Every finding on record at Odyssey Healthcare Operating A, LP

Upon patient record review, 1 of 19 records (Patient #3) did not have evidence in the patient record that the patient received information about the services covered under the hospice benefit. Patient #3: The Physicians Certification of Terminal Illness and the RN Start of Care Assessment, indicated that the patient was admitted for Primary Diagnosis of Late On-Set Alzheimer's Disease. Pt presents per documentation with episodic visual hallucinations of sharks, decrease in visual acuity due to macular degeneration, limited vocabulary and oriented only to self, Fast Scale- 7-A and PPS 20%. The record indicated that the patient signed own her consents and legal admission documents.

Upon patient record review, 1 of 19 records (Patient #3) did not have evidence in the patient record that the patient received information about the services covered under the hospice benefit. Patient #3: The Physicians Certification of Terminal Illness and the RN Start of Care Assessment, indicated that the patient was admitted for Primary Diagnosis of Late On-Set Alzheimer's Disease. Pt presents per documentation with episodic visual hallucinations of sharks, decrease in visual acuity due to macular degeneration, limited vocabulary and oriented only to self, Fast Scale- 7-A and PPS 20%. The record indicated that the patient signed own her consents and legal admission documents.

Upon patient record review, 1 of 19 records (Patient #3) did not have evidence in the patient record that the patient received information about the services covered under the hospice benefit. Patient #3: The Physicians Certification of Terminal Illness and the RN Start of Care Assessment, indicated that the patient was admitted for Primary Diagnosis of Late On-Set Alzheimer's Disease. Pt presents per documentation with episodic visual hallucinations of sharks, decrease in visual acuity due to macular degeneration, limited vocabulary and oriented only to self, Fast Scale- 7-A and PPS 20%. The record indicated that the patient signed own her consents and legal admission documents.

Upon patient record review, 1 of 19 records (Patient #3) did not have evidence in the patient record that the patient received information about the services covered under the hospice benefit. Patient #3: The Physicians Certification of Terminal Illness and the RN Start of Care Assessment, indicated that the patient was admitted for Primary Diagnosis of Late On-Set Alzheimer's Disease. Pt presents per documentation with episodic visual hallucinations of sharks, decrease in visual acuity due to macular degeneration, limited vocabulary and oriented only to self, Fast Scale- 7-A and PPS 20%. The record indicated that the patient signed own her consents and legal admission documents.

Upon patient record review, 1 of 19 records (Patient #3) did not have evidence in the patient record that the patient received information about the services covered under the hospice benefit. Patient #3: The Physicians Certification of Terminal Illness and the RN Start of Care Assessment, indicated that the patient was admitted for Primary Diagnosis of Late On-Set Alzheimer's Disease. Pt presents per documentation with episodic visual hallucinations of sharks, decrease in visual acuity due to macular degeneration, limited vocabulary and oriented only to self, Fast Scale- 7-A and PPS 20%. The record indicated that the patient signed own her consents and legal admission documents.

Upon patient record review, 1 of 19 records (Patient #3) did not have evidence in the patient record that the patient received information about the services covered under the hospice benefit. Patient #3: The Physicians Certification of Terminal Illness and the RN Start of Care Assessment, indicated that the patient was admitted for Primary Diagnosis of Late On-Set Alzheimer's Disease. Pt presents per documentation with episodic visual hallucinations of sharks, decrease in visual acuity due to macular degeneration, limited vocabulary and oriented only to self, Fast Scale- 7-A and PPS 20%. The record indicated that the patient signed own her consents and legal admission documents.

Upon patient record review, 1 of 19 records (Patient #3) did not have evidence in the patient record that the patient received information about the services covered under the hospice benefit. Patient #3: The Physicians Certification of Terminal Illness and the RN Start of Care Assessment, indicated that the patient was admitted for Primary Diagnosis of Late On-Set Alzheimer's Disease. Pt presents per documentation with episodic visual hallucinations of sharks, decrease in visual acuity due to macular degeneration, limited vocabulary and oriented only to self, Fast Scale- 7-A and PPS 20%. The record indicated that the patient signed own her consents and legal admission documents.

Upon patient record review, 1 of 19 (Patient #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 #10: The record indicated that the patient was using oxygen 2-4L/min via nasal cannula. There was not evidence that this was on the medication profile. Corrected on site.

Upon patient record review, 3 of 19, (Patient #4, #7, #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 #4: Wound not assessed per documentation upon start of care 1/17/24- 2/06/24. Patient #7: Wound assessment not completed upon Start of Care on 10/13/23 until recorded documentation on 10/27/23. Patient #8: Wound assessment not completed upon Start of Care on 12/21/23 until recorded documentation on 01/16/24.

Upon patient record review, 4 of 19 records, (Patient #2,#3,#4, #6 ) 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 #2: Skilled Nursing frequency documented as OXWK, 2WK and 3 PRN for symptom management. In addition, Social Worker frequency documented as 0XMTH1, 2 PRN, and Chaplain frequency documented as 0XMTH1, 2MTH for Benefit period of 01/05/24-03/04/24. Patient #3: Social Worker frequency documented as 0XMTH, 1XMTH and 2PRN for Benefit Period 12/26/23-02/23/24 Patient #4: Skilled Nursing frequency documented as 0XWK1, 2WK and 3 PRN for symptom management. For benefit period beginning 01/17/24. Patient #6: Social worker Frequency 0Xwk

Upon patient record review, 1 of 19 (Patient #10) 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 #10: The record indicated that the patient was using oxygen 2-4L/min via nasal cannula. There was not evidence of an order. Corrected on site.

Upon patient record review, 1 of 19 (Patient #12) 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 #12: The record indicated that the patient went into respite on 2/7/24 and was later converted to routine care in the SNF. There was not not evidence that the plan of care was updated to reflect respite or a change in location to the SNF. Corrected on site.

Upon client record review, 2 of 19 records, (Patient #3 ,#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: The spiritual care counselor visit frequency did not require a visit for the week of (admission) 12/26/23-12/30/23. The record indicated a visit by the spiritual care counselor on 12/29/23 Patient #12: The record indicated for a volunteer evaluation. There was not evidence that this had occurred.

Upon patient record review, 1 of 19 (Patient #13) 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 #13: The visit frequency for the aide was written as 0week1, then 2x/week.

Upon patient record review 4 of 19 (Patient #2,#4,#5,#11) 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: Plan of Care Frequency schedule of 3 visits a week, per documentation Aide completed 2 visits on 1/15/24 and 1/17/24. Patient #4: The aide plan of care indicated to shampoo and provide nail care 1x/week. The aide visit frequency was 2x/week. The aide documentation indicated that these tasks were provided at each visit for the weeks of 1/28/24-2/3/24 and 2/4/24-2/10/24. not following plan. Aide not following plan of care due to providing nailcare and shampoo week 1/28/23 2 X weekly. Patient #5: The aide care plan documented task of shampooing every visit. Aide documented that shampoo was not done per frequency, not needed on 02/12/24, 02/14/23, 2/19/23. Patient #11: The aide visit frequency was 2x/week. For the week of 1/14/24-1/20/24 the record indicated only 1 visit each of these weeks.

Upon patient record review, 1 of 19 records (Patient #3) did not have evidence in the patient record that the patient received information about the services covered under the hospice benefit. Patient #3: The Physicians Certification of Terminal Illness and the RN Start of Care Assessment, indicated that the patient was admitted for Primary Diagnosis of Late On-Set Alzheimer's Disease. Pt presents per documentation with episodic visual hallucinations of sharks, decrease in visual acuity due to macular degeneration, limited vocabulary and oriented only to self, Fast Scale- 7-A and PPS 20%. The record indicated that the patient signed own her consents and legal admission documents.

Upon patient client record review, 1 of 19 (Patient #7) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient #7 Upon record review no evidence of signed CTI from attending.

Upon patient client record review, 1 of 19 (Patient #12) did not have evidence that each patient record contains Advance Directives. Patient #12: The social worker documentation indicated that the patient had a POA. There was not evidence of this document in the patient record. (The patient was declining, was a full code and the care plan was revised for imminently dying)

Upon patient client record review, 2 of 19 (Patient #12,#13) 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 #12: The certification of terminal illness signed by the attending physician did not include the date that the document was signed. Patient #13: The signed legal admission paperwork of another patient was scanned into this patient's medical record.

Upon observation, and record review, 1 of 19 records (Patient #3) 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. Patient #3: The physician's certification of terminal illness and the RN start of care assessment indicated that the patient was admitted with a primary diagnosis of late onset Alzheimer's Disease. Documentation indicated that the patient has visual hallucinations, seeing sharks, a decrease in visual acuity due to macular degeneration, limited vocabulary and was only oriented to self. FAST scale, 7A and PPS 20%. The patient signed her own benefit election and legal admission documents.

Upon observation, and record review 1 of 19 records (Patient #3) did not contain evidence 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. Patient #3: The physician's certification of terminal illness and the RN start of care assessment indicated that the patient was admitted with a primary diagnosis of late onset Alzheimer's Disease. Documentation indicated that the patient has visual hallucinations, seeing sharks, a decrease in visual acuity due to macular degeneration, limited vocabulary and was only oriented to self. FAST scale, 7A and PPS 20%. The patient signed her own benefit election and legal admission documents.

Upon client record review, 1 of 19 (Patient #3) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #3: The Physicians Certification of Terminal Illness and the RN Start of Care Assessment, indicated that the patient was admitted for Primary Diagnosis of Late On-Set Alzheimer's Disease. Pt presents per documentation with episodic visual hallucinations of sharks, decrease in visual acuity due to macular degeneration, limited vocabulary and oriented only to self, Fast Scale- 7-A and PPS 20%. The record indicated that the patient signed own her consents and legal admission documents.

Upon client record review, 1 of 19 (Patient #1) 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 #1: Nurse documentation on 02/13/24 indicated that patient presented with active symptoms of decrease in lung sounds, heart rate tachycardia @ 125 BPM, Temperature 100.9, Periods of apnea 20-30 seconds and tachypneic respirations @ 28 breaths per minute which was a noted change in patient vitals however, there was no evidence of an update to the plan of care.

Upon patient record review, 1 of 19 (Patient #5) did not have evidence that the hospice provided the following information: • Physician certification and recertification of the terminal illness specific to each patient. Patient #5 Absence of Certification of Terminal Illness observed in Home Visit chart review in Skilled Nursing Facility. Agency. Corrected on sight.