Every finding on record at Odyssey Healthcare Operating B, LP

Upon patient record review 4 of 11 (Patient #1, #8, #9, #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 #1-The patient was admitted 05/04/22 and a spiritual assessment was completed 5/10/22. Patient #8-The patient was admitted on 01/01/21 and initially declined Chaplain services. On 09/21/21 a spiritual assessment was performed when the family accepted the service. Patient #9- The patient was admitted 01/06/22 and the spiritual assessment was performed 01/14/22. Patient #10-The patient was admitted 02/02/22 and the spiritual assessment was performed 02/09/22.

Upon patient record review 1 of 11 (Patient #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 #6- The patient was admitted on 01/11/22 and declined Chaplain services. A spiritual assessment was not completed by the RN or Social worker as part of the comprehensive assessment. A spiritual assessment is not on record.

Upon patient record review, 5 of 11 (Patient #5, #6, #8, #9, #11) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient #5-The patient was admitted on Oxygen 05/09/22. Oxygen is not included on the medication profile. (corrected on site) Patient #6-The medication profile includes orders for Morphine 100 mg/5ml .25-1ml hourly for pain /SOB. The profile does not include parameters for decision making in the dosage administration. The patient is on Oxygen and Oxygen is not on the medication profile. Patient #8-The patient is on Oxygen and the medication profile does not include Oxygen. Patient #9-The medication profile includes orders for Morphine 100 mg/5ml .25-1ml hourly for pain /SOB. The profile does not include parameters for decision making in the dosage administration. Patient #11-The medication profile includes Levimir Flextouch U-100 100u/ml inject 3 ml sq as directed for BS above 200. The frequency is unclear regarding how often blood sugars are to be checked.

Upon patient record review, 1 of 11 (Patient #1) 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- On 05/04/22 the nurse documents in the admission visit the patient has Pancreatic Cancer with daily intermittent cramping and tenderness in the abdomen interfering with appetite and sleep. The plan of care does not include interventions and goals for alteration in comfort/pain. (corrected on site)

Upon patient record review, 5 of 11 (Patient #5, #6, #8, #9, #11) 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 #5-The plan of care 05/09/22 includes orders to teach the patient on the usage of Oxygen. The orders do not include the patients liter flow and Oxygen frequency. (corrected on site) Patient #6-The 01/11/22 plan of care includes orders for Morphine 100 mg/5ml .25ml-1ml hourly for pain /SOB. The plan of care does not include parameters for decision making in the dosage administration. The patient is on Oxygen and Oxygen liter flow and frequency is not included in the plan of care. Patient #8- The record contains orders on 09/17/21 to update the plan of care which read Mepilex to sacral DTI. The orders do not include the cleansing agent and/or frequency of dressing change. The patient is on Oxygen and the 08/31/21 plan of care does not include Oxygen liter flow and frequency. Patient #9-The 01/06/22 plan of care includes orders for Morphine 100 mg/5ml .25-1ml hourly for pain /SOB. The plan of care does not include parameters for decision making in the dosage administration. Patient #11-The 02/24/22 plan of care includes Levimir Flextouch U-100 100u/ml inject 3 ml sq as directed for BS above 200. The frequency is unclear how often blood sugars are to be checked. (corrected on site)

Upon patient record review, 3 of 11 (Patient #3, #7, #10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3-On 05/15/22 the nurse documents the patient was assessed and was on Oxygen at 8 liters per minute. The patient stated he was to be on Oxygen at 6.5 liters/min. The nurse documents turning the Oxygen down to 6.5 liters per minute which was greater than the ordered liter flow. Orders on record 04/28/22 indicate the patient is to be on Oxygen 2-6 lpm and Hospice is to be notified if the patient requires Oxygen greater than 6 liters per minute. The patient has orders effective 02/18/22 for Spiritual care 1q2m2. There are no Chaplain visits on record for April 2022. On 04/25/22 and 04/29/22 the Chaplain documents visits were not made due to military duty. There is no documentation to evidence the Chaplain offered coverage in his absence due to military service. Patient #7- On 02/08/22 the nurse documents performing a manual disimpaction as the patient had not had a bowel movement in 4 days. There are no orders on record for disimpaction. Patient #10-The spiritual care provider is ordered to visit once monthly. There are no Chaplain visits on record for April 2022. On 04/26/22 and 04/29/22 the Chaplain documents visits were not made due to military duty. There is no documentation to evidence the Chaplain offered coverage in his absence due to military service.

Upon patient record review, 1 of 11 (Patient #7) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient #7-The patient revoked the Hospice election on 02/24/22. The Aide visited 02/25/22 am and documented providing care to the patient. There was no documentation on the record the IDG notified the Aide the patient had revoked the election.

Upon patient record review, 2 of 10 applicable (Patient #2, #7) did not have evidence in the patient record that hospice aide assignments and duties are: • Complete written patient care instructions for a hospice aide prepared by a Registered Nurse. Patient #2-The patient was admitted on Eliquis and on the 05/02/22 nursing visit the RN documents the patient has rectal bleeding from hemorrhoids. The Aide care plan does not include bleeding precautions. (corrected on site) Patient #7-The patient was admitted on 02/23/22 with dysphagia and was at risk for aspiration. The aide care plan does not include aspiration precautions.

Upon patient record review, 1 of 11 (Patient #1) 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. Patient #1- On 05/09/22 the Social Worker documents the patient has "Pance Camcer and Diet" (unclear documentation). On 05/11/22 there is a paper nursing visit on record that does not contain a date by the nurses signature. (corrected on site)

Upon patient record review, 1 of 1 applicable (Patient #6) 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 #6-The patient transferred to another hospice on 04/22/22. There is no documentation on record a transfer summary was sent to the receiving hospice.

Upon patient record review, 1 of 1 applicable (Patient #7) did not have evidence that the discharge summary includes all required information. Patient #7-On 02/24/22 the patient revoked their election. The discharge summary on record only documents the patient no longer desires hospice. The summary does not include a summary of the patient's stay, including treatments, symptoms and pain management.