Every finding on record at Odyssey Healthcare Operating B, LP

Upon patient record review, 7 of 14 records (Patient #2,#4,#5,#7,#8,#9,#10) 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 #2: The IDG narrative dated 12/4/24 documented by the nurse indicated that the patient completed a course of antibiotics for a suspected UTI. There was not evidence of an antibiotic on the medication profile. Corrected on site. Patient #4: Aquaphor 41% q4h prn. Apply thin layer topically to skin as needed for skin irritation. There was not evidence of a specific location. Patient #5: Lantus 35u SQ daily, Omeprazole, and Benefiber were on the MAR at the facility. There was not evidence that these medications were on the hospice medication profile. Corrected on site. Patient #7: Copper Citrate was noted on the hospice medication profile but not on the facility MAR. In addition, Nasal spray, Meclizine, Mupirocin ointment, Nystatin powder and Ocuvite were on the facility MAR but there was not evidence that these were on the medication profile of the hospice record. Corrected on site. In addition, the medication profile included Miralax 17 Gm daily without evidence of a diluent. Corrected on site. Patient #8: The medication profile included Duplicate listings for Bisacodyl. Corrected on site. In addition, oxygen 2-4L/min prn dyspnea without evidence of a route. Corrected on site. Also Bisacodyl, MOM, and Fleets enema without evidence of which medication to use first and under what circumstances to use the others. Corrected on site. Patient #9: The medication profile contained Lactulose 10GM/15ml 2x/day as needed without evidence of a reason to use the medication. Corrected on site. Patient #10: The record indicated oxygen 2-4L/min as needed without evidence of a route. Corrected on site. In addition, the medication profile contained Polyethylene Glycol prn, Bisacodyl prn, and MOM prn. There was not evidence of which medication to use first, and under what conditions to advance to the next medication. Corrected on site.

Upon patient record review, 1 of 14 records (Patient #3) 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 #3: The record indicated a call from triage on 9/5/24 at 8:00 pm requesting a visit because the facility reported that the patient had consumed cleaning solution (Poison Control center was notified). There was not evidence that a visit was conducted until 9/6/24 at 11:24am.

Upon patient record review, 1 of 14 records (Patient #6) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect 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 #6: The record indicated that the patient was on Xarelto 15 mg daily. There was not evidence that bleeding precautions were a part of the plan of care. Corrected on site.

Upon patient record review, 3 of 14 records (Patient #4,#6,#8) 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 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 frequencies for the social worker and the spiritual care counselor was 1 prn. Upon evaluation, the spiritual care counselor was declined and a social worker was ordered monthly. Patient #6: The initial visit frequencies for the social worker and the spiritual care counselor was 1 prn. Upon evaluation, both disciplines were ordered monthly. Patient #8: The initial visit frequencies for the social worker and the spiritual care counselor was 1 prn. Upon evaluation, both disciplines were ordered monthly.

Upon patient record review, 8 of 14 records (Patient #2,#4,#5,#6,#7,#8,#9,#10) 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 #2: The IDG narrative dated 12/4/24 documentation by the nurse indicated that the patient completed a course of antibiotics for a suspected UTI. There was not evidence of an order for an antibiotic. Corrected on site. Patient #4: Aquaphor 41% q4h prn. Apply thin layer topically to skin as needed for skin irritation. There was not evidence of a specific location. Patient #5: Lantus 35u SQ daily, Omeprazole, and Benefiber were on the MAR at the facility. There was not evidence of an order for these medications in the hospice record. Corrected on site. Patient #6: The record indicated a wound care order for wound #4, dated 12/1/24, 'Stage 2 pressure wound, clean with wound wash. Apply skin prep to surrounding peri wound area...' There was not evidence of a location. Corrected on site. Patient #7: The record included Miralax 17 Gm daily without evidence of a diluent. Corrected on site. In addition, Nasal spray, Meclizine, Mupirocin ointment, Nystatin powder and Ocuvite were on the facility MAR but there was not evidence of an order for these medications in the hospice record. Corrected on site. Patient #8: The record indicated an order for oxygen 2-4L/min prn dyspnea without evidence of a route. Corrected on site. Also Bisacodyl, MOM, and Fleets enema without evidence of which medication to use first and under what circumstances to use the others. Corrected on site. Patient #9: The record indicated Lactulose 10GM/15ml 2x/day as needed without evidence of a reason to use the medication. Corrected on site. Patient #10: The record indicated an order for oxygen 2-4L/min needed without evidence of a route. Corrected on site. In addition, the record contained orders for Polyethylene Glycol prn, Bisacodyl prn, and MOM prn. There was not evidence of which medication to use first, and under what conditions to advance to the next medication. Corrected on site.

Upon patient record review, 2 of 14 records (Patient #2,#7) 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 #2: The IDG narrative dated 12/4/24 documented by the nurse indicated that the patient completed a course of antibiotics for a suspected UTI. There was not evidence that the care plan was revised to include urinary issues or infection. Corrected on site. Patient #7: The patient was started on Augmentin, Flonase, and Guaifenesin, date 12/5/24 for a URI. There was not evidence that the care plan was revised to include the infection. Corrected on site.

Upon patient record review, 3 of 14 records (Patient #1,#7,#9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The initial order for the social worker was for an evaluation. Upon evaluation, the visit frequency was 1m4, effective 10/12/24. There was not evidence of a routine visit until 11/19/24. Patient #7: The visit frequency for the spiritual care counselor for the benefit period beginning 10/16/24 was 2 visits for 1 month. The record indicated 4 visits in November and 2 in December. Patient #9: The visit frequency for the nurse was 2x/week. For the week of 11/24/24-11/30/24, the record indicated only 1 visit

Upon patient record review, 2 of 14 records (Patient #1,#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 specific 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 Patient #1: The record indicated that the patient had a diagnosis of malignant neoplasm of the bronchus/lung and used oxygen. There was not evidence that oxygen precautions were on the aide plan of care. Corrected on site. Patient #6: The record indicated that the patient was on Xarelto 15 mg daily. There was not evidence that bleeding precautions were on the aide plan of care. Corrected on site.

Upon patient record review 1 of 14 records (Patient #1) 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 #1: The aide visit frequency effective 12/1/24 was 3w3, 3 every 2w2, 4w1. The record indicated that visits were conducted 12/2/24, 12/4/24, 12/5/24, and 12/6/24.

Upon patient record review 1 of 14 records (Patient #2) 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 #2: The record indicated that an aide supervisory visit was conducted on 11/12/24. There was not evidence of another aide supervisory visit until 12/2/24.

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. The documented percentage of usage for the year 2023 was 3.2%.

Upon patient record review, 2 of 14 records (Patient #1,#10) did not have evidence that each patient record contains Advance Directives. Patient #1: The plan of care indicated that the patient was a DNR. There was not evidence that this document was a part of the record. Corrected on site. Patient #10: The legal admission documents indicated that the patient had an OOH DNR. There was not evidence that this was a part of the record.

Upon patient record review, 1 of 14 records (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: The visit frequency for the spiritual care counselor was 1x/month for 3 months effective 9/22/24. There was not evidence of a routine visit for the month of September.

Upon patient record review, 1 of 14 records (Patient #5) did not have evidence that the hospice provided the following information to the SNF/NF: • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice's 24-hour on-call system

Upon patient record review, 2 of 11 (Patient #3,9) 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 #3: 12/17/21 RN visit note documents Senna is the medication used for patient's bowel regimen. No evidence of medication included on the patient's medication profile. Patient #9: 11/19/21 Plan of Care orders state 02 at 2L. No evidence of oxygen included on the patient's medication profile.

Upon patient record review, 3 of 11 (Patient #3,8,9) 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: 12/17/21 Nursing note stated that Senna was the medication used for patient's bowel regimen. No evidence of an order for Senna. Patient #8: 07/28/21 Initial Plan of Care order states Hospice RN to place indwelling urine catheter with 10 cc balloon, may irrigate with 30ml, change Foley catheter every month or as needed. No evidence of size of catheter to be used. Patient #9: Nursing notes on 11/18/21, 11/26/21 include documentation of 18fr Foley catheter present. Nursing note on 11/29/21 include documentation of 22fr Foley catheter present. No evidence of an order for Foley catheter in the medical record.

Upon patient record review 4 of 10 applicable (Patient #1,2,3,8) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #1: 12/3/21 order for Aide visit frequency effective 12/12/21 1wk 8. No evidence of Aide visit for week of 12/26/21 or refusal of visits. In home visit on 1/04/22 with surveyor, Aide used Hoyer lift while providing care. No evidence of Hoyer lift use included in the current Aide Care Plan dated 11/21/21. Patient #2: 12/3/21 order for Aide visit frequency effective 12/14/21 1wk 9. No evidence of Aide visit for week of 12/26/21 or refusal of visits. Patient #3: 11/30/21 order for Aide visit frequency 1wk 1. No evidence of Aide visit for week of 11/28/21or refusal of visits. Patient #8: 07/29/21 order for Aide visit frequency 1wk 13. No evidence of Aide visit for week of 09/05/21 or refusal of visits.

Upon patient client record review, 3 of 11 (Patient #4,6,7) 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 #4: 12/29/21 RN visit note documented LPN supervisory visit completed. No evidence that a LPN was a member of the patient's care team. Patient#6: 11/23/21, 11/29/21, 12/06/21, 12/12/21, 12/16/21,12/20/21, 12/27/21, 01/03/22 RN visit notes documented LPN supervisory visits completed. No evidence that a LPN was a member of the patient's care team. Patient #7: 12/23/21, 12/30/21, 01/04/22 RN visit notes documented LPN supervisory visits completed. No evidence that a LPN was a member of the patient's care team.

Upon client record review, 1 of 1 applicable (Patient #8) 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 #8: 10/08/21 Coordination note states that a Summary was faxed to Attending Physician. No evidence that a Transfer Summary was sent to receiving Hospice.

Upon client record review, 2 of 3 applicable (Patient #6,8) 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 #6: 10/29/21 visit frequency order effective 11/10/21 SW 1month3, 2 PRN. No evidence of visit for the month of November after 11/10/21 or refusal of visit. Patient #8: 07/28/21 Initial Plan of care order states Foley change monthly. Nursing visits from 8/24/21-09/28/21 do not provide clear evidence of when Foley catheter changes occurred.