Every finding on record at Odyssey Healthcare Operating B, LP

Upon patient record review 1 of 14 (Patient #8) 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 #8-The patient was admitted 07/12/23 and a spiritual assessment was not performed until 08/17/23.

Upon patient record review 2 of 14 (Patient #3, #9) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and 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 #3-The patient was admitted on 09/26/23 and refused Chaplain services. A spiritual assessment was not performed by the RN, Social Worker or Chaplain. A spiritual assessment is not on record. (corrected on site) Patient #9-The patient was admitted on 09/14/23 and refused Chaplain services. A spiritual assessment was not performed by the RN, Social Worker or Chaplain. A spiritual assessment is not on record. (corrected on site)

Upon patient record review, 1 of 14 (Patient # 8) did not have evidence in the patient record that a complete review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #8-The medication profile includes Latanoprost .005% eye drops 1 drop at bedtime. The profile does not specify which eye(s) for administration. (corrected on site)

Upon patient record review, 2 of 14 (Patient #1, #2) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component within 5 days 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. Patient #1-The patient was admitted on 07/18/23 and a bereavement risk assessment was not performed until 08/02/23. Patient #2-The patient was admitted on 08/22/23 and a bereavement risk assessment is not on record. (corrected on site)

Upon patient record review, 1 of 14 (Patient #4) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient #4-The patient was admitted 10/05/23 and the medication section on the plan of care indicates the patient's hepatic drain is to be flushed with 10 ml 0.9% sterile saline irrigation twice daily. The medication section also indicates hospice is to be notified if unable to flush. There is no documentation on record that the patient was educated on the hepatic flushes and/or able to perform the flushes. (late entry clarification correction on site)

Upon patient record review, 2 of 14 (Patient #4, #8) 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/accurate orders for all medications and treatments. Patient #4-The patient was admitted 10/05/23 with an implanted port. The plan of care does not address management of the port. On 10/05/23 an order is on record to update the plan of care to discontinue multiple medications including Metformin. Metformin was not discontinued from the medication profile and upon interview, Metformin was not to be discontinued. The order to update the plan of care including discontinuing Metformin was an error. (corrected on site). Patient #8-The plan of care includes Latanoprost .005% eye drops 1 drop at bedtime. The order does not specify which eye(s) for administration. (corrected on site)

Upon patient record review, 2 of 14 (Patient #1, #5) did not have evidence the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1-The patient was admitted 07/18/23 with a cane, raised toilet seat, wheeled walker and wheelchair. Also on 09/19/23 the IDG documents the patient has a gel cushion for chair. The plan of care does not include this equipment. (corrected on site) Patient #5-On 10/03/23 the IDG documents the patient has a wheelchair and bed in place. The plan of care was not updated with this equipment. (corrected on site)

Upon patient record review, 1 of 14 (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 Chaplain visited the patient for an evaluation on 10/04/23 and documented the patient and family were Catholic, were active in religious participation, and coped through prayer. The IDG documentation/revised plan of care on 10/17/23 did not document the spiritual findings/goals. The documentation only stated the patient would be visited twice monthly by the Chaplain. (late entry correction on site)

Upon patient record review, 3 of 14 (Patient #4, #8, #10) did not evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4-On 10/05/23 orders were received for the nurse to visit twice weekly and perform site care to the patient's rt upper quadrant hepatic drain twice weekly. The orders were to cleanse site with NS, apply drain sponge and cover with gauze, secure with transparent dressing. On 10/11/23, 10/13/23 and 10/20/23 the nurse documented wound care was not provided and not ordered these visits. The visits were routine visits when site care was due to be performed. Patient #8-On 08/01/23 the Chaplain was ordered to visit the patient once monthly for one month then twice monthly for one month. The Chaplain visited twice in August on 08/17/23 and 08/24/23 and a visit is not on record for September 2023. There is no documentation on record regarding the missed visit. Patient #10- On 08/18/23 the Chaplain was ordered to visit twice monthly. One visit was performed in August on 08/21/23.

Upon patient record review, 1 of 14 (Patient # 2) did not 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 #2-The Aide began visiting the patient on 09/02/23. An Aide supervisory visit is not on record until 09/26/23.

Upon patient review, 2 of 14 (Patient #1, #7) did not have evidence that each patient record contains Advance Directives. Patient #1-On 07/19/23 the nurse documented the patient has a POLST and is a DNR. The Advanced Directive is not on record. (corrected on site) Patient #7-On 10/03/23 the nurse documented the patient has a POLST and is a DNR. The Advanced Directive is not on record. (corrected on site)