Every finding on record at Avalon Hospice & Palliative Care, Inc

Observed in Record Review. In 10 of 10 patient records reviewed, Confirmed by the Administrator. The initial patient assessment had not documented a patient safety risk assessment that would identify the need for further evaluation by health professionals or general safety concerns.

Observed in Record Review. In 1 of 14 patient records reviewed and confirmed by the Administrator. The patient goals within the plan of care had not been measurable: Example1: During review of HOSrr#6 all goals were to be met by the end of the certification to include that the patient symptoms of restlessness and agitation would be met. Example2: Caregiver will have realistic understanding of patient abilities.

Observed in Record Review. In 3 of 10 patient records reviewed, Confirmed by the Administrator. During review of HOSv#2 it had been reviewed the plan of care had not been updated to reflect the care provided. Example: A volunteer had been providing service to the patient with goal and intervention, however the plan of care had not been updated with the volunteer frequency and duration. During review of HOSrr#5 a volunteer had been visiting patient with goal and intervention but had not documented frequency or duration for the volunteer. Also. the plan of care had been developed but had not documented disciplines frequency and duration to be provided to include the RN, MSW and Chaplain.

Observed in Record Review. In 5 of 10 patient records reviewed, Confirmed by the Administrator. During review of patient record HOS#6 the plan of care had not been reflective of care being provided. Example: The plan of care /IDG update had documented that the caregiver had been providing care to decubitus ulcer on buttocks, but the plan of care had not documented the treatment being provided as ordered by the physician. During review of HOSv#2 documentation of the initial assessment at the start of care had stated that the patient had a foley catheter but the size and care for the catheter had not been documented. During review of HOSrr#3 documentation had assessed the pressure sores but had not specified the wound treatment to be provided. The plan intervention had stated for the SN to instruct the caregiver with the wound care as ordered. Also, HOSrr#3 had a J tube but the plan of care had not specified the care to be provided to the J tube .

Observed in Record Review. In 3 of 10 patient records reviewed, Confirmed by the Administrator. During review of HOSrr#1 it had been identified that the record had not contained all documentation of care provided. Example: HOSv#2 and HOSrr#5 volunteer notes had not been documented within the patient record. During observation of HOSv#3 the caregiver had stated that the patient had been utilizing MiraLAX . It had not been documented in the medication profile.

Observed in Record Review. In 1 of 2 Hospice live discharge records reviewed and confirmed by the Administrator. The organization had not informed the health care professional ,who will be responsible for continued care, about the availability of discharge summary of care provided by the Hospice.

Observed in Record Review. In 4 of 11 patient records reviewed, During RR#1, it was noted the chaplain initial assessment was 20 days after the RN initial comprehensive assessment. There was lack of documentation to indicate the reason the chaplain visit was not completed within 5 day after the election of hospice care. During RR#3 it was noted the chaplain initial visit was 11 days after the RN comprehensive assessment. During RR#4 it was noted the chaplain initial assessment was 14 days after the initial comprehensive assessment. There was lack of documentation to indicate the reason the visit was not completed within 5 days of the initial comprehensive assessment. During RR#5 it was noted the chaplain initial assessment was 6 days after the comprehensive assessment without documentation to indicate the reason the assessment was not completed within 5 days.

Observed in Record Review. In 9 of 11 patient records reviewed, During HV#1 record review it was noted although the IDG met at least every 15 days, the IDG meeting notes lacked documented patient care review and collaboration from the MSW, Chaplain and RN on a consistent basis. During HV#2 record review it was noted 1 IDG meeting lacked documentation of patient care review and collaboration from the MSW, RN and Chaplain. During RR#1 it was noted lack of consistent documentation during IDG meetings from RN, MSW and Chaplain. During multiple IDG meetings covering 3 certification periods the clinical summary is documented by an LVN even though there is documentation of every 14 days visits from the RN as part of the comprehensive assessments. During RR#2 it was noted lack of consistent documentation of patient care review and collaboration by the IDG. Nursing summaries were documented by an LVN. During RR#3 it was noted lack of documentation of IDG review and collaboration in the first and second certification to date. The LVN completed the clinical summary and sporadically the MSW and Chaplain documented their summary reviews. During RR#4, it was noted sporadic IDG documentation to review and collaborate on the POC. During RR#5 it was noted sporadic IDG documentation to summarize clinical findings and response to care. During RR#6 it was noted lack of IDG summary from the IDG members with response to care at IDG meeting for 4 certification periods to date in 2021. During RR#7 it was noted sporadic documentation of clinical, psycho/social, emotional, spiritual findings during IDG meetings. Clinical documentation was completed by an LVN. During RR#8 it was noted IDG minutes lacked documentation from the IDG members at each IDG meeting. Clinical summary was completed by an LVN although the RN visited the patient every 14 days prior to each IDG meeting. Observed in Record Review. During HV#3 record review it was noted lack of documentation of an IDG meeting to establish the POC since the initial comprehensive assessment 22 days to date.

Observed in Record Review. During RR#4 it was noted on the POC an order for wound care to an abdominal wound with the following intervention Instruct family/cg to report immediately any changes in skin integrity, Perform wound care and apply treatment as ordered. Educate pt/cg on wound care. The order was incomplete and documentation in the SN notes did not specify the components of the wound care provided. Observed in Record Review. In 4 of 11 patient records reviewed, During HV#1 record review it was noted the patient's BP was documented as 172/106 the end of August 2021. The SN documented All VS WNL according to patient's baseline. The POC lacked interventions and goals for hypertension, a comorbidity identified on the initial comprehensive assessment. There was lack of documentation that the physician was notified of the elevated BP. Another comorbidity listed on the initial comprehensive assessment, malignant neoplasm of unspecified ovary, was not included on the IDG/POC. During HV#2 record review it was noted on the RN initial comprehensive assessment summary the patient was diabetic with poor control, not currently on anything for the diabetes. The POC lacked orders for assessment, interventions and goals for diabetes which was listed as a comorbidity on the POC. During RR#5 it was noted a comorbidity of schizophrenia on the initial POC. The POC lacked assessment, interventions or goals related to the patient's mental illness until the second certification period. During RR#7 it was noted a comorbidity of aphasia on the initial comprehensive assessment. The POC lacked assessment, interventions and outcomes associated with the aphasia deficit.

Observed in Record Review. During HV#2 record review it was noted the SNs performed phone call visits to the patient per his request for 4 scheduled visits. There is lack of documentation of notification to the IDG that the method of providing visits were not in person per the established frequency.

Observed in Record Review. In 7 of 11 patient records reviewed, During HV#1-2 and RR#1 it was noted goals established on the POC were not measurable with outcomes to be accomplished by death or discharge or at the end of the certification period. For example: Patient / Caregiver will be knowledgeable in achieving and maintaining adequate urinary function without complications within 1 certification period. Patient comfort will be maintained. Patient will maintain optimum cardiac function within constraints of disease. Caregiver will have realistic understanding of patients abilities within 0-24 hours. The plan lacked teaching interventions for the goal with the intervention identified was to assess blood pressure and pulse. Pain level maintained at or below patient defined threshold or nonverbal patient remains calm & relaxed. Patient / caregiver will demonstrate knowledge in use of pharmacological and non-pharmacological pain management measures. Caregiver will verbalize understanding and recognition of non-verbal signs and symptoms of pain Grimacing - Moaning - Guarding, Etc. within 1 certification. RR#2 goal for example: Patient/Caregiver knowledgeable in actions to take to reduce respiratory distress/increase respiratory comfort within the cert period. This goal included an assessment order but lacked interventions to achieve the goal. During RR#5 it was noted many goals to be accomplished by death or discharge or within the certification period. During RR#6 it was noted generic goals with end dates either at death or discharge or within the certification period. During RR#7 it was noted generic goals with outcomes to be accomplished by death/discharge, within the certification period or within one month. For example,pain level maintained at or below patient defined threshold or nonverbal patient remains calm & relaxed. Patient / caregiver will demonstrate knowledge in use of pharmacological and non-pharmacological pain management measures. Caregiver will verbalize understanding and recognition of non-verbal signs and symptoms of pain Grimacing - Moaning - Guarding, Etc. within one month. During RR#8 it was noted the goals were generic with end dates by death or discharge or within the certification period. For example: Patient / caregiver verbalizes an understanding and demonstrate compliance with prescribed medication administration, current medication regime, doses, and signs and symptoms reportable to physician. Patient will have effective symptom control. Medications in home/facility will match hospice medication list within 1 certification period.

Observed in Patient Home. In 1 of 11 patient records reviewed, During HV#1 record review it was noted on the medication profile an order for Percocet 10-325 mg 1 tab PRN mod-severe pain that lacked the frequency of the PRN administration.

Observed in Record Review. In 4 of 11 patient records reviewed, During HV#1 record review it was noted a communication note that the pt. was seen in the ED and prescribed doxycycline 100mg twice a day for 10 days for an abdominal infection with notification to the RNCM. The IDG note 2 days later lacked an update to the IDG on the ED visit and order for the antibiotic. During RR#2 it was noted the patient fell the middle of August 2021. The IDG meeting the next week lacked an updated summary from the RN on the fall. During RR#3 it was noted on a comm note the patient was to be evicted from her trailer. The next IDG meeting note lacked documentation of this environment change. During RR#8 it was noted on the comprehensive assessment a comorbidity of hepatitis C which was not added to the POC as a condition to be assessed. COPD was noted as a comorbidity on the comprehensive assessment and included multiple respiratory medications on the med profile. The POC lacked assessments, interventions and goals related to the respiratory status. In addition the patient developed cellulitis of the LEs, an order for antibiotics was obtained but the POC was not updated to include skin assessment and effectiveness of antibiotic therapy. Review of the communication logs noted the hospice liaison received information from the patient that was conveyed to the RNs about possible seizure activity. This information was not documented at the IDG meeting 3 days later for discussion by the IDG members.

Observed in Patient Home. In 3 of 3 home visits conducted, During HV#1-3, it was noted the SNs did not adhere to the organization policy 9-009 Hand Hygiene. HV#1 and #2 the SN entered her bag multiple times during patient care without performing hand hygiene. During HV#3 the SN entered her bag multiple times during patient care without removing her gloves and disinfecting her hands. In addition the SN gelled her gloved hands during the visit. Observed in Patient Home. In 3 of 3 home visits conducted, During HV#1-3 it was noted the equipment the SNs used to assess vital signs were not cleaned prior to returning to the nursing bag per organization policy No. 9-014 Bag Technique. The equipment included BP wrist cuff, pulse oximeter and stethoscope.