Every finding on record at Avalon Hospice Care, Inc

Upon patient record review, 8 of 14 (Patients #1,2,3,4,5,7,8,10) 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 equipment and supply needs. Patient #1:This patient had a cane, rollator, SC and oxygen. These were not included on the Plan of Care. Patient #2: This patient had a nebulizer machine, FWW and SC. These were not included on the Plan of Care. Patient #3: This patient had a cane, rollator, nebulizer machine and oxygen. These were not included on the Plan of Care. Patient #4: The record reflected that this patient had a cane. This item was not included on the Plan of Care. Patient #5: The record reflected that this patient had a oxygen supplies. This item was not included on the Plan of Care. Patient #7:The record reflected that this patient had a Duo-neb 0.5/3mg order. The nebulizer machine was not included on the Plan of Care. Patient #8: The record reflected that this patient had a WC, BSC and SC. These were not included on the Plan of Care. Patient #10: The record reflected that this patient had a cane and rollator. These were not included on the Plan of Care.

Upon patient record review 8 of 14 (Patients #1,2,3,4,5,6,7,10) 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 Patient #1: The POC listed Aide visit frequency of, 2 X's per week ordered on 9/22/23. For the first Benefit Week there were no visits made. Patient #2: The POC listed Aide visit frequency of, 2 X's per week ordered on 10/16/23. For Benefit Week 12/22/23 there was only one visit made on 12/26/23. Patient #3: Patient #1: The POC listed Aide visit frequency of, 2 X's per week ordered on 9/2/23. For the first Benefit Week there were no visits made. Patient #4: The POC listed Aide visit frequency of, 1 X's per week ordered on 10/5/23. For the first Benefit Week there were no visits made. Patient #5: The POC listed Aide visit frequency of, 2 X's per week ordered on 9/9/23. For the first Benefit Week there were no visits made. Patient #6: The POC listed Aide visit frequency of, 1X's per week ordered on 10/26/23. For the first Benefit Week there were no visits made. Patient #7: The POC listed Aide visit frequency of, 2 X's per week ordered on 9/25/23. For the first Benefit Week there were no visits made. Patient #10: Patient #1: The POC listed Aide visit frequency of, 1 X's per week ordered on 9/18/23. For the first Benefit Week there were no visits made.

Upon patient record review, 7 of 14 (Patients #1,2,3,4,5,7 and 10 ) did not have evidence in the patient record that the interdisciplinary group, as part of the review of the plan of care, determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home. If the patient and/or family are not capable of safely administering drugs and biologicals in the home, the hospice must address this issue in the patient's plan of care. Patients #1, 5, 7, 9: Did not have assessment form checked in space provided that the patient/caregiver can safely administer medications Patients #2,3,4: Did not have assessment form that patient/caregiver can safely administer medications in patients record.