Every finding on record at Odyssey Healthcare Operating A, LP

Upon patient record review, 1 of 14 (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: During the home visit, the patients caregiver stated that the patient does not take Dulcolax suppository, Eliquis, famotidine, Geri-knot, loratadine, or mirtazapine which are all listed on the active medication profile. Reports that the patient only takes Losartan 50mg, Lexapro 20mg, Lactulose 10grams, acetaminophen 500mg PRN. The patient also uses MiraLAX PRN daily. No evidence that MiraLAX was included on the active medication list. Corrected on site. New orders received to remove medications that are not being taken from the active medication list and add MiraLAX.

Upon patient record review, 5 of 14 (Patient #2,3,6,10,13) 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 08/24/25. There was no evidence of a bereavement risk assessment completed within 5 days of admit. Assessment completed on 09/25/2025. Patient 3: The patient was admitted on 09/20/25. There was no evidence of a bereavement risk assessment completed within 5 days of admit. Assessment completed on 10/2/2025. Patient 6: The patient was admitted on 08/26/25. There was no evidence of a bereavement risk assessment completed within 5 days of admit. Assessment completed on 09/09/2025. Patient 10: The patient was admitted on 07/31/25. There was no evidence of a bereavement risk assessment completed within 5 days of admit. Assessment completed on 08/06/2025. Patient 13: The patient was admitted on 11/15/24. There was no evidence of a bereavement risk assessment completed within 5 days of admit. Assessment completed on 02/13/2025.

Upon patient record review, 5 of 14 (Patient #2,3,4,6,9) 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 medical record indicated that the patient has an unsteady gait and increased weakness. No evidence of problems, interventions, and goals related to altered mobility included in the plan of care at the time that the chart was surveyed. Corrected on site. New order written to update the plan of during survey. Patient 3: The medical record indicated that the patient is a risk for falls, risk for aspirations due to dysphagia, depression (takes medications daily), and is incontinent of bowel and bladder. No evidence of problems, interventions, and goals related to falls, dysphagia, depression, or incontinent problems at the time the chart was surveyed. Corrected on site. New order written to update the plan of during survey. Patient 4: The medical record indicated that the patient has a related diagnosis of depression and currently takes 2 medication daily for depression. No evidence of problems, interventions, and goals related to depression included in the plan of care at the time that the chart was surveyed. Corrected on site. New order written to update the plan of during survey. Patient 6: Pre-bereavement risk assessment was completed by the nurse on 09/09/2025 and was scored as moderate. Another bereavement risk assessment was completed by the chaplain on 04/10/2025 that also scored high. No evidence that the bereavement care plan was updated to reflect the caregivers needs. Patient 9: Pre-bereavement risk assessment was completed by the nurse on 09/09/2025 and was scored as moderate. Another bereavement risk assessment was completed by the chaplain on 04/10/2025 that also scored high. No evidence that the bereavement care plan was updated to reflect the caregivers needs.

Upon patient record review, 3 of 14 (Patient #3,4,5) 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 3: SW and SCP frequency was PRN only without a standing order on the initial evaluation order, order corrected once the disciplines completed their evaluations. Patient 4: SW and SCP frequency was PRN only without a standing order on the initial evaluation order, order corrected once the disciplines completed their evaluations. Patient 5: SCP frequency was PRN only without a standing order on the initial evaluation order, order corrected once the disciplines completed their evaluations.

Upon patient record review, 3 of 14 (Patient #3,4,6) 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 equipment and supply needs. Patient 3: The medical record indicated that the patient used a high-back wheelchair daily. No evidence that the high-back wheelchair was placed on the current supply list. Corrected on site. New order written to update the supply list during survey. Patient 4: The medical record indicated that patient had wound while on services that was discontinued on 07/14/2025. No evidence that the current supply list was updated to remove wound care supplies from the supply list. New order written to update the supply list during survey. Patient 6: The medical record indicated that patient used a bedside commode. No evidence that the bedside commode was placed on the current supply list. New order written to update the supply list during survey.

Upon client record review, 1 of 14 (Patient #4) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient 4: The medical record show that patient choose an attending physician at the time of admit. No evidence that IDG was conducted in collaboration with the attending physician at the time of survey.

Upon patient record review, 1 of 14 (Patient #2) 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 2: The plan of care, 11/22/25, has spiritual and psychosocial problems, goals, and interventions listed. The medical record indicated that social services were ended on 10/14/2025 and the chaplain was discontinued on 10/08/25. Corrected on site. Plan of care updated during survey.

Upon patient record review 2 of 14 (Patient #6,9) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 6: Pre-bereavement risk assessment was completed by the nurse on 09/09/2025 and was scored as moderate. Another bereavement risk assessment was completed by the chaplain on 04/10/2025 that also scored high. No evidence that a follow-up was completed or that anything was done to start supporting the caregiver. Patient 9: Pre-bereavement risk assessment was completed by the nurse on 09/09/2025 and was scored as moderate. Another bereavement risk assessment was completed by the chaplain on 04/10/2025 that also scored high. No evidence that a follow-up was completed or that anything was done to start supporting the caregiver.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient 9: The medical record contained nursing documentation 10/19/2025 indicated that the patient had an unwitnessed fall. There was no evidence that an investigation of the incident occurred at the time that the chart was surveyed.

Upon patient record review, 1 of 14 (Patient #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 • 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 6: The RN documentation indicated that the patient requires 2 aide per visit for bath/transfer. No evidence that the aide plan of care was updated to include the 2 person assist at the time that the chart was surveyed. Also the current aide plan of care included diabetic precautions. No evidence that the patient has diabetes. Corrected on site. Aide plan of care updated during survey.

Upon patient record review 1 of 14 (Patient #3) 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 3: Plan of care has aide frequency ordered as 3 times weekly. No evidence that the patient received 3 visits for the week of 12/10/25. No evidence that the visit was missed at the request of the patient/CG or that an order was received to decrease visits for the week. Missed visit documentation stated that the visit was missed due to 'other".

Upon client record review, 2 of 5 records (Patient #1,#5) 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 visit frequency for the skilled nurse was 3w1, 2w12. The record indicated for the week of 2/13/23 (admission) - 2/18/23, only 2 visits were conducted (on 2/13/23 and 2/14/23). And for the week of 2/19/23-2/25/23, only 1 visit was conducted on 2/22/23. Patient #5: The visit frequency for the skilled nurse was 2w13. For the week 2/12/23-2/18/23, the record indicated only 1 visit on 2/15/23. And for the week of 2/19/23-2/25/23, the record indicated only 1 visit on 2/22/23.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 6 of 11 (Patients #1,#4,#7,#9,#10,#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 1: The medical record contained an initial spiritual assessment completed 6/16/22. Patient admitted 6/9/22. Patient 4: The medical record contained an initial spiritual assessment completed 9/30/22. Patient admitted 8/18/22. Patient 7: The medical record contained an initial spiritual assessment completed 11/7/22. Patient admitted 10/31/22. Patient 9: The medical record contained an initial psychosocial assessment completed 6/7/22 and initial spiritual assessment completed 6/29/22. Patient admitted 5/28/22. Patient 10: The medical record contained an initial spiritual assessment completed 10/31/22. Patient admitted 9/12/22. Patient 11: The medical record contained an initial spiritual assessment completed 1/12/23. Patient admitted 12/29/22.

Upon patient record review 3 of 11 (Patients #3,#5,#6) 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 3: There was no evidence of a spiritual assessment. Patient 5: There was no evidence of a spiritual assessment. Patient 6: There was no evidence of spiritual and psychosocial assessments.

Upon patient record review, 5 of 11 (Patients #3,#4,#7,#8,#9) 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 3: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. Corrected on site. Patient 4: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. Corrected on site. Patient 7: The medication profile contained oxygen with no defined delivery method. Patient 8: The medical record contained nursing documentation 6/7/22 identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. Patient 9: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. The medication profile contained Miralax oral powder with no instructions for a diluent.

Upon patient record review, 7 of 11 (Patients #3,#4,#5,#6,#7,#9,#10) 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 3: The medical record contained an initial bereavement assessment dated 12/28/22. Patient admitted 12/21/22. Patient 4: The medical record contained an initial bereavement assessment dated 8/25/22. Patient admitted 8/18/22. Patient 5: There was no evidence of an initial bereavement assessment. Patient 6: The medical record contained an initial bereavement assessment dated 12/28/22. Patient admitted 12/19/22. Patient 7: The medical record contained an initial bereavement assessment dated 11/7/22. Patient admitted 10/31/22. Patient 9:The medical record contained an initial bereavement assessment dated 6/29/22. Patient admitted 5/28/22. Patient 10: The medical record contained an initial bereavement assessment dated 9/19/22. Patient admitted 9/12/22.

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

Upon patient record review, 3 of 11 (Patient #4,#7,#8) 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 4: The medical record contained nursing documentation upon recertification visit 11/4/22 identifying falls within the benefit period. There was no evidence of problems, goals, and interventions related to patient safety or fall prevention. Corrected on site. The plan of care contained an active care plan for social work. The patient was not receiving social work services and had no ordered frequency for social work visits. Patient 7: The plan of care contained a problem of active need for aide services and a current aide care plan. The patient was not receiving aide services and had no ordered frequency for aide services. The medical record also contained nursing documentation 1/3/23 identifying patient complained of shortness of breath resulting in oxygen ordered for delivery. There was no evidence of problems, goals, and interventions related to respiratory dysfunction or oxygen safety. Patient 8: The medical record contained nursing documentation 6/6/22 identifying patient need for suction and 6/7/22 identifying patient need for oxygen. There was no evidence of problems, goals, and interventions related to respiratory dysfunction or oxygen safety. The medical record also contained nursing documentation upon admission identifying patient had history of multiple falls occurring before admission to hospice. There was no evidence of problems, goals, and interventions related to patient safety or fall prevention.

Upon patient record review, 5 of 11 (Patients #3,#4,#7,#8,#9) 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 3: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen. Corrected on site. Patient 4: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen. Corrected on site. Patient 7: The medical record contained an order for oxygen with no defined delivery method. Patient 8: The medical record contained nursing documentation 6/7/22 identifying patient use of oxygen. There was no evidence of an order for oxygen. Patient 9: The medical record contained nursing documentation upon admission identifying patient use of oxygen and a stage II decubitus ulcer to the coccyx. There was no evidence of an order for oxygen or wound care. The medical record contained an order for Miralax oral powder with no instructions for a diluent.

Upon patient record review, 6 of 11 (Patients #2,#3,#4,#5,#8,#9) 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: The medical record contained orders for a duoneb prescription. There was no evidence of the nebulizer included as DME on the plan of care. Corrected on site. Patient 3: The medical record contained nursing documentation upon admission identifying patient use of bed rails, over the bed table, and walker. There was no evidence of the rails, table, and walker included as DME on the plan of care. Corrected on site. Patient 4: The medical record contained nursing documentation upon admission identifying patient use of a low air loss mattress, bed rails, and over the bed table. There was no evidence of the mattress, rails, and table included as DME on the plan of care. Corrected on site. Patient 5: The medical record contained nursing documentation upon recertification visit 11/8/22 identifying patient use of a wheelchair and over the bed table. There was no evidence of the wheelchair and table included as DME on the plan of care. Corrected on site. Patient 8: The medical record contained nursing documentation 6/6/22 identifying a suction machine was ordered for delivery and 6/7/22 identifying oxygen equipment was ordered for delivery from the supplier. There was no evidence of the oxygen and suction machine included as DME on the plan of care. Patient 9: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, over the bed table, wheelchair, and oxygen. There was no evidence of the bed, table, wheelchair, and oxygen included as DME on the plan of care.

Upon client record review, 7 of 11 (Patients #1,#4,#5,#8,#9,#10,#11) 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 medical record contained an ordered nursing frequency of once weekly. There was no evidence of a visit completed the week of 12/25/22. The medical record also contained an ordered social work frequency of once monthly. There was no evidence of a visit completed in December. Patient 3: On admission order for chaplain to complete evaluation, this was not completed. Patient 4: The medical record contained an ordered nursing frequency of twice weekly. There was no evidence of a second visit completed the week of 12/18/22. On admission 8/18/22 order for Chaplain to complete evaluation, not completed until 9/30/22 when monthly visits began. Patient 5: The medical record contained an ordered social work frequency of once monthly. There was no evidence of a visit completed in December. On admission order for chaplain to complete evaluation, this was not completed. Patient 6: On admission order for chaplain and social worker to complete evaluation, this was not completed. Patient 8: The medical record contained an ordered nursing frequency of twice weekly. There was no evidence of a second visit completed the week of 5/29/22. Patient 9: The medical record contained an ordered nursing frequency of three times weekly. There was no evidence of a third visit completed the week of 5/29/22. Patient 10: The medical record contained an ordered nursing frequency of once weekly. There was no evidence of a visit completed the weeks of 11/20/22 and 11/27/22. The medical record also contained an ordered social work frequency of once monthly. The social worker documented two scheduled visits for the month of November with neither indicated as a PRN visit. On admission 9/12/22 order for Chaplain to complete evaluation, not completed until 10/30/22 when monthly visits began. Patient 11: The medical record contained an ordered nursing frequency for three visits the first week of service. There was no evidence of a third visit completed the week of admission.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 5: The clinician did not wash or sanitize hands between glove changes witnessed twice. Patient 7: The clinician placed their work bag on the floor and the vital sign equipment bag on the patient's night stand without any barriers.

Upon patient record review, 2 of 11 (Patients #8,#9) 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 8 and 9: There was no evidence provided of the bereavement care plan tasks being completed.

Upon patient record review 3 of 11 (Patients #2,#8,#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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 2: The medical record contained an ordered aide frequency of three times a week. There was no evidence of a third visit completed the week of 1/1/23. Patient 8: The medical record contained an ordered aide frequency of two times a week. There was no evidence of a second visit completed the weeks of 5/22/22 and 6/5/22. Patient 9: The medical record contained an ordered aide frequency of three times a week. There was no evidence of a third visit completed the week of 5/29/22.

Upon patient client record review, 2 of 11 (Patient #10 and 11) did not evidence that each patient record contains physician orders. Patient 10: There was no evidence of an order to discharge patient when discharged for cause. Patient 11: There was no evidence of an order to discharge patient for transfer to another hospice agency.

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 contract for Seton contained the provision explaining responsibility for training, however, there was no evidence of training completed since 2010.

Upon personnel record review, 4 of 13 (Personnel #1,#4,#7,#8) 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 1, 4, 7, 8: There was no evidence of a criminal background check in the personnel file.

Upon observation, there was no evidence there is a copy of the CLIA certificate for the laboratory used for specimen testing. The CLIA available at the agency expired 1/6/23.

Upon personnel record review, 1 of 13 (Personnel #7) did not have evidence that all personnel have been fully vaccinated for COVID-19. Personnel 7: There was no evidence of a COVID-19 vaccination status in the personnel record.