Every finding on record at Odyssey Healthcare Operating B, LP

Upon patient record review, 1 of 19 (Patient #3) 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 3: The clinical documentation from the RN indicated that the patient had PRN oxygen in the home and oxygen supplies/equipment were listed on the current supply list. No evidence that PRN oxygen was included on the active medication profile. COS-new order written and active medication profile updated to include oxygen via NC at a rate of 2-4LPM prn for SOB during survey.

Upon patient record review, 2 of 19 (Patient #6, 19) 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: No evidence that an initial bereavement risk assessment was completed with 5 days of the election of hospice. The patient was admitted on 10/18/2024. The assessment was completed on 10/24/2024. Patient 19: No evidence that an initial bereavement risk assessment was completed. The patient was admitted on 07/20/2024. Clinical documentation indicated that the first bereavement assessment was completed 2 days post death on 11/04/2024.

Upon patient record review, 1 of 19 (Patient #7) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 7: No evidence that a comprehensive assessment was completed every 15 days. The comprehensive assessment was completed 03/07/2025, the update was not completed until 03/28/2025. 21 days between comprehensive assessments.

Upon patient record review, 2 of 19 (Patient #4,12) did not have evidence the plan of care must 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 4: The initial visit frequency for the social worker was ordered as 1 prn visit. Patient 12: The initial visit frequency for both the social worker and the spiritual care counselor was ordered as 1 prn visit.

Upon patient record review, 1 of 19 (Patient #3) 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 medical record indicated that patient had PRN oxygen in the home, oxygen supplies and equipment was listed on the current supply list. No evidence that an order for oxygen was ever received from the MD. COS-new order written for oxygen via NC at a rate of 2-4LPM prn for SOB during survey.

Upon patient record review, 1 of 19 (Patient #2) 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 2: The medical record indicated that the patient developed wounds while on service that were discontinued on 05/08/2025 and that a Hoyer lift was used daily for transfers due to altered mobility. Wound care supplies remained listed on the active supply list at the time of survey. No evidence that the wound care supplies were removed. No evidence that a Hoyer lift was not included on the current DME supply list. COS-order written to remove wound care supplies from the supply list and add Hoyer lift to the active DME list during survey.

Upon patient record review, 2 of 19 (Patient #11,12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 11: The visit frequency for the skilled nurse was indicated at 2x/week and 2 prn on the current plan of care. No evidence that 2 visits occurred for the weeks of 02/16/2025, 03/30/2025, and 5/04/2025. No evidence that those visits were missed at the request of the patient/CG or that an order was placed to change the visit frequency for that week at the time of survey. Patient 12: The visit frequency for the chaplain was ordered at once a week to start on 05/21/2025. There was no evidence that weekly visits occurred for the weeks of 05/25/2025, 06/01/2025, 6/15/2025, and 06/22/2025. The visit frequency changed at the start of the current benefit period that started on 07/06/2025. No evidence that the visits were missed at the request of the patient/CG or that an order was placed to change the visit frequency for those months at the time of survey.

Upon patient record review, 1 of 19 (Patient #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 2: The medical record indicated that the patient had altered mobility and a Hoyer lift was being used for all transfers. No evidence that the aide plan of care included instructions that included the use of a Hoyer lift for mobility. COS-aide plan of care updated to include a Hoyer lift for transfers during the survey.

Upon patient record review 1 of 19 (Patient #8) 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 #8: POC dated 5/11/2025 contained orders for the aide to visit 3 times a week. No evidence that 3 visits occurred for the week of June 1st. No evidence that the visit was missed at the request of the patient/CG or that an order was placed to change the visit frequency for that week at the start of survey.

Upon patient record review 2 of 19 (Patient #7,8) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 7: No evidence that a registered nurse made supervised visits every 14 days between the dates of 03/07/25-03/28/2025 (21 days). Patient 8: No evidence that a registered nurse made supervised visits every 14 days between the dates of 06/02/25-06/17/2025 (15 days).

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. No evidence that the agency utilized volunteers for at least 5% of the total patient care hours in 2024. The total usage of volunteers for 2024 was 1.8%

Upon patient record review, 1 of 19 (Patient #14) 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 14: The visit frequency for the SW was ordered at 2 times a month on the plan of care to start on 04/01/2025. There was no evidence that 2 visits occurred for the months of April 2025 or May 2025. The visit frequency changed to one visit a month at the start of the current benefit period that started on 06/01/2025. No evidence that the visits were missed at the request of the patient/CG or that an order was placed to change the visit frequency for those months at the time of survey.

Upon patient record review, 6 of 13 (Patients #5, #6, #9, #10, #11, #13) 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 #5-The medication profile includes Questran Powder 1 packet po qid per instructions. A diluent is not included in the profile. On 06/16/22 the nurse documents Oxycodone 5mg bid was started. The medication profile was not updated with Oxycodone. On 06/23/22 the nurse documents Aleve is to be held 06/26, 06/27, 06/28/22 and may be resumed 06/29/22. The medication profile was not updated with the dates the medication was to be held. (corrected on site) Patient #6- On 07/03/22 the nurse documents the physician was contacted for orders for Morphine and Lorazepam. The medication profile was not updated with Morphine and Lorazepam. (corrected on site) Patient #9- The medication profile includes Novolin Regular U-100 100units/ml injection 5-20 units 4 times daily prn sliding scale at ac and hs. The sliding scale is not listed on the medication profile. Patient #10- On 07/01/22 orders were received for Lantus Insulin 15 units sq qhs. The medication profile was updated with qd and did not specify qhs. (corrected on site) Patient #11-The medication profile includes Hydralazine 25 mg 1 q8h prn hypertension. The profile does not include BP parameters for administration. (corrected on site) Patient #13- The medication profile has the following tablets to be administered through the patients Peg tube. Claritin 10 mg 1 tab qd via PEG, Omeprazole 20 mg delayed release 1 capsule daily via PEG, Ondansetron 4mg 1 tab q6h via PEG; Tamsulosin .4mg cap daily via PEG; Trazadone 50 mg 1 tab at hs via PEG. The profile does not address crushing/diluting medications for administration.

Upon patient record review, 6 of 13 (Patients #5, #6, #8, #9, #11, #13) 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 specific orders for all medications and treatments. Patient #5-The plan of care was updated on 06/22/22 with orders for Questran Powder 1 packet po qid per instructions. A diluent is not included in the orders. (corrected on site). On 06/23/22 an order was obtained which reads: Patient scheduled for abdominal tunnel drainage cath 06/28/22. CBC, PT, PTT. The lab work orders do not specify the date labs are to be obtained and who is to obtain the labs. Patient #6- On 07/03/22 the nurse documents the patient has pain in the right hip and is hallucinating. The physician was contacted and ordered Morphine and Lorazepam. Orders were not written for Morphine and Lorazepam to update the plan of care. (corrected on site) Patient #8-On 08/23/21 the nurse documents the patient has a condom catheter. The plan of care 08/20/21 only addresses catheter supplies. The management of the catheter and type is not included in the plan. On 09/03/21 the nurse documents receiving orders to insert an indwelling Foley catheter. The plan of care was not updated with orders for the Foley insertion and management. Patient #9- The 01/10/22 plan of care includes Novolin Regular U-100 100 units/ml injection 5-20 units 4 times daily prn sliding scale at ac and hs. The sliding scale is not listed on the plan of care. Patient #11-The plan of care 06/25/22 includes Hydralazine 25 mg 1 q8h prn hypertension. The plan of care does not include BP parameters for administration. (corrected on site) Patient #13- The 06/16/22 plan of care has the following tablets to be administered through the patients Peg tube. Claritin 10 mg 1 tab qd via PEG, Omeprazole 20 mg delayed release 1 capsule daily via PEG, Ondansetron 4mg 1 tab q6h via PEG; Tamsulosin .4mg cap daily via PEG; Trazadone 50 mg 1 tab at hs via PEG. The plan of care does not address crushing/diluting medications for administration.

Upon patient record review, 4 of 13 (Patients #5, #6, #8, #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 #5- On 06/23/22 orders were obtained that the patient would have an abdominal tunnel drainage catheter placed 06/28/22. According to interview with leadership the physician who was to place the catheter decided not to perform the procedure and this was not documented in the medical record. The IDT/revised plan of care 07/12/22 documents 06/28/22 patient had appointment for cath placement for paracentesis. The plan of care was not updated to reflect the procedure was not performed. Patient #6- On admission 06/25/22 the nurse documents the patient recently broke a window because he was out of cornstarch. The patient eats 16 ounces of cornstarch a day to help with stomach and nerves. On 07/12/22 the nurse also documents the patient eats 50 per cent of meals but more cornstarch than anything else. Patient eats 16 ounces of corn starch daily. The IDG update/revised plans of care 06/29/22 and/or 07/13/22 do not address the patient's intake/behavior related to cornstarch. On 07/07/22 the nurse documents the patients defibrillator was shocking the patient. The defibrillator did stop and the patient caregiver had administered Morphine for pain. The 07/13/22 IDG update/revised plan of care did not address the defibrillator discharge. Patient #8- The 09/03/21 and 09/17/21 IDG/revised plan of care does not address documentation by the nurse regarding progress towards outcome/goals from the plan of care. The nursing documentation on the IDG notes are blank. Patient #10-The patient was admitted with Hypertensive Heart Disease. The nurse documented the following BP readings: 07/08/22 190/68, 07/20/22 197/88, 07/29/22 179/93, and 08/03/22 180/69. On 07/20/22 the nurse also documented vital signs were within normal limits. There is no documentation on record to evidence recognition of the elevated BP readings and/or reporting to MD/IDG team.

Upon patient record review, 2 of 13 (Patients #10, #13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #10- The Social Worker was ordered to visit once monthly effective 07/01/22. A visit is not on record for July and there is no documentation of a missed visit. Patient #13- On 07/05/22 orders were received to cleanse the patients left and right heel with NS, pat dry with gauze, apply betadine then cover with a dry dressing every other day. On 07/07/22 , 07/12/22 and 07/29/22 the nurse documented cleansing the right heel wound with NS, patting dry with gauze, Xeroform was applied over the wound bed only and covered with a dry dressing.

Upon patient record review, 1 of 10 applicable (Patient #11) did not have evidence in the patient record that hospice aide assignments and duties are: • Complete 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 Patient #11-On 07/26/22 the patient was placed on droplet precautions as the patient and family in home tested positive for COVID. The Aide care plan was not updated with droplet precautions.

Upon personnel record review, 2 of 12 (Personnel #7, #8) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #7- The Bereavement Coordinator does not have a competency on record for this role. (corrected on site) Personnel #8- The Volunteer Coordinator does not have a competency on record for this role. (corrected on site)