Every finding on record at Otterbein Hospice LLC

Upon patient record review, 5 of 19 (Patient #2,3,4,10,14) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 2: The patient was admitted on 09/19/24. The comprehensive assessment does not assess for imminence of death. Patient 3: The patient was admitted on 02/10/25. The comprehensive assessment does not assess for imminence of death. Patient 4: The patient was admitted on 02/10/25. The comprehensive assessment does not assess for imminence of death. Hospice Actively Dying Assessment section marked NA. Patient 10: The patient was admitted on 03/14/25. The comprehensive assessment does not assess for imminence of death. Hospice Actively Dying Assessment section marked NA. Patient 14: The patient was admitted on 04/29/25. The comprehensive assessment does not assess for imminence of death. Hospice Actively Dying Assessment section marked NA.

Upon patient record review, 6 of 19 (Patient #1,5,6,7,12,13) 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 1: Current medication record include(s) orders for Iodosorb gel 0.9% apply thin layer topically daily, order does not include a site of application. Patient 5: Current medication record include(s) Polyethylene glycol powder 17 grams po daily prn for constipation without diluent. Patient 6: Current medication record include(s) orders for Phosphorous-SO 280-160-250mg (1) packet packet oral 3 times daily for CHF. Order does not include a diluent. Patient 7: Current medication record include(s) Polyethylene glycol powder 17 grams po daily prn for constipation without diluent. Patient 12: Current medication record include(s) Polyethylene glycol powder 17 grams po daily prn for constipation without diluent. Patient 13: Current medication record includes Polyethylene glycol powder 17 grams po daily prn for constipation & Metamucil powder 3.4 grams po daily, without diluent.

Upon patient record review, 5 of 19 (Patient #3,7,9,13,14) 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: The current POC dated 11/11/25 includes orders for ASA. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions. Patient 7: The current POC dated 11/11/25 includes orders for Eliquis. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions. Patient 9: The current POC dated 11/11/25 includes orders for ASA. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions. Patient 13: The current POC dated 11/11/25 includes orders for Eliquis. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions. Patient 14: The current POC dated 11/11/25 includes orders for ASA. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions.

Upon patient record review, 6 of 19 (Patient #1,5,6,7,12,13) 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 1: POC includes orders for Iodosorb gel 0.9% apply thin layer topically daily, order does not include a site of application. Patient 5: POC dated 11/11/25 include(s) Polyethylene glycol powder 17 grams po daily prn for constipation without diluent. Patient 6: POC dated 11/13/25 include(s) orders for Phosphorous-SO 280-160-250mg (1) packet packet oral 3 times daily for CHF. Order does not include a diluent. POC dated 11/13/25 include(s) orders for Stage 4 ulcer to sacrum without frequency. Patient 7: POC dated 11/11/25 includes Polyethylene glycol powder 17 grams po daily prn for constipation without diluent. Patient 12: POC dated 11/11/25 includes Polyethylene glycol powder 17 grams po daily prn for constipation without diluent. Patient 13: POC dated 11/11/25 includes Polyethylene glycol powder 17 grams po daily prn for constipation & Metamucil powder 3.4 grams po daily, without diluent.

Upon patient record review, 2 of 19 (Patient #7,14) 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 for a hospice aide 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; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 7: Current aide POC dated 11/11/25 does not include frequencies for bath, shampoo, hair, nails, oral hygiene, assist with dressing, assist with shaving, lotion, deodorant and assist with transfers. Patient 14: Current aide POC dated 11/11/25 does not include frequencies for assist with shaving.

Upon patient record review, 1 of 19 (Patient #6) 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 6: POC dated 11/13/25 includes orders for wound care. Patient resides in a facility. POC does not indicate who is to complete the dressing changes.

Upon patient record review, 3 of 11 (Patient #2, #4, #5) 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, 4, 5: The medical record contains documentation that patient is on oxygen at admission. There is no evidence of oxygen in the plan of care. Corrected on Site.

Upon patient record review, 8 of 11 (Patient #1, #2, #3, #7, #8, #9, #10, #11) 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: The medical record contains an initial bereavement assessment that was completed on 5/13/22, SOC was on 2/2/22. Patient 8: The medical record contains an initial bereavement assessment that was completed on 2/21/22, SOC was on 1/28/22. Patient 11: The medical record contains an initial bereavement assessment that was completed on 3/7/22, SOC was on 3/1/22. Patients 2, 3, 7, 9, 10: The medical record does not contain an initial bereavement assessment.

Upon patient record review, 1 of 11 (Patient #4) did not have evidence the plan of care must 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 medical record contains an ordered MSW frequency change from 1-3 times every 3 month to an unknown frequency or no change to frequency even though the order states frequency increase. The new order on 9/5/22 is unclear to new frequency or unchanged frequency. Corrected on Site.

Upon patient record review, 4 of 11 (Patient #2, #4, #5, #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, 4, 5, 10: The medical record contains documentation at admission that patient in on oxygen therapy. There is no evidence of oxygen on the medication profile. Corrected on Site. Patient 2: The medical record indicated wound treatment in the plan of care as of 7/6/22. There was no evidence of wound location for treatment in the order. Corrected on Site.

Upon patient record review, 7 of 11 (Patient #1, #2, #3, #4, #5, #6, #7) 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 1, 2, 3, 4, 5, 6, 7: The medical record contains documentation at admission that patient is using a wheelchair. There is no evidence of wheelchair in the plan of care. Corrected on Site.

Upon client record review, 1 of 11 (Patient #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5: The medical record contains an ordered nursing frequency of once to twice weekly. There was no evidence of SN visit or missed visit note during week of 9/4/22. Corrected on Site.

Upon patient record review 4 of 11 (Patient #5, #6, #7, #9) 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 5: The medical record contains an ordered aide frequency of twice weekly at SOC. There was no evidence of any aide visits. Corrected on Site. Patient 6: The medical record contains an ordered aide frequency of twice weekly at SOC. There was no evidence of any aide visits. Corrected on Site. Patient 7: The medical record contains an ordered aide frequency of twice weekly. There was evidence of 1 visit during weeks of 8/21/22, 8/28/22, and 9/4/22. Patient 9: The medical record contains an ordered aide frequency of twice weekly. There was no evidence of aide visit during week of 7/24/22.

Upon client record review, 3 of 8 applicable (Patient #4, 6, 9) 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 4: The medical record indicated wound treatment to coccyx in nursing documentation on 9/16/22. There was no evidence of wound order. Corrected on Site. Patient 6: The medical record contains an ordered nursing frequency of once to twice weekly. There was no evidence of SN visit or missed visit note during week of 7/24/22. Corrected on Site. Patient 9: The medical record contains an ordered nursing frequency of twice weekly. There was no evidence of SN visit during week of 7/24/22.