Every finding on record at Odyssey Healthcare Operating B, LP

Upon patient record review, 3 of 14 (Patient #1, 5, 8) 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 #1: The patient was admitted on 3-10-26. The record indicated that the bereavement risk assessment was completed on 3-23-26 which is greater than the 5 day requirement. Patient #5: The patient was admitted on 3-26-26. The record indicated that the bereavement Risk assessment was completed on 4-3-26 which is greater than the 5 day requirement. Patient #8: The patient was admitted on 10-24-25. The record indicated that the bereavement risk assessment was completed on 10-30-25 which is greater than the 5 day requirement.

Upon patient record review, 1 of 14 (Patient #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 #9 The patient record had documented the patient had a diagnosis of anxiety. There was no evidence of a problem statement with goals and interventions and progress toward outcomes related to the management of anxiety.

Upon patient record review, 2 of 14 (Patient #3,8) 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 record indicated that the patient had a wheelchair, raised toilet seat and bed alarm. There was not evidence that this was in the plan of care. Patient #8: The clinical record indicates the patient has a shower chair in the home. There was not evidence that this was in the plan of care.

Upon patient record review, 1 of 14 (Patient #4) 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 4: There was not evidence that the care plan was updated to reflect problems, goals and interventions for the volunteer.

Upon client record review, 2 of 14 (Patient #7,9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #7: The record indicated a new order was received on 5-25-26 to replace the current foley catheter with a 16 Fr. with a 10cc. balloon. The RN documented in the clinical record that the foley catheter was replaced with 16Fr 5cc balloon. This incorrect verbiage was also carried over into the patients plan of care which did not match the current physician order. Patient #9: The record indicated the patient has orders to change the indwelling foley catheter as needed for occlusion, infection or if problems noted. Documentation noted in the clinical record on 5-20-26 RN states the patients foley is due to be changed without noting a reason in her documentation. During a home visit patient states his foley catheter is changed on a regular basis. There was not evidence that scheduled foley catheter changes were a part of the care plan.

Upon patient record review, 2 of 14 (Patient #11,12) 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 #11: A post bereavement risk assessment was completed on 12-17-25 and a care plan was created for the bereavement personnel to follow. There is no evidence stated in the bereavement coordination notes that the sympathy card or holiday letter were mailed to the bereaved. Patient #12: A post bereavement risk assessment was completed on 11-20-2025 which generated a care plan for the bereavement personnel to follow. There is no evidence stated in the bereavement coordination notes that the sympathy card or holiday or memorial service invitation was mailed to the bereaved.

Upon patient record review, 2 of 14 (Patient #1,2) 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:The aide plan of care indicated the patient to transfer with use of walker. Order written on 4-8-26 to discontinue the patients walker. No Evidence found that the aide care plan was updated to reflect the change. Patient #2: Documentation indicated the patient had orders for bilateral heel protectors. This was not reflected in the current aide plan of care.

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: The Aide was assigned to provide cares 2 times a week. During the Medicare week of 5-10-26 patient received only 1 aide 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 agency volunteer utilization rate was 3.62% for 2025.

Upon patient record review 1 of 14 records (Patient #2) 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 #2: The patient was admitted on 1/18/23. The record indicated that the spiritual assessment was completed on1/26/23

Upon patient record review, 1 of 14 records (Patient #2) 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: The record indicated for Psyllium Husk .52 Gm daily, Senna Plus 2 tabs, BID, Glycerine supp 1 daily prn severe constipation, Dulcolax 100mg caps 2-4 times daily prn, and Senna 8.6-50, 1 additional tablet for mild constipation, 2 for moderate constipation and to use the supp for severe constipation. The list of medications for constipation were numerous and unclear as to the order to be administrated. Corrected on site.

Upon patient record review, 4 of 14 records (Patient #7,#9,#12,#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 #7: The patient was admitted on 4/28/23. The record indicated that the bereavement assessment was completed on 5/4/23. Patient #9: The patient was admitted on 6/5/23. The record indicated that the bereavement assessment was completed on 6/12/23. Patient #12: The patient was admitted on 12/13/22. The record indicated that the bereavement assessment was completed on 12/20/22. Patient #13: The patient was admitted on 10/19/22. The record indicated that the bereavement assessment was completed on 10/25/22.

Upon patient record review, 3 of 14 records (Patient #3,#7,#9) 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 #3: The patient was admitted with a diagnosis of Alzheimer's Disease. There was not evidence that the plan of care reflected patient/family goals and interventions based on Alzheimer's or Neurological problems. The patient had wound care orders dated 5/16/23 for wounds on his right heel and left heel. Also on 6/1/23, the record indicated wound care orders for a wound on the patient's right lateral foot. There was not evidence that the revised plan of care included goals and interventions related to skin, wounds or wound care. Corrected on site. Patient #7: The patient was admitted with a diagnosis of hypertensive heart disease with failure. The record indicated that the patient's ejection fraction was 18.7%. There was not evidence that the plan of care reflected goals and interventions related to the patient's cardiac disease. Corrected on site. Patient #9: The patient was admitted with a diagnosis of Alzheimer's Disease. There was not evidence that the plan of care reflected patient/family goals and interventions based on Alzheimer's or Neurological problems. Corrected on site.

Upon patient record review, 1 of 14 records (Patient #2) did not have evidence that the plan of care 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 #2: The record indicated an order dated 5/26/23 for the spiritual care counselor visit frequency and the social worker visit frequency as 2 prn. Corrected on site.

Upon patient record review, 1 of 14 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: The record indicated for psyllium husk .52 Gm daily, Senna Plus 2 tabs, BID, Glycerine supp 1 daily prn severe constipation, Dulcolax 100mg caps 2-4 times daily prn, and Senna 8.6-50, 1 additional tablet for mild constipation, 2 for moderate constipation and to use the supp for severe constipation. The list of medications for constipation were numerous and unclear as to the order to be administrated. Corrected on site.

Upon patient record review, 1 of 14 records (Patient #13) 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 bereavement plan of care. Patient #13: The plan of care indicated that the 3 month letter was due to be sent by 3/18/23. There was not evidence that this was sent until 5/26/23.

Upon patient record review, 2 of 14 records (Patient #2,#5) did not have evidence in the patient record that hospice aide assignments and duties include: • There is evidence in the patient record that the plan of care specifically 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 #2; The aide plan of care indicated for the aide to offer a shower and if the patient was unable to tolerate a shower, to notify the nurse and offer a bed bath as an alternative. Corrected on site. Patient #5: The aide plan of care indicated for both a shower and a bed bath to be performed at every visit. In addition, nail care was indicated to be performed both weekly and q visit. Corrected on site.

Upon patient record review 1 of 14 records (Patient #4) did not have evidence of 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 #4:The aide plan of care indicated to provide nail care and a shampoo weekly. The record indicated that these tasks were provided at each visit from 5/9/23 to current (Aide visit frequency was ordered 2x/week on 5/9/23).

Upon observation, there was no evidence the hospice designates a physician to serve as Medical Director which includes: • When the Medical Director is not available, a physician designated by the hospice assumes the same responsibilities and obligations as the Medical Director. There was not evidence of a contract for an Alternate Medical Director.

Upon patient client record review, 1 of 14 records (Patient #12) did not have evidence that each patient record contains physician orders. Patient #12: The record indicated that the patient was discharged on 1/6/23 due to being admitted to a non-contracted facility. There was not evidence of an order for the discharge.