Every finding on record at Odyssey Healthcare Operating A, LP

Upon patient record review 5 of 19 (Patients #2, #3, #5, #10, #11) 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 2: The comprehensive assessment was not complete within the 5 calendar day window. Patient was admitted on 01/17/25, spiritual assessment was not performed until 02/21/25. Patient 3: The comprehensive assessment was not complete within the 5 calendar day window. Patient was admitted on 03/06/25, spiritual assessment was not performed until 03/12/25. Patient 5: The comprehensive assessment was not complete within the 5 calendar day window. Patient was admitted on 11/11/24, spiritual assessment was not performed until 11/18/24. Patient 10:The comprehensive assessment was not complete within the 5 calendar day window. Patient was admitted on 05/02/24, spiritual assessment was not performed until 05/09/24. Patient 11:The comprehensive assessment was not complete within the 5 calendar day window. Patient was admitted on 01/02/25, spiritual assessment was not performed until 01/09/25.

Upon patient record review 3 of 19 (Patients #4, #6, #14) 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 4: There was no spiritual assessment found in the patient record. corrected on site Patient 6: There was no spiritual assessment found in the patient record. corrected on site Patient 14: There was no spiritual assessment found in the patient record. corrected on site

Upon patient record review, 4 of 19 (Patients #2, #6, #8, #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 • Actual or potential drug interactions • Duplicate drug therapy order does not specify area for administration. Patient 2: Upon patient interview, multiple medication discrepancies were identified, Multiple entries for Ativan, one for 1 mg and one for 0.5 mg, nurse states that she wrote an order to increase the Ativan to 1.5 mg, but was confused how it should be written in the chart, there are no instructions listed to combine both doses for a total of 1.5 mg. Hospice has vitamin D3 1250 Mcg take daily profiled on medication list, patient states he does not take this medication. Per patient he takes Pepcid 20mg tab is taken twice a day, the medication profile only has daily. Per patient he takes Zanaflex 4mg, hospice has 2 mg dose profiled-Corrected on site. Patient 6: Upon interview with patient, patient states she is taking Ventolin, Symbicort, Combivent, omeprazole, alendronate, Vitamin D3 50mg, vitamin C 1000mg, magnesium 200mg, Potassium 99mg, and atorvastatin, none of these medications are profiled. She denies having bisacodyl in home or having to take stool softeners, which is listed on hospice med profile Patient 8: Bengay is listed on medication profile, but there is no site of application documented-Corrected on site. Patient 9: Per facility med profile, cyclobenzaprine, glucagon, loperamide, midodrine, phenol aerosol 1.44% sol, tussin cough syrup are profiled, which are not profiled by hospice. Simethicone 80mg is written in facility profile as q 4 hours prn, hospice has written for daily. Senna plus on facility med profile is 2 capsules q 12 hours prn vs. 1 tab daily prn-Corrected on site.

Upon patient record review, 4 of 19 (Patients #4, #6, #8, #10) 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 4: The patient was admitted to hospice on 04/15/24, the bereavement risk assessment was not documented until 05/10/24. Patient 6: The patient was admitted to hospice on 11/18/24, the bereavement risk assessment was not documented until 11/27/24 for two different bereavement contacts. Patient 8:The patient was admitted to hospice on 01/28/25, the bereavement risk assessment was not documented until 02/14/25. Patient 10:The patient was admitted to hospice on 05/03/24, the bereavement risk assessment was not documented until 05/13/24.

Upon patient record review, 1 of 19 (Patient #5) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 5: There were documented wounds to Left heel, top of Left foot, Left 2nd, toe, inside and outside of left foot only have assessments and measurements for dates of 2/11/25, 3/8/25, 3/27/25, which is not in compliance with company policy of weekly measurements.

Upon patient record review, 3 of 19 (Patients #4,#5,#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 4: It is noted in admission visit that patient has dysphagia, there is no plan of care problems, goals, or interventions for dysphagia.-Corrected on site. Patient 5: Oxygen use was charted in the plan of care since admission, upon further investigation during survey, it was noted that patient does not use oxygen. Corrected on site. Patient 9: It was noted that oxygen use was listed on the plan of care, upon investigation during survey, it was noted that this was charted in error. Also noted that patient has dysphagia but there is no plans, goals or interventions for identified problem.-Corrected on site.

Upon patient record review, 4 of 19 (Patient #2, #6, #8, #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 medications and treatments. Patient 2: Upon patient interview, multiple medication discrepancies were identified, Multiple orders are written for ativan, one order for 1 mg and one for 0.5 mg, nurse states that she wrote an order to increase the ativan to 1.5 mg, but was confused how it should be written in the chart, there are no instructions listed to combine both doses for a total of 1.5 mg. Hospice has vitamin D3 1250 Mcg take daily ordered, patient states he does not take this medication. Per patient he takes Pepcid 20mg tab is taken twice a day, the order has daily. Per patient he takes Zanaflex 4mg, hospice has 2 mg dose ordered-Corrected on site. Patient 6: Upon interview with patient, patient states she is taking Ventolin, symbicort, Combivent, omeprazole, alendronate, Vitamin D3 50mg, vitamin C 1000mg, magnesium 200mg, Potassium 99mg, and atorvastatin, none of these medications are ordered. She denies having bisacodyl in home or having to take stool softeners, which is ordered. New wound care order entered on 03/12/25 did not contain the location of wound-Partially corrected, the updated mediation orders still did not list the patient's inhalers prior to end of survey, the rest of the orders were corrected. Patient 8: Bengay is ordered, but there is no site of application documented- Corrected on site. Patient 9: Per medication review, the facility medication profile has cyclobenzaprine, glucagon, loperamide, midodrine, phenol aerosol 1.44% sol, tussin cough syrup profiled, which there is no evidence of orders in hospice record. Simethicone 80mg is written in facility profile as every 4 hours as needed, the hospice has written for daily. Senna plus on facility medication profile is ordered as 2 capsules every 12 hours as needed, the hospice order is written as 1 tab daily as needed-Corrected on site.

Upon patient record review, 4 of 19 (Patients #1,#4,#10,#14) 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: There is no orders written for transport chair or shower chair identified in nurse visit on 03/13/25-Corrected on site. Patient 4: The patient has breathing treatments ordered, but there is no written order for a nebulizer. In addition, there is a documented Hoyer lift since admission, but no order written-Corrected on site. Patient 10: Nurse note identifies a wheelchair and cane upon recertification visit but there are no written orders for either.-Corrected on site. Patient 14: A cane is listed as in use, but no written orders identified.-Corrected on site.

Upon client record review, 1 of 19 (Patient #1) 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 1: There is no evidence that the attending physician is being updated on an on-going basis.-Corrected on site.

Upon patient record review, 4 of 19 (Patients #2, #4, #8, #9) 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 2: Nurse documents in visit for 3/18/25 that patient is having unrelieved nausea and vomiting, the plan of care is not updated to reflect this change-correct Patient 4: Plan of care has not been updated to identify current goals, plans, and interventions patient with dysphagia identified in Nurse Practitioner note on 2/13/25 and nurse note on 3/20/25 states that patient is on a puree diet with nectar thickened liquids. Also the Plan of care has an active wound care pathway requiring nurse to assess wound site each week however, wound is not active.-correct Patient 8: Physical therapy completed frequency on 3/3/25, the Physical therapy plan of care is still active.-corrected on site. Patient 9: Upon admission, patient has a surgical wound plan of care that is still active, with no open wounds.-Corrected on site.

Upon client record review, 2 of 19 (Patients #1,#7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: It was noted that volunteers have been making visits, no volunteer orders noted.-Corrected on site. Patient 7: The patient was readmitted to hospice on 03/11/25, there is an uploaded volunteer visit to the patient chart with a visit date of 03/18/25 and the volunteer coordinator charted in the IDG meeting notes that the frequency of the volunteer will be twice a month. There is no volunteer orders documented in the medical chart.-Corrected on site.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient 2: Nursing documented a patient fall 3/18/25. There was no evidence of a fall report to investigate the incident. Corrected on site with late data entry. Patient 6: Nursing documented a patient fall 3/11/25. There was no evidence of a fall report to investigate the incident and occurrence. Corrected on site with late data entry.

Upon patient record review, 2 of 19 (Patients # 15, #17) did not have evidence the hospice offers bereavement counseling that includes: • 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:No evidence of Holiday letter was sent out per bereavement plan of care. Patient 17:No evidence of Holiday letter was sent out per bereavement plan of care.

Upon personnel record review, 1 of 15 (Personnel #3) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel 3: There was no evidence the aide was observed obtaining temperature and pulse, or giving a tub bath.

Upon patient record review, 1 of 19 (Patient #5) did not have evidence in the patient record that hospice aide assignments and duties are: • 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 5: Patient has documented multiple wounds to left lower leg and foot, there are no instructions in the aide care plan that inform the aide how to care for these dressings during a shower. Corrected on site.

Upon patient record review 1 of 19 (Patient #13) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Included in the plan of care Patient 13: The ordered frequency for the aide is 3 visits weekly, only two visits are recorded for the week of 3/9/25. Updated with late note-corrected on site.

Upon patient record review 1 of 19 (Patient #8) 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 8: There are no supervised visits since admission of patient on 1/28/25 through date of survey on 4/7/25.

Upon client record review, 1 of 19 (Patient #9) 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 9: The nurse frequency is 2 times a week, for the week of 03/02/25, there is only 1 documented nurse visit, with no missed visit notification or ordered adjustment for that week-corrected

Upon client record review, 1 of 19 (Patient #5) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 5: The wound care order on 3/14 does not designate hospice and facility responsibilities-Corrected on site.

Upon personnel record review, 2 of 15 (Personnel #14, #15 ) 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. Personnel 14: There was no evidence of a criminal background check. Personnel 15: There was no evidence of a criminal background check.

Upon patient record review, 1 of 16 (Patient #8) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #8 The 3/27/22 MD order for MSW and the 3/29/22 SC poc updates both indicate frequency as prn.

Upon patient record review, 1 of 16 (Patient #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 #13 The 3/17/2022 plan of care reads nephrostomy dressing change and bag change q week and prn with no qualifier.

Upon client record review, 4 of 16 (Patient #6, 8, 11, 15) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6 The 4/19/22 wound care order reads SN to perform Pressure Ulcer care q3days however no evidence of wound care provision to date. Patient #8 The 4/14/22 MD order reads PT eval however not completed to date. Patient #11 The 4/11/22 wound care order reads Hospice nurse to change 1xweek and measure however no wound care provision to date. Patient #15 1/23/22 SN frequency order reads daily however no evidence of snv 1/25/22 and 1/26/22.

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 #2 Home visit no barrier use with items removed from nursing bag as per agency policy.

Upon patient record review 7 of 10 applicable (Patient #2, 3, 4, 6, 9, 14, 15) 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 #2 The 4/1/22 physician order reads aide 2xwk 12 however only 1 visit was completed for the weeks of 4/10/22 and 4/17/22 with no associated explanation noted to date. Patient #3 On the 4/5/22, 4/7/22, and 4/12/22 visits all tasks were not completed as per 4/3/22 aide task assignment. Patient #4 On the 4/26/22 aide visit not all tasks were completed as per 4/25/22 task assignment. Patient #6 On the 4/22/22- 4/26/22 aide visits all tasks not completed as per 4/19/22 aide task assignment. Patient #9 The 4/25/22 aide visit note all tasks were not completed as per the 4/13/22 aide task assignment. Patient #14 The 4/20/22 aide visit note all tasks not completed as per the 4/13/22 aide task assignment. Patient #15 The 1/23/22 plan of care reads Aide 2week8 however no visits completed to date.

Upon patient client record review, 5 of 16 (Patient #1, 3, 4, 6, 14) 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 4/22/22 RN signature contains initials and does not match employee signature on file. Patient #3 The 4/1/22 RN signature does not match electronic signature which has no credentials or signature on file. Patient #4 The 4/25/22 and 4/26/22 aide visit contains signature with no credentials. Patient #6 The 4/22/22 aide visit contains signature with no credentials. Patient #14 The 4/20/22 aide visit contains signature with no credentials.

Upon observation, there was no evidence the storage of medical gases in a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. Existing Construction Indoor storage of empty and full oxygen tanks do not meet requirements as not labeled empty vs full in storage site.

Upon observation, there was no evidence the inpatient facility has adequate supply of hot water at all times and include plumbing fixtures with control valves that automatically regulate the temperature of hot water used by patients. No evidence of water temp testing for patient rooms.

Based on record review, observation, and interview, the facility failed to ensure emergency egress lighting was maintained (K281). The facility failed to ensure corridors were maintained (K363). The facility failed to ensure fire and evacuation drills were completed quarterly on each shift or under varied conditions (K712). The facility failed to test and inspect the electrical receptacles within patient care rooms (K912). The facility failed to ensure exterior oxygen storage area was maintained (K923).

Based on observation, interview, and record review, the facility failed to meet the requirements for life safety, specifically Chapter 19 of the applicable provisions of the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association. At this survey, Promedica Hospice was found not in substantial compliance with the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC) Chapter 19, Existing Healthcare. This could affect all patients receiving services from the inpatient unit. The facility census was two. Findings include: 1. K281 - the facility failed to ensure emergency egress lighting was maintained. 2. K363 - the facility failed to ensure corridors were maintained. 3. K712 - the facility failed to ensure fire and evacuation drills were completed quarterly on each shift or under varied conditions. 4. K912 - the facility failed to test and inspect the electrical receptacles within patient care rooms. 5. K923 - the facility failed to ensure exterior oxygen storage area was maintained.

Based on observation and interview, the facility failed to ensure emergency egress lighting was maintained in accordance with NFPA 101-2012 Edition, Sections 7.8.1.2; 7.8.1.3*. This could affect all patients receiving services from the inpatient unit. The facility census was two. Findings include: Observation on 10/07/21 at 9:10 A.M. during tour of the facility, identified the application of the exterior canopy recessed can lights which provided emergency illumination to the exit discharge across from the nurses' station south exit. Further examination revealed the light fixture, located directly above the exit door, was missing a bulb and could not provide lighting to the exterior concrete pathway. Interview with Staff C verified the noted exterior canopy recessed can lights were connected to the emergency generator system. Staff B and Staff C verified the findings at the time of discovery.

Based on observation and interview, the facility failed to ensure corridors were maintained in accordance with NFPA 101-2012 Edition, Section 19.3.6.3.5*; Code Federal Regulations (CFR) Parts 403, 418, 460, 482 and 485. This could affect all patients receiving services from the inpatient unit. The facility census was two. Findings include: Observation on 10/07/21 at 8:47 A.M. during tour of the facility, identified the integrity of the west electrical panel closet located within the west patient room corridor. Further examination revealed the right leaf contained a roller latch and failed to positively latch into the frame. In addition, the left inactive leaf enclosed a manual slide lock and failed to positivity latch into the frame. Lastly, the east hall storage room located within the east patient corridor failed to positively latch into the frame at the inactive leaf side. Interview with Staff B verified the findings at the time of discovery.

Based on record review and interview, the facility failed to ensure fire and evacuation drills were completed quarterly on each shift or under varied conditions in accordance with NFPA 101-2012 Edition, Section 19.7.1.6. This could affect all patients receiving services from the inpatient unit. The facility census was two. Findings include: Record review with Staff B on 10/06/21 at 10:45 A.M. of the quarterly fire and evacuation drills from the previous 12 months revealed fire drills were not completed quarterly on each shift. Specifically, the facility failed to perform a fire drill for the second shift (7:00 P.M. to 7:00 A.M.) staff for first quarter (January, February, March) 2021. First shift (7:00 A.M. to 7:00 P.M.) fire drills were completed at the following occurrences: 02/02/21 11:00 A.M.; 02/18/21 5:30 P.M.; 04/08/21 8:30 A.M.; 07/21/21 10:45 A.M. Second shift (7:00 P.M. to 7:00 A.M.) fire drills were completed at the following occurrences: 05/17/21 6:30 P.M.; 06/29/21 12:30 A.M.; 09/09/21 2:00 A.M. Interview with Staff B verified the findings at the time of discovery.

Based on record review and staff interview, the facility failed to test and inspect the electrical receptacles within patient care rooms in accordance with NFPA 99-2012 Edition, Sections 6.3.4.1.1. This could affect all patients receiving services from the inpatient unit. The facility census was two. Findings include: Record review with Staff B on 10/06/21 at 10:15 A.M. of the facility inspection and test records from the previous 12 months revealed the documentation lacked an initial electrical receptacle retension test after installation of the hospital grade electrical outlets. No additional documentation was provided to validate the electrical outlets were tested. Interview with Staff B verified the findings at the time of discovery.

Based on observation and interview, the facility failed to ensure exterior oxygen storage area was maintained in accordance with NFPA 99-2012 Edition, Sections 11.3.1; 11.3.2; 11.3.3; 11.3.4 and 11.6.5. This could affect all patients receiving services from the inpatient unit. The facility census was two. Findings include: Observation on 10/07/21 at 10:02 A.M. during tour of the facility, identified the application of 16, secured H size compressed oxygen cylinders and one large vertical type unknown gallon size liquefied oxygen storage tank within the exterior six foot chain linked fenced area, located on the southwest corner of the facility. Further examination revealed the "no smoking" signs were missing at the gate side and was faded and not legible on the end signs of the fenced area. In addition, the oxygen storage area lacked precautionary warning signs to warn occupants of the compressed gases stored. Interview with Staff B and C verified the findings at the time of discovery.