Every finding on record at Odyssey Hospice Care LLC

Upon patient record review, 1 of 14 (Patient #10) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient 10: On the patient consent there is a signature from the hospice agency advanced nurse practitioner as the patient legal representative, the relationship to the patient line below this signature is left blank. The same signature appears on the signature of witness on the consents.

Upon patient record review, 1 of 14 (Patient #10) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient 10: On the patient consent there is a signature from the hospice agency advanced nurse practitioner as the patient legal representative, the relationship to the patient line below this signature is left blank. The same signature appears on the signature of witness on the consents.

Upon patient record review, 1 of 14 (Patient #10) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient 10: On the patient consent there is a signature from the hospice agency advanced nurse practitioner as the patient legal representative, the relationship to the patient line below this signature is left blank. The same signature appears on the signature of witness on the consents.

Upon patient record review, 1 of 14 (Patient #10) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 10: On the patient consent there is a signature from the hospice agency advanced nurse practitioner as the patient legal representative, the relationship to the patient line below this signature is left blank. The same signature appears on the signature of witness on the consents.

Upon patient record review, 1 of 14 (Patient #10) did not have evidence of the appropriate documentation for release of confidential information. Patient 10: On the patient consent there is a signature from the hospice agency advanced nurse practitioner as the patient legal representative, the relationship to the patient line below this signature is left blank. The same signature appears on the signature of witness on the consents.

Upon patient record review, 1 of 14 (Patient #10) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient 10: On the patient consent there is a signature from the hospice agency advanced nurse practitioner as the patient legal representative, the relationship to the patient line below this signature is left blank. The same signature appears on the signature of witness on the consents.

Upon patient record review, 1 of 14 (Patient #10) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient 10: On the patient consent there is a signature from the hospice agency advanced nurse practitioner as the patient legal representative, the relationship to the patient line below this signature is left blank. The same signature appears on the signature of witness on the consents.

Upon patient record review and home visits, 5 of 14 (Patient #2,3,4,8,10) 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: Upon a home visit the patient is taking, Atorvastatin 40mg, Metformin 500mg Methenamine Hippurate 1gm, Seroquel 25mg, Refresh tears, Rexulti 1mg, Zoloft 50mg, Docusate 100mg, Trospium Chloride 20mg, these medications are not on the medication profile. Corrected on Site. Patient 3: The medication profile list MiraLAX 17gm daily as needed, there is no diluent for this medication. Corrected on site. Patient 4: Upon home visit the patient is taking Lorazepam 0.5mg one tablet every day and every four hours as needed, the medication profile lists Lorazepam 1mg every 4 hours as needed and there is not a scheduled dose of 0.5 mg daily. On the home visit there are medications not on the medication profile: Atropine Sulfate drops, Dulcolax 10mg, and Acetaminophen 650mg Suppository. Corrected on site. Patient 8: The medication profile list Acetaminophen 650mg suppository every 4 hours as needed and Acetaminophen PM 500-25mg 2 tablets at bedtime there is not a daily limit for the Acetaminophen. Patient 10: The medication profile list Acetaminophen 650mg suppository every 4 hours as needed and Acetaminophen 500mg, 1 tablet every 8 hours as needed, there is not a daily limit for the Acetaminophen.

Upon patient record review, 3 of 14 (Patient #3,4,8) 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 3: In the patient record there is an order for Aspirin and Plavix in the patient record, there is not a risk for bleeding with goals and interventions on the plan of care. Corrected on site Patient 4: In the patient record there is Aspirin ordered, there is not a risk of bleeding on the plan of care with goals and interventions. Corrected on site. Patient 8: In the patient record there is an order for Aspirin, there is not a risk for bleeding on the plan of care with goals and interventions.

Upon patient record review, 5 of 14 (Patient #2,3,4,8,10) 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: Upon a home visit the patient is taking, Atorvastatin 40mg, Metformin 500mg Methenamine Hippurate 1gm, Seroquel 25mg, Refresh tears, Rexulti 1mg, Zoloft 50mg, Docusate 100mg, Trospium Chloride 20mg, these medications are not on the plan of care. Corrected on Site. Patient 3: On the plan of care there is MiraLAX 17gm daily as needed, there is no diluent for this medication. Corrected on site. Patient 4: Upon home visit the patient is taking Lorazepam 0.5mg one tablet every day and every four hours as needed, on the hospice plan of care there is an order for Lorazepam 1mg every 4 hours as needed and there is not a scheduled dose of 0.5 mg daily. On the home visit there are medications not on the hospice plan of care: Atropine Sulfate drops, Dulcolax 10mg, and Acetaminophen 650mg Suppository. Corrected on site. Patient 8: On the plan of care there is an order record for Acetaminophen 650mg suppository every 4 hours as needed and Acetaminophen PM 500-25mg 2 tablets at bedtime there is not a daily limit for the Acetaminophen. Patient 10: On the plan of care there is an order for Acetaminophen 650mg suppository every 4 hours as needed and Acetaminophen 500mg, 1 tablet every 8 hours as needed, there is not a daily limit for the Acetaminophen.

Upon patient record review, 2 of 14 (Patient #7,9) 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 equipment and supply needs. Patient 7: In the patient record there is an order for oxygen, there is not an oxygen concentrator listed on the plan of care. Corrected on site. Patient 9: On the patient medication profile there is an order for oxygen, there is not an order for an oxygen concentrator on the plan of care.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: In the patient record there is an order for SN 1W1, 2W2, 1W10. There was a nursing visit on 7/31/25 and 8/1/25 in the first week of admission. Corrected on site.

Upon observation and home visits 1 of 3 (Patient #1), there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 1: On a home visit the RN did not follow the bag technique of the hospice's policy, the RN did not wash her hands before patient care and performing vitals and before removing equipment from the bag.

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. No evidence that the agency utilized volunteers for at least 5% of the total patient care hours in 2024. The total usage of volunteers for 2024 was less than 1%.

Upon patient record review, 1 of 14 (Patient #10) 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 Patient 10: On the patient election of benefit form there is a signature from the hospice agency advanced nurse practitioner as the patient legal representative.

Upon patient record review, 3 of 14 (Patient #1,2,4) 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. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 1: On the psychosocial assessment 7/19/25 there is documentation, “Pt. is 8, Y O F”, 8 is the incorrect age of the patient and F is not an approved abbreviation. On the SN assessment there is documentation, “Cgs verbalize understanding and cooperation”, Cgs is not an approved abbreviation. Corrected on site. Patient 2: On the psychosocial assessment 08/01/25 there is documentation, “92Y Y O M”, Y Y O M is not an approved abbreviation. Corrected on site. Patient 4: On 9/4/25 the RN comprehensive assessment contains a goal to have acute confusion/delirium/agitation reduced to a manageable level to return to routine level of care. The patient is not on GIP and is currently in routine level of care, this documentation is not clear and complete. Corrected on site.

Upon personnel record review, 1 of 12 (Personnel #4) did not have evidence of State and Federal criminal background checks being obtained on all contracted individuals who have direct patient care and access to patient records and in accordance with state requirements according to Michigan state Act 28 of 2006; MI Choice Waiver Minimum Operating Standards. Personnel 4: Upon record review there is no evidence of a state and federal background check for the Medical Director.