Every finding on record at Odyssey Healthcare Operating A, LP

Upon patient record review, 1 of 19 (Patient #1) 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#1: The medication profile contains MiraLAX 17 gram oral powder. However, there is no evidence of dilutant instructions. Corrected on site.

Upon patient record review, 8 of 19 (Patient #1,#2,#3,#4,#5,#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 record indicates fall precautions are indicated on the aide plan of care, however is not included on plan of care. Corrected on site. Patient#2: The record indicates patient has PEG for feedings. There is no evidence of goals or interventions related to PEG care or for aspiration precautions. Corrected on site. Patient#3: The record indicates patient is ordered oxygen. There is no evidence of goals or interventions for oxygen safety precautions on plan of care. Corrected on site. Patient#4: The record indicates patient takes seizure medications daily and requires nebulizer treatments. However, there is no evidence of goals or interventions related to seizure precautions or nebulizer use. Corrected on site. Patient#5: Nurse documentation in 1/30/25 indicates patient is a high fall risk with unsteady gait. Fall precautions are indicated on aide plan of care. There is no evidence of goals and interventions for fall precautions on plan of care. Corrected on site. Patient#7: Bleeding precautions are listed on aide plan of care. There is no evidence of goals or interventions for bleeding precautions on plan of care. Corrected on site. Patient#8: Oxygen safety precautions are on aide plan of care. There is no evidence of goals or interventions for oxygen safety precautions on pan of care. Corrected on site. Patient#10: The record indicates patient is taking insulin and requires monitoring of blood sugar. There is no evidence of problems, goals, or interventions related to these needs. Corrected on site.

Upon patient record review, 4 of 19 (Patient #1,#5,#6,#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#1: The medical record contained an order for MiraLAX 17 gram oral powder. There is no evidence of dilutant instructions on order. Corrected on site. Patient#5: The medical record contained an order for thickener. There is no evidence of instructions for preparing for thickness needed for patient or patient. Corrected on site. Patient#6: The record indicates patient is taking ensure for nutrition supplement. There is no evidence of an order for ensure. Corrected on site. Patient#10: The record indicate patient was admitted with a PICC line in place. There is no evidence of order for PICC removal in record.

Upon patient record review, 6 of 19 (Patient #2,#4,#7,#8,#10,#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#2: During home visit it was noted that patient is bedbound in hospital bed and also requires oxygen. There is no evidence of bed or oxygen on plan of care order. Corrected on site. Patient#4: The record indicates per nurse documentation that patient requires use of rollator. There is no evidence of rollator on plan of care order. Corrected on site. Patient#7,#8: The record indicates patient requires use of hospital bed. There is no evidence of a bed listed on plan of care order. Corrected on site. Patient#10: During home visit it was noted that patient requires use of hospital bed and suction. IDG on 2/19/25 indicates patient requires use of Hoyer lift for transfers. There is no evidence of these items on plan of care order. Corrected on site. Patient#14: The record indicates the patient requires bed bolsters, however there is no evidence of hospital bed or over the bed table listed on plan of care order. The supply order list feeding/nutritional supplies. There is no documentation that patient requires these supplies. Per conversation with administrator these supplies were listed in error. Corrected on site.

Upon patient record review, 1 of 19 (Patient #10) 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#10: The plan of care includes an intervention for SN to assess shunt. There is no evidence in record that patient has a shunt. Upon discussion with Administrator it was determined that patient does not have a shunt and intervention was entered in error. Plan of care was not updated. Corrected on site

Upon client record review, 1 of 19 (Patient #10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#10: The record indicates patient was admitted with a PICC in place. There was no evidence of documentation regarding removal or follow-up of PICC nor an order was present for removal of PICC. Per discussion with Administrator the nurse removed PICC the day after admit. COS with a late coordination note was entered by nurse.

Upon patient record review, 3 of 19 (Patient #17,#18,#19) did not have evidence 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. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • 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#17,#18,#19: There is no evidence of Holiday letter being sent after Christmas as listed on bereavement plan of care.

Upon patient record review, 5 of 19 (Patient #2,#3,#10,#11,#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#2: The record indicates patient is ordered oxygen and requires peg tube feedings. The aide care plan did not contain aspiration precautions or oxygen safety precautions. Corrected on site. Patient#3: The record indicates bleeding precautions are included on plan of care. There is no evidence of bleeding precautions on aide plan of care. Additionally, the record indicates patient requires use of oxygen. There is no evidence of oxygen safety precautions on aide plan of care. Corrected on site. Patient#10: The record indicates patient has a foley catheter. There is no evidence of foley catheter on aide plan of care. Corrected on site. Patient#11: The plan of care indicates patient requires aspiration precautions. There is no evidence of aspiration precautions on aide plan of care. Corrected on site. Patient#13: The record indicates patient has a foley catheter in place. There is no evidence of foley catheter on the aide plan of care. Corrected on site.

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 agency report shows the percent of volunteer use for January 2025 is 3.43% and did not have a total for 2024.

Upon patient record review, 1 of 19 (Patient #10) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice's 24-hour on-call system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient Patient#10: There is no evidence of hospice election form found at facility.

Upon patient record review, 1 of 5 records (Patient #4) did not have evidence the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #4: The record indicated that the patient had a Pleurix catheter/drain which the nurse was draining 1 time/week. The order indicated to instruct patient/caregiver on treatment/management of drainage system including assessment of site, dressing change. Assessment of output of drainage system. The order was incomplete as it did not contain the frequency, including prn when the system was to be drained and instructions for dressing changes.

Upon client record review, 1 of 4 applicable records (Patient #1) 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 record indicated skilled nurse visits daily while the patient was in respite (4/6/22-4/10/22). There was not evidence of skilled nurse visits for 4/6/22, 4/7/22, and 4/8/22. Visits on 4/9/22 and 4/10/22 were indicated as prn.

Upon patient record review, 1 of 13 (Patient #11) 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 #11 - The patient was admitted on 2/4/22 and the spiritual assessment was performed on 2/11/22.

Upon patient record review, 1 of 13 (Patient #9) 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 #9 - The patient was admitted on 7/9/21 and there is not a spiritual assessment on record.

Upon patient record review, 6 of 13 (Patient #1, #4, #5, #10, #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 #1 The med profile includes Acetaminophen 650mg rectal suppository q4 PRN for temperature. The correct indication is fever. On 2/17/22 the RN documents the patient is taking Pepto bismol. Pepto bismol is not included on the med profile. Patient #4 - The med profile includes Acetaminophen 650mg rectal suppository for fever q6 PRN, Acetaminophen 500mg tablet take 2 tablets q6 PRN for pain or fever, Hydrocodone 5mg - Acetaminophen 325mg tablet take 1 tablet q6 PRN. The meds are duplicative for symptom management and do not differentiate which medication to administer when choosing. There is no maximum allowable daily dosage for Acetaminophen on the profile. Patient #5 The med profile indicates the patient is on Oxygen. Upon interview with leadership this is an error as Oxygen was refused and equipment was never delivered. Patient #10 - On 11/18/21 The RN documented Tramadol 50mg q6 PRN for pain was ordered. The med profile was updated with Tramadol 50mg 4x daily PRN for pain. On 11/30/21 The RN documented receiving an order to discontinue Metoprolol while patient takes Seroquel. The med profile was not updated with the discontinuance of Metoprolol Patient #12 - The med profile includes Dulcolax 10mg rectal suppository take 1 suppository every 48 hours (every other day) PRN for constipation and Dulcolax 10mg rectal suppository take 1 suppository q12 PRN for constipation. The med profile includes Seroquel 25mg tablet give 1 tablet po 2x daily for psychosis and Seroquel 100mg tablet give 1 tablet po every bedtime for psychosis. The med profile includes Tylenol 325mg tablet give 1 tablet po every hour PRN for mild pain, Tylenol 325mg tablet give 2 tablets po q6 PRN for pain, Acetaminophen 500mg tablet give 1 tablet po 3x daily for pain and Acetaminophen 650mg rectal suppository give 1 suppository q6 PRN for pain. There is no maximum allowable daily dosage for Acetaminophen on the profile. The meds are duplicative for symptom management and do not differentiate which medication to administer when choosing. Patient #13 - The med profile includes Acetaminophen 325mg tablet give 2 tablets po q4 PRN for mild pain/sob and Acetaminophen 650mg rectal suppository administer 1 suppository q6 PRN for mild pain/fever. The meds are duplicative for symptom management and do not differentiate which medication to administer when choosing.

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

Upon patient record review, 2 of 13 (Patient #4, #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 #4 - On the 1/26/22 visit, the RN documents that the facility director of nursing hasn't received discharged medications since the patient left the hospital from the MPOA. The meds are Diltiazam 360mg ER daily and Losartan 25mg daily. The RN documented that she will follow up with MPOA to bring the meds into the facility, notify the MD and that the patient's blood pressure was elevated and heart rate tachy and irregular. On the 2/2/22 visit the RN documents that she informed the facility nurse that she called in meds and MPOA should be bringing them into the facility. Patient's blood pressure continues to be elevated and heart rate tachy. The record doesn't evidence follow up with the concerns and the next visit was not until 2/11/22 and did not evidence follow up for the meds or changes in condition. Patient #6 - On 12/26/21 triage documented receiving a phone call from patient's family asking if a refill was placed for Tramadol. The caller stated the patient had one dose left. Triage documented that the call would be dispatched to the on-call nurse and there is no documentation of follow up.

Upon patient record review, 6 of 13 (Patient #1, #2, #3, #5, #11, #13) 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. Patient #1 - On 1/26/22 and 2/21/22 the RN documents that the patient sustained a fall. The plan of care did not include goals related to fall risk. The patient was admitted with asthma and PRN Oxygen and there are no goals related to altered respiratory status. The patient has a left nephrostomy tube and there are no goals related to the management of the nephrostomy tube on the plan of care. Patient #2 - The patient was admitted on 1/5/22 with lung cancer and severe dyspnea. The plan of care does not include goals related to altered respiratory status. Patient #3 - The patient was admitted with oxygen and the plan of care does not include goals related to altered respiratory status. The plan of care indicated the patient is a fall risk and there are no goals related to fall and home safety. Patient #5 - The plan of care indicates the patient is a high fall risk and there are no goals related to fall and home safety. The plan of care indicates the patient was at a high risk for skin breakdown due to disease process and there are no goals related to altered skin integrity. Patient #11 - On 2/6/22 the RN documented the patient was at high risk for falls and there are no goals related to fall and home safety. Patient #13 - The plan of care indicates the patient has oxygen ordered and there are no goals related to oxygen management and safety.

Upon patient record review, 9 of 13 (Patient #1, #4, #5, #6, #7, #10, #11, #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 medications and treatments. Patient #1 - The plan of care on 12/7/21 includes Acetaminophen 650mg rectal suppository q4 PRN for temperature. The correct indication is fever. On 2/17/22 the RN documents the patient is taking Pepto bismol. Pepto bismol is not included on the plan of care. The plan of care also includes instruct on nephrostomy tube, the plan is not specific for the actual management of the nephrostomy tube and or dressing. Patient #4 - The plan of care on 1/11/22 includes Acetaminophen 650mg rectal suppository for fever q6 PRN, Acetaminophen 500mg tablet take 2 tablets q6 PRN for pain or fever, Hydrocodone 5mg - Acetaminophen 325mg tablet take 1 tablet q6 PRN. The meds are duplicative for symptom management and do not differentiate which medication to administer when choosing. There is no maximum allowable daily dosage for Acetaminophen on the plan of care. Patient #5 - The plan of care on 1/8/22 indicates the patient is on Oxygen. Upon interview with leadership this is an error as Oxygen was refused and equipment was never delivered. Patient #6 - The record contains an order to update the plan of care on 2/16/22 which reads - cleanse wound with wound cleanser, pat dry with gauze, apply medi-honey, cover with foam border dressing and secure with tape daily. The location of the wound is not included in the order. Patient #7 - The record contains an order to update the plan of care on 1/5/22 which reads - cleanse wound with wound cleanser, pat dry with gauze, apply medi-honey, cover with foam border dressing and secure with tape daily. The location of the wound is not included in the order. Patient #10 - On 11/30/21 the RN documented orders to discontinue the Metoprolol while the patient takes Seroquel. The plan of care was not updated with orders to discontinue Metoprolol. Patient #11 - On 2/6/22 The RN documents the patient has a new skin tear that the facility is treating. The plan of care was not updated with an order for the skin tear management. Patient #12 - The plan of care 2/2/22 includes Dulcolax 10mg rectal suppository take 1 suppository every 48 hours (every other day) PRN for constipation and Dulcolax 10mg rectal suppository take 1 suppository q12 PRN for constipation. The plan of care includes Seroquel 25mg tablet give 1 tablet po 2x daily for psychosis and Seroquel 100mg tablet give 1 tablet po every bedtime for psychosis. The plan of care includes Tylenol 325mg tablet give 1 tablet po every hour PRN for mild pain, Tylenol 325mg tablet give 2 tablets po q6 PRN for pain, Acetaminophen 500mg tablet give 1 tablet po 3x daily for pain and Acetaminophen 650mg rectal suppository give 1 suppository q6 PRN for pain. There is no maximum allowable daily dosage for Acetaminophen on the profile. The meds are duplicative for symptom management and do not differentiate which medication to administer when choosing. Patient #13 - The plan of care 2/2/22 includes Acetaminophen 325mg tablet give 2 tablets po q4 PRN for mild pain/sob and Acetaminophen 650mg rectal suppository administer 1 suppository q6 PRN for mild pain/fever. The meds are duplicative for symptom management and do not differentiate which medication to administer when choosing.

Upon client record review, 1 of 13 (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 1/5/22 includes orders for the MSW to visit 1x monthly. The MSW documents on 1/8/22 and 2/14/22 phone calls were made instead of in person visits and the plan of care does not include orders for phone calls in lieu of onsite visits.

Upon observation, on 2 of 3 home visits, (Patient #6, #7) there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #6 & #7 On home visits 3/2/22, the staff were observed placing their supply bags directly on the floor with no barrier to prevent the transmission of infections.

Upon personnel record review, 1 of 1 applicable (Personnel # 2) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient or pseudo-patient. Personnel #2 - The aide competency on record listed vital signs as not applicable and all other tasks were verbally observed instead of directly observed.

Upon patient record review, 5 of 13 (Patient #3, #4, #8, #9, #11) did not have evidence in the patient record that hospice aide assignments and duties include the tasks to be provided and the frequency of those tasks. Patient #3, #4, #8, #9 - The initial comprehensive plan of care indicates that the patient is a fall risk. The aide plan of care does not include fall precautions. Patient #11 - The initial comprehensive plan indicates the patient is a fall risk and on oxygen. The aide plan of care does not include fall or oxygen precautions.

Upon personnel record review, 1 of 14 (Personnel # 9) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #9 - A skills competency assessment is not on record for the spiritual care provider.

Upon patient client record review, 2 of 13 (Patient #1, #2) did not have evidence that all entries are clear and complete. Patient #1 - On 1/13/22 and 1/20/22 the RN documented changing the patient's nephrostomy tube dressing as ordered. The documentation is not specific to the actual dressing change performed. On 2/18/22 The RN documented the patient's comfort is increased with Trazadone tid. This is a documentation error as the patient is not prescribed Trazadone. On 2/18/22 the RN documented that the physician ordered a Chem 7 and Lisinopril due to elevated blood pressure. Upon interview, the physician later stated to disregard the order as the patient had not taken ordered anti-hypertensives. The clarification to disregard the order was corrected on site with a late visit entry note 3/2/22. Patient #2 - On 1/9/22 the MSW documented "provided care to patients that are ignorant at times 3/4. Patient lives with spouse and two adult daughters in outdoors in home." The documentation is unclear. On 2/3/22 the RN documents "he is a little". Incomplete sentence.

Upon client record review, 1 of 1 applicable (Patient #5) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #5 - The patient transferred to another hospice on 1/15/22 and there is no evidence that the transfer summary was sent to the hospice.

Upon client record review, 1 of 1 applicable (Patient #10) did not have evidence that the discharge summary includes all required information. Patient #10 - The patient discharged 1/3/22 and the discharge summary only documents that the patient was discharged home to self care upon revocation. The discharge summary does not include a summary of the patient's stay, including treatments, symptoms and pain management.

Upon patient record review and home visit to facility, 1 of 2 applicable (Patient #6) did not have evidence that the hospice provided the SNF a copy of the most recent plan of care. Patient #6 - Upon visit to SNF on 3/2/22 the facility record did not include the most recent hospice plan of care. The agency was not able to provide evidence that it was sent.

Upon observation, there was no evidence the hospice provides orientation to personnel of a SNF/NF or ICF/IID regarding the policies and procedures of the provision of care/service including all required content. The agency did not have evidence training had occurred for skilled facilities where patients are served.

Upon personnel record review, 2 of 10 applicable (Personnel #2, #5 ) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at renewal or in accordance with specific state practice act requirements. Personnel #2 - The nurse aide certification on record expired 12/26/21. (Corrected on site) Personnel #5 - The professional license on record expired 9/30/20. (Corrected on site)

Upon personnel record review, 1 of 14 (Personnel #11) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel #11 - The agency did not have a background check in the record.