Every finding on record at Odyssey Healthcare Operating B, LP

Upon patient record review, 2 of 14 records (Patient #6,#8) 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 #6: The medication profile indicated for A & D topical ointment, apply to affected area daily. There was not evidence of a specific location. Corrected on site. Patient #8: The medication profile indicated a duplicate entry; Diclofenac 1% topical gel 3x/day bilateral feet and Voltaren 1% topical gel 3x/day bilateral feet. Corrected on site.

Upon patient record review, 1 of 14 records (Patient #2) 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: There was not evidence of a bereavement assessment within 5 days of admission.

Upon patient record review, 1 of 14 records (Patient #4) did not have evidence that a Registered Nurse ensured continuous assessment of the patient and family's needs and coordinated 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 #4: The record indicated a call to triage on 6/23/24 at 4:14 pm with the called stating that the patient had taken 3 doses of Morphine for chest pain and the pain was still present. A visit need was identified per policy. There was not evidence of a visit or contact with the patient/caller until 6/25/24 at 10:48 am when a visit was conducted.

Upon patient record review, 1 of 14 records (Patient #6) 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 #6: The record contained an order for A&D topical ointment, apply to affected area daily. There was not evidence of a specific location. Corrected on site.

Upon patient record review, 2 of 14 records (Patient #1,#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 #1: The record indicated that the patient developed a UTI with antibiotics starting on 7/12/24. There was not evidence that infection/UTI was added to the plan of care, noting progress towards outcomes and goals. Patient #4: The spiritual care counselor provided an initial evaluation and then the patient/representative declined these services. The care plan continued to have goals and interventions specifically related to the services of a spiritual care counselor; These were not resolved. Corrected on site.

Upon client record review, 3 of 14 records (Patient #3,#4,#9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: The visit frequency for the skilled nurse for the benefit period beginning 5/30/24 was 1 every 2w2, 1w7. The record indicated that visits were conducted on 5/31/24, 6/7/24 and 6/10/24. Patient #4: The visit frequency for the skilled nurse for the benefit period beginning 5/18/24 was 2 every 2w2, 1w7. The record indicated that visits were conducted on 5/22/24, 5/24/24, 5/29/24 and 5/31/24. Patient #9: The visit frequency for the spiritual care counselor was 2 every 2m2, 2m1, 1m1, effective 6/20/24. The record indicated that the first visit occurred on 7/2/24.

Upon patient record review, 2 of 14 records (Patient #5,#10) did not have evidence in the patient record that hospice aide assignments and duties are: • 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 #5: The aide plan of care indicated for bed bath, may wash in bathroom sitting on toilet and partial sponge bath, may wash in bathroom sitting on toilet. Corrected on site. Patient #10: The aide care plan dated 5/7/24 indicated for skin care every visit; Apply dime sized amount to left and right groin area (dry skin) smoothed to a thin lather without evidence of a product to use. Corrected on site.

Upon patient record review 5 of 14 records (Patient #4,#5,#6,#8,#9) 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 Patient #4: The aide visit frequency was 2w13. For the week of 6/30/24-7/6/24, the record indicated only 1 visit, and no evidence of a missed visit document. Patient #5: The aide visit frequency was 5w13. For the week of 6/30/24-7/6/24, the record indicated only 4 visits, and no evidence of a missed visit document. Patient #6: The aide visit frequency was 5w13. For the week of 6/30/24-7/6/24, the record indicated only 4 visits, and no evidence of a missed visit document. Patient #8: The aide visit frequency was 5w12. For the week of 6/30/24-7/6/24, the record indicated only 4 visits, and no evidence of a missed visit document. Patient #10: The aide visit frequency was 2w1,3w8 effective 6/5/24. The record indicated only 1 visit for week 1 of the aide visit order.

Upon patient client record review, 1 of 14 records (Patient #6) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #6: The benefit election statement (on admission, 2/26/24) indicated that the patient/representative wished to receive the Patient Notification of Hospice Non-Covered Items, Services, and Drugs. Requests for updated notifications were made on 3/11/24, 5/17/24, and 5/24/24. The record indicated that the date that all of these documents were furnished was May 2024 (No day).

Upon patient client record review, 3 of 14 records (Patient #1,#2,#9 ) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #1: There was not a visit frequency for the aides and there was not evidence that that an aide conducted a visit however an aide supervisory visit was conducted on 7/12/24, and all questions related to the aide were answered as if the patient was receiving visits by an aide. This included but was not limited to, "Did the patient receive a visit by the aide in the past 14 days?" The name of the aide was documented, "Was the client satisfied with the care?" "Was the aide care plan reviewed?" Patient #2: The record indicated that the last aide visit was 4/16/24. Aide supervisory visits were still conducted until 6/3/24, with all questions answered as if an aide was still providing care. Patient #9: The medication profile indicates Oxygen 3L/min via nasal cannula continuously. Documentation by the nurse on 6/21/24, 6/27/24, and 7/2/24 indicated that the patient was not on oxygen.

Upon client record review, 1 of 14 records (Patient #11) 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 #11: The patient was discharged for no longer meeting hospice criteria. There was not evidence that a copy of the hospice discharge summary was sent to the attending physician.