Every finding on record at Odyssey Healthcare Operating A, LP

Upon patient record review 2 of 14 (Patient #7,10) 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 #7: The patient was admitted on 1/07/24. The record indicated that the spiritual assessment was not completed until 2/21/24. No evidence that a mini spiritual assessment was completed before that time. Patient #10: The patient was admitted on 1/13/24. The record indicated that the spiritual assessment was not completed until 01/24/24. No evidence that a mini spiritual assessment was completed before that time.

Upon patient record review, 1 of 14 (Patient #8) 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 8: Duplicate drug therapy for constipation: Sennalax 8.6mg by mouth PRN daily and Dulcolax 100MG by mouth PRN daily. No evidence that instructions were given for which medication to us first for constipation.

Upon patient record review, 3 of 14 (Patient #1,3,4) 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: Patient takes Symbicort for COPD. There was no evidence that the plan of care included goals and interventions related to his altered respiratory status. Patient 3: The patient documentation shows that the patient is contracted and uses a wheelchair for mobility. There was not evidence that the plan of care included goals and interventions related to her altered mobility. Patient 4: Patient admitted with basal cell carcinoma and has metastatic disease to the brain. RN documentation shows steady decline of neurological status. There was not evidence that the plan of care included goals and interventions related to his neurological status.

Upon patient record review, 1 of 14 (Patient #7) 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 #7: The initial visit frequency for the social worker 4 prn visits which is not a detailed frequency to meet patient/family needs.

Upon client record review, 1 of 14 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: Elected volunteer services on initial RN assessment. Volunteer referral placed on 05/16/2024 and 06/03/2024. No evidence that any follow up was completed or order placed for volunteer services. Completed during survey.

Upon patient record review, 1 of 14 (Patient #1) 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 #1: Aide plan of care has orders for the aide to use the Hoyer lift and the wheelchair at every visit. RN discontinued the order for using the Hoyer lift and wheelchair but did not take those orders off the aide plan of care. Documentation shows that the aide continues use to the Hoyer lift and the wheelchair. Plan of care updated during survey.

Upon patient record review 3 of 14 (Patient #1,8,9) 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 #1: Aide frequency set at twice to start on the week 04/21/2024. No evidence that 2 visits occurred for the week of 04/21/2024. One documented visit occurred on 04/23/24. No missed visit note or order to decreased visit frequency for the week noted. Patient #8: Patient admitted on 05/30/2024, aide documented completed visit on 06/03 and a missed visit on 05/31. There was no evidence of an order for the aide to start visiting the patient. Patient 9: Aide plan of care has orders for the aide to provide nail care, shampoo, shave, and change linens at the first visit of the week. Aide documentation showed that those task were being performed at every 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 documented annual usage for the year 2023 was 0.9%. 2 months with volunteer hours for the year September 1.25, December 2.75.

Upon patient client record review, 1 of 14 (Patient #7) 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 7: On 04/05/2024 an order was placed and signed by the physician to insert an indwelling foley catheter and change foley catheter every month. No evidence that this patient ever required the use of a catheter.

Upon client record review, 1 of 19 (Patient #11) did not have evidence that the discharge summary includes all required information. Patient 11: No evidence that a discharge summary was completed.