Every finding on record at Odyssey Healthcare Operating A, LP

Upon patient record review, 3 of 19 (Patient #1,2,6) 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: During medication reconciliation, the facility and hospice medication profiles did not match. The hospice medication profile contained MiraLAX 17g once a daily as needed, but the facility medication profile contained MiraLAX ordered at twice daily as needed. The facility medication profile also contained orders Lidocaine patch 4% topically every 12 hours as needed and Simethicone tabs 80MG 1 tab before meals and at bedtime. Patient 2: During medication reconciliation, the facility and hospice medication profiles did not match. The facility medication profile contained orders for acetaminophen 2 tabs 3 times a day, guaifenesin every 6 hours PRN for cough, hydrocortisone cream 1% as needed for skin irritation, Lactulose 15ml as needed every 24 hours for constipation, and Mylanta 400-40mg/5ml as needed every 6 hours, Preparation H as needed every 8 hours. The hospice medication profile did not contain those medications. The hospice medication profile contained orders for Lorazepam 0.25ml once a day after lunch and oxygen as needed via nasal cannula but the facility did not have those medications listed. Patient 6: Medication profile has as needed oxygen orders. No evidence that a delivery method was added.

Upon patient record review, 1 of 19 (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. the care and service for each patient and family. Patient 1: No evidence of weekly wound measurements between 12/22/25 through 1/11/2026. Wound was assessed as healed and orders discontinued on 1/22/2026.

Upon patient record review, 1 of 19 (Patient #5) 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 5: The medical record indicated that the patient had wounds that were healed on 12/18/25 and 01/05/26. Wound care orders, wound interventions and goals remained active on the current plan of care.

Upon patient record review, 3 of 19 (Patient #1,2,6) 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 facility medication profile also contained orders Lidocaine patch 4% topically every 12 hours as needed and Simethicone tabs 80MG 1 tab before meals and at bedtime however, the hospice did not have orders for these medications. Patient 2: During medication reconciliation, the facility and hospice medication profiles did not match. The facility medication profile contained orders for acetaminophen 2 tabs 3 times a day, guaifenesin every 6 hours PRN for cough, hydrocortisone cream 1% as needed for skin irritation, Lactulose 15ml as needed every 24 hours for constipation, and Mylanta 400-40mg/5ml as needed every 6 hours, Preparation H as needed every 8 hours. The hospice did not have orders for these medications. Patient 6: The medical record contained as needed oxygen orders. No evidence that a delivery method was added.

Upon patient record review, 1 of 19 (Patient #2) 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: Foley catheter supplies active on the current plan of care that started on 12/29/2025. No evidence that the patient has had a foley catheter while on service.

Upon patient record review, 1 of 19 (Patient #3) 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 3: Aide documentation on 12/22, 12/26, 12/29, 12/31, 01/02, 01/07, 01/12/26, 01/14/26, 01/19/26, 1/23/26, 1/26/26, 01/28/26, 01/30/26, 2/2/26, 2/5/26 indicated that the patient was requesting to only have showers instead of the bed bath on the plan of care. No evidence that the RN updated to the aide plan of care to included the patients request for showers.

Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Nursing services • Medical social services • Physician services • Counseling services, including spiritual counseling, dietary counseling and bereavement counseling • Hospice aide, volunteer, homemaker services • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care • Medical supplies (including drugs and biologicals) and medical appliance Patient #4: Medical record indicated that the LPN added problems, goals, and interventions related to safety to the plan of care. Those problems that remained active in current benefit period that started on 01/27/2026. This is not within the LVN acceptable standards of practice. Patient #9: Medical record indicated that the LPN added problems, goals, and interventions related to GI/constipation to the plan of care. Those remain active in the current benefit period that started on 01/16/2026. This is not within the LVN acceptable standards of practice.

Upon personnel record review, 1 of 12 (Personnel #12) 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 #12: No evidence that a criminal background check was completed at the time that the survey was completed. This deficiency was identified on the last survey for this agency. It was stated in the plan of correction that the agency would complete a background check at that time.

Upon patient record review, 6 of 13 (Patient #1, #3, #8, #9, #11, #12) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient #1- On 02/03/23 the nurse documents the patient received Oxygen. The medication profile was not updated with Oxygen. (corrected on site) Patient #3- On 12/15/22 the nurse documents refills were ordered for Benzonatate and Docusate. Benzonatate and Docusate are not on the medication profile. (corrected on site) Patient #8- The medication profile lists Morphine Concentrate 20mg/ml. Administer 5mg q4h SL prn pain or SOB. Special instructions 0.1ml =5mg. The correct instructions are 0.25 ml=5mg. Patient #9- As of 09/03/22 the medication profile includes Fleet enema 19gm-7gm/118 ml dose per instructions as directed for constipation. The frequency is not specific. On 09/07/22 the nurse documents the patient is on Oxygen. Oxygen is not included in the medication profile. Patient #11- On 01/31/23 the nurse documents the patient was on Oxygen. Oxygen was not added to the medication profile. (corrected on site) Patient #12-The medication profile includes Colchicine .6mg tablet three times daily. The dosage is listed as per instructions and take as directed. The number of tabs /instructions is not included in the profile. (corrected on site)

Upon patient record review, 8 of 13 (Patient #1, #3, #8, #9, #10, #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 specific orders for all medications and treatments. Patient #1- On 02/03/23 the nurse documents the patient received Oxygen. The plan of care does not include Oxygen, (corrected on site) Patient #3- On 12/15/22 the nurse documents refills were ordered for Benzonatate and Docusate. Benzonatate and Docusate are not on the plan of care. (corrected on site) Patient #8- The 12/27/22 plan of care lists Morphine Concentrate 20mg/ml. Administer 5mg q4h SL prn pain or SOB. Special instructions 0.1ml =5mg. The correct instructions are 0.25 ml=5mg. Patient #9- On 09/03/22 the plan of care was updated with Fleet enema 19gm-7gm/118 ml dose per instructions as directed for constipation. The frequency is not specific. On 09/07/22 the nurse documents the patient is on Oxygen. Oxygen is not included in the plan of care. Patient #10- On 08/26/22 the nurse documents the patient has a PICC line, The plan of care does not address management of the PICC. Patient #11- On 01/31/23 the nurse documents the patient was on Oxygen. Oxygen was not added to the plan of care. (corrected on site) Patient #12-The 02/19/23 plan of care includes Colchicine .6mg tablet three times daily. The dosage is listed as per instructions and take as directed. The number of tabs /instructions is not specified in the orders. (corrected on site) Patient #13- The 02/19/23 plan of care includes orders for the nurse to provide instructions for performing gastrostomy feedings. The orders are not specific for the tube feeding management and actual feedings to be administered. (corrected on site)

Upon patient record review, 2 of 13 (Patient #2, #9) did not have evidence that a revised plan of care includes all information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #2- The patient was admitted on 01/12/23 without Advanced Directives. On 01/31/23 the nurse documents the patient signed a DNR and the DNR is in the patient record dated 01/30/23. The updated plan of care/IDG 02/02/23 and 02/16/23 were not updated with the patients change in code status. (corrected on site) Patient #9- The patient signed a DNR on 09/05/22. The revised plan of care/IDG 09/08/22 lists Advanced Directives as none.

Upon patient record review, 3 of 13 (Patient #6, #9, #10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6- On 02/04/23 the physician ordered a urine culture. The record does not include documentation that the urine culture was obtained. (late entry documentation of patient refusal corrected on site ) Patient #9- The patient died on 09/22/22. The bereavement care plan includes the bereaved will receive a phone call within 2-4 weeks of death. There is no documentation of a phone call on record. Patient #10- On 08/29/22 the nurse documents flushing the patients right urostomy tube. There are no orders on record for the flush.

Upon patient record review, 3 of 13 (Patient #2, #9, #10) did not have evidence that all entries complete and accurate. Patient #2- On 01/13/23 the nurse documented the patient's biliary drain flush was completed. The documentation does not include the type and amount of flush. On 01/17/23 the nurse documented the family flushed the biliary tube with 10 ml. The type of solution is not documented. (late entry correction made on site) Patient #9-On 09/06/22 the nurse documented Morphine was administered. The documentation is not specific for the dosage and route administered. Patient #10-On 08/26/22 the Chaplain documents the patient is 75 years old. The patient was 95 years old. On 08/29/22 the nurse documents the patients urostomy tube was flushed with 5 ml. The documentation is not specific for the type of flush.

Upon patient record review, 1of 13 (Patient #8) 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 #8-The patient transferred to another Hospice on 01/05/23. The record does not document a transfer summary was sent to the receiving Hospice.

Upon patient record review, 1 of 13 (Patient #7 ) did not have evidence that the discharge summary includes all required information. Patient #7- On 10/07/22 the patient was discharged due to revocation. The discharge summary does not include a summary of the patient's stay, including treatments, symptoms and pain management. The discharge summary only states the patient was admitted to the hospital and revoked the election.

Upon personnel record review, 1 of 12 (Personnel #12) 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 #12-A background check is not on record for the contracted SLP.

Based on record review, and interview the Agency failed to ensure 1 of 5 patients (Patient #5) received effective pain management and symptom control. This failure has the potential that patients symptoms including pain, will not be managed and may result in substandard care. --- Findings Included: Review of the clinical record of Patient #5 revealed a start of care date of 09/22/2022 for a terminal diagnosis of Parkinsons Disease. Further review of the clinical record of Patient #5 revealed Patient #5 expired on 12/10/2022. Review of the IDG Plan of Care Update, dated 11/23/2022 revealed Patient #5 was to receive Morphine 10 mg. sublingually every two hours as needed for pain or shortness of breath. Review of a skilled nursing visit note dated 12/06/2022 documented by the Licensed Vocational Nurse revealed at this visit during medication reconciliation, Patient #5 had 4 pre-filled syringes of Morphine 10 mg/0.2mL. Review of the documentation revealed the visit took place at 1:43 PM. Review of the Agencys on-call log for the week of 12/04/2022 to 12/10/2022 revealed on 12/06/2022 at 9:49 PM, a call was received from the SNF Nurse A with a message of ";Waiting all day for delivery of morphine and (patient) completely out now." Further review of the Agencys on-call log revealed on 12/07/2022 at 6:18 AM, a call was received from the SNF Nurse B with a message of ";Morphine delivery needed." Review of the Pharmacy A delivery log for Patient #5 for the week of 12/04/2022 to 12/10/2022 revealed 30 pre-filled syringes of Morphine 10mg./0.2mL were picked up by the Registered Nurse on 12/07/2022 at 10:47 AM and on 12/09/2022 at 10:21 AM. An interview was conducted with the Administrator/Supervising Nurse on 12/13/2022 at 1:40 PM. Surveyor requested the pharmacy delivery log for Patient #5 for the week of 12/04/2022 to 12/10/2022. The Administrator/Supervising Nurse provided pharmacy pick up receipts for medications provided to Patient #5 on 12/07/2022, 12/08/2022, and 12/09/2022. The Administrator/Supervising Nurse stated there was a delay in getting ordered Morphine to Patient #5 on 12/06/2022. The Administrator stated the Registered Nurse picked up medication on 12/07/2022 and 12/09/2022 to ensure Patient #5 received the medications. An interview was conducted with the Alternate Supervising Nurse on 12/13/2022 at 1:56 PM. The Alternate Supervising Nurse stated that she conducted a visit with Patient #5 on 12/05/2022. The Alternate Supervising Nurse stated that the Agencys typical back-up policy was to re-route after hours medications to Pharmacy B. The Alternate Supervising Nurse stated that the Agency was unable to do this with Patient #5 due to the Morphine requiring delivery in pre-filled syringes at the SNF. The Alternate Supervising Nurse was asked if Patient #5 was experiencing pain. The Alternate Supervising Nurse stated that Patient #5 was non-verbal. The Alternate Supervising Nurse was asked if Patient #5 was experiencing any other non-verbal indicators of pain such as facial grimacing. The Alternate Supervising Nurse stated that Patient #5 was not observed to be grimacing. The Alternate Supervising Nurse stated Patient #5 had been having oxygen saturations in the 80s and other fluctuations in vital signs. The Alternate Supervising Nurse stated that Patient #5 had been receiving the Morphine every two hours. A telephone and/or face-to-face interview was attempted with the Registered Nurse on 12/13/2022 at 1:45 PM. The Administrator/Supervising Nurse stated the Registered Nurse was unavailable for an interview. During an additional interview conducted with the Administrator/Supervising Nurse on 12/13/2022 at approximately 4:30 PM, the Administrator was asked what the Agency was doing to ensure that medications were delivered to clients in a timely manner. The Administrator stated that she was working to have Agency nurses pick up medications from the pharmacy and deliver them. The Administrator/Supervising Nurse stated this process was something they would be discussing at their next IDG meeting on Thursday (12/15/2022). Review of the Agencys policy and procedure manual revealed a policy entitled ";Pharmacy Services," dated January 2020 which read in part, ";Pharmacy, biological and infusion services needed by hospice patients and families/caregivers and hospice personnel will be available 24 hours a day...Controlled substances and other medications will be available through these pharmacy contracts for patients on the Medicare, Medicaid, private insurance hospice benefits, and for those unexpected situations requiring pain and symptom management after normal business hours.