Every finding on record at Am Ventures LLC

Upon patient record review 1 of 14 (Patient #1) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #1 - Patient was admitted to hospice on 08/17/25. There was evidence that patient refused spiritual care, however there was no evidence that the elements of the spiritual comprehensive assessments were assessed by the nurse or MSW upon admission.

Upon patient record review, 4 of 14 (Patient #1,7,9,11) 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 - Patient was admitted on 08/17/25. There was no evidence that the initial bereavement risk assessment was completed. Patient #7 - Patient was admitted on 06/06/25. There was no evidence that the initial bereavement risk assessment was completed. Patient #9 - Patient was admitted on 01/14/26. There was no evidence that the initial bereavement risk assessment was completed. Patient #11 - Patient was admitted on 04/17/25. There was no evidence that the initial bereavement risk assessment was completed.

Upon patient record review, 8 of 14 (Patient #2,3,4,5,6,7,8,10) 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 #2 - The nursing comprehensive dated 07/10/24, noted patient was on a pureed diet. There was no evidence of problems, goals or interventions related to dysphagia. The patient's medication profile contained aspirin daily as a blood thinner. There was no problems, goals, or interventions related to bleeding risk. Patient #3 - The medication profile contained Eliquis daily as a blood thinner. There was no evidence of problems, goals or interventions related to bleeding risk. There was documentation in the medical record that patient was on a mechanical soft diet. There was no problems, goals or interventions related to that diet. Patient #4 - The nursing comprehensive dated 10/28/24, noted patient was on a mechanical diet. There was no evidence of problems, goals or interventions related to that diet. The patient's medication profile contained aspirin daily as a blood thinner. There was no problems, goals, or interventions related to bleeding risk. Patient #5 - The patients advanced directives indicated patient wanted to remain a full code status. There was no evidence of problems, goals or interventions related to that full code status. Patient #6 - The patients advanced directives indicated patient wanted to remain a full code status. There was no evidence of problems, goals or interventions related to that full code status. Patient #7 - The nursing comprehensive dated 06/06/25, noted patient was on a pureed diet. There was no evidence of problems, goals or interventions related to dysphagia. The patient's medication profile contained aspirin daily as a blood thinner. There was no problems, goals, or interventions related to bleeding risk. Patient #8 - The patients advanced directives indicated patient wanted to remain a full code status. There was no evidence of problems, goals or interventions related to that full code status. The medication profile contained Eliquis daily as a blood thinner. There was no evidence of problems, goals or interventions related to bleeding risk. Patient #10 - The patients medication profile contained ASA 81 mg daily and Plavix 75 mg daily. There was no evidence of problems, goals, or interventions related to bleeding risk.

Upon patient record review, 4 of 14 (Patient #3,4,7,10) 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 equipment and supply needs. Patient #3 - The nursing recertification visit completed on 01/19/26, documented that patient incontinent of bowel and bladder. There was no evidence that these supplies were added to the plan of care. Patient #4 - The nursing recertification visit completed 02/14/26, documented that patient incontinent of bowel and bladder. There was no evidence that these supplies were added to the plan of care. Patient #7 - The nursing recertification visit completed on 02/02/26, documented that patient incontinent of bowel and bladder. There was no evidence that these supplies were added to the plan of care. Patient #10 - The nursing recertification visit completed on 01/12/26, documented that patient incontinent of bowel and bladder. There was no evidence that these supplies were added to the plan of care.

Upon patient record review, 2 of 14 (Patient #2,6) 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 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 #2 - The aide frequency order dated 08/26/24 stated aide visits to decrease from five visits per week to three visits per week. There was no evidence that the aide plan of care was updated with this new frequency order, the aide plan of care stated five visits per week. Patient #6 - The medical record showed a new order dated 01/11/26 to increase aide frequency from three visits per week to five visits per week. There was no evidence that the aide plan of care was updated with this new frequency order, the aide plan of care showed stated three visits per week.

Upon patient record review, 2 of 14 (Patient #1,8) 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 #1 - The aide frequency order dated 09/08/25, stated to increase aide frequency to three times per week. The week of 12/28/25-01/03/26, there was only documented visits for 12/30/25 and 01/01/26 only. There was no evidence of a third visit for that week or missed visit documentation. Patient #8 - The aide frequency order dated 02/12/26 stated visits to be five times per week. The week of 02/22/26, there were visits completed on 02/23/26, 02/25/26, and 02/26/26. There was a missed visit note dated for 02/27/26, but no other evidence of a fifth visit or missed visit note for that week.

Upon personnel record review, 1 of 12 (Personnel #4) did not have evidence in the hospice aide personnel file that a registered nurse made an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. Personnel #4 - The personnel file contained the initial competency completed on 08/01/22. There was no evidence of an annual on-site visit by the RN completed in 2023, 2024, or 2025.

Upon personnel record review, 1 of 12 (Personnel #2) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Personnel #2 Did not have evidence of a signed job description for Alt Administrator. Corrected on site

Upon patient client record review, 3 of 5 (Patient #2,#3,#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 #2,#3, and #5 elected to receive 'Notice of non-covered items, services, and drugs". No evidence on the chart that list was ever provided.

Upon personnel record review, 5 of 12 (Personnel #8,9,10,11,12) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel 8,9,10,11,12 did not have evidence that criminal background checks were obtained. Had signed consent on file but did not have results in file. Corrected on site.

Upon personnel record review, 7 of 12 (Personnel #1,2,3,4,5,6,7) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel 1-7 did not have evidence that criminal background checks were obtained. Had signed consent on file but did not have results in file. Corrected on site.