Every finding on record at Odyssey Healthcare Operating A, LP

Upon patient record review, 2 of 14 (Patients #1, #5) 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 Patient 1: The admission note charts that patient requires oxygen, this is not included on the medication profile. Corrected Patient 5: Patient was ordered Oxygen therapy upon admit, patient would refuse delivery of oxygen concentrator, per nurse visit charting. Oxygen remained on the medication profile. Corrected on site

Upon patient record review, 2 of 14 (Patients #1, #8) 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: Patient was admitted on 02/17/25, the bereavement risk assessment was not performed until 02/27/25. Patient 8: Patient was admitted on 12/20/24, the bereavement risk assessment was not performed until 12/26/24.

Upon patient record review, 1 of 14 (Patient #6) 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 6: The wound to greater trochanter that was initiated on 3/20/25 only has one measurement charted on 3/27/25 and the wound to left patellar initiated on 4/7/25- has no wound care measurements since onset, company policy is for wounds to measured weekly.

Upon patient record review, 1 of 14 (Patient #2 ) 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 2: The admission noted that patient has dysphagia, there are no goals, plans, or interventions for identified problem.-Corrected on site

Upon patient record review, 3 of 14 (Patients #1, #5, #7) 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 admission note charts that patient requires oxygen, there is no orders written of oxygen therapy. Corrected on site Patient 5: Patient was ordered Oxygen therapy upon admit, she would refuse delivery of oxygen concentrator charted in nurse visit. No order written to remove oxygen from plan of care. Corrected on site Patient 7: The facility profile is missing lorazepam 0.5 tablet. Also, methadone is listed as oral solution on hospice chart, on the facility chart, methadone order is in tablet form, there is no evidence in the hospice chart of an order for the discontinuation of medications or changes.-Corrected on site

Upon patient record review, 5 of 14 (Patients #1, #2, #4, #6, #7) 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 admitting nurse note charts that a hospital bed, bedside table nebulizer, oxygen concentrator is in patient's home. There are no orders written for this listed medical equipment.-Corrected on site Patient 2 The admitting nurse note charts that a nebulizer is in use. There is no order written for this.-Corrected on site Patient 4 A bedside commode was added in the nurse recertification note, there is no order written for this medical equipment.-Corrected on site Patient 6 The nurse recertification note, charts that a raised toilet seat added, there is no order written to supply this medical equipment-Corrected on site. Patient 7 The patient has breathing treatment medications ordered since admission, there is no nebulizer order written-Corrected on site

Upon patient record review, 1 of 14 (Patient #1) 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 1: Upon review of the medical record, it was noted on visit on 3/23/25 that patient has been having multiple pancreatic flair ups, the nurse recommended clear liquid diet during episodes, the plan of care was not updated to address the identified problems.-Corrected on site.

Upon patient record review, 3 of 14 (Patients #8, #11, #12) did not have evidence the hospice offers bereavement counseling that includes: • 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 8: Upon review of medical record, the bereavement plan of care requires that a sympathy card, a 1 month letter, and 3 month letter be delivered to the identified bereavement contacts, there is no evidence that these tasks have been completed. Bereavement phone call was documented but was not on bereavement care plan to perform. Patient 11: The bereavement plan of care, there is no evidence that the Holiday letter was sent out. Patient 12: The bereavement plan of care, there is no evidence that the Holiday letter was sent out.

Upon patient record review, 2 of 14 (Patient #3, #6) 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 Patient 3: The patient developed a wound on 3/29/25, the aide care plan was not updated to reflect care or maintenance of wound sites during bathing.-Corrected on site Patient 6: The patient developed wounds on 03/20/25 and 04/07/25, the aide care plan was not been updated to reflect care or maintenance of wound sites during bathing. Corrected on site

Upon patient record review 1 of 14 (Patient #9) 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 9: Aide frequency was increased to 3 times a week with order written on 01/29/25. Only two aide visits were made for the week of 02/02/25, with a missed visit notification stating that the aide was "not available to make the visit".

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The volunteer report showed a total percent for the year of 2024 is 0.17%, below the minimum 5% requirement.

Upon patient client record review, 1 of 14 (Patient #10) 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 10: The transfer form signed on 02/28/25 does not have an effective date filled out on the signed form.

Upon patient record review 1 of 13 (Patient #1) 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 #1-The patient was admitted on 03/14/22 and the Chaplain did not visit until 3/21/22 to perform a complete spiritual assessment. A spiritual assessment was not performed by an RN or SW. The only documentation of spiritual evaluation was the initial Social Worker visit on 3/16/22 which documented patient was of the Church of the Nazarene faith.

Upon patient record review, 7 of 13 (Patient #2, #3, #4, #5, #8, #12, #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. Patient #2-On 4/12/22 the medication profile was updated with Prednisone 10mg 7 day oral dose pack as per packet instructions (Packet instructions/dosing were not included in the profile.) Corrected on site. Patient #3- Atropine ophthalmic was listed as 2 drops every 4 hours as needed for secretions with an ophthalmic route. The correct route is sublingual. The following medications are listed on the plan of care to be administered orally: Descovy, Diazepam, Fluoxetine, Gabapentin, Glycopyrrolate, Miralax, Omeprazole, Senna, Tivicay, Zithromax. The patient is at risk for aspiration and has a PEG tube. The correct route for administration is via PEG tube. Corrected on site. Patients #3, #4, #5, #8-Miralax 17 gm oral powder qd for constipation is listed on the profiles without a diluent. Corrected on site. Patient #12- The medication profile contains two separate dosages of Carbidopa-Levodopa. 3/10/22 Carbidopa ER 50mg -Levodopa 200 mg extended release 1 tab 6X/day. The profile also contains 03/16/22 Carbidopa 25mg -Levodopa 100 mg 1 tab 6X/day. It is unclear whether the meds are to be administered together versus duplicative dosing. Patient #13-The medication profile includes Bleph-10 10% eye drops ophthalmic eye use 1 wipe prn, did not include which eye(s) for administration. The medication profile also includes Levetiracetam 100mg/ml oral solution as directed per instructions for seizure, no evidence of instructions.

Upon patient record review, 5 of 13 (Patient #1, #3, #7, #10, #11) 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- Between 04/14/22 and 04/28/22 the nurse documents the patient is not having regular bowel movements. Documentation on 04/14/22 indicated the patient had not had a bowel movement in a week. The plan of care was not updated with altered GI status and/or constipation. (corrected on site) Patient #3-The patient was admitted 04/04/22 with a PEG tube and feedings. The plan of care does not include interventions and goals related to altered nutrition. The patient was also actively being managed for pain related to a malignant neoplasm at the base of the tongue. The plan of care does not include goals for alteration in comfort/pain. (corrected on site) Patient #7-Beginning 03/07/22 the nurse documents the patient is complaining of pain and asking to go to the hospital. Hydrocodone was ordered and the record indicates the patients pain was actively managed on subsequent visits. The plan of care was not updated with interventions and goals for alteration in comfort/pain management. Patient #10-Beginning 11/4/22 the nurse documents Roxanol was increased for pain and the patient had a coccyx wound . The plan of care was not updated with alteration in skin integrity or alteration in comfort/pain. There were no goals on record for the wound or pain management. Patient #11-The Social Worker performed an evaluation 04/07/22 and the IDG note 04/14/22 indicates the social worker plans to visit once monthly; however there are no Psychosocial goals or interventions on record.

Upon patient record review, 6 of 13 (Patient #2, #3, #6, #11, #12, #13) 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. Patient #2- The 4/4/22 plan of care includes Nursing frequency written as 4x/weekly, 3xweekly, 2x/weekly and 4 prn. The duration for each frequency is not included in the orders. Corrected on site. Patient #3-The plan of care 3/30/22 includes orders for nursing written as 3X/weekly, 2X/weekly. A duration for the frequencies is not included on the plan of care. Aide is also ordered 1X/weekly, 2X/weekly without a duration. Corrected on site. Patient #6-On 04/25/22 orders were written as Bereavement Coordinator is needed for pre bereavement visits. A frequency for visits is not included in the plan of care. Corrected on site. Patient #11- The plan of care 04/07/22 includes nursing frequency as 1X/week, 2X/week. A duration for the frequencies is not included on the plan of care. The Social Worker visited the patient on 04/07/22 and IDG documentation on 04/14/22 indicates the social worker plans to visit the patient monthly. There are no frequency or interventions for Social Worker on record. Corrected on site. Patient #12-The plan of care 03/16/22 includes nursing frequency as 1X/week, 2X/week. Aide is also ordered 1X/weekly, 2X/weekly without a duration. On 4/25/22 two orders were entered for Volunteer. Volunteer 1X/month and Volunteer 2X/mo (frequency unclear). Corrected on site Patient #13- The plan of care 3/24/22 includes orders for nursing written as 3X/weekly, 2X/weekly. Corrected on site.

Upon patient record review, 7 of 13 (Patient #2, #3, #4, #5, #8, #12, #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 specific/accurate orders for all medications and treatments. Patient #2-On 4/04/22 the plan of care was updated with orders for Prednisone 10mg 7 day oral dose pack as per packet instructions (Packet instructions/dosing were not included in the orders. corrected on site Patient #3-On 03/30/22 the patient was admitted with a PEG tube. The plan of care does not address management of the PEG tube/site. The plan of care includes orders for the nurse to provide instructions/reinforcement of trach care, including stoma care, suctioning, trach care and dressing changes. The orders do not include the size and type of the trach and orders are not specific for the actual care to be performed. Atropine ophthalmic was listed as 2 drops every 4 hours as needed for secretions with an ophthalmic route. The correct route is sublingual. The following medications are listed on the plan of care to be administered orally: Descovy, Diazepam, Fluoxetine, Gabapentin, Glycopyrrolate, Miralax, Omeprazole, Senna, Tivicay, Zithromax. The patient is at risk for aspiration and has a PEG tube. The correct route for administration was via PEG tube. Miralax 17 gm oral powder qd for constipation is listed on the profile without a diluent. On 03/31/22 the plan of care was updated with Osmolite 1.2 Cal 2 cans 4 times daily via Peg. The orders do not specify the delivery method (bolus). corrected on site Patient #4-Miralax 17 gm oral powder qd for constipation is listed on the plans of care without a diluent. corrected on site Patient #5-The plan of care 04/17/22 includes interventions to insert or change Foley catheter per orders and instruct on irrigation of catheter. The patient does not have a Foley catheter. Miralax 17 gm oral powder qd for constipation is listed on the plans of care without a diluent. corrected on site Patient #8- The plan of care includes multiple medications for constipation without differentiation for usage. Miralax 17 gm oral powder daily prn constipation; Milk of Magnesia 400mg/5ml 30 ml daily prn constipation and Fleet Enema 19gm 7gm/118ml as needed for constipation. corrected on site Patient #12- The 03/16/22 plan of care contains two separate dosages of Carbidopa-Levodopa. Carbidopa ER 50mg -Levodopa 200 mg extended release 1 tab 6X/day. The plan of care also contains Carbidopa 25mg -Levodopa 100 mg 1 tab 6X/day. The orders are unclear whether the meds are to be administered together versus duplicative dosing. Patient #13-The plan of care 03/24/22 includes Bleph-10 10% eye drops ophthalmic eye use 1 wipe prn, do not include which eye(s) for administration. The plan of care also includes Levetiracetam 100mg/ml oral solution as directed per instructions for seizure. Instructions are not included in orders.

Upon client record review, 1 of 13 (Patient #7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #7- On 03/23/22 the nurse documents applying a condom catheter. Thee are no orders on record for the the condom catheter.

Upon patient record review, 1 of 13 (Patient #1) did not have evidence that licensed professional actively participate in the coordination of all aspects of the patient's hospice care, including participating in ongoing interdisciplinary comprehensive assessments, developing and evaluating the plan of care, and contributing to patient and family counseling and education. Patient #1-On 3/21/22 the Chaplain documented the patient stated she was in so much pain she was in tears. The chaplain documents the patient stated she had been out of her pain medicine since last Tuesday and neither friend who provides assistance was available. There is no documentation by the Chaplain that the situation was discussed with the RN and/or Social Worker to assist in evaluating the plan of care.

Upon patient record review, 1of 9 applicable (Patient #7) did not have evidence in the patient record that hospice aide assignments and duties are: • Complete written patient care instructions prepared by the registered nurse. Patient #7-The patient was admitted on aspirin and on 03/14/22 was prescribed Clopidogrel for clotting prevention. The Aide care plan does not include bleeding precautions.

Upon patient record review, 1 of 13 (Patient #11) did not have evidence that each patient record contains • A complete signed election statement in accordance with 418.24 Patient #11 -The patient elected to receive the notification of non covered items addendum when signing the election on 04/07/22. There is no evidence on record the addendum was provided.

Upon patient record review, 3 of 13 (Patient #3, #9, #12) did not have evidence that all entries are complete and accurate. Patient #3- On 3/30/22 and 04/03/22 the nurse documents the patients outer cannula of the trach was cleansed and the inner cannula was replaced. The documentation is not specific for the type and size of trach utilized. On 04/11/22 the nurse documented the patients Fentanyl patch was changed by nurse during the visit. The documentation does not specify the dosage of the patch. Patient #9- On the 04/04/22 CTI the medical director documented the patient was eating 7500% of 2 meals/day. (Documentation error) Patient #12- On 04/01/22 the RN documented administered patient his prescribed dose of Hydrocodone. Documentation is not specific for the actual dosage administered.

Upon client record review, 2 of 2 applicable (Patient #8, #9) did not have evidence that the discharge summary includes all required information. Patient #8-The patient revoked the election on 04/12/22. The discharge summary only states the reason for the discharge. The discharge summary does not include a summary of the patient's stay, including treatments, symptoms and pain management. Patient #9-The patient was discharged on 04/07/22 as patients condition had plateaued and was no longer terminally ill. The discharge summary only includes the reason for discharge and does not include a summary of the patient's stay, including treatments, symptoms and pain management.