema and notify physician. The facility profile also contained acetaminophen 325mg tabs, give 3 tabs three times daily for fever/pain, latanoprost ophthalmic solution 1 drop both eyes at bedtime, an additional melatonin 3mg tab give 3 tabs at dinnertime, and senna 8.6mg give 2 tabs PRN. Corrected on site with orders received and medication profile updated. Patient 9: During home visit medication reconciliation, the facility and hospice medication profiles did not match. The facility med profile contains breo ellipta inhaler daily, hydrocortisone topical cream twice daily, lorazepam concentrate 0.25ml every 4 hours PRN, all listed were discontinued by hospice orders previously and no longer on hospice profile. The facility profile contained an albuterol inhaler instead of nebulizer on hospice, and the facility did not contain the morphine and ativan PRNs that are on the hospice profile. Corrected on site with order clarifications and providing the medication orders to the facility.

Upon patient record review, 2 of 14 (Patients #1,#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 1: The record identified patient was on hospice services for Alzheimer's disease. There was no evidence of problems, goals, and interventions related to neurological disorder. The plan of care also contained inaccurate goals and interventions related to oxygen safety when the patient did not have oxygen. Corrected on site with plan of care update. Patient 9: The plan of care contained inaccurate goals and interventions related to oxygen safety when the patient did not have oxygen. Corrected on site with plan of care update.

Upon patient record review, 3 of 14 (Patients #1,#4,#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 medications and treatments. Patient 1: During home visit medication reconciliation, the facility and hospice medication orders did not match. The facility profile contained haloperidol and Metamucil PRN orders that the hospice did not have. Patient 4: The medical record contained nursing documentation 7/29/25 identifying patient use of oxygen and the record also contained an order for oxygen supplies. There was no evidence of an order for oxygen rate, frequency, and delivery method. Corrected on site with order clarification. Patient 8: During home visit medication reconciliation, the facility and hospice medication orders did not match. The facility had bowel protocol orders of step 1 give 3 oz prune juice if no BM in 2 days, step 2 give Miralax if no BM in 3 days, step 3 bisacodyl suppository if no BM in 8 hours, step 4 Fleets enema if no results in 8 hours, step 5 repeat Fleets enema and notify physician. The facility also had orders for acetaminophen 325mg tabs, give 3 tabs three times daily for fever/pain, latanoprost ophthalmic solution 1 drop both eyes at bedtime, an additional melatonin 3mg tab give 3 tabs at dinnertime, and senna 8.6mg give 2 tabs PRN. Corrected on site with orders received and medication profile updated.

Upon patient record review, 2 of 14 (Patients #1,#9) 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 5/27/25 identifying patient use of full bedrails. There was no evidence of an order for the DME included in the plan of care. Corrected on site with order received. Patient 9: The medical record contained nursing documentation upon admission identifying patient use of bed rails. There was no evidence of an order for the DME included in the plan of care. Corrected on site with order received.

Upon patient record review, 1 of 14 (Patient #8) 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 8: The medical record contained a signed DNR order 5/21/25. There was no evidence the plan of care was updated to reflect the change in code status, the plan of care identified the patient as full code. Corrected on site with plan of care update.

Upon patient record review, 1 of 14 (Patients #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 nursing documentation 8/7/25 and 8/14/15 identifying the oxygen was being administered at 4 liters per minute. The order for oxygen was for 2 liters per minute.

Upon patient record review, 1 of 14 (Patient #9) did not have evidence in the patient record that hospice aide assignments and duties are specific to patient needs. Patient 9: The medical record contained nursing documentation identifying patient wound with bandage. The aide care plan did not contain instructions for wound management during bathing. Corrected on site with aide care plan update.

Upon patient client record review, 1 of 14 (Patient #7) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 Patient 7: There was no evidence of a signed copy of Patient Rights.

Upon patient record review,1 of 14 (Patient #7) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient 7: There was no evidence of patient receiving policies on controlled substances. Patient had orders for tramadol starting 6/4/25 and Norco starting 7/21/25. Corrected on site with information provided to patient.

Upon patient record review, 1 of 14 (Patient #8) 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 8: Upon observation during home visit, there was no evidence the facility had received names of hospice personnel involved with care, the CTIs for benefit periods two and three, the election form, and an updated plan of care since 7/23/25. Corrected on site with delivery of items to facility.

Upon patient record review, 2 of 13 (Patients #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 #6 The patient was admitted on 4/4/22, the initial bereavement assessment was completed on 4/12/22. Patient #7 The patient was admitted on 5/4/20, the initial bereavement assessment was completed on 6/29/20.

Upon patient record review, 1 of 13 (Patient #4) 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 #4 Upon admission the initial comprehensive assessment shows evidence of shortness of breath requiring treatment with opioids and albuterol inhaler, the plan of care does not reflect the patients needs for management of the symptom, there is no problem statement, interventions or goals. The patient also reported pain (rated as 6/10) that requires management including changes to his medication regimen at the time of admission, there are no identified goals or interventions for the management of pain added to the plan of care.

Upon patient record review, 5 of 13 (Patients #3, 4, 6, 8, 13) 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 record reflects that the patient has had multiple UTI's documented with medication treatment initiated on 2/3/22 with Bactrim and 3/28/22 with Macrobid, the plan of care does not include a problem statement for the ongoing management of urological symptoms/infections with interventions or goals. The patient has evidence of respiratory infections treated on 1/27/22 and 5/12/22 that were not included in the plan of care with goals or interventions. The patient is currently on prophylactic antibiotics and no evidence of current goals and interventions for recurrent infections. Patient #4 The patient record reflects that the patient has pain management needs due to pancreatic cancer with metastasis to liver, requiring medication changes on 5/20/22, 7/19/22 & 9/8/22 there is no problem statement added to the patient record with interventions or goals for the management of the patients pain. The patient level of care was changed to respite care on 9/3/22 there was no update to the plan of care with documented interventions or goals for the respite care or coordination with the facility. Patient #6 The comprehensive assessment identified the need for pain management on 4/19/22 with new orders for Lortab 5/325, there is no evidence in the POC of a problem statement with goals or interventions for the management of patients pain. Patient #8 The updated comprehensive assessment identified the need for management of altered skin integrity on 7/27/22 with a large skin tear to the left forearm. The patient received stitches to his forehead (not clearly documented when this occurred but required removal of stitches by the hospice nurse on 8/12/22) with no problem statement, goals or intervention added to the plan of care. The patient also has evidence for ongoing needs for management of constipation which is not updated in the POC with interventions or goals added to the plan of care. Patient #13 The patient record indicates evidence of approaching death on or about 8/23, there is no update to the plan of care to include an identified problem or interventions/goals for the imminence of death.

Upon client record review, 1 of 13 (Patient #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2 On 9/7/22 the visit nurse documented a wound to the left heel and provided treatment and instructions to facility staff for continued care, there is no evidence of an order for the care of the wound.

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. Home Visit #3 The RN performed her patient assessment without completing hand washing prior to patient contact. The nurse also removed her assessment tools from her bag without properly cleaning or disinfecting the tools prior or after use.

Upon patient record review, 1 of 9 applicable (Patient #13) 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 #13 There is evidence in the patient record, per nursing documentation, that the patient became bedbound and remained in bed effective 8/22/22 until her death on 8/30/22. There were 3 different aides who inaccurately documented that the patient received a bath via shower chair on 8/24/22, 8/26/22 and 8/29/22. Aide care plan was not updated to reflect bedbound status.

Upon patient record review 1 of 9 applicable (Patient #9) 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 #9 The Hospice Aide orders are indicated for 1x per week. The record indicates there were no aide visits made between 12/7/21 and 12/28/21.