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 a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #11-The medication profile included Sarnna 1% lotion, apply to affected area 4 x daily for itching. The entry did not include a specified site for application.

Upon patient record review, 5 of 19 (Patient #3,5,8,9,10) 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 Patient #3,8,9- The initial plan of care included order for SW and Chaplain 1PRN with no defined frequency ordered. Patient #5- The initial plan of care included order for SW 1PRN with no defined frequency ordered. Patient #10- The initial plan of care included order for Chaplain 1PRN with no defined frequency ordered.

Upon patient record review, 1 of 19 (Patient #11) 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 #11-The record included an order dated 6/11/24 for Sarnna 1% lotion, apply to affected area 4 x daily for itching. The order did not include a specified site for application.

Upon client record review, 1 of 19 (Patient #13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #13- The record included an order for chaplain to evaluate dated 6/21/24. There was no evidence of an evaluation completed to date.

Upon home visit, 2 of 4( Patient 3, 6) there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #3- The aide did not wash or sanitize hands prior to physical contact with the patient in order to provide care. Patient #6- The SN placed clean equipment from nursing bag directly on a table surface prior to use without first cleaning the surface, equipment was then used on patient and returned to the same area of the table. Nursing bag was left unzipped during visit. Equipment was immediately placed back in the nursing bag after cleaning the equipment without allowing equipment to dry.

Upon patient record review 5 of 19 (Patient #7,8,10,12,14) 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 Patient #7- The aide care plan included the assignment: Monthly weight the 1st visit of the month. Visits 5/16/24 and 6/6/24 were the 1st visit of the month and tasks were not documented as completed. The note reflected "not needed" and "already done". Patient #8- The aide care plan included the assignment: Monthly weight the 1st visit of the month. Visit 6/8/24 was the 1st visit of the month and task was not documented as completed. The note reflected "not needed". Patient #10- The aide care plan included the assignment: Monthly weight the 1st visit of the month. Visit 6/3/24 was the 1st visit of the month and task was not documented as completed. The note reflected "already completed". Patient #12- The aide care plan included the assignment: Monthly weight the 1st visit of the month. Visit 5/14/24 was the 1st visit of the month and task was not documented as completed. The note reflected "already completed". Patient #14- The aide care plan included the assignment: Monthly weight the 1st visit of the month. Visit 6/4/24 was the 1st visit of the month and task was not documented as completed. The note reflected "not required".

Upon patient client record review, 1 of 19 (Patient #2) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #2- The patient/ representative requested the notice of non-covered items, services and drugs at the time of election. There was no evidence in the record to demonstrate the notice had been provided.

Upon client record review, 2 of 5 (Patient #3 and #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3 initial plan of care included RN frequency of 4w1, 2w12 and 3prn. RN visits made on 9/15/21, 9/16/21 and 9/17/21. No evidence of a refusal or 4th visit this week. Patient #5 initial plan of care included RN frequency of 1w14 and 3prn. RN visits made on 9/16/21 and 9/17/21.

Upon patient record review 1 of 3 applicable (Patient #4) 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 Patient #4 aide care plan included weigh on 1st visit of the month. Aide visits on 9/29/21 and 10/6/21 both documented weight completed and these were not the first visits of the month.

Upon patient client record review, 1 of 5 (Patient #3) 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 #3 chaplain initial assessment completed on 9/16/21 and second visit on 10/4/21. Chaplain frequency ordered as 1 visit within every 30 days and 3prn. Another chaplain documented IDG note on 9/22/21 as patient/family has not requested SCC services as part of the patients plan of care. Chaplain that did both visits completed addendum to 9/22/21 IDG note during survey.

Upon client record review, 1 of 2 applicable (Patient #4) 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 initial plan of care included RN frequency of 1w14 and 3prn. RN visits made on 9/17/21 and 9/18/21.