Every finding on record at Odyssey Healthcare Operating B, LP

Upon patient record review, 3 of 19 (Patient #5,6,7) 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 #5: The facility MAR indicates Amlodipine and Prednisone daily. There was not evidence of these medications on the agency medication profile. In addition, the SNF MAR indicates Gabapentin 100 mg 2 times a day, the agency medication profile indicates 300 mg every 8 hour, the facility MAR indicates Levothyroxine 75 mcg daily, the agency medication profile indicates 88 mcg daily. All facility medications mentioned were effective 8/1/24. Corrected on site. Patient #6: The facility MAR indicates Vitamin D2, Vitamin D3, Iron, Lutein, Melatonin, Fluticasone, Prednisone, Rosuvastatin, Potassium, and Pantoprazole, these medication are not indicated on the agency medication profile. In addition, the agency medication profile indicates Colace, the facility MAR does not. Corrected on site. Patient #7:The agency medication profile indicates Aspirin, Citalopram, and Trazadone, the patient's care giver states he no longer takes them. In addition, The agency medication profile indicates Hydrocodone 5 mg - Acetaminophen 325 mg, the patient has and is taking Hydrocodone 7.5 mg - Acetaminophen 325 mg. Corrected on site.

Upon patient record review, 1 of 19 (Patient #6) 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 #6: There was not evidence that the bereavement assessment was completed within 5 days. The bereavement assessment was completed 01/25/2024 and the SOC 1/19/2024

Upon patient record review, 3 of 19 (Patient #2,13,14) 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 #2: The record indicated a diagnosis of restlessness and agitation. The care plan does not indicate a goal and interventions for restlessness and agitation. Corrected on site. Patient #13: The record indicated the patient is taking Aspirin, the care plan did not indicate a goal and interventions for bleeding precautions. Corrected on site. Patient #14: The record indicated on SOC that the patient was a high risk for falls, the care plan did not indicate a goal and interventions for fall prevention. Corrected on site.

Upon patient record review, 3 of 19 (Patient #5,#6,#7) 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 #5: The facility MAR indicates Amlodipine and Prednisone daily. There was not evidence of orders for these medications. In addition, the SNF MAR indicates Gabapentin 100 mg 2 times a day, the agency order is for 300 mg every 8 hour, the facility MAR indicates Levothyroxine 75 mcg daily, the agency order indicates 88 mcg daily. All facility medications mentioned were effective 8/1/24. Corrected on site. Patient #6: The facility MAR indicates Vitamin D2, Vitamin D3, Iron, Lutein, Melatonin, Fluticasone, Prednisone, Rosuvastatin, Potassium, and Pantoprazole, there was not evidence of hospice orders for these medications. Corrected on site. Patient #7:The agency order is for Hydrocodone 5 mg - Acetaminophen 325 mg, the patient has and is taking Hydrocodone 7.5 mg - Acetaminophen 325 mg. Corrected on site.

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 annual volunteer usage for 2023 was 2.33%.

Upon patient record review, 4 of 11 (Patient #3, #5, #8, #9) 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. Patient #3-The medication profile lists Morphine concentrate oral 100mg/5ml .5-1ml hourly prn SOB/pain under the skin (incorrect route). (corrected on site) Patient #5, #8- The medication profiles include Miralax 17 gm dose oral powder q6h prn constipation. A diluent and amount is not listed for the powder.(corrected on site) Patient #9- On 10/12/21 the nurse documents the patient is taking Miralax. Miralax is not included in the medication profile. (corrected on site)

Upon patient record review, 1 of 11 (Patient #4) 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. Patient #4-Between 10/18/21 and 10/27/21 the nurse documents on each of the visit notes patient complains of constipation and instruction/intervention provided. The Plan of care was not updated with goals and a problem for Alteration in GI status /constipation. (corrected on site)

Upon patient record review, 5 of 11 (Patient #3, #5, #6, #8, #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 medications and treatments. Patient #3- The plan of care 10/12/21 lists Morphine concentrate 100mg/5ml .5-1ml hourly prn SOB/pain under the skin (incorrect route) (corrected on site) Patient #5- The plan of care 09/19/21 includes Miralax 17 gm dose oral powder q6h prn constipation. A diluent and amount is not listed. On 10/22/21 the nurse documents the DME company was contacted for suction. The plan of care was not updated with suction orders. (corrected on site) Patient #6- The plan of care 02/17/21 includes orders for Flurometholone .1% eye drops 1 three times daily. The orders do not specify which eye(s) are to receive the drops. Patient #8- The plan of care 09/25/21 includes Miralax 17 gm dose oral powder q6h prn constipation. A diluent and amount is not listed. (corrected on site) Patient #10- On 10/12/21 the nurse documents the patient is taking Miralax, Miralax is not included in the plan of care. (corrected on site)

Upon patient record review, 2 of 9 applicable (Patient #5, #6) did not have evidence in the patient record that the hospice aide assignments were complete. Patient #5, #6- The patients have Oxygen ordered and the Aide Care plan does not include Oxygen precautions. (corrected on site)

Upon patient record review, 1 of 11 (Patient #5) did not have evidence that the medical director or physician designee provides an accurate written certification of terminal illness. Patient #5- The initial CTI on 01/23/21 documents the patient is a 9 year old woman with a stroke and hemiplegia. On the 09/19/21 recertification CTI the Medical Director documents the patient is a 21 year old female with a stroke and hemiplegia. The correct age of the patient is 91 years old.

Upon patient record review, 2 of 11 (Patient #4, #5) did not have evidence that all entries are accurate. Patient #4- On 10/22/21 the nurse documents giving the patient Hydrocodone. The document is not clear regarding the specific dose administered. The nurse also documented Hydrocodone in error according to leadership as the actual medication that was ordered, present in the home and instructed/administered was Oxycodone. On 10/27/21 the nurse documented the patient was taking Colace. Upon interview with leadership and clarification, the nurse documented the medication on the wrong patient record. (Late entries/corrections made on site). Patient #5- On 10/26/21 in the skin integumentary assessment section of the note included documentation that the patient has wounds. This is a documentation error as the patients skin was intact on the visit date.