Every finding on record at Odyssey Hospice Care LLC

Upon patient record review, 5 of 5 (Patients #1,#2,#3,#4,#5) 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 #1, #2, #3, #4, #5: There was no evidence in the medical record that a bereavement assessment was completed within the 5 day requirement.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patients #1,#2,#3: Upon observation at each visit, the RN failed to follow bag technique including placing bag on the floor, failed to utilize a bag barrier, failure to clean equipment prior to placing back into the bag and keeping the bag closed to prevent from contaminating inside the bag. * Infection Control-Agency Policy 5.7A: (1)"Floors are considered to be highly contaminated, bags are never to be placed on the floor". (2) "In order to keep the bag as clean as possible, the bag is to be kept zipped and should be placed in a large plastic storage container with a lid while in the car". (3) "Bag should be kept on the shoulder until a waterproof disposable barrier can be placed on a table or a hard chair and placed on the clean side of the barrier". (5) "Employees must cleanse hands before entering/removing supplies, before examination and after patient care". (7) "If additional supplies are needed during the visit, hands are to be cleansed before reentering the bag. Hand sanitizer may be used". (10) "All equipment is cleansed with disinfectant after use and before returning to the bag".

Upon personnel record review, 1 of 2 applicable (Personnel #5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #5: There is no evidence of an aide competency at the time of hire.

Upon patient client record review, 5 of 5 (Patient #1,#2,#3,#4,#5) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patients #1,#2,#3,#4 and #5: There is no evidence in any of the records that the Notice of non-coverage is included as part of the election of benefit. The election does not address it nor is there an addendum being utilized.