Every finding on record at Odyssey Healthcare Operating B, LP

Upon patient record review 1 of 14 (Patient #4) 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 4: Patient admitted on 01/27/2023, psychosocial assessment completed on 02/02/2023.

Upon patient record review, 1 of 14 (Patient #4) 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 4: Patient admitted on 01/27/2023, bereavement risk assessment completed on 02/02/2023.

Upon patient record review, 1 of 14 (Patient #10) 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 10: SW current plan of care only has orders for 3 PRN visits. Patient declined services during MS01 assessment. No evidence of scheduled routine visits on plan of care.

Upon patient record review, 1 of 14 (Patient #5) 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: Patient admitted with several wounds. All wounds discontinued by 07/23/2023. All wound care orders and supplies remain on plan of care.

Upon patient record review, 2 of 14 (Patient #2,6) 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: Current aide care plan has wound dressing precautions instructing aide to leave coccyx dressing in place while providing care. No evidence that patient has had an active wound. RN documented no skin integrity issues at the time of admit. RN/LPN continue to document that patient does not have skin integrity issues during all 3 benefit periods. Patient 6: Current aide care plan has wound dressing precautions instructing aide to leave dressing to left elbow/posterior forearm in place while providing care. Left elbow/posterior forearm wound deactivated on 08/25/2023. No evidence that aide care plan updated to reflect current stage II right buttock wound.

Upon patient record review 1 of 14 (Patient #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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 9: Aide care plan has monthly weights to be obtained on the first Monday visit of the month. No evidence that a weight was obtained for the month of August or October. September weight was completed on 09/13, not the first scheduled Monday.

Upon client record review, 1 of 14 (Patient #11) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient 11: No evidence that transfer summary was sent to receiving hospice. Patient transferred to another hospice on 02/05/2023.

Upon client record review, 1 of 14 (Patient #8) 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 8: Current recertification plan of care (08/29/2023) stated that patient refused volunteer services at this time. Patient seen by volunteer once in September on the 21st. Volunteer services started on 03/15/2023 and patient has received one monthly visit since that date. No evidence that volunteer services were discontinued before the start of the current recertification plan of care.