Every finding on record at Avalon Hospice Minnesota, LLC

Upon observation, there was not evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency. Corrected on site.

Upon patient record review 1 of 14 records (Patient #1) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #1: The patient was admitted on 6/2/23. The record indicated that the spiritual assessment was completed on 7/13/23.

Upon patient record review, 1 of 14 records (Patient #3) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #12: The record indicated a nursing assessment and RN visit on 7/17/23. The next documented RN assessment was 8/3/23, which is greater than the 15 day requirement.

Upon patient record review, 5 of 14 records (Patient #1,#2,#3,#4,#6) did not have evidence the plan of care 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 #1: The visit frequency at the start of care for the social worker was 1 prn. Patient #2: The visit frequencies at the start of care for the social worker and the spiritual care counselor were both 1 prn. Patient #3: The visit frequency at the start of care for the social worker was 3 prn. Patient #4: The visit frequencies at the start of care for the social worker and the spiritual care counselor were both 1 prn. Patient #6: The visit frequencies at the start of care for the social worker and the spiritual care counselor were both 1 prn.

Upon patient record review, 1 of 14 records (Patient #7) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #7: The record indicated that a Foley catheter was placed on 6/9/23. Due to an obstruction, it was removed on 6/30/23. The patient did not want it placed back in. There was not evidence the physician was notified or that an order was received to keep the Foley catheter out.

Upon patient record review, 2 of 14 records (Patient #8,#11) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and notes the patient's progress towards outcome/goals from the plan of care. Patient #8: The record indicated that the patient had tested positive for COVID and the hospice staff was donning PPE. There was not evidence that the plan of care was revised to reflect the updated assessment and the changes related to COVID. Patient #11: The patient was discharged for extended prognosis on 7/5/23. There was not evidence of discussion among the IDG and update to the plan of care, regarding the patient's plateau of the disease and hospice diagnosis. The last IDG prior to discharge was dated 6/28/23 and indicated that the patient was on a steady decline, sleeps the majority of the day with minimal responsiveness. At times gives 1-2 word answers, primarily non-responsive, oral intake is limited to bites, dependent for all ADL's, and has had a gradual decline throughout the certification period.

Upon client record review, 1 of 14 records (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: The record indicated a visit by the volunteer on 8/21/23. There was not evidence of a volunteer visit frequency in the plan of care.

Upon patient record review 1 of 14 records (Patient #4) did not have evidence of 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 #4: The aide visit frequency dated 8/16/23 was increased to 2x/week. There was not evidence that the aide conducted 2 visits for the weeks of 8/13/23-8/19/23 or 8/20/23-8/26/23. Also for the next benefit period (8/24/23-11/21/23), the aide visit frequency was 1x/week but increased to 2x/week on 8/29/23. The record indicated only 1 visit for the week of 8/27/23-9/2/23.

Upon patient record review 2 of 14 records (Patient #3,#7) did not have evidence of documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #3: The record indicated a supervisory visit on 8/8/23. There was not evidence of another supervisory visit until 8/25/23 which is greater than the 14 day requirement. Patient #7: The record indicated a supervisory visit on 7/5/23. There was not evidence of another supervisory visit until 7/21/23.

Upon personnel record review, 1 of 14 records (Personnel #12) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient for the annual competency dated 12/28/22 (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) for the annual aide competency. (All tasks for the initial competency had the required return demonstration). There was not evidence in the hospice aide personnel file that a registered nurse that the RN observed and assessed each aide while he or she is performing care. The supervising nurse must assess an aide's ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include all required content. Personnel #12: The area on the document that indicates that the task is to be observed during direct patient care was blank with no initials indicating if the task was observed and by which method (Annual competency 12/28/22).

Upon personnel record review, 1 of 14 records (Personnel #7) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #7: The staff member was in the role of spiritual care counselor and bereavement counselor. There was not evidence of a competency for the role of bereavement counselor.

Upon patient client record review, 1 of 14 records (Patient #2) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #2: The benefit election statement that was signed on admission indicated that the patient/representative wished to receive the Patient Notification of Hospice Non-Covered Items, Services, and Drugs. There was not evidence that this document was furnished.

Upon client record review, 1 of 14 records (Patient #2) 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 #2: The record indicated that the volunteer conducted a visit on 7/28/23. There was not evidence of a volunteer frequency in the plan of care.

Upon patient record review, 1 of 14 records (Patient #2) did not have evidence that the hospice provided the following information: •Recertification of the terminal illness specific to each patient Patient #2: The record at the SNF did not contain evidence that the recertification for the dates of 7/16/23-10/13/23 was in the record. Corrected on site.