Every finding on record at Odyssey Healthcare Operating A, LP

Upon patient record review, 3 of 19 (Patients #1,#3,#6) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 1: Upon medication reconciliation during the home visit, the facility and hospice medication profiles did not match. The facility ativan instructions were for 2mg/ml concentrate, give 1 ml every four hours as needed. Hospice profile contained instructions for ativan 0.5mg tablets every four hours as needed. Corrected on site with order clarification and update to medication profile. Patient 3: Upon medication reconciliation during the home visit, the facility and hospice medication profiles did not match. The facility profile contained pantoprazole that was not on hospice, and hospice profile contained aspirin that was not on the facility profile. Corrected on site with order clarification and update to medication profile. Patient 6: Upon medication reconciliation during the home visit, the facility and hospice medication profiles did not match. The facility acetaminophen instructions were for 1000 mg scheduled three times daily. Hospice profile contained instructions for 100 mg every six hours as needed. The medication profile also contained two seroquel instructions for 25 mg twice daily and 50 mg at bedtime without instructions to take the second 25 mg dose with the 50 mg dose at bedtime. Corrected on site with order clarification and update to medication profile.

Upon patient record review, 3 of 19 (Patients #1,#3,#6) 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: Upon medication reconciliation during the home visit, the facility and hospice medication orders did not match. The facility ativan order instructions were for 2mg/ml concentrate, give 1 ml every four hours as needed. Hospice ativan order contained instructions for ativan 0.5mg tablets every four hours PRN. Corrected on site with order clarification. Patient 3: Upon medication reconciliation during the home visit, the facility and hospice medication orders did not match. The facility contained a pantoprazole order that hospice did not have, and hospice had an aspirin order that the facility did not have. Corrected on site with order clarification. Patient 6: Upon medication reconciliation during the home visit, the facility and hospice medication orders did not match. The facility acetaminophen instructions were for 1000 mg scheduled three times daily. Hospice acetaminophen order contained instructions for 100 mg every six hours as needed. The hospice medical record also contained two seroquel orders for 25 mg twice daily, and 50 mg at bedtime without instructions to take the second 25 mg dose with the bedtime dose. Corrected on site with order clarifications.

Upon patient record review, 3 of 19 (Patients #3,#6,#7) 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 3: The medical record contained nursing documentation since admission identifying patient use of a Hoyer lift for transfers. There was no evidence of an order for the lift included in the plan of care. Corrected on site with order clarification. Patient 6: The medical record contained nursing documentation 9/3/25 identifying patient use of a low air loss mattress. There was no evidence of an order for the mattress included in the plan of care. Corrected on site with order clarification. Patient 7: The medical record contained nursing documentation 6/30/25 identifying patient use of a wheelchair. There was no evidence of an order for the wheelchair included in the plan of care. Corrected on site with order clarification.

Upon patient record review, 1 of 19 (Patient #2) 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: The medical record contained an order to discontinue spiritual care visits 8/28/25. There was no evidence the plan of care was updated to remove problems, goals, and interventions to be addressed by the chaplain. Corrected on site with update to plan of care.

Upon observation during 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. The RN observed set bag down on an unclean surface without a barrier and stored dirty equipment in clean section of her bag prior to cleansing, then replacing the clean equipment back into contaminated area.

Upon patient record review, 1 of 19 (Patient #16) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 16: The bereavement care plan contained tasks to send 6 month letters to the bereaved. There was no evidence of task completion. Corrected on site with letters sent.

Upon client record review, 3 of 19 (Patients #4,#13,#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 4: The medical record contained an order for nursing visits twice weekly. There was no evidence of a second visit completed the week of 7/20/25. Patient 13: The medical record contained an order for social work visits once monthly. There were two scheduled visits completed in August. Patient 14: The medical record contained an order for spiritual care visits twice monthly for two months effective 6/1/25. There was no evidence of a second visit completed in July.

Upon patient record review, 1 of 5 (Patient #2) 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 #2 The medical record contains wound care orders effective 9/26/22. There was no evidence of wound assessments performed after 10/3/22 and to survey date.

Upon patient record review, 5 of 5 (Patient #1, 2, 3, 4, 5) 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 medical records shows that the patient resides in a SNF with routine hospice care, the medical record does not contain a written plan of care for the coordination of care with the SNF. Patient #2 The medical record does not show evidence of interventions or goal for the altered skin integrity in response to the orders for wound care to bilateral feet on 9/26/22. Patient #3 The medical record does not show evidence of interventions or goals for the altered skin integrity in response to the orders for wound care to rt buttocks on 10/10/22. The plan of care does not include the coordination of care with facility staff to include goals and interventions. Patient #4 The medical records shows evidence of patient concern for medication diversion due to family member with addiction a lock box has been provided to the patient, there is no evidence in the plan of care related to the goals and interventions for medication reconciliation and patient concerns. Patient #5 The medical record shows evidence of orders to discontinue SCC services effective 10/18/22. The plan of care has not been updated to reflect the updated goals and interventions.

Upon patient record review 2 of 2 applicable (Patient #4, 5) 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 #4 The medical record contains ordered aide visits of 3 times per week. There was evidence of 2 visits the week of 10/3/22 - 10/8/22. Patient #5 The medical record contains ordered aide visits for 2 times per week. There was evidence of only 1 visit the week of 9/26/22, and 1 visit the week of 10/10/22.

Upon patient record review, 1 of 13 (Patient #1) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient 1: The medical record contains documentation of a legal POA stating patient is unable to make sound decisions. There is contradicting nursing documentation that states the patient is A/Ox3 and signed revocation paperwork at discharge.

Upon patient record review, 6 of 13 (Patients #1,#2, #5, #6, #7, #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. 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 contains morphine with contradicting frequency and instructions. The frequency stated every 2 hours as needed and written instructions stated every 4 hours as needed. Patient 2: The medical record contains nursing documentation 3/3/22 and 3/9/22 identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. Patient 5: The medical record contains nursing documentation identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. Corrected on site. Patient 6: The medical record contains nursing documentation identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. Corrected on site. Patient 7: The plan of care identifies patient use of oxygen equipment. There was no evidence of oxygen listed on the medication profile. Corrected on site. Patient 13: The medication profile contains Azithromycin order for 5 days on 8/8/2022. Medication was not d/c'd from the medication profile. Corrected on site.

Upon patient record review, 3 of 13 (Patient #5, #8, #9) 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 5: The medical record indicated an admission date of 4/29/22. There was no evidence of a bereavement risk assessment completed. Patient 8: The medical record indicated an admission date of 7/21/22, the bereavement risk assessment was completed on 7/30/22. Patient 9: The medical record indicated an admission date of 7/1/22. There was no evidence of a bereavement risk assessment completed.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 1 of 13 (Patient #8) 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 8: The medical record indicated wound treatment in the plan of care. There was no evidence of wound assessments from 8/2/22-8/23/22.

Upon patient record review, 2 of 13 (Patients #1 and 8) 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 medical record contains nursing documentation upon admission identifying patient use of an indwelling catheter. There was no evidence of problems, goals, and interventions related to catheter use included on the plan of care. Patient 8: The medical record did not show evidence of goals and interventions or follow up on effectiveness or response to new order for Keflex and infections. Corrected on site

Upon patient record review, 5 of 13 (Patients #1,#2,#5,#6,#7) 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: The medical record contains an order for morphine with contradicting frequency and instructions. The frequency stated every 2 hours as needed and written instructions stated every 4 hours as needed. Patient 2: The medical record contains nursing documentation upon admission identifying patient use of a CPAP, and 3/9/22 identifying patient use of oxygen. There was no evidence of orders for oxygen or CPAP parameters. Patient 5, 6, 7: The medical record identifies patient use of oxygen. There was no evidence of an order for oxygen. Corrected on site.

Upon patient record review, 6 of 13 (Patients #1,#2,#3,#4,#7,#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 equipment and supply needs. Patient 1: The medical record contains nursing documentation upon admission identifying patient use of a hospital bed, table and indwelling catheter. There was no evidence of the bed, table, and catheter included as equipment and supplies on the plan of care. Patient 2: The medical record contains nursing documentation upon admission identifying patient use of a CPAP and 3/9/22 identifying use of oxygen. There was no evidence of the CPAP and oxygen included as equipment on the plan of care. Patient 3: The medical record contains nursing documentation 5/24/22 identifying patient use of a wheelchair. There was no evidence of the wheelchair included as equipment on the plan of care. Patient 4: The medical record contains nursing documentation 8/10/22 identifying patient use of a walker. There was no evidence of the walker included as equipment on the plan of care. Patient 7: The medical record contains nursing documentation on admission identifying patient use of a walker. There was no evidence of the walker included as equipment on the plan of care. Corrected on site Patient 13: The medical record contains nursing documentation on admission identifying patient use of a walker. There was no evidence of the walker included as equipment on the plan of care. Corrected on site

Upon client record review, 6 of 13 (Patients #2,#4, #6,#7,#9, #10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: The medical record contained an ordered frequency of 2w1, 1w12 at start of care on 2/8/22. Nursing visits were completed twice weekly for the second and third week of service. The medical record contained an order 2/9/22 for wound care to be completed every other day by the hospice nurse. Wound care was completed twice weekly 2/9-2/21/22 not meeting frequency ordered. The medical record contained nursing documentation 2/17/22 stating nurse received an order to remove staples from patient abdomen and the procedure was completed and documentation 2/27/22 stating nurse covered bony prominences with Mepilex. There was no evidence in the record of orders for staple removal or treatment to bony prominences. Patient 4: The medical record contained an ordered nursing frequency of 3 times per week. There was no evidence of second or third visits completed for the week of 7/3/2022. Patient 6: The medical record contained an ordered frequency for weekly nursing visits. There was no evidence of nursing visits for week of 7/17/22 and week of 8/14/22. Spiritual Care ordered frequency was 2 times monthly. There was no evidence of visit for month of June. Corrected on Site. Patient 7: The medical record contained an order 8/14/22 for wound care to be completed every other day by the hospice nurse. Wound care was completed 8/15/22 and 8/18/22 not meeting frequency ordered. Corrected on site. Patient 9: The medical record contained an ordered frequency for weekly nursing visits. There was no evidence of visit for week of 8/7/22. There was an attempt to straight cath patient on 8/2/22 and no evidence at time of survey of an order for straight cath. Corrected on Site. Patient 10: The medical record contained nursing documentation of treatment to a skin tear on 8/23/22, there was no evidence of an order to treat the skin tear at time of survey.

Upon patient record review 1 of 13 (Patient #6) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 6: The medical record indicated a request for volunteer services at the patient's request after respite care. There is no evidence that volunteer services were reinstated after respite.

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 6: The medical record indicated 3 falls for patient on 8/6/22, and two falls on 8/22/22. There was no evidence of investigation of adverse event on 8/6/22.

Upon patient record review 7 of 10 applicable (Patients #2, #4, #6, #7, #8, #9, #13 ) 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 medical record contains ordered aide frequency of twice weekly. There was evidence of 1 visit week of 2/13/22. Patient 4: The medical record contains an ordered aide frequency of twice weekly. There was no evidence of a second visit completed the week of 7/31/22. Patient 6: The medical record contains an ordered aide frequency of twice weekly. There was no evidence of visits by the aide during the weeks of 6/12/22, 6/19/22, 6/26/22, and 7/3/22. The plan of care indicated for weights to be performed on the first visit of every month, aide documented in medical record "already completed" on 8/2 visit, with no evidence that the task was performed. Patient 7: The medical record contains an ordered aide frequency of daily visits. There was evidence of 4 visits completed the week of 7/24/22 and 5 visits completed the week of 8/7/22. Patient 8: aide visit frequency on the aide care plan was indicated at twice weekly. There was evidence of 1 visit during week of 7/24/22 and 1 visit week of 8/14/22. Patient 9: The medical record contains an ordered aide frequency of twice weekly. There was evidence of 1 visit during week of 7/31/22. Patient 13: The medical record contains an ordered aide frequency of twice weekly. There was evidence of 1 visit during week of 7/10/22.

Upon patient client record review, 5 of 13 (Patients #2, #5, #6, #7, #12) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 2: The medical record contains documentation the patient representative requested the Notice of Non-Covered Hospice Items. There was no evidence that the representative received the form. Patient 5: The medical record contains admission paperwork and consents to treat with effective date of election as 4/29/22 and election forms signed on 4/30/22. Patient 6: The medical record contains documentation the patient representative requested the Notice of Non-Covered Hospice Items on 5/17/22, there is evidence that it was given and signed late on 6/15/22. Patient 7: The medical record contains documentation the patient representative requested the Notice of Non-Covered Hospice Items. There was no evidence that the representative received the form. Patient 12: The medical record contains documentation the patient representative requested the Notice of Non-Covered Hospice Items. There was no evidence that the representative received the form.

Upon patient client record review, 1 of 13 (Patient #5) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 5: The medical record contained evidence of a verbal order from the RN for the initial CTI, no evidence of verbal or written CTI within 48 hours.