Every finding on record at Odyssey Healthcare Operating B, LP

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. There was not evidence of a full-scale exercise that is community-based every two years. The only emergency plan activation was in Jan of 2023 for an IT crash.

Upon observation, and record review there was not evidence that all alleged violations involving mistreatment, neglect, or verbal, mental, sexual and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone furnishing services on behalf of the hospice, are reported immediately to the Administrator or appropriate designee. Patient #6: Nurse documentation dated 9/13/23 indicated that the patient was on a respite stay at a SNF and the patient told the hospice nurse that she had been in New York and was raped. A visit by the NP on 9/15/23 revealed the same verbiage but the NP also indicated that the patient was having periods of confusion and forgetfulness. There was not evidence that the Administrator of the SNF or the Hospice Administrator was notified of the claim.

Upon patient record review 3 of 19 records (Patient #6,#9,#10) 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 #6: The patient was admitted on 4/14/23. The record indicated that the spiritual assessment was completed on 4/20/23. Patient #9: The patient was admitted on 5/26/23. The record indicated that the spiritual assessment was completed on 6/1/23. Patient #10: The patient was admitted on 5/10/23. The record indicated that the spiritual assessment was completed on 5/16/23.

Upon patient record review 2 of 19 records (Patient #2,#4) did not have evidence in the patient record that the comprehensive assessment identifies the 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 #2,#4: There was not evidence of a spiritual assessment.

Upon patient record review, 3 of 19 records (Patient #6,#8,#12) 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 contained Oxygen 3L/min via nasal cannula. There was not evidence of prn in the order and there was not evidence that the patient was wearing oxygen from 10/1/23 to current. Corrected on site. Patient #8: The record indicated oxygen at 2L/min continuous via nasal cannula, dated 9/30/23. From 11/2/23 to current, nurse documentation indicated that oxygen was not in use and the patient was not short of breath. There was not evidence the oxygen was changed to prn or discontinued. Corrected on site. Patient #12: The record indicated for Miralax 17 Gm powder, 1 daily prn if no BM in 3 days. There was not evidence of a diluent. Corrected on site.

Upon patient record review, 3 of 19 records (Patient #8,#11,#13) 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 #8: The patient was admitted on 9/30/23. The record indicated that the bereavement assessment was not completed until 10/6/23. Patient #11: The patient was admitted on 8/11/23. The record indicated that the bereavement assessment was not completed until 8/31/23. Patient #13: The patient was admitted on 6/27/23. The record indicated that the bereavement assessment was not completed until 7/5/23.

Upon patient record review, 1 of 19 records (Patient #18) 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 #18: The record indicated a call through triage on 4/29/23 at 1658 that the patient's oxygen saturation was 64%, heart rate 31, and the patient was declining. The facility requested a visit by the nurse. There was not evidence of a visit by a nurse until 4/30/23 at 1009. The patient expired on 5/1/23 at 0621.

Upon patient record review, 1 of 19 records (Patient #14) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient that reflects 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 #14: The patient was admitted with a diagnosis of ALS. The record indicated that she had difficulty eating/swallowing, she had some paralysis and had a gastrostomy tube. There was not evidence that the plan of care reflected patient/family goals and interventions based on the patient's neurological problems or the gastrostomy tube. Corrected on site.

Upon patient record review, 3 of 19 records (Patient #6,#8,#12) 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 #6: The record contained an order for Oxygen 3L/min via nasal cannula, dated 6/28/23. There was not evidence of prn in the order and there was not evidence that the patient was wearing oxygen from 10/1/23 to current. Corrected on site. Patient #8: The record indicated oxygen at 2L/min continuous via nasal cannula, dated 9/30/23. From 11/2/23 to current, nurse documentation indicated that oxygen was not in use and the patient was not short of breath. There was not evidence the oxygen was changed to prn or discontinued. Corrected on site. Patient #12: The record indicated an order for Miralax 17 Gm powder, 1 daily prn if no BM in 3 days, dated 10/30/23. There was not evidence of a diluent. Corrected on site.

Upon patient record review, 1 of 19 records (Patient #6) 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 #6: The patient's level of care was changed to respite on 9/7/23 and then again on 9/13/23. There was not evidence that goals for respite were resolved on the plan of care. Respite remained active. Corrected on site.

Upon patient record review, 3 of 19 records (Patient #2,#8,#13) 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 including alerts and precautions for a hospice aide that 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 specifically indicate what tasks are to be done by the Aide and the frequency of these tasks. Patient #2: Nurse recertification documentation dated 8/31/23 and 10/31/23 indicated that the patient remains a high fall risk. In addition, the record indicated that the patient had a fall during the certification period of 5/22/23-7/20/23. There was not evidence that fall risk was on the aide plan of care. Corrected on site. Patient #8: The aide plan of care indicated to provide routine catheter care at every visit. From 10/24/23 to current, there was not evidence that the patient had a catheter in place. Corrected on site. Patient #13: The record indicated that the patient was on Eliquis 5mg daily. There was not evidence that bleeding precautions were on the aide plan of care. Corrected on site.

Upon patient record review 1 of 19 records (Patient #14) 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 #14: The aide plan of care indicated for all assigned tasks to be completed at every visit. For the date of 10/20/23, the aide documentation for transfer patient from bed to chair, transfer patient from chair to bed, assist with feeding and linen change revealed, 'per frequency not needed.'

Upon patient client record review, 1 of 19 records (Patient #11) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #11: The record indicated that the patient/representative wished to receive the Patient Notification of Hospice Non-Covered Items, Services, and Drugs. The election statement indicated that the requested date was 8/11/23. The Notification document indicated that it was furnished and signed on 8/18/23. A second document was requested on 10/11/23, and the furnished date was 10/19/23.

Upon client record review, 1 of 19 records (Patient #15) did not have evidence that the discharge summary includes all required information. Patient #15: There was not evidence of a summary of the patient's stay, including treatments, symptoms and pain management.

Upon client record review, 1 of 19 records (Patient #8) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. patient #8: The record indicated an order for the hospice nurse/or facility nurse to provide wound care to the sacral area wound BID. Cleanse with Dakin's solution, sprinkle with collagen particles to wound bed, pack with Dakin's soaked gauze. Cover with foam dressing. There was not specific evidence of which provider was to perform the wound care. Corrected on site.

Based on a review of clinical records, the complaint log, on-call roster, on-call policy, and interviews with staff, the agency failed to manage a patients symptoms related to terminal illness and related conditions in a timely manner. Specifically, agency staff failed to make after hours visits for one (1) of six (6) patients in the survey sample (Clinical record #1). --- The findings:Agency complaint log and six clinical records were reviewed in the agency on May 31-June 1, 2023, with read only access for the electronic medical records with the following findings: On 05/31/2023 at 11:30 AM the agency's complaint log was reviewed with the following: The agency's complaint log contained a complaint from patient #1 dated 03/10/2023. The patient called the on-call service requesting a nurse visit for feeling dizzy. The on-call nurse suggested the patient go to the emergency room but the patient did not want to go hospital. The agency offered to make a visit from another nurse but the patient declined, stating he was okay now. The agency's resolution for this complaint was to always make the visit and if unable to notify the supervisor immediately. The clinical record for patient #1 was reviewed for the certification period of 02/11/2023 to 5/11/2023. The patient's plan care contained a primary diagnosis of Nonrheumatic Mitral Valve Insufficiency with functional limitations of legally blind, and a goal for the patient that safety needs will be met. On 05/31/2023 the MFI (Medical Facilities Inspector) obtained the on-call roster for the patient. The roster contained multiple phone calls needing assistance during a 12-week span varying from falls, passing out, difficulty breathing, medication refill, chest pains, knocking over medication, and an issue with a hospice nurse. The following are on-call reports where no nurse visit was made as follows: -On 03/04/2023 at 4:53 PM, the patient called to report dizzy and made it to the foot of bed. Also complained of still feeling dizzy and had an issue before with dizziness because of the combination of Lisinopril and Metoprolol (both medications are used for hypertension). A SN visit was not made until the next scheduled visit of 03/06/2023. -On 03/05/2023 at 12:41 PM, the patient called to report a nurse did not visit when called on 03/04/2023. No SN visit made until the next scheduled visit of 03/06/2023. -On 04/24/2023 at 2:11 AM, the patient called to report fell, hit head and possibly passed out. No SN visit made. -On 04/24/2023 at 10:49 PM, the patient called to report a fall, hit head. No SN visit made. Patient was discharged from hospice on 04/25/2023. Select Agency Policy Review:A copy of the agency's on-call policy was provided on 06/01/2023 at 9 AM to the MFI (Medical Facilities Inspector). The policy was titled, On-Call/Weekend Services Policy No. 4-036 a select portion read as follows: "The on-call nurse will provide follow up appropriated to the call: Guidelines The following list is meant to guide the on-call nurse. It is not an exhaustive list, but includes many problems that may require a visit from the hospice nurse. Respiratory difficulty, report of patient falling (observed and unobserved, increased anxiety and/or confusion and duplicate calls regarding the same problem." On 06/01/2023 at 2:50 PM the MFI conducted an interview with the Executive Director (ED) regarding the on-call SN visits that were not made. The ED explained the patient called on-call many times where the SN visited and there was no injury or the patient was anxious or depressed due to current living situation in a motel, sparse food, and no family support due to a protection court order from the spouse. The ED also explained the hospice's Medical Social Worker and Chaplain was increased to weekly visits on 03/09/2023 to help relieve the patient's anxiousness with the living and family situations. The clinical record reflected the increased visits of the disciplines. The ED acknowledged the on-call visits with reported falls should have been visited by the SN. The above noted findings regarding on-call care were reviewed with the ED, Area Director of Education, Administrator and the Area Vice President of Operations on 06/01/2023.

Based on a review of clinical records and staff interview it was determined the agency failed to ensure their interdisciplinary group (IDG) documented the patient's progress toward outcomes and goals specified in the plans of care for six (6) of six (6) patients in the survey sample (Clinical record #'s 1 - 6). --- The findings:Six clinical records were reviewed in the agency on May 31-June 1, 2023 with read only access. The IDG failed to contain evidence of IDG documentation of the patient's progress toward outcomes and goals specified in the plans of care below. Many were left blank, or POC (plan of care) effective and/or the nurse wrote in how many Skilled Nurse visits to manage care, patient will report symptom management with current regimen, patient will remain free from falls, anxiety and pain. 1. The clinical record for patient #1 was reviewed for the time period of 02/11/2023 through 05/11/2023. 2. The clinical record for patient #2 was reviewed for the time period of 02/02/2023 through 05/02/2023. 3. The clinical record for patient #3 was reviewed for the time period of 11/01/2022 through 12/30/2022. 4. The clinical record for patient #4 was reviewed for the time period of 09/26/2022 through 1/24/2022. 5. The clinical record for patient #5 was reviewed for the time period of 06/24/2022 through 08/22/2022. 6. The clinical record for patient #6 was reviewed for the time period of 06/06/2022 through 09/03/2022. Interview:During the electronic medical record review conducted on 06/01/2023 at 3:00 PM the Area Director of Education acknowledged the failure of IDG to document the patients progress towards outcomes and goals, and further stated "We changed the template but nothing is there indicating progress". The lack of documentation by the agency's IDG regarding the patient's progress toward outcomes and goals specified in the plans of care for the above noted patients was acknowledged and reviewed with the Executive Director, Area Director of Education, Administrator and the Area Vice President of Operations during the exit conference of 06/01/2023.

Based on clinical record review, agency discharge planning policy and staff interview it was determined the agency failed to ensure two (2) of six (6) clinical records reviewed which were live discharge records received five days oral and written notice of a discharge (Clinical record #s 1 and 5). --- The findings:Six closed/live discharge clinical records were reviewed in the agency on May 31-June 1, 2023 with read only access. 1. The clinical record for patient #1 was discharged from the hospice on 04/25/2023 due to patient clinical condition has plateaued per review (extended prognosis). The clinical record documented a Skilled Nurse (SN) nurse visit on 04/20/2023 whereas the patient was orally advised of discharge. Another SN visit was documented on 04/21/2023 and the patient refused to sign a Notice of Medicare Non-Coverage (NOMNC-notice that the care is set to end). The clinical record failed to contain evidence that any forms pertaining to discharge were left with the patient. Select Agency Policy Review:A copy of the agency's discharge policy was provided on 06/01/2023 at 9:30 AM to the MFI (Medical Facilities Inspector). The policy was titled, Discharge: No Longer Terminally Ill Policy, a select portion read as follows: "A discharge due to no longer terminally ill occurs when the patient's condition stabilizes or improves, and they are no longer considered terminally ill with a prognosis of 6 months or less. Prior to discharge the hospice must issue, at a minimum, a two day notice to the patient of the intent to discharge. Patients with Medicare as a payor source must be provided the written notice of discharge using the CMS required form, NOMNC. Some states require longer notification periods prior to discharge. Refer to Policy No 4-076 Live Discharge and Discharge Planning for state specific guidance. If patient refuses to sign the form, note the refusal in the blank section above the staff signature of the form. Include date notice provided and name of person refusing to sign. A copy of the forms provided will be left with the patient/representative and the original will be turned in to be scanned in the EMR (electronic medical record). If unable to provide the discharge instructions in person, they will be mailed and a coordination note in Home Care Home Base will be created recording the date the instructions were sent." According to the Code of Virginia 12VAC5-391-290, regarding discharge: "A. Patients shall receive five days oral and written notice of a transfer or discharge initiated by the hospice program except under the following circumstances:1. When a medical emergency exists; 2. For the welfare of the patient or the welfare of employees; or 3. The welfare of other patients in a dedicated hospice facility operated by the hospice program. B. The hospice program shall make all arrangements necessary to assure continuing care and services including a discharge summary for the receiving hospice or provider". On 06/01/2023 at 2 PM the MFI asked the Executive Director if the patient's discharge forms were mailed to the patient. The Executed Director stated, "not that I know of". The ED explained patient #1 was referred to a home health agency and is currently receiving services. The ED provided the patients face sheet from (agency name redacted) with a start of care date of 04/28/2023. 2. The clinical record for patient #5 was discharged from the hospice on 08/15/2022 due to patient clinical condition has plateaued per review. The clinical record documented a signed NOMNC on 08/15/2022. The discharge notice was signed on the date of patient's discharge with no written notice before the discharge. The lack of providing live discharges a five days written notice of discharge was reviewed with the ED, Area Director of Education, Administrator and Area Vice President of Operations during the exit conference on 06/01/2023.