Every finding on record at Avid Hospice, Inc.

Observed in Emergency Management Session. It was found on review of the Emergency Management Plan that documentation of how staff will be identified during the emergency was not documented in the Emergency Plan. This was verified with the QI Director and DPCS.

Observed in Individual Tracer. In 2 of 3 home visits conducted, It was observed on HV#1 and HV#2 that the nurse did not perform a compete medication reconciliation. On HV#1 the nurse checked the medications that were in a plastic box on the table however there were other over the counter meds that she did not inquire about. Patient has been on service since September and caregiver stated she gives them to the patient. This was discussed with the DON and Alt. Administrator. On HV#2 again the nurse checked the medications sitting on the counter where the caregiver stated she gave these medications. Also sitting on the counter were Vitamin D Vitamin C and Biotin. These medications were not on the medication profile. This was verified with the DPCS who was on the visit.

Observed in Tracer Visit. In 2 of 3 home visits conducted, It was found on 2 of 3 home visits, HV#1 and HV#3 that the staff were not following organization P&P to clean equipment used on patient s with 70% alcohol. On HV#1 the nurse was using Wet Wipes. On HV#3 the nurse was using Clorox wipes. THis was verified with the DPCS who was on the visits.

Observed in Tracer Visit. The bereavement program for 2020 and 2021 could not be evaluated. Organization stated there were no deaths in 2021 and bereavement data for 2020 was not available. Organization also stated that there has been one death in 2022 which was 11/15/22. Interviewed new Coordinator as of 8/2022 and verbalized a program going forward.

Observed in HR File Review. It was found on review of in-service sign in sheets that the HHA as of 11/18/2022 only had 7 hours of education. This was verified with the DPCS.

Observed in Document Review. During review of the Volunteer program, there was no documentation to validate efforts had been made to recruit volunteers. In discussion with the Volunteer Coordinator, recruitment efforts are conducted; however, these efforts are not being documented.

Observed in Tracer Activities. It was found on review of the contract for GIP and Respite services that the contract was outdated. The organization had transferred ownership in 2021 and the contracts were signed by the previous CEO and the license for the facility had expired. This was verified with the business office manger.

Observed in Individual Tracer. In 2 of 3 home visits conducted, It was found on HV#1 and on HV#2 that the current medication profile was incorrect. On HV#1 the nurse checked the medications that were in a plastic box on the table however there were other over the counter meds that she did not inquire about. Patient has been on service since September and caregiver stated she gives them to the patient. The medications were over the counter, Tylenol, Magnesium, cranberry. On HV#2 While the nurse was performing medication reconciliation there were three other over the counter medications on the counter that were not on the medication profile. They were Biotin, Vitamin D and Vitamin C. This was verified with the nurse and the DPCS.

Observed in Individual Tracer. In 2 of 3 home visits conducted, It was found in review of the patient folder in the home on 2 of 3 patients visited that there was no documentation as to the patients code status. On HV#2 there was no documentation in the home as to the DNR status of the patient. The surveyor asked the nurse and the caregiver if patient was a DNR and they both stated they did not know. On Hv#3 there was no documentation in the home folder if the patient was a DNR. Nurse supervisor, DPCS was also not aware of code status of the patient..