Every finding on record at A-Vow Hospice, Inc

Based on record review and interview, the hospice failed to ensure completion of the initial spiritual assessment no later than 5 calendar days after the election of hospice care for one (Patient #2) of 14 patients. --- Findings:Patient #2A review of the clinical record showed an election of the hospice benefit on 07/16/25 with no completion of the social worker assessment from 07/16/25 to 07/22/25 (6 days after the election of the hospice benefit), Documentation showed no patient or caregiver refusal of the initial bereavement risk assessment or initial spiritual assessment.On 08/15/25 at 1:00 pm., Staff A stated the initial spiritual assessment for Patient #2 was not completed within the first five days of the election of the hospice benefit.

Based on record review and interview, the hospice failed to ensure skilled nursing services were provided in accordance with the plan of care frequency for three (Patients #1, 6 and 8) of 11 patients. --- Patient #1 A review of the plan of care dated11/29/22 to 02/26/23 and plan of care updates dated 12/02/22, 12/16/22 and 12/30/22 showed skilled nurse visits at a frequency of two visits per week. A review of the clinical record showed the following: A skilled nurse assessment dated 12/05/22 for the week of 12/05/22 to 12/11/22 (one of two ordered visits completed. Documentation showed no patient or family refusal of visits and no changes in the ordered frequency. A skilled nurse assessment dated 12/15/22 for the week of 12/12/22 to 12/18/22 (one of two ordered visits completed). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency. A skilled nurse assessment dated 12/23/22 for the week of 12/19/22 to 12/25/22 (one of two ordered visits completed). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency. No skilled nurse assessments for the week of 12/26/22 to 01/01/22 (zero of two ordered visits completed). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency. A skilled nurse assessment dated 01/05/23 for the week of 01/02/23 to 01/08/23 (one of two ordered visits completed). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency. Patient #8 A review of the plan of care dated 11/28/22 to 02/25/23 and plan of care updates dated 12/02/22, 12/16/22 and 12/30/22 showed skilled nurse visits at a frequency of two visits per week. A review of the clinical record showed the following: A skilled nurse assessment dated 11/28/22 for the week of 11/28/22 to 12/04/22 (one of two ordered visits completed. Documentation showed no patient or family refusal of visits and no changes in the ordered frequency. A skilled nurse assessment dated 12/05/22 for the week of 12/05/22 to 12/11/22 (one of two ordered visits completed). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency. A skilled nurse assessment dated 12/15/22 for the week of 12/12/22 to 12/18/22 (one of two ordered visits completed). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency. No skilled nurse assessments dated for the week of 12/19/22 to 12/25/22 (zero of two ordered visits completed). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency. A skilled nurse assessment dated 12/29/22 for the week of 12/26/22 to 01/01/22 (one of two ordered visits completed). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency. A skilled nurse assessment dated 01/05/23 for the week of 01/02/23 to 01/08/23 (one of two ordered visits completed). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency. On 01/10/23 at 3:20 pm, Staff B stated the skilled nurse frequencies were not completed as ordered for Patients #1 and 8.

Based on record review and interview, the hospice failed to ensure the plan of care was fully developed to include all services necessary for the palliation and management of the terminal illness for eight (Patients #1, 2, 3, 4, 6, 7, 8 and 11) of 11 patients reviewed. --- Patient #1A review of the plan of care dated 11/23/22 to 02/26/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #2A review of the plan of care dated 10/19/22 to 01/16/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #3A review of the plan of care dated 09/20/22 to 11/18/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #4A review of the plan of care dated 11/06/22 to 03/05/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #6A plan of care dated 09/22/22 to 12/20/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #7A review of the plan of care dated 10/18/22 to 12/16/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #8A review of the plan of care dated 11/28/22 to 02/25/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #11A plan of care dated 10/04/22 to 12/02/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. On 01/10/23 at 3:20 pm, Staff B stated the plans of care for Patients #1, 2, 3, 4, 6, 7, 8 and 11 failed to include services necessary for the palliation and management of the terminal illness.

Based on record review and interview, the hospice failed to ensure the plan of care documented the frequency for hospice aide visits for two (Patients #4 and 6) of 11 patients. --- Patient #4 A review of the plan care dated 12/06/22 to 03/05/23 with plan of care updates dated 12/16/22 and 12/30/22 showed no hospice aide frequencies ordered for visits made on 12/13/22 and 12/16/22. Patient #6 A review of the plan of care dated 09/22/22 to 12/20/22 showed no hospice aide frequencies ordered for visits made on 09/22/22 and 09/29/22. On 01/10/23 at 3:10 pm, Staff B stated there were no documented hospice aide frequencies for Patient #4 and 6.

Based on record review and interview, the hospice failed to ensure the plan of care was revised to reflect increased spiritual services for one (Patient #2) of 11 patients. --- Patient #2A review of the clinical record showed a plan of care dated 10/19/22 to 01/16/23 and plan of care updates dated 10/21/22, 11/04/22, 11/18/22, 12/02/22 and 12/16/22 which showed a Chaplain frequency of two as needed visits every 30 days. A review of the clinical record showed: Chaplain visits dated 10/24/22 and 10/27/22 for the week of 10/24/22 to 10/30/22 (two visits made). A Chaplain visit dated 11/04/22 for the week of 10/31/22 to 11/06/22 (one visit made). A Chaplain visit dated 11/07/22 for the week of 11/07/22 to 11/13/22 (one visit made). A Chaplain visit dated 11/22/22 for the week of 11/21/22 to 11/27/22 (one visit made). A Chaplain visit dated 12/09/22 for the week of 12/05/22 to 12/11/22 (one visit made). On 01/10/23 at 3:30 pm, Staff B stated the plan of care should have been updated to reflect the increased spiritual services provided for Patient #2.

Based on record review and interview, the hospice failed to maintain evidence of an ongoing, hospice-wide data-driven QAPI program. This failed practice had the potential to place 36 current patients and all employees at risk of substandard patient care and poor employee practices as a result of unidentified, uninvestigated and/or unresolved problematic areas. (See L560) Based on record review and interview, the hospice failed to maintain evidence that its QAPI program showed measurable improvement in indicators related to improved palliative outcomes and hospice services. This failed practice had the potential to place 36 current patients and any new patient admitted to the hospice at risk of poorly identified outcome measures related to symptom control. (See L561) Based on record review and interview, the hospice failed to analyze quality indicators. This failed practice had the potential to place 36 current patients and any new patient admitted to the hospice at risk for repeated hospice mishaps due to failure of the hospice to self-identify problem areas. (See L562) Based on record review and interview, the hospice failed to ensure implementation and evaluation of PIPs for all employees and 36 patients on service during the calendar year of 2022. This failed practice had the potential to place 36 current patients and any new patient admitted to the hospice at risk for failed improvement to patient and hospice specific problem areas. (See L571) Based on a record review and interview, the governing body failed to ensure a QAPI program was maintained and evaluated annually. This failed practice had the potential to place all patients on service in 2021 and 2022 at risk for poor outcomes due to the lack oversight and governing body involvement. (See L574) Based on record review and interview, the hospice's Governing Body failed to ensure the hospice-wide quality assessment and performance improvement efforts addressed priorities for improved quality of care and patient safety, and that all improvement actions were evaluated for effectiveness. This failed practice had the potential to place 36 current patients and any new patient admitted to the hospice at risk for poor outcomes and oversight. (See L575) --- .

Based on record review and interview, the hospice failed to maintain documentation of a QAPI Program for 2021 and 2022 for all patients on service and all personnel employed by the hospice during the calendar years of 2021 and 2022. --- A review of agency records showed no documentation of a QAPI Program for 2021 and 2022. On 01/10/22 at 1:15 pm, Staff B stated there was no documentation of the QAPI Program for 2021 and 2022.

Based on record review and interview, the hospice failed to maintain evidence that it's QAPI Program showed measurable improvement in indicators related to improved palliative outcomes and hospice services. --- A review of agency records showed no evidence of a QAPI program with measurable improvements in indicators related to improved palliative outcomes and hospice services for 2020 and 2022. On 01/10/22 at 1:15 pm, Staff B stated they had no documented QAPI program for 2021 and 2022 showing measurable improvement in indicators related to palliative outcomes and hospice services.

Based on record review and interview, the hospice failed to analyze quality indicators for any potential new patients admitted to hospice services. --- A review of agency records showed no analysis of quality indicators for 2021 and 2022. On 01/10/22 at 1:15 pm, Staff B stated there was no analysis of quality indicators for 2021 and 2022.

Based on record review and interview, the hospice failed to ensure implementation and evaluation of PIPs for all employees and all patients on service during the calendar year of 2022. --- A review of agency records for showed no implementation or evaluation of PIPs for 2022. On 01/10/22 at 1:15 pm, Staff B stated there were no PIPs implemented or evaluated for the hospice for 2022.

Based on a record review and interview, the governing body failed to ensure an agency specific QAPI program was evaluated annually for all patients on hospice services and all agency staff for 2021 and 2022. --- A review of administrative records showed no governing body review of the agency specific QAPI program for 2021 and 2022. On 01/10/22 at 1:15 pm, Staff B stated the governing body minutes did not show review of the agency specific QAPI for the hospice in 2021 and 2022.

Based on record review and interview, the hospice's Governing Body failed to ensure the hospice-wide quality assessment and performance improvement efforts addressed priorities for improved quality of care and patient safety, and that all improvement actions were evaluated for effectiveness for eleven (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11) of 11 patients. --- A review of Governing Body minutes for 2021 and 2022 showed no Governing Body evaluation of quality assessment and performance improvement efforts for care and patient safety. Documentation showed no improvement efforts and no evaluation for effectiveness. On 01/10/22 at 1:15 pm, Staff B stated the Governing Body minutes failed to address hospice quality assessment, performance improvement and other agency specific issues for 2021 and 2022.

Based on record review and interview, the hospice failed to ensure an effective infection control program was documented and maintained for the calendar years of 2021 and 2022. This failed practice had the potential to place 36 current patients at risk for infections. (See L578) Based on record review and interview, the agency failed to ensure it provided the surveillance, identification, prevention, control and investigation of infectious and communicable diseases in the agency QAPI program for 2021 and 2022. This failed practice had the potential to affect the care and health of all 36 current patients. (See L580) Based on record review and interview, the agency failed to ensure an infection control program was maintained for the identification of infectious and communicable disease problems for 2021 and 2022. This failed practice had the potential to affect the identification of infections within the patient population for all 36 current patients. (See L581) --- .

Based on record review and interview, the hospice failed to ensure an effective infection control program was documented and maintained for the calendar years of 2021 and 2022. --- A review of agency records showed no documentation of an effective infection control program was maintained for the calendar years of 2021 and 2022. On 01/10/22 at 1:20 pm, Staff B stated there was no documentation of an infection control program for the calendar years of 2021 and 2022.

Based on record review and interview, the agency failed to ensure it provided the surveillance, identification, prevention, control and investigation of infectious and communicable diseases in the agency QAPI program for 2021 and 2022. --- A review of agency records showed no documented surveillance, identification, prevention, control and investigation of infectious and communicable diseases for 2021 and 2022. On 01/10/22 at 1:20 pm, Staff B stated there was no documentation of a QAPI program which included the surveillance, identification, prevention, control and investigation of infectious and communicable diseases for 2021 and 2022.

Based on record review and interview, the agency failed to ensure an infection control program was maintained for the identification of infectious and communicable disease problems for 2021 and 2022. --- A review of agency records showed no established infection control program was maintained for the identification of infectious and communicable disease problems for 2021 and 2022. On 01/10/22 at 1:20 pm, Staff B stated the agency had not established an infection control program for 2021 and 2022.

Based on record review and interview, the hospice failed to ensure the hospice aide notified the supervising nurse of missed visits for one (Patient #3) of 11 patients. --- Patient #3A review of the plan of care dated 09/20/22 to 11/18/22 showed a hospice aide frequency of two visits per week. A review of the clinical record showed: No hospice aide visits for the week of 09/26/22 to 10/01/22. No missed visit notes were found and no documentation the supervising nurse was notified of missed visits. On 01/10/23 at 2:55 pm, Staff B stated the patient had refused hospice aide visits that week and hospice aides failed to document they notified the supervising nurse of missed visits.