Every finding on record at Odyssey Healthcare Operating B, LP

Upon patient record review, 2 of 19 (Patient #9,13) 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 9: Patient admitted on 02/24/2023, bereavement risk assessment completed on 04/28/2023. Patient 13: Patient admitted on 04/10/2023, bereavement risk assessment completed on 04/28/2023.

Upon patient record review 2 of 19 (Patient #2,4) 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: Aide visit frequency ordered at 2 times a week. Visits for 07/06/2023 and 07/08/2023 missed. Aide entered the reason for missing visit as 'scheduling error" on missed visit note. No evidence that visit was declined by patient or caregiver. Patient 4: Aide visit frequency ordered at 2 times a week. Visit for 04/11/2023 missed. Aide entered the reason for missing visit as "other" on missed visit note. No evidence that visit was declined by patient or caregiver.

Upon patient client record review, 1 of 19 (Patient #16) did not have evidence that each patient record contains physician orders. Patient 16: No evidence that a discharge order was obtained at the time of discharge.

Upon client record review, 1 of 19 (Patient #15) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient 15: No evidence that a discharge summary was completed and sent to the attending physician.

Upon client record review, 1 of 19 (Patient #13) 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 13: Volunteer services ordered to start on 04/27/2023. Ordered frequency was: One visit for April and three visits for May. Volunteer visits continued for the month of June, July, and August. Patient seen 4 times in June, 4 times in July, and once in August. No evidence that an order was placed for volunteer visits to continue. Clarification orders entered during survey. POC has SN visit frequency as 2 times a week. MD order entered on 08/17/2023 and 08/18/2023 to decrease SN visits to once a week to start on 08/13/2023. Patient was seen twice that week. Order clarification entered during survey.