Every finding on record at Avia Hospice Inc.

Upon observation, there was missing evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees and Federal, state, tribal, regional, and local emergency management agencies.

Condition of Participation: Patient’s Rights. L500

Upon patient record review, 2 of 14 records (Patient #7,#12) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law.

Upon patient record review, 2 of 14 records (Patient #7,#12) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities.

Upon patient record review, 2 of 14 records (Patient #7,#12) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #7,#12: There was not evidence of consents including the benefit election and all legal admission paperwork. Missing evidence the patient's chose an attending physician.

Upon patient record review, 2 of 14 records (Patient #7,#12) did not have evidence of the appropriate documentation for release of confidential information.

Upon patient record review, 2 of 14 records (Patient #7,#12) did not have evidence that the patient received information about the services covered under the hospice benefit.

Upon patient record review, 2 of 14 records (Patient #7,#12) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services.

Upon patient record review, 4 of 14 records (Patient #2,#6,#8,#14) 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. Patient #2,#14: The record indicated Miralax powder 17 GM daily as needed for constipation. There was not evidence of a diluent. Patient #6: The record indicated Nystatin powder 100,000u topical to fungal infection. There was not evidence of a specific location. Patient #8: The record indicated that the patient was on Tylenol 325 mg, 2 tabs q12h (scheduled) and Acetaminophen 650 rectal supp q6h as needed for fever. There was not evidence of a maximum allowable dose/24h.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 2 of 14 (Patient #5,#14) did not have evidence in the patient record that the written plan of care is developed by the IDG, in consultation with the patient's attending physician. Patient #5,#14: The was no evidence of a plan of care or orders on record for these patients.

Upon patient record review, 2 of 14 records (Patient #8,#9) did not have evidence that a Registered Nurse ensured continuous assessment of the patient and family's needs and coordinated 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 #8: The record indicated that the patient had a stage 2 wound on her buttocks. There was not evidence of an assessment including measurements. Patient #9: The record indicated that the patient had a wound on her right lower leg, and then developed a wound on her forehead after a fall on 5/21/21. There was not evidence of wound assessments.

Upon patient record review, 11 of 12 applicable (Patient #1,#2,#3,#4,#6,#7,#9,#10,#11,#12#13) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: The record indicated that the patient was admitted on 4/8/21, however, the POC was not developed until 4/14/21. Additionally, there is missing evidence of goals and interventions related to the spiritual well being or the psycho-social well being of the patient/family. Patient #2: The record indicated that the patient was admitted on 5/29/21, however, the POC was not developed until 6/8/21. In addition, there is missing evidence of goals and interventions related to the spiritual well being or the psycho-social well being of the patient/family. Also, the patient was admitted with a diagnosis of protein-calorie malnutrition. There was not evidence of goals and interventions related to nutrition and diet. Patient #3: The record indicated that the patient was admitted on 5/22/21, however, the POC was not developed until 6/8/21. In addition, the record indicated that the patient had a Foley and there was not evidence that altered elimination interventions/goals were included in the care plan. Patient #4: The record indicated that the patient was admitted on 7/29/21, however, the POC was not developed until 8/4/21. In addition, there was not evidence of goals and interventions related to the spiritual well being or the psycho-social well being of the patient/family. Patient #6: There was not evidence of goals and interventions related to the spiritual well being or the psycho-social well being of the patient/family. Patient #7: The patient was admitted with malignant neoplasm of the tongue and the record demonstrated that the tumor was enlarging. He also had a trach. There was not evidence of goals and interventions related to respiratory or the trach. In addition, there was not evidence of goals and interventions related to the spiritual well being or the psycho-social well being of the patient/family. Patient #9: The record indicated that the patient was admitted on 1/26/21, however, the POC was not developed until 2/9/21. In addition, there was not evidence of goals and interventions related to the spiritual well being or the psycho-social well being of the patient/family. Patient #10: The patient was admitted with Heart Failure Unspecified. The record indicated that the patient was SOB with minimal exertion, had a lung mass, history of pneumonia, atrial fib, pacemaker, Diabetes, and cellulitis of her lower extremities There was not evidence of care plan problems related to cardiac, respiratory, or the cellulitis. The only recognized problems were mobility and ADL. Also, there was not evidence of goals and interventions related to the spiritual well being or the psycho-social well being of the patient/family. Patient #11: There was not evidence of goals and interventions related to the spiritual well being on the patient/family. Patient #12: The record indicated that the patient was admitted on 1/18/21, however, the plan of care was developed until 1/26/21. Patient #13: The patient was admitted with moderate protein calorie malnutrition. There was not evidence of goals and interventions related to nutrition and diet.

Upon patient record review, 1 of 14 records (Patient #12) 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: Patient #12: The visit frequency for the social worker and the spiritual was for an initial visit then prn. There was not evidence of a quantified number of prn visits.

Upon patient record review, 6 of 14 records (Patient #2,#5,#6,#7,#8,#14) 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 #2: The order indicated Miralax powder 17 GM daily as needed for constipation. There was not evidence of a diluent. Patient #5: The was no evidence of orders for any medication/treatments. Patient #6: The record indicated Nystatin powder 100,000u topical to fungal infection. There was not evidence of a specific location. Patient #7: The record, including the certification of terminal illness indicated that the patient had a stage 2 pressure wound on her coccyx. There was not evidence of orders for wound care. In addition, the patient had a diagnosis of malignant neoplasm of the tongue and his main source of food was feedings through a G-tube. There was not evidence of an order for the tube feedings or a diet in the plan of care. In addition, the record indicated that the patient had a trach. There was not evidence of orders surrounding the care of the trach. Patient #8: The record indicated an order for a Stage 2 pressure wound on the patient's buttocks dated 5/25 to cleanse wound with wound cleanser, pat dry and cover with 4x4 bordered foam dressing. There was not evidence of a frequency. Also, the record indicated that the patient was on Tylenol 325 mg, 2 tabs q12h (scheduled) and Acetaminophen 650 rectal supp q6h as needed for fever. There was not evidence of a maximum allowable dose/24h. Patient #14: There was not evidence of a plan of care. In addition, an order indicated Miralax powder 17 GM daily as needed for constipation. There was not evidence of a diluent.

Upon patient record review, 4 of 14 records (Patient #7,#10,#11,#12) 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 #7: The patient had a trach and a G-tube. There was not evidence that equipment and supply needs were ordered on the plan of care. Patient #10: The assessment indicated that the patient had a walker and needed an oxygen concentrator, an E tank a bed and an overbed table. There was not evidence that equipment was included in the plan of care. Patient #11: The record indicated that the patient had a cane. There was not evidence that this was in the plan of care. Patient #12: The record indicated that the patient used a cane, a walker and a wheelchair. There was not evidence that this was in the plan of care.

Upon patient record review, 4 of 14 records (Patient #1,#3,#7,#9) 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#1: The record indicated that the patient went to respite for 5 days on 8/3/21 and 5 days on 10/12/21. There was not evidence that the plan of car was revised to include the respite stay. Patient #3: The nurse documentation on 8/30/21 indicated that the patient was declining. The patient was becoming confused and forgetful, had increased fluid retention and a hospital bed was ordered. There was not evidence that the care plan was revised to include imminence of death or any updates related to this change in status. Patient #7: The patient was admitted in a progressive decline and minimally responsive. There was not evidence of imminence of death in the care plan or any other updates related to this change in status. Patient #9: The documentation dated 5/21 indicated that the patient was disoriented and unable to make needs known. She was in bed, she had a fall, she was incontinent, had a decreased appetite, required max assist. The caregiver stated that she had not had to administer the prn Haldol past week. There was not evidence that imminence of death was added to care plan or any updates related to this change in status.

Upon client record review, 13 of 14 records (Patient #1,#2,#3,#4,#5,#6,#8,#9,#10,#11,#12,#13,#14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The record indicated that the patient was admitted on 4/8/21. There was not evidence that the plan of care was developed until 4/14/21. There were no orders/interventions for the care provided during these dates. In addition, upon development of the plan of care the spiritual care and social work visit frequencies was 1x/month and 1 prn. There was not evidence of a visit by the spiritual care counselor after 11/30/21 and no evidence of a visit by the social worker after 6/28/21. Patient #2: The record indicated that the patient was admitted on 5/29/21. There was not evidence that the plan of care was developed until 6/8/21. There were no orders/interventions for the care provided during these dates. Patient #3: The record indicated that the patient was admitted on 5/22/21. There was not evidence that the plan of care was developed until 6/8/21. There were no orders/interventions for the care provided during these dates. In addition, when the plan of care was established there was not evidence of a visit frequency for the spiritual care or the social worker. The record indicated that the spiritual care counselor conducted visits on 5/25/21, 6/17/21, and 6/21/21, and the social worker conducted visits on 6/18/21, 7/12/21, 7/26/21, and 8/9/21. Also, the nurse visit frequency was ordered on 7/20/21 at 1x/week and 3prn/week. The record indicated routine visits on 7/12/21, 7/14/21, 7/16/21 and no evidence of visits between 8/30/21 and 9/10/21. Patient #4: The record indicated that the patient was admitted on 7/29/21. There was not evidence that the plan of care was developed until 8/4/21. There were no orders/interventions for the care provided during these dates. Patient #5,#14: Care provided by staff was done without orders as there was no evidence of a plan of care or orders for these records. Patient #6: The social work visit frequency was 1x/week and 2 prn. The record indicated that the social worker conducted an assessment on 3/4/21 and visits on 4/6/21 and 5/23/21. Patient #8: The patient was admitted on 5/7/21. There was not evidence that the plan of care was developed until 5/11/21. There were no orders/interventions for the care provided during these dates. Patient #9: The record indicated that the patient was admitted on 1/26/21. There was not evidence that the plan of care was developed until 2/9/21. There were no orders/interventions for the care provided during these dates. The visit frequency for the skilled nurse was not ordered until 3/3/21 however the nurse was conducting visits 3x/week. Patient #10: The social worker and spiritual care counselor visit frequency was 1x/month and 1 prn. There was not evidence of visits by either discipline after the initial assessments which were conducted on 3/19/21 by the social worker and 3/18/21 by the spiritual care counselor. Patient #11: The patient was admitted on 12/11/20. There was not evidence that the plan of care was developed until 12/15/20. There were no orders/interventions for the care provided during these dates. In addition, the social work and spiritual care frequency was 1x/month and 2 prn. There was not evidence of a visit by the spiritual care counselor during the month of February and the social worker did not conduct any visits after the initial on 12/15/20. Patient #12: The record indicated that the patient was admitted on 1/18/21. There was not evidence that the plan of care was developed until 1/26/21. There were no orders/interventions for the care provided during these dates. Patient #13: The visit frequency for the social worker and the spiritual care counselor was prn. The record indicated a scheduled visit on 1/2 by the spiritual care counselor and scheduled visits by the social worker on 10/29/20, 11/30/20 and 1/27/21.

Upon patient record review, 1 of 14 records (Patient #12) did not have evidence that Social work services are based on the patient's psychosocial assessment and the patient/family's needs and acceptance of these services. Patient #12: The nurse documentation from the initial assessment indicated that the patient will need extensive assistance from the social worker for resources. There was not evidence of follow-up by the social worker until 2/27/21 (with only a phone call).

Upon patient record review, 3 of 3 applicable records (Patient #3,#4,#9) did not have evidence the hospice offers bereavement counseling. Patient #3,#4,#9: There was not evidence of bereavement follow-up post death (including an updated risk assessment, evidence bereavement services were offered, a plan of care, activities).

Upon patient record review, 4 of 10 applicable records (Patient #1,#4,#10,#12) did not have evidence in the patient record that hospice aide assignments and duties include the task to be provided and the frequency of those tasks. Patient #1: The record indicated that the patient was started on Eliquis 5mg, 1/2 tab daily (date 6/16/21). There was not evidence that bleeding precautions were added to the aide plan of care. Patient #4: The nurse documentation dated 8/3/21indicated that the patient was less responsive, was unresponsive to verbal stimuli and was a total assistance with all ADL's. The aide care plan indicated for a shower, and the record did not indicate a care plan revision for the type of bath. For the date of 8/3/21, the aide indicated that a shower was provided. Patient #10: The record indicated that the patient was on Coumadin 7.5 mg daily. There was not evidence that bleeding precautions were added to the aide plan of care. Patient #12: The record indicated that the patient was started on Eliquis 5mg BID. There was not evidence that bleeding precautions were added to the aide plan of care.

Upon patient record review 2 of 10 applicable records (Patient #5,#12) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #5: The record indicated that the aide visited and provided care 3x/week. There was not evidence of an aide visit frequency. Patient #12: The aide plan of care indicated for a shower. For the date of 2/4/21, the aide documented that she gave a bed bath because the patient was weak. There was not evidence that the nurse was notified. In addition, the aide visit frequency was discontinues on 2/9/21 and was not reordered. The record indicated that the aide provided visits 2x/week starting 3/1/21.

Upon patient record review, 1 of 14 records (Patient #2) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. Patient #2: There was not evidence of a certification of terminal illness.

Upon patient record review, 1 of 7 applicable records (Patient #2) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #2: There was not evidence of a narrative for the third certification period (7/28/21-9/25/21). The area for the narrative indicated, 'as above.'

Upon patient client record review, 6 of 14 records (Patient #1,#4,#6,#7,#12,#14) did not have evidence that each patient record contains a signed election statement in accordance with 418.24. Patient #1: The record 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. Patient #4: The benefit election statement contains an area to indicate what date the hospice services are to begin. The day was written over several times and it could not be determined the actual date that the patient/representative indicated. Patient #6: There was not evidence that the agency offered to furnish the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs.” Patient #7, #12: There was not evidence of the Benefit Election Statement (or any legal admission paperwork). Patient #14: There was not evidence that the name of the chosen hospice was included on the election statement and there was not evidence of a date in which the care was to begin.

Upon patient client record review, 2 of 14 records (Patient #2,#12) did not evidence that each patient record contains physician orders. Patient #2: The patient was discharged for extended prognosis. There was not evidence of a discharge order by the medical director. Patient #12: The record indicated that the patient was discharged due to hospitalization. There was not evidence of a discharge order.

Upon patient client record review, 1 of 14 records (Patient #2) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #2: The patient was admitted with a diagnosis of unspecified protein calorie malnutrition. There was multiple times were the nurse documented a primary diagnosis of COPD.

Upon client record review, 1 of 3 applicable records (Patient #14) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. The record indicated that the patient was transferred to another hospice.

Upon client record review, 1 of 4 applicable records (Patient #11) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested

Upon client record review, 4 of 4 applicable records (Patient #5,#10,#11,#13) did not have evidence that the discharge summary includes all required information. There was not evidence that the summary included: • A summary of the patient's stay, including treatments, symptoms and pain management • The patient's current plan of care • The patient's latest physician orders • Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility • The date and reason for discharge • Any instructions or referral information given to the patient or family • Patient identifying information • Patient's physician • Hospice diagnosis • Significant health history • Discharge orders, instructions, medication profile and allergies, if discharge is other than patient death • A brief description of services provided and ongoing needs that cannot be met • Status of patient at the time of discharge • Presence of Advance Directives • End of life decisions • Any third party revocation or termination • Any other additional information provided to the receiving organization

Upon client record review, 2 of 14 records (Patient #7,#12) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed.