Every finding on record at Odyssey Healthcare Operating A, LP

Upon patient record review 1 of 5 (Patient #2) 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 2: There was no evidence of a comprehensive spiritual assessment. Corrected on site with late data entry 3/10/25 during survey of a spiritual assessment completed by the RN on 3/7/25.

Upon patient record review, 1 of 5 (Patient #4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 4: The medical record contained nursing documentation and a physician order for DME upon admission 2/13/25 identifying an oxygen concentrator was ordered. There was no evidence of oxygen rate, frequency, and delivery method included on the medication profile. After agency investigation, leadership reported that the patient did not have an oxygen concentrator. Corrected on site with an order to discontinue equipment and note entered to clarify the patient did not have oxygen.

Upon patient record review, 1 of 5 (Patient #5) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient 5: The medical record contained nursing documentation 2/21/25 identifying the patient was transitioning and daily nursing visits were to begin due to patient decline. There was no evidence of patient and family receiving education on the change in condition or addressing of the full code status.

Upon patient record review, 1 of 5 (Patient #5) 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 5: The medical record contained the last plan of care update order 2/19/25 identifying social work and spiritual care frequencies as 1 PRN each discipline. The patient had declined both services.

Upon patient record review, 1 of 5 (Patient #4) 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 4: The medical record contained nursing documentation and a physician order for DME upon admission 2/13/25 identifying an oxygen concentrator was ordered. There was no evidence of an order for oxygen rate, frequency, and delivery method. After agency investigation, leadership reported that the patient did not have an oxygen concentrator. Corrected on site with an order to discontinue equipment and note entered to clarify the patient did not have oxygen.

Condition of Participation: Patient’s Rights. L500

Upon patient record review, 9 of 23 records (Patient #1,#2,#6,#7,#8,#10,#15,#17,#18) 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, 9 of 23 records (Patient #1,#2,#6,#7,#8,#10,#15,#17,#18) 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, 9 of 23 records (Patient #1,#2,#6,#7,#8,#10,#15,#17,#18) 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.

Upon patient record review, 9 of 23 records (Patient #1,#2,#6,#7,#8,#10,#15,#17,#18) did not have evidence of the appropriate documentation for release of confidential information.

Upon patient record review, 9 of 23 records (Patient #1,#2,#6,#7,#8,#10,#15,#17,#18) did not have evidence that the patient received information about the services covered under the hospice benefit.

Upon patient record review, 9 of 23 records (Patient #1,#2,#6,#7,#8,#10,#15,#17,#18) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 8 of 23 records (Patient #1,#2,#10,#12,#13,#14,#16,#17) did not have evidence in the patient record that the comprehensive assessment identifies the 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 #1,#2,#10,#12,#13,#14,#16,#17: There was not evidence of a spiritual assessment.

Upon patient record review, 7 of 23 records (Patient #2,#4,#5,#7,#8,#10,#18) 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 #2: The medication profile contained Amoxicillin 500 mg 3x/day, dated 9/18/24. The order indicated that this medication was to be for 7 days. This remained on the medication profile. Corrected on site. Patient #4: Upon home visit, Clopidogrel, Furosemide, IBU, Miralax Potassium Chloride were on the hospice medication profile but not the facility MAR. Corrected on site. Patient #5: Upon home visit, the hospice record contained Tylenol 500mg, 2 caps q6h prn and the facility MAR contained Tylenol 500mg, 1 tab q6h prn. Corrected on site. Also the hospice record contained Potassium liquid 20 mEq/15ml and the facility MAR contained Klor Con 10 mEQ, 2 tabs. Corrected on site. In addition, Zofran, Preparation H, Loperamide and Hydroxyzine were on the hospice medication profile but not on the facility MAR. Corrected on site. Patient #7: The medication profile contained oxygen 2L/min continuous without evidence of a route. Corrected on site. Upon home visit, ASA was included on the hospice medication profile but was not on the facility MAR. Corrected on site. Patient #8: The medication profile contained Hydrocortisone 1% topical cream to affected areas. There was not evidence of a specific location or a specific frequency. Corrected on site. Upon home visit, Robitussin was on the hospice Medication profile but was not on the facility MAR. Duo-nebs, Vistaril and joint supplement were on the facility MAR but were not included on the hospice medical record. Corrected on site. In addition, Nystatin 100,000/Gm topical powder to affected area without evidence of a specific location. Corrected on site. Patient #10: The medication record contained Acetaminophen 325mg 2 caps q4h prn pain or fever and Acetaminophen 650mg rectal suppository 1 q4h prn fever. There was not evidence of a maximum allowable dose for 24h or a parameter for fever. Corrected on site. Patient #18: The medication profile contained Latanoprost eye drops, 1 drop at bedtime without evidence of which eye.

Upon patient record review, 4 of 23 records (Patient #4,#12,#15,#17) 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,#12: There was not evidence of a bereavement assessment. Patient #15: The patient was admitted on 11/7/24. The bereavement assessment was completed on 11/19/24. Patient #17: The patient was admitted on 8/15/24. The bereavement assessment was completed on 8/22/24

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

Upon patient record review, 2 of 23 records (Patient #12,#18) did not have evidence that a Registered Nurse ensured continuous assessment of the patient and family's needs and coordinated 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 #12: Nurse documentation dated 12/27/24 indicated that the patient had a deep tissue injury on both heels. There was not evidence of an assessment or dressing change since this date. Patient #18: On 10/12/24, the record contained orders for wound care to a coccyx wound. On 10/28/24, the record indicated a skin tear. There was not evidence of assessments, measurements, or wound care, or if the wound was still present or was healed.

Upon patient record review, 6 of 23 records (Patient #1,#6,#8,#10,#12,#15) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient 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 record indicated that the patient resided at home. The plan of care had goals and interventions for facility coordination. Corrected on site. Patient #6: The record indicated that the patient was on Eliquis. There was not evidence of bleeding precautions on the plan of care. Corrected on site. In addition, The patient was admitted with a diagnosis of cerebral atherosclerosis. The record indicated that the patient was confused, dependent for bathing, dressing, grooming and toileting. She also had decreased muscle coordination, balance problems and was disoriented X3. There was not evidence that the plan of care reflected patient/family goals and interventions based on the neurological problems. Corrected on site. Patient #8: The record indicated that the patient was on Xarelto daily. There was not evidence of bleeding precautions on the plan of care. Corrected on site. Patient #10: The patient was admitted with a diagnosis of malignant neoplasm of the esophagus. The patient was only able to eat small bites and a small amount of food. Eating would lead to vomiting. He had dysphasia when eating solids. He had Barrett's esophagus and weight loss. There was not evidence of nutritional needs in the plan of care. Corrected on site. In addition, GI listed only assess for signs and symptoms of impaired GI system without addressing the issues that the patient had. Corrected on site. Patient #12: The plan of care contained problems with goals and interventions for assessing and managing a gastrostomy tube and a tracheostomy. There was not evidence that the patient had either of these devices. Corrected on site. Patient #15: The record indicated that the patient had a history of bladder cancer. His primary hospice diagnosis was end stage renal, and he was having hematuria with clots. There was not evidence that the plan of care reflected patient/family goals and interventions based on this problem. Corrected on site.

Upon patient record review, 4 of 23 records (Patient #1,#7,#10,#11) 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 #1: The visit frequency for the social worker was for an evaluation. The evaluation was conducted on 8/26/24. After the evaluation, the visit frequency for the social worker was for 2 prn. This is not a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Patient #7: The initial visit frequency upon admission for the social worker and the spiritual care counselor was 2 prn. This is not a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Patient #10: The visit frequency for the spiritual care counselor dated 11/19/24 was 2 prn effective 2/1/25. This is not a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Patient #11: The visit frequency for the social worker and the spiritual care counselor at admission was 1 prn for an evaluation. This is not a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.

Upon patient record review, 5 of 23 records (Patient #5,#7,#8,#10,#18) 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 #5: Vistaril was included on the facility MAR There was not evidence of an order in the hospice record. Corrected on site. Patient #7: The record contained an order for oxygen 2L/min continuous without evidence of a route. Corrected on site. Patient #8: The record contained an order for Hydrocortisone 1% topical cream to affected areas. There was not evidence of a specific location or a specific frequency. Corrected on site. Also, Duo-nebs, Vistaril and joint supplement were on the facility MAR but there was not an order in the hospice record. Corrected on site. In addition, Nystatin 100,000/Gm topical powder to affected area without evidence of a specific location. Corrected on site. Patient #10: The record contained an order for Acetaminophen 325mg 2 caps q4h prn pain or fever and Acetaminophen 650mg rectal suppository 1 q4h prn fever. There was not evidence of a maximum allowable dose for 24h or a parameter for fever. Corrected on site. Patient #18: The record contained an order for Latanoprost eye drops, 1 drop at bedtime without evidence of which eye.

Upon client record review, 1 of 23 records (Patient #20) 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 #20: The patient was discharged for extended prognosis/no longer meeting criteria, on 8/26/24. There was not evidence of discussion or collaboration with the IDG prior to delivering the NOMNC, to discuss and to plan for the discharge.

Upon patient record review, 3 of 23 records (Patient #11,#12,#18) 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 #11: The record indicated that a Foley catheter was inserted on 11/21/24. There was not evidence that the revised plan of care included information from the patient's updated comprehensive assessment. Patient #12: Nurse documentation dated 12/27/24 indicated that the patient had a deep tissue injury on both heels. There was not evidence that wounds were a part of the care plan. Patient #18: On 10/12/24, the record contained orders for wound care to a coccyx wound. On 10/28/24, the record indicated a skin tear. There was not evidence that a revised plan of care includes information from the patient's updated comprehensive assessment.

Upon client record review, 8 of 23 records (Patient #1,#8,#10,#11,#14,#15,#17,#18) 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 visit frequency for the social worker for the benefit period beginning 11/21/24 was 1m4. There was not evidence of a visit by the social worker for this benefit period. Patient #8: The frequency for the volunteer was 1x/month to start 12/4/24. The record indicated visits were conducted on 12/11/24 and 12/17/24. Patient #10: The visit frequency for the social worker for the benefit period beginning 11/19/24 was 1m3. There was not evidence of a visit by the social worker. In addition, the visit frequency for the spiritual care counselor was 1m3. There was not evidence of a visit in December. Patient #11: The record indicated an order dated 11/21/24 to insert a 16F Foley catheter with a 10cc Balloon, with no order to change or irrigate the catheter. Documentation revealed that the catheter was changed on 12/24/24 due to a triage call stating that the catheter was leaking. (There was not evidence of an order). Corrected on site. Patient #14:The visit frequency for the social worker for the benefit period beginning on 12/11/24 was 1m3. There was not evidence of a visit by the social worker for this certification period. Patient #15: The visit frequency for the spiritual care counselor was 1m1, 2m2 effective 11/11/24. The record indicated only 1 visit for month 2 (December). Patient #17: The social work frequency for the benefit period beginning on 11/13/24 was 2m3, 1m1. The record indicated only 1 missed visit document in November and 1 visit in December. Patient #18: The visit frequency for the spiritual care counselor effective 11/1/24 was 1x/week until 1/10/25 when they were decreased to 1x/month. Visits were conducted only on 11/22/24, 11/29/24, 12/9/24, 12/27/24 and 1/3/25. In addition, the social work visit frequency for the benefit period beginning 10/10/24 was 1m3. There was not evidence of a visit in October.

Upon patient record review 2 of 23 records (Patient #1,#16) 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 #1: The visit narrative by the social worker dated 8/26/24 indicated that the patient/family was interested in meals on wheels. There was not evidence of follow-up. Patient #16: The record indicated that the patient was interested in updating his POA to make his x-wife his MPOA. The social worker note from admission dated 11/21/24 revealed that the SW would help to coordinate this. There was not evidence of follow-up.

Upon patient record review, 1 of 23 records (Patient #15) did not have evidence that Social work services are based on the patient's psychosocial assessment and the patient/family's needs and acceptance of these services. Patient #15: The initial bereavement assessment that was conducted upon admission indicated that the patient's spouse was a high risk. There was not evidence of follow-up for bereavement due to the risk level.

Upon patient record review, 4 of 23 records (Patient #1,#5,#7,#11) 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 including alerts and precautions, 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 #1: The aide plan of care indicated to change linens on Monday, Wednesday and Friday. The aide visit frequency was 2x/week. Corrected on site. Patient #5: The record indicated that the patient had a fall on 11/10/24. The recertification visit conducted by the nurse indicated that the patient was a fall risk and had sustained falls within the past 3 months. There was not evidence of fall precautions on the aide plan of care. Corrected on site. Patient #7: The patient was on Plavix 75 mg daily. On 1/7/25, she had an episode of blood in her urine. There was not evidence that bleeding precautions were on the aide plan of care. Corrected on site. Patient #11: The aide plan of care indicated to provide a shower every visit and to provide a bed bath every visit. Corrected on site.

Upon patient record review 4 of 23 records (Patient #4,#7,#11,#17) 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: The aide plan of care indicated to provide nail care weekly. The aide visit frequency was 2x/week. The record indicated that nail care was provided at most visits. Patient #7: The aide plan of care indicated to provide a shower, haircare, shampoo, and linen change 1x/week. The aide visit frequency was 2x/week. For the week of 1/12/25-1/18/25, these tasks were conducted at both visits. Patient #11: The visit frequency for the aide was increased on 1/6/25 to 2x/week on Mondays and Thursdays. For the week of 1/5/25-1/11/25, the record indicated only 1 visit (On a Wednesday). For the week of 1/12/25-1/18/25, visits were conducted on Monday and Wednesday. In addition, the tasks of check for emesis, date of last BM and weight were all ordered every visit. For many visits, the documentation by the aide indicated, 'per frequency not needed.' There was also documentation stating, 'completed by other assigned HHA.' There was not evidence that another aide was assigned to provide care. Patient #17: The aide plan of care indicated to provide a shower weekly. The aide visit frequency was 2x/week. The aide documentation revealed that a shower was provided at all visits.

Upon observation, and client record review. 9 of 23 records (Patient #1,#2,#6,#7,#8,#10,#15,#17,#18) did not contain evidence that a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family.

Upon observation, and record review 9 of 23 records (Patient #1,#2,#6,#7,#8,#10,#15,#17,#18) did not contain evidence that the hospice discussed the policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and the family in a language and manner that they understand to ensure that these parties are educated regarding the safe use and disposal of controlled drugs.

Upon client record review, 9 of 23 record (Patient #1,#2,#6,#7,#8,#10,#15,#17,#18) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed.

Upon client record review, 2 of 23 records (Patient #5,#11) 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 #5: The visit frequency for the social worker for the benefit period beginning on 12/10/24 was 2m1, 3m1,1m1. There was not evidence of 2 visits for month 1 (December). Patient #11: Upon admission, the record indicated that a volunteer was accepted. There was not evidence of follow-up. Corrected on site.

Upon client record review, 1 of 6 (Patient #5) did not have evidence that the plan of care included IDG's documentation of the patient's or families level of understanding, involvement and agreement with the plan of care. Patient 5: There was no evidence of the patient or family's level of understanding, involvement, and agreement with the plan to discharge.

Upon patient record review, 1 of 6 (Patient #1) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 1: The medication profile contained oxygen with no defined delivery method. Corrected on site.

Upon patient record review, 1 of 6 (Patient #1) 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 1: The medical record contained nursing documentation since admission identifying patient has wounds to bilateral dorsum. There was no evidence of wound measurements between 12/3/23 and 12/16/24 as required per agency policy for weekly measurements.

Upon patient record review, 1 of 6 (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 medications and treatments. Patient 1: The medical record contained an order for oxygen with no defined delivery method. Corrected on site.

Upon patient record review, 2 of 6 (Patients #1,#2) 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 upon admission identifying patient use of oxygen, a nebulizer, and hospital bed. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 2: The medical record contained nursing documentation upon recertification assessment 11/22/24 identifying patient use of bedrails. There was no evidence of an order for the rails included in the plan of care.

Upon patient record review, 4 of 6 (Patients #2,#3,#4,#5) 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: There was no evidence the revised plan of care 10/24/24, 11/21/24, and 12/5/24 included clinical updates on patient progress towards goals. There was no evidence of a revised plan of care on 11/7/24. Patient 3: There was no evidence the revised plan of care 10/30/24, 11/13/24, ang 11/27/24 included clinical updates on patient progress towards goals. Corrected on site with late data entry. Patient 4: There was no evidence the revised plan of care 10/24/24 and 11/7/24 included clinical updates on patient progress towards goals and plan to discharge patient due to extended prognosis. Patient was discharged 11/11/24. Patient 5: There was no evidence the revised plan of care 10/17/24 and 10/31/24 included the plan to discharge patient due to extended prognosis. Patient was discharged 11/2/24.

Upon patient client record review, 1 of 6 (Patient #5) did not evidence that each patient record contains physician orders. Patient 5: There was no evidence of an order to discharge patient due to extended prognosis.

Upon personnel record review, 1 of 4 (Personnel #1) 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 1: There was no evidence of a criminal background check.

Upon patient record review, 4 of 16 records (Patients #2,#12,#13,#15) 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 2: The medication profile contained duplicative oxygen instructions PRN, one stated 2L and one stated 2-5L, neither identified delivery method. Corrected on site. Patient 12: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. Corrected on site. Patient 13: The medication profile contained oxygen with no delivery method. Patient 15: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile.

Upon patient record review, 2 of 16 records (Patients #1,#12) 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 1: The medical records contained an initial bereavement assessment dated 3/14/22. Patient admitted 2/24/22. Patient 12: The medical records contained an initial bereavement assessment dated 1/6/22. Patient admitted 9/9/20.

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

Upon patient record review, 5 of 16 records (Patients #1,#2,#7,#8,#10) 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 contained evidence patient was receiving home health aide services. There was no evidence of a problem statement, goals and interventions for HHA services included in the plan of care. corrected on site. Patient 2: The plan of care identified active problem statement for social worker. Patient was not currently receiving social worker services. Corrected on site. Patient 7: The plan of care continued to identify active problems for PT and OT. Patient received order for eval at admission and no further orders or treatment from PT and OT. Patient 8: The plan of care identified active problem statement for social work. Patient was not receiving MSW services. The plan of care identified problems of need for skilled teaching related to care of gastrostomy and altered genitourinary function. There was no evidence of goals and interventions for gastrostomy and genitourinary problems identified. Corrected on site. Patient 10: The medical record contained nursing documentation upon admission identifying dyspnea and orthopnea. There was no evidence of problems, goals, or interventions related to respiratory deficits included in the plan of care.

Upon patient record review, 6 of 16 records (Patients #2,#8,#11,#12,#13,#15) 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 medical record contained wound care order 2/9/22 with no identified location of wound for care. There was identified use of oxygen with no evidence of order. corrected Patient 8: The medication profile contained medications with route for administration via feed tube. There was no evidence of a treatment order for instructions to flush the feeding tube with med administration. Corrected on site. Patient 11: The medical record contained nursing documentation 2/15/22 identifying patient use of bipap. There was no evidence of a treatment order for settings, parameters, and frequency. Patient 12: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen. Patient 13: The medical record contained an order for oxygen with no delivery method. Patient 15: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen.

Upon patient record review, 10 of 16 records (Patients #1,#3,#7,#8,#10,#11,#12,#13,#15,#16) 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 medication profile contained medication with use of nebulizer. There was no evidence of the nebulizer being included as equipment on the plan of care. Patient 3: The medication profile contained oxygen and bipap settings. There was no evidence of the oxygen and bipap being included as equipment on the plan of care. Patient 7: The medical record contained nursing documentation upon admission identifying patient use of a commode and cane 2/15/22. There was no evidence of the the commode and cane being included as equipment on the plan of care. Corrected on site. Patient 8: The medical record contained nursing documentation upon admission identifying patient use of a walker, wheelchair, commode, and shower chair. There was no evidence of the the nebulizer being included as equipment on the plan of care. Corrected on site. Patient 10: The medical record contained nursing documentation upon admission identifying patient use of a nebulizer. There was no evidence of the the nebulizer being included as equipment on the plan of care. Corrected on site. Patient 11: The medical record contained nursing documentation upon admission identifying patient use of a nebulizer, over the bed table and bipap. There was no evidence of the the nebulizer, table and bipap being included as equipment on the plan of care. Corrected on site. Patient 12: The medical record contained nursing documentation upon admission identifying patient use of oxygen and an over the bed table, and a mechanical lift on 3/7/22. There was no evidence of the oxygen, table and lift being included as equipment on the plan of care. mechanical lift, oxygen, over bed table. Corrected on site. Patient 13: The medical record contained nursing documentation upon admission identifying patient use of a walker. There was no evidence of the walker being included as equipment on the plan of care. Patient 15: The medical record contained nursing documentation upon admission identifying patient use of oxygen, hospital bed, bed rails, and a commode. There was no evidence of the oxygen, bed, rails, and commode being included as equipment on the plan of care. Patient 16: The medical record contained nursing documentation upon admission identifying patient use of a walker. There was no evidence of the walker being included as equipment on the plan of care.

Upon client record review, 3 of 16 records (Patient #9, #11, #16) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 9: The medical record contained scheduled spiritual care visits 1/13, 2/11, and 3/7. There was no evidence of an order for scheduled frequencies identified in the plan of care. Patient 11: The medical record contained scheduled social work visits. There was no evidence of an order for scheduled frequencies identified in the plan of care. Patient 16: The medical record contained ordered nursing frequency of 4 visits for the week of 2/13/22. There was evidence of 3 visits and no documentation regarding missed frequency.

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 4: The medical record contained nursing documentation 3/10/22 identifying patient fall. There was no evidence of a report and investigation completed to prevent similar events. Corrected on site.

Upon observation, there was no evidence in the QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. Patient 14: The medical record contained an order for cipro 1/28/22 to treat a UTI. There was no evidence of an infection report to identify, investigate and survey the infection for QAPI. Corrected on site.

Upon patient client record review, 1 of 16 records (Patient #5) 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 5: The medical record contained presence of oxygen equipment and safety instructions documented in RN visit 3/9/22. Leadership investigated issue during survey to inquire presence of an order and confirmed there was no oxygen present in the home, hence why oxygen was not on the medication profile and there was not an order for the oxygen.