Every finding on record at Odyssey Healthcare Operating B, LP

Upon patient record review 4 of 19 records (Patient #1,#10,#12,#13) 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 on 6/11/24. The record indicated that the spiritual assessment was not completed until 6/19/24. Patient #10: The patient was admitted on 5/29/24. The record indicated that the spiritual assessment was not completed until 6/14/24. (Coordination notes from 6/10/24 and 6/11/24 stated, "unable to contact.") Patient #12: The patient was admitted on 4/1/24. The record indicated that the spiritual assessment was not completed until 4/8/24. Patient #13: The patient was admitted on 6/13/24. The record indicated that the spiritual assessment was not completed until 6/20/24. (Coordination notes from 6/17/24 and 6/19/24 stated, "unable to contact.")

Upon patient record review, 3 of 19 (Patient #2,7,8) 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 #2: Cyanocobalamin was on the MAR at the SNF but not on the hospice MAR. Corrected on site. Patient #7: Miralax and Ondansetron were on the hospice MAR. There was not evidence that these medications were on the facility MAR. In addition, Albuterol Nebulization and Doxycycline were discontinued on the Hospice MAR but were listed as PRN on the facility MAR. Patient #8: Bisacodyl and Imodium were listed on the Hospice MAR. There was not evidence that they were in the home and the caregiver verbally verified that they were not in the home.

Upon patient record review, 1 of 19 records (Patient #9) 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 #9: The patient was admitted on 5/22/24. The record indicated that the bereavement assessment was completed on 6/14/24 which is greater than the 5 day requirement.

Upon patient record review, 1 of 19 records (Patient #6) did not have evidence that a Registered Nurse ensured continuous assessment of the patient and family's needs and coordinated 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 #6: The nurse documentation dated 6/14/24 indicated that the patient sustained a wound after a fall. There was not evidence of a wound assessment until 6/27/24 when documentation revealed that the wound was healed. Agency policy states that wound assessments are to be conducted weekly.

Upon patient record review, 3 of 19 records (Patient #1,#5,#10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient that reflects 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 indicated that the patient did not have end of life plans. There was not evidence that the plan of care reflected patient/family goals and interventions based on the problems related to end of life planning. Corrected on site. Patient #5: The record indicated that the patient was on Aspirin 325mg, BID prn pain. Documentation confirmed that the patient was taking this medication for pain. There was not evidence that bleeding precautions were a part of the plan of care. Corrected on site. Patient #10: The record indicated that the patient was on Aspirin 81 mg daily and Plavix 75 mg daily. There was not evidence that bleeding precautions were on the plan of care. Corrected on site.

Upon patient record review, 1 of 19 records (Patient #2) 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 medications and treatments. Patient #2: Cyanocobalamin was on the MAR at the SNF however there was not evidence of an order for Cyanocobalamin in the hospice record. Corrected on site.

Upon patient record review, 2 of 19 records (Patient #9,#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 equipment and supply needs. Patient #9: The certification of terminal illness indicated that the patient was O2 dependent, and also used a wheelchair for transport. Nursing documentation revealed this equipment was being used by the patient. There was not evidence that these items were in the plan of care. Corrected on site. Patient #10: The record indicated an order for oxygen dated 8/6/24. There was not evidence that an oxygen concentrator, tanks, and supplies were on the plan of care. Corrected on site

Upon patient record review, 1 of 19 records (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 record indicated an order for oxygen dated 8/6/24. There was not evidence that a revised plan of care includes information from the patient's updated comprehensive assessment, including oxygen. Corrected on site.

Upon client record review, 2 of 19 records (Patient #1,#8) 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 spiritual care counselor was for an evaluation and then 1m2. The evaluation was conducted on 6/19/24. There was not evidence of a visit in the month of July. The missed visit document dated 7/31/24 indicated, "contact attempt unsuccessful." Patient #8: The visit frequency for the spiritual care counselor was 1m2 effective 6/1/24. There was not evidence of a visit in June or July. The missed visit documents dated 6/28/24 and 7/31/24 indicated, "Unable to contact." Patient #9: The visit frequency for the spiritual care counselor was 1m3. There was not evidence of a visit in June or July. The missed visit documents dated 6/28/24 and 7/31/24 indicated, "Unable to contact."

Upon patient record review, 1 of 19 records (Patient #17) 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, and following the established plan of care Patient #17: The bereavement plan of care documentation revealed that the 2 week card was due to be sent by 4/8/24. The record indicated that this was sent on 5/29/24. Also, the 1 month letter was due to be sent by 4/24/24. The record indicated that this was sent on 5/29/24.

Upon patient record review, 2 of 19 records (Patient #5,#10) 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 specifically indicate what tasks are to be done by the Aide, including alerts and precautions 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 #5: The record indicated that the patient was on Aspirin 325mg, BID prn pain. Documentation confirmed that the patient was taking this medication for pain. There was not evidence that bleeding precautions were a part of the aide plan of care. Corrected on site. Patient #10: The record indicated an order for oxygen dated 8/6/24. There was not evidence that oxygen precautions were added to the aide plan of care. Corrected on site. In addition, the patient was on Aspirin 81 mg daily and Plavix 75 mg daily. There was not evidence that bleeding precautions were on the aide plan of care. Corrected on site.

Upon patient record review 1 of 19 records (Patient #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 Patient #9: The visit frequency for the aide was 2w12. There was not evidence of 2 visits for the week of 6/30/24-7/6/24.

Upon personnel record review, 1 of 13 records (Personnel #2) did not have evidence the alternate administrator's personnel record verifies that: • There is a signed job description for this role • The employee has been orientated to this role Corrected on site.

Upon contract review, 1 of 6 contracts (GC physician contract) did not have evidence of a contract to fulfill the role of medical director or alternate medical director. GC hospice physician contract: The contract stated only that this physician was a hospice physician without evidence of provisions that specified alternate medical director/medical director designee. Corrected on site.

Upon client record review, 1 of 19 records (Patient #11) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #11: The visit frequency for the skilled nurse was 2w13. There was not evidence of 2 visits for the week of 7/14/24-7/20/24