Every finding on record at Odyssey Healthcare Operating B, LP

Upon patient record review 1 of 19 (Patient #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 #13: The patient was admitted on 01/05/24, the spiritual assessment was completed on 03/01/24.

Upon patient record review 1 of 19 (Patient #11) 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 #11:There was not evidence of a spiritual assessment.

Upon patient record review, 7 of 19 (Patient #2, #5,#10,#11,#12,#13,#14) 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: Methocarbamol and Tylenol extra strength were on the medication profile but not in the home. In addition, the medication profile indicated MS Contin 30 mg 3 times a day, the medication bottle in the home read 2 times a day. Patient stated he was taking it 2 times a day. Corrected on site. Patient #5: The medication profile indicated for oral cannabis, (dose per instructions). Administer CBD oil by mouth as directed on package. Corrected on site. Patient #10: The agency medication profile indicated Cholecalciferol 50 mcg daily. There was not evidence that is was on the ALF MAR. Corrected on site. Patient #11,#12: The medication profile indicated Oxygen 2-4L continuous without evidence of a route. Corrected on site. Patient #13: The medication profile indicated Acetaminophen 2 tabs tid prn for pain and fever. There was not evidence of fever parameters. Corrected on site. Patient #14: The medication profile contained Dorzolamide 2% eye drops, 1 drop 2x/day. There was not evidence of which eye(s) to instill the drops. Corrected on site.

Upon patient record review, 4 of 19 (Patient #2,#5,#12,#14) 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 #2: Patient was admitted on 04/03/24. The bereavement assessment was completed on 04/09/24. Patient #5,#14: There is no evidence of a bereavement assessment. Patient #12: Patient was admitted on 05/05/24. The bereavement assessment was completed on 05/14/24.

Upon patient record review, 1 of 19 (Patient #12) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate 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 #12: Record indicated that the patient had a fall that and sustained a wound that required wound care. There was not evidence of follow up until 07/24/24 and no evidence of a wound assessment.

Upon patient record review, 1 of 19 (Patient #12) 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 #12: The patient has a history of cardiac decline, ischemia, seizures, falls, smokes, weakness, aneurism and stroke. There's no evidence of goals and interventions for potential safety issues on the care plan including falls. Corrected on site.

Upon patient record review, 6 of 19 (Patient #2,#5,#11,#12,#13,#14) 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 medications and treatments. Patient #2: The record indicated the nurse removed the J-tube per doctors orders on 04/07/24. The nurse cleaned the site and applied a non-adherent dressing. There was no evidence of a order for wound care. Patient #5: The order indicated for oral cannabis, (dose per instructions). Administer CBD oil by mouth as directed on package. Corrected on site. Patient #11: The order indicated Oxygen 2-4L continuous without evidence of a route. Corrected on site. Patient #12: The order indicated Oxygen 2-4L continuous without evidence of a route. Corrected on site. In addition, the record indicated an order for wound care dated 06/05/24 to cleanse area with soap and water, cover with bandage, change bandage prn, RN to assess weekly. There was not evidence of a wound location. Patient #13: The order indicated Acetaminophen 2 tabs tid prn for pain and fever. There was not evidence of fever parameters. Corrected on site. Patient #14: The order contained Dorzolamide 2% eye drops, 1 drop 2x/day. There was not evidence of which eye(s) to instill the drops. Corrected on site.

Upon patient record review, 2 of 19 (Patient #2,12) 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 #2: There were goals and interventions relating to the nurse monitoring the feeding tube. The record indicated that the feeding tube was discontinued on 04/07/24. The goals and interventions remain on the care plan as of this date. Corrected on site. Patient #12: The record indicated a wound which required wound care dated 06/05/24. There was not evidence that the revised plan of care reflects patient/family goals and interventions based on the wound or skin integrity. The record indicated additional wound due to a fall on 07/17/24, the plan of care continued with no evidence of an update regarding wounds or skin integrity.

Upon client record review, 4 of 19 (Patient #1,#12,#13,#14) 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 social worker was 1M2 effective 06/05/24. There was not evidence of a visit during the month of June. Patient #12: The record indicated wound care was provided by the nurse with the date 07/17/24. Wound care consisted of cleansing the wound with wound cleanser and sterile, covering with an abdominal pad and a thin coat of Vaseline, wrap with kerlix, and secure with paper tape. There was not evidence that this was on the plan of care. Patient #13: The record indicated an order dated 05/30/24 for a PT eval. There was not evidence that the PT eval was completed until 06/27/24. Patient #14: The visit frequency for the spiritual care counselor was 2m3. The record indicated only 1 visit during the month of July.

Upon patient record review 1 of 19 (Patient #5) 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 #5: The aide visit frequency effective 06/09/24 was 2w8. For the weeks of 07/21/24 - 07/27/24 and 07/28/24 - 08/03/24, the record indicated there was one missed documented visit note for each of these weeks and no documented visits completed.

Upon personnel record review, 1 of 13 (Personnel #11) did not have evidence in the hospice aide personnel file that a registered nurse made an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. The supervising nurse must assess an aide's ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include all required content. Personnel #11: There was not evidence that the aide competency assessment for the tub bath was return demonstrated with a patient or pseudo-patient.

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. Documentation reveals volunteer usage for 2023 was 2.42%.