Every finding on record at Odyssey Healthcare Operating A, LP

Upon client record review, 1 of 5 records (Patient #2) 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 order for spiritual care was effective 7/26/2022 4EVERY1M2, 4M1, 3M1, 3 PRN for spiritual support however, there was not evidence of visit the week of 07/31/2022.

Upon patient client record review, 1 of 5 records (Patient #2) 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 #2: The record indicated on plan of care effective 07/26/2022 for social work visits 3E2M2, 2M1, 1M1, 3 PRN for psychosocial support however, on the order the social worker added (once per week for 3 weeks, then every other week , with 3 PRNS for support).

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.

Upon observation, there was no evidence the Emergency Plan communication plan includes alternate means for communicating with hospice's employees.

Upon patient record review 1 of 13 records (Patient #6) 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 #6: The patient was admitted on 2/24/22. The record indicated that the spiritual assessment was completed on 3/2/22.

Upon patient record review 2 of 13 records (Patient #1,#8) 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 and 8: There was not evidence of a spiritual assessment.

Upon patient record review, 3 of 13 records (Patient #6,#8,#10) 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 #6: The record indicated an order dated 6/1/22 for Cipro 500mg, 1 tab BID (for a UTI) x 7 days. This medication remained listed in the medication profile. The nurse documentation dated 5/29/22 indicated that the daughter put Hydrocortisone cream on the patient's legs due to a pink color and itchiness. There was not evidence that this was in the medication profile. Corrected on site. Patient #8: The medication profile contained Acetic acid 0.25% irrigation solution. Flush indwelling Foley catheter daily, dated 5/15/22. An order dated 6/1/22 indicated to discontinue all previous catheter flushes. The Acetic acid flush continues to be on the medication profile. Corrected on site. Patient #10: The medication profile included Hydrogen peroxide and normal saline, mix 1/2 peroxide and 1/2 normal saline to help ear wax dissolve, date 6/3/22. There was not evidence of a frequency.

Upon patient record review, 2 of 13 records (Patient #2,#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 #2: The patient was admitted on 3/2/22. The record indicated that the bereavement assessment was completed on 4/28/22. Patient #12:The patient was admitted on 11/19/21. The record indicated that the bereavement assessment was completed on 12/1/21.

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

Upon patient record review, 1 of 13 records (Patient #1) 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 #1: A coordination note from triage dated 4/2/22 at 8:58 am indicated a call from the patients wife where she stated in the call that the patient had significant chest pain through the night. She described that the patient had Cheyne Stokes breathing, and episodes of shortness of breath. Also that she gave the patient 4 NTG tablets 5 minutes apart and at 3:30 am, she administered 4 doses of Morphine 1 hour apart. She denied having oxygen in the home and stated that the patient was moaning. The record then indicated that a message would be sent to the RNOC (RN on call) to contact the caregiver for further assistance with a plan /prn visit to assess changes and concerns. There was not evidence of follow up. The next documented visit was the routine visit on 4/4/22 by the case manager and documentation revealed that the patient was comfortable at this visit. At this visit, the caregiver did relay that the patient had a rough Friday night into Saturday.

Upon patient record review, 5 of 13 records (Patient #1,#4,#7,#12,#13) 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 several visits by the spiritual care counselor where the patients wife indicated that she was tired and received no respite time away from the patient, a comment that the patient talked about ending his life and also that the patient was depressed. There was not evidence that the plan of care reflected patient/family goals and interventions based on the problems identified. Corrected on site. Patient #4: The record indicated that the spiritual care counselor conducted visits and provided spiritual counseling to the patient and caregivers. There was not evidence that the plan of care reflected patient/family goals and interventions based on the problems identified. Corrected on site. Patient #7: The spiritual care counselor conducted visits on 2/25/22, 4/25/22, 5/3/22, 5/9/22, 5/19/22, 5/24/22, and 6/1/22. There was not evidence that the plan of care reflected patient/family goals and interventions based on the problems identified. Corrected on site. Patient #12: The spiritual care counselor visit frequency was for an evaluation then 3 every 2m2, 2m1, 1m1 and 4 prn. The record indicated that visits were conducted however there was not evidence that the plan of care reflected patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments in regards to the patients and the family's spiritual wellness. Patient #13: The spiritual care counselor visit frequency was for an evaluation then 1 every 2m2, 1m2, and 4 prn. The record indicated that visits were conducted however there was not evidence that the plan of care reflected patient/family goals and interventions based on the problems identified.

Upon patient record review, 5 of 13 records (Patient #1,#3,#4,#7,#9) did not have evidence the plan of care 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 spiritual care counselor written on 4/11/22 was 3 prn effective 4/11/22. Patient #3: The visit frequency for the spiritual care counselor dated 4/6/22 was 1 prn, another order was 5 prn effective 4/6/22. On 5/10/22, the order was 1m1 and 3 prn and then another order effective 6/1/22 was 3 prn. Patient #4: For the benefit period starting 5/6/22, the frequency was 3 prn, then ordered 2m1 and 2 prn effective 5/6/22, then 3 prn effective 6/1/22. Patient #7: The visit frequency for the spiritual care counselor was for an evaluation. On 4/20/22and order was written for 3 prn effective 4/1/22, on 4/25/22, an order was written for 5 prn effective 4/1/22. An order was then written effective 5/24/22 for a frequency of 1m1 and 2 prn and then another order on 6/1/22 for 3 prn. Patient #9: The spiritual care counselor visit frequency was for an initial evaluation. an order was written on 3/30/22 for 3 prn visits effective 3/25/22 and then another order on 6/1/22 for 4 prn.

Upon patient record review, 3 of 13 records (Patient #2,#6,#10) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2: The nurse narrative in the IDG dated 6/8/22 indicated that education was provided to the patients wife about low blood sugar and not giving the insulin when the blood sugar is low. There was not evidence of an order for parameters related to administering/not administering insulin for low blood sugars. Patient #6: The nurse documentation dated 5/29/22 indicated that the daughter put Hydrocortisone cream on the patient's legs due to a pink color and itchiness. There was not evidence of an order. Corrected on site. Patient #10: The record indicated an order dated 6/3/22 for Hydrogen peroxide and normal saline, mix 1/2 peroxide and 1/2 normal saline to help ear wax dissolve. There was not evidence of a frequency.

Upon patient record review, 3 of 13 records (Patient #8, 10 and 11) 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 #8: IDG narrative statements by the social worker for the dates of 5/4/22, 5/18/22, and 6/1/22 indicated that the social worker 'has no open problems.' The social work visit frequency was indicated at an initial then 1 every 2m2,1m1 and 1 prn. The record indicated that the current problems with goals and interventions were imminence of death, environmental, companionship, personal affairs and grieving. The record indicated only 1 visit was conducted on 3/28/22. Patient #10 The record indicated, in an IDG narrative by the nurse that the 'patient fell in the middle of the night,' and in an IDG dated 6/1/22, that 'the patient had a fall and hit her eye.' There was not evidence that the plan of care was updated to include fall precautions. Corrected on site. Patient #11: The IDG held on 4/13/22 indicated that the patient was dependent for 6/6 ADL's, she was a 7E on the FAST scale, dysphasic and would cough. She had increased agitation and pain with movement. The scribe noted to 'see the recertification notes by the RN and the Medical Director for evidence of decline.' There was no evidence of a discussion regarding improvement, no longer meeting hospice criteria or plans to discharge the patient. The patient was discharged for extended prognosis on 4/16/22.

Upon client record review, 7 of 13 records (Patient #3,#7,#8,#9,#10,#11,#12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: During an observed home visit, the patient developed respiratory distress and required oxygen. The caregiver placed oxygen on the patient at 5L/min via mask. The plan of care order in the record indicated for 1-5L/min via nasal cannula. Corrected on site In addition, a phone visit (evaluation) was conducted by the spiritual care counselor on 1/10/22 without evidence that telehealth was in the plan of care. Patient #7: The visit frequency for the social worker was for an evaluation and then 1m3 and 1 prn. The evaluation was conducted on 3/1/22, a visit on 3/29/22 and no evidence of a visit in April or May. Patient #8: The social work visit frequency was indicated at an initial evaluation then 1 every 2m2,1m1 and 1 prn. The record indicated that only 1 (evaluation) visit was conducted on 3/28/22. No evidence of a visit in May Patient #9: A phone visit (evaluation) by the spiritual care counselor was conducted on 3/30/22 without evidence that telehealth was in the plan of care. This visit was conducted with the son, and not the patient. Patient #10: A phone visit (evaluation) by the social worker dated 5/2/22 was conducted without evidence that telehealth was in the plan of care. Patient #11: A phone visit (evaluation) by the spiritual care counselor was conducted on 2/21/22 without evidence that telehealth was in the plan of care. In addition, the visit frequency for the social worker was 1 every 2m2, 1m1, 1 prn. The record indicated an evaluation was conducted on 2/21/22 and further visits were conducted on 3/24/22 and 4/14/22. Patient #12: The week beginning on 12/5/21, the record indicated 2 visits (should be 1), for the week beginning on 12/12/21, the record indicated 2 visits (should be 3), and for the week starting 12/26/21, the record indicated 2 visits (should be 3).

Upon patient record review, 2 of 2 applicable records (Patient #12,#13) did not have evidence that 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. • 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 #12,#13: The bereavement plan of care indicated to send a card 2 weeks after the death of the patient. There was not evidence that this card was sent.

Upon medical record review, 1 of 13 records (Patient #2) did not have evidence in the patient record that the hospice has offered and/or provided spiritual counseling in accordance with the patient/family's desires which include: • Providing spiritual counseling to meet these needs in accordance with the patient's and family's acceptance of this service and in a manner consistent with their beliefs and desires • Making all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or other individuals who can support the patient's spiritual needs to the best of their ability Patient #2: The spiritual care counselor evaluation indicated that the patient's spouse talked about 'Last Rites,' and that the patient's illness does not seem real. Also a phone call by the spiritual care counselor dated 4/8/22 indicated that the patient's spouse was not religious or spiritual but it seemed like the patient was seeking to renew his Catholic commitment to church and might be interested in a visit from a priest (St Joseph's). There was not evidence of follow up. Corrected on site.

Upon patient record review, 1 of 9 applicable records (Patient #8) did not have evidence in the patient record that hospice aide assignments and duties are: • Written patient care instructions for a hospice aide which include alerts and precautions that 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 Patient #8: The record indicated that the patient had a trach and intermittent oxygen. There was not evidence that these alerts/precautions were on the aide plan of care. Corrected on site.

Upon patient record review 3 of 9 applicable records (Patient #6,#7,#10) 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 #6: The visit frequency for the aide was 2x/week. For the weeks beginning on 5/22/22 and 5/29/22, the record indicated only 1 visit each of these weeks. And for the week beginning on 6/5/22, there was not evidence of any visits by the aide. Patient #7: The aide plan of care dated 4/15/22 and 5/11/22 indicated for nail care and shave weekly. For the weeks from 5/22/22-6/4/22, nail care and shave were done at all visits (Aide visit frequency was 2x/week). From 5/11/22 to current, a shave was performed at all visits. In addition, the visit frequency was 2x/week. For the weeks starting 4/3/22, 4/10/22, and 4/17/22, the record indicated only 1 visit each of these weeks. Patient #10: The aide visit frequency was 2x/week. There was not evidence of a visit or missed visit documentation for the week of 5/15/22-5/21/22.

Upon patient client record review, 1 of 13 records (Patient #3) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #3: The patient was admitted on 1/6/22. A Patient Notification of Hospice Non-Covered Items, Services, and Drugs was requested on 4/25/22. The record indicated that this document was furnished on 5/4/22.

Upon patient client record review, 1 of 13 records (Patient #6) did not have evidence that each patient record contains Advance Directives. Patient #6: The consents and legal admission forms indicated that the patient had an advance directive. There was not evidence that this was a part of the patient record.

Upon patient client record review, 1 of 13 records (Patient #8) 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. Patient #8: The record indicated a chaplain COVID assessment that listed the names of the household members for a husband and a daughter. The remaining documentation in the record indicated that the patient lived with a son and a daughter-in-law and the names listed were not those of the household family members. The agency confirmed that the names and relationships listed were incorrect.

Upon client record review, 1 of 1 applicable record (Patient #9) 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 #9: The record indicated a wound order dated 5/2/22 for a stage 1 ulcer on the patient's coccyx. May be performed by caregiver or hospice nurse. A second order dated 5/5/22 for a drain site left upper abdomen, care to be performed by facility licensed nurse and/or hospice nurse. There was not evidence that 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.