Every finding on record at Odyssey Healthcare Operating A, LP

Upon patient record review, 1 of 5 (Patient #5) 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 5: The medical record contained nursing documentation upon admission identifying patient use of a shower chair. There was no evidence of an order for the shower chair included in the plan of care.

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

Upon patient record review, 1 of 5 (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: No evidence found of wound measurement from the week of 2/19/24 through 3/12/24. Wound assessment completed in entirety within EMR with all other required documentation completed. Verified with leadership agency policy is for wound measurements to be obtained weekly.

Upon patient record review, 1 of 5 (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: Plan of Care at the time of admission on 2/15/24 does not contain a route for Oxygen. Clarification order found dated 2/25/24 adding per Nasal Cannula.

Upon patient record review, 2 of 5 (Patient #1 & 3) 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: Admission assessment per RN states WC is needed by patient with a walker present in home. Neither of these items are present on Plan of Care. Patient 3: Admission assessment per RN states hospital bed, bed rails, and BSC are present in home. These items are not found on Plan of Care.

Upon client record review, 1 of 5 (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 4: Foley catheter changed 2/14/24 per nursing documentation. MD order states to change catheter every 3 weeks and as needed with no evidence of change from 2/14/24-3/12/24.

Upon patient client record review, 2 of 5 (Patient #1 & 4) 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: RN admission assessment 2/15/24 documents Oxygen as "continuous". Plan of Care and medication list have Oxygen as "PRN". Patient 4: Recertification Plan of Care specifies catheter size as 18Fr on 1/18/24. RN documentation states catheter is 20Fr on 2/5/24. No evidence found of an order for a size 20Fr catheter or a change in catheter utilizing a 20 Fr. Documentation at the time of catheter change on 2/14/24 states present catheter size as 18Fr.

Upon patient record review, 1 of 19 (Patient #2) 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. Patient 2: There was no evidence that information was provided to patient regarding advanced directives.

Upon patient record review, 1 of 19 (Patient #2) 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. Patient 2: There was no evidence confirming receipt of patient rights and responsibilities.

Upon patient record review, 1 of 19 (Patient #2) did not have evidence of the appropriate documentation for release of confidential information. Patient 2: There was no evidence of documentation for release of confidential information located in chart.

Upon patient record review 2 of 19 (Patients #10,#13) 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 10: The medical record contained an initial comprehensive spiritual assessment completed 6/13/23. Patient admitted to hospice 6/5/23. Patient 13: The medical record contained an initial comprehensive spiritual assessment completed 10/26/23. Patient admitted to hospice 10/18/23.

Upon patient record review 2 of 19 (Patients #5,#12) 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 5: There was no evidence of a comprehensive spiritual assessment. Patient 12: There was no evidence of a comprehensive spiritual assessment.

Upon patient record review, 6 of 19 (Patients #2,#3,#5,#9,#11,#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 2: The medication profile contained nursing documentation upon admission identifying patient use of oxygen. The medication profile did not contain oxygen and contained polyethylene glycol oral powder with no instructions for a diluent. Corrected on site. Patient 3: The medication profile contained miralax oral powder with no instructions for a diluent and oxygen with no delivery method. Corrected on site. The medication profile also contained warfarin tablets with frequency as directed, dose per instructions, and instructions state amount given varies depending on day. Patient 5: The medication profile contained oxygen with no delivery method. Corrected on site. Patient 9: The medical record contained an order for oxygen equipment. There was no evidence of oxygen listed on the medication profile and polyethylene glycol oral powder contained no instructions for a diluent. Corrected on site. Patient 11: The medication profile contained nursing documentation upon admission identifying patient use of oxygen. The medication profile did not contain oxygen. Corrected on site. Patient 13: The medication profile contained nursing documentation upon admission identifying patient use of oxygen. The medication profile did not contain oxygen and contained polyethylene glycol oral powder with no instructions for a diluent. Corrected on site.

Upon patient record review, 2 of 19 (Patients #7,#14) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 7: There was no evidence of a comprehensive physical assessment completed by an RN since 1/4/24. Patient 14: There was no evidence of a comprehensive physical assessment completed by an RN between 1/2/24 and 1/23/24.

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

Upon patient record review, 1 of 19 (Patient #4) 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 4: There was no evidence of wound assessments between 12/1/23 and 12/22/23, and 12/22/23 and 1/3/24. the care plan orders stated SN to assess and measure at least weekly.

Upon patient record review, 4 of 19 (Patient #1,#3,#5,#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 contained nursing documentation upon admission identifying patient had chronic issues with hypotension causing fainting, dizziness, and falls. There was no evidence of problems, goals, and interventions related to cardiac dysfunction and fall safety. Corrected on site. Patient 3: The medication profile contained instructions for insulin based on a sliding scale. There was no evidence of problems, goals, and interventions related to endocrine dysfunction. Corrected on site. Patient 5: The medical record contained nursing documentation upon admission identifying patient was a high fall risk. There was no evidence of problems, goals, and interventions related to fall safety. Patient 8: The medical record contained nursing documentation upon admission identifying patient was a high fall risk. There was no evidence of problems, goals, and interventions related to fall safety. Corrected on site.

Upon patient record review, 6 of 19 (Patients #2,#3,#5,#9,#11,#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 2: The medication profile contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen dose, frequency, and delivery method. The medical record also contained an order for polyethylene glycol oral powder with no instructions for a diluent. Corrected on site. Patient 3: The medical record contained orders for miralax oral powder with no instructions for a diluent and oxygen with no delivery method. Corrected on site. The record also contained an order for warfarin with no dose and frequency. Patient 5: The medical record contained an order for oxygen with no delivery method. Corrected on site. Patient 9: The medication profile contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen dose, frequency, and delivery method. The medical record also contained an order for polyethylene glycol oral powder with no instructions for a diluent. Corrected on site. Patient 11: The medication profile contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen dose, frequency, and delivery method. Corrected on site. Patient 13: The medication profile contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen dose, frequency, and delivery method. The medical record also contained an order for polyethylene glycol oral powder with no instructions for a diluent. Corrected on site.

Upon patient record review, 9 of 19 (Patients #1,#2,#3,#4,#6,#7,#8,#13,#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: The medical record contained nursing documentation upon admission and 12/7/23 identifying patient use of a hospital bed, bedside table, commode, and wheelchair. There was no evidence of orders for the listed equipment included in the plan of care. Patient 2: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, bedside table, and wheelchair. There was no evidence of orders for the listed equipment included in the plan of care. Corrected on site. Patient 3: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, bedside table, nebulizer, and wheelchair. There was no evidence of orders for the listed equipment included in the plan of care. Corrected on site. Patient 4: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, bed rails, bedside table, trapeze, wheelchair, and oxygen equipment. There was no evidence of orders for the listed equipment included in the plan of care. Corrected on site. Patient 6: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, and wheelchair. There was no evidence of orders for the listed equipment included in the plan of care. Corrected on site. Patient 7: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, bedrails, bedside table, commode, and wheelchair. There was no evidence of orders for the listed equipment included in the plan of care. Corrected on site. Patient 8: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed and bedside table. There was no evidence of orders for the listed equipment included in the plan of care. Corrected on site. Patient 13: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed and wheelchair. There was no evidence of orders for the listed equipment included in the plan of care. Corrected on site. Patient 14: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, bedrails, trapeze, wheelchair, Hoyer lift, and CPAP. There was no evidence of orders for the listed equipment included in the plan of care. Corrected on site.

Upon client record review, 5 of 19 (Patients #4,#6,#8,#10,#14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 4: The medical record contained an ordered nursing frequency of twice weekly. There was no evidence of a second visit completed the week of 1/14/24. Patient 6: The medical record contained an ordered nursing frequency of twice weekly. There was no evidence of a second visit completed the week of 1/14/24. Patient 8: The medical record contained an ordered spiritual frequency of once weekly starting 1/1/24. There was no evidence of a visit completed the week of 1/14/24. Patient 10: The medical record contained an ordered spiritual frequency of once monthly. There was no evidence of a visit completed December 2023. Patient 14: The medical record contained an ordered nursing frequency of once weekly. There was no evidence of a visit completed the week of 1/7/24.

Upon patient record review, 4 of 19 (Patients #1,#4,#6,#7) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 1: The aide care plan contained a task to shower every visit and bed bath every visit if patient unable to complete shower or per request. There was no information on the aide care plan declaring if patient is able to make their own decisions. Corrected on site. Patient 4: There was no evidence of instructions for transfer assistance needed included on the aide care plan. Corrected on site. Patient 6: There was no evidence of instructions for transfer assistance needed included on the aide care plan. Corrected on site. Patient 7: The aide care plan contained tasks to obtain temperature, complete oral care, change linens, and wheelchair PRN, and a task to obtain respirations. There were no parameters for reporting temperature and respirations, and no information declaring if patient is able to make their own decisions. There was no evidence of instructions for transfer assistance needed included on the aide care plan. The tasks for temperature and respirations were removed and transfer assist requirements were added on site.

Upon patient record review 5 of 19 (Patients #1,#4,#6,#7,#8) 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 1: The medical record contained an ordered frequency for aide visits once weekly. There was no evidence of a visit completed the week of 1/7/24. Patient 4: The medical record contained an ordered frequency for aide visits twice weekly. There was no evidence of second visits completed the weeks of 12/17/23 and 1/14/24. In addition, the medical record contained a missed aide visit document with unclear description of date of missed visit and reason unable to complete. The template in the form was incomplete. Patient 6: The medical record contained an ordered frequency for aide visits once weekly. There was no evidence of a visit completed the week of 1/17/24. The record did contain a coordination note labeled missed visit entered 1/17/24 with no information to explain reason visit was not completed. Patient 7: The medical record contained an ordered frequency for aide visits twice weekly. There was no evidence of aide visits completed since admission. Patient 8: The medical record contained an ordered frequency for aide visits once weekly. There was no evidence of a visit completed the week of 12/24/23.

Upon personnel record review, 1 of 14 (Personnel #5) did not have evidence in the hospice aide personnel file that a registered nurse made an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. Personnel 5: There was no evidence of an annual on-site observation visit.

Upon patient client record review, 3 of 19 (Patients #2,#3,#8) 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: There was no evidence the patient/representative received a copy of the patient rights. Patient 3: The medical record contained an election form identifying the patient representative elected to receive the notification of non-covered items upon admission 9/26/22. The notification was provided outside of the allowed 5 day time period on 10/5/22. Patient 8: The medical record contained an election form identifying the patient representative elected to receive the notification of non-covered items upon admission. There was no evidence the patient representative received the notification.

Upon client record review, 1 of 19 (Patient #18) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary Patient 18: There was no evidence the discharge summary was sent to an attending physician for continuity of care.

Upon client record review, 1 of 19 (Patient #2) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient 2: There was no evidence patient was provided verbally and written policies and procedures for managing controlled drugs.

Upon SNF/NF contract review, 1 of 6 (West Hills contract) did not have evidence of a provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.

Upon SNF/NF contract review, 1 of 6 (OHSU hospital contract) did not have evidence that it is the hospice's responsibility to provide services at the same level and to the same extent as those services would be provided if the SNF/NF resident were in his or her own home.

Upon SNF/NF contract review, 1 of 6 (West Hills contract) did not have a delineation of the hospice's responsibilities, which include, but are not limited to the following: providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary and bereavement); social work; provision of medical supplies, durable medical equipment and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions.

Upon SNF/NF contract review, 1 of 6 (OHSU hospital contract) did not have a provision that the hospice may use the SNF/NF nursing personnel where permitted by state law and as specified by the SNF/NF to assist in the administration of prescribed therapies included in the plan of care only to the extent that the hospice would routinely use the services of a hospice patient's family in implementing the plan of care.

Upon SNF/NF contract review, 1 of 6 (OHSU hospital contract) did not have a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation.

Upon SNF/NF contract review, 1 of 6 (OHSU hospital contract) did not have a delineation of the responsibilities of the hospice and the SNF/NF to provide bereavement services to SNF/NF personnel.

Upon client record review, 1 of 19 (Patient #2) 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 2: The medical record contained an ordered nursing frequency of twice weekly. There was no evidence of a second visit completed the week of 1/14/24.

Upon personnel record review, 1 of 14 (Personnel #6) did not have evidence that all Medical Social Services are provided by a qualified Medical Social Worker in accordance with the state's Social Work Practice Act, the hospice's policies and procedures and/or job descriptions. Personnel 6: There was no evidence the social worker was registered with the state of Oregon as required per state job description requirements.

Upon personnel record review, 1 of 14 (Personnel #14) 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.