Every finding on record at Avalon Hospice Ohio, LLC

Upon patient record review, 1 of 14 (Patient #9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 9: Paxlovid 150mg-100mg tablet 2 times daily for 5 days ordered on 12/07/2023. No evidence that a stop date was entered on the MAR. Drug remains active on the current MAR.

Upon patient record review, 6 of 14 (Patient #1,2,3,6,7,10) 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: Bereavement risk assessment completed on 01/11/2024. Patient admitted on 12/15/2023. Patient 2: Bereavement risk assessment completed on 01/11/2024. Patient admitted on 08/22/2023. Patient 3: Bereavement risk assessment completed during survey process. Patient admitted on 11/30/2023. Patient 6: Bereavement risk assessment completed on 01/17/2024. Patient admitted on 12/19/2023. Patient 7: Bereavement risk assessment completed during survey process Patient 10: Bereavement risk assessment completed during survey process

Upon patient record review, 1 of 14 (Patient #4) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 4: No evidence that the hospice nurse measured the wound at the time that the wound was reported on 12/13/2023. No evidence that the wound was measured weekly as ordered/per Gentiva policy during the following weeks of 12/17-12/23, 12/24-12/30, 12/31-01/04, and 01/14-01/20 at the time of survey.

Upon patient record review, 4 of 14 (Patient #1,2,3,7) did not have evidence the plan of care must 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: SW and SC only have PRN orders on initial POC. No evidence of routine visits on plan of care. Patient 2: SC was declined however 2 PRN visits were ordered for 4th BP. Patient 3: SW and SC only have PRN orders on initial POC. No evidence of routine visits on plan of care. Patient 7: SW only have PRN orders on initial POC. No evidence of routine visits on plan of care.

Upon patient record review, 1 of 14 (Patient #6) 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 medications and treatments. Patient 6: Patient had a wound on admit that was inactivated on 12/27/2023 on the wound care chapter. Wound care orders remain active at the time during. Corrected during survey.

Upon client record review, 1 of 14 (Patient #9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 9: Patient had developed a wound on 12/27/2023. Wound care orders were entered to for the Hospice nurse to assess and measure the wound once weekly. No evidence of charting to support that the wound was assessed or measured during at that time or during the weeks to follow.