Every finding on record at Amavi Hospice and Palliative Care, LLC

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. 2 of 14 (14%) clinical records reviewed revealed that the agency did not ensure the initial comprehensive assessments were completed within five (5) calendar days after the election of hospice care. CLINICAL RECORD 1: The hospice benefit was elected on 04/06/2025. The clinical record lacked evidence of a psychosocial initial assessment no later than five (5) days after the election of hospice services. The initial nursing assessment was dated 04/06/2025, the initial psychosocial assessment was dated 04/12/2025 (6 days), and spiritual care was declined by the family on 04/06/2025. CLINICAL RECORD 8: The hospice benefit was elected on 04/23/2025. The clinical record lacked evidence of an initial spiritual assessment no later than five (5) days after the election of hospice services. The initial nursing assessment was dated 04/23/2025, the initial psychosocial assessment was dated 04/25/2025, and the initial spiritual assessment was completed on 04/29/2025 (6 days). During an interview with the Administrator (PERSONNEL RECORD 5) on 11/05/2025 she stated that they have done some education to the staff about documenting if the initial assessment visit is moved outside of the 5-day window. Specifically, if the patient/family/caregiver requests that the initial assessment is scheduled outside of the 5-day window, it is documented; those two must have just fallen through. However, they will be doing some additional education to remind the clinical staff of the process.

It is required that the comprehensive assessment includes an initial bereavement assessment of 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 considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. 1 of 14 (7%) clinical records reviewed of patients that elected the hospice benefit revealed that the agency did not ensure that the initial bereavement assessment was completed as part of the initial comprehensive assessment and incorporated into the plan of care. CLINICAL RECORD 13: The hospice benefit was elected by the patient on 04/11/2025. The clinical record lacked evidence that an initial bereavement assessment was completed as part of the initial comprehensive assessment and incorporated into the plan of care. The initial nursing assessment was completed on 04/11/2025, the initial social work assessment was completed on 04/12/2025, spiritual services were declined on 04/11/2025, and the initial bereavement risk assessment was completed on 05/06/2025. During an interview with the Administrator/Bereavement Coordinator (PERSONNEL RECORD 5) on 11/05/2025 she stated she realized it had not been done as part of the initial comprehensive assessment and completed it as soon as it was identified. Also, she stated they have been working on the process and completing the initial bereavement risk assessment in a timely manner.

It is required that the documented number and scope of performance improvement projects conducted annually represent the needs of the hospice population served; represent the internal needs of the organization; and reflect the scope, complexity, and past performance of the hospice’s services and operations. This standard was not met as evidenced by document review and interview. Review of the QAPI program and activities revealed that the agency did not ensure that performance improvement projects were developed, implemented, or evaluated. There were no performance improvement projects documented in the agency evaluation for 2024 or 2023 and no current performance improvement projects in evidence. During an interview with the Administrator (PERSONNEL RECORD 4) on 11/05/2025, she stated that that she thought that they did have some performance improvement projects but they just switched out their binder to streamline its contents, however she does not know what happened to the performance improvement projects that she thought were present.

It is required that the documented number and scope of performance improvement projects conducted annually represent the needs of the hospice population served; represent the internal needs of the organization; and reflect the scope, complexity, and past performance of the hospice’s services and operations. Documentation of selected PI projects include: the reason for conducting the projects and measurable progress achieved. This standard was not met as evidenced by document review and interview. Review of the QAPI program and activities revealed that the agency did not ensure that performance improvement projects were documented inclusive of the reason for conducting the projects and measurable progress achieved. There were no performance improvement projects documented in the agency evaluation for 2024 or 2023 and no current performance improvement projects in evidence. During an interview with the Administrator (PERSONNEL RECORD 4) on 11/05/2025, she stated that that she thought that they did have some performance improvement projects but they just switched out their binder to streamline its contents, however she does not know what happened to the performance improvement projects that she thought were documented.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. 1 of 2 (50%) clinical records reviewed for patients that have been discharged revealed that the agency did not ensure that the attending physician was sent a copy of the hospice discharge summary. CLINICAL RECORD 14: The patient elected the hospice benefit on 03/29/2025 and transferred to another hospice on 05/01/2025. The clinical record review was absent evidence of the discharge summary being sent to the attending physician after discharge. During an interview with the Administrator (PERSONNEL RECORD 5) on 11/05/2025 she stated that she thought sending the information to the accepting agency was all that was required, but that she would do some education with the staff and they would send the discharge summary to the attending physician with all discharges.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 11 (18%) clinical records reviewed it was revealed that the agency did not ensure that the patient’s individualized written Plan of Care (POC) included planned interventions based on problems identified in the initial and updated comprehensive assessments.. Clinical Record 3: The patient elected the hospice benefit on 12/13/22. In the initial comprehensive nursing assessment completed by the Registered Nurse (RN) on 12/13/22, it was documented that the patient had 2/10 pain. Shortness of breath (SOB) screening indicated that patient was SOB with minimal exertion. A narrative note stated, "Patient noted with constant intermittent shifting of position and inability to keep still, with shortness of breath even with minimal exertion". The POC effective for the current benefit period (BP# 1), started 12/13/23 did not contain any problems, goals or interventions to address the patient's pain. Clinical Record 4: The patient elected the hospice benefit on 4/15/22. On 12/5/22 the Registered Nurse (RN) completed a rectification visit and it was documented that the patient had 4/10 pain in their feet. On 1/2/23, a skilled nursing visit documented that patient had 4/10 pain in their feet and that "facility staff administered analgesics, arthritis pain relief". The patient had an order dated 4/15/22 for Arthritis Pain Relief Oral Tablet Extended Relief 650mg, 1 tablet every 8 hours by mouth as needed for pain. The patient's POC effective for the current benefit period, (BP#4) dated, 12/11/22 to 2/8/23 or any previous benefit periods did not contain any problems, goals or interventions to address the patient's pain. An interview conducted on 1/12/23 with the Supervising Nurse regarding the POC for record 3 and record 4. They did verify that clinical record 3 did not contain any problems, goals or interventions to address the patient's pain and shortness of breath and it should have. They also verified that clinical record 4 did not contain any problems, goals or interventions to address the patient's pain and it should have.

It is required that written patient care instructions for a hospice aide are prepared by a registered nurse who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by a review of clinical records, interviews and observations. In 1 of 8 (12%) clinical records reviewed where a hospice aide care plan was required, the agency did not ensure that written patient care instructions were updated by the Registered Nurse (RN) who was responsible for supervision of the aide.. Clinical Record 5: The patient elected the hospice benefit on 5/27/22. On admission a Hospice Aide Care Plan (CP) was established by the Registered Nurse (RN) that included the intervention "transfer patient with 1 assist". It was documented on 9/12/22 by the RN that the family had notified the Hospice that the patient had fallen on 9/10/22. A mobile X-ray was performed, and a right hip fracture was identified. The caregiver declined any treatment for the fracture. The patient could no longer bear weight for transfers or ambulation. During a home visit observed on 1/11/23, the care giver confirmed that the patient had been chair or bedbound since fracture on 9/10/22. A Health Aide supervisory visit was documented by the RN on 9/14/22, with no update to the health aide care plan to indicate that the patient was now bedbound. For the current benefit period (BP#3), dated 11/23/22 to 1/22/23 the Health Aide CP dated 11/23/22 continued to include the intervention to "transfer patient with 1 assist". Home Visit 2: During a home visit observed on 1/11/23 the care giver confirmed that the the patient had been chair or bedbound since the fall and fracture on 9/10/22. In a joint clinical record review conducted with the Supervising Registered Nurse on 1/12/23 they did confirm that the health aide care plan had not been updated after the patient fell on 9/10/22 and should have been.