Every finding on record at Avon Hospice Care, Inc.

Observed in Document Review. During review of the Admission Paperwork and Patient Education, the nurse surveyor noted that prior to providing care, the organization did not inform the patient in writing regarding their financial responsibility or that their insurance would be billed for services. Findings were discussed with the Assistant Administrator and the DPCS.

Observed in Record Review. In 2 of 10 patient records reviewed, for active patients, it was noted by the nurse surveyor that the bereavement risk assessment was not completed as part of the comprehensive assessment. For RRNHV#1, and RRNHV#7 there was no documented Bereavement Risk Assessment by any member of the Interdisciplinary Team. Finding was discussed and verified with the Assistant Administrator and the DPCS.

Observed in Record Review. In 1 of 10 patient records reviewed, for active patients, it was noted by the nurse surveyor that for RRNHV#1 the RN did not visit the hospice patient no less than 15 days to conduct an assessment. There were 16 days between RN assessments. An LPN had seen the patient in between. Finding was verified by the Assistant Administrator and the DPCS.

Observed in Record Review. In 1 of 10 patient records reviewed, for active patients, it was noted by the nurse surveyor that the spiritual risk assessment was not completed as part of the comprehensive assessment. For RRNHV#5 there was no documented Spiritual Assessment by any member of the Interdisciplinary Team. Finding was discussed and verified with the Assistant Administrator and the DPCS.

Observed in Record Review. In 1 of 6 patient records reviewed, for active patients with the hospice aide, it was noted by the nurse surveyor that hospice aide supervisory visits were not documented no less frequently than every fourteen days. For RRNHV#1, hospice aide supervisory visits were two days late (sixteen days between supervisory visits). Finding was verified with the Assistant Administrator and the DPCS.

Observed in Tracer Activities. It was noted by the nurse surveyor during the Volunteer Program Review that there was no documentation to support recruitment and retention activities. Findings were discussed with the Assistant Administrator/Volunteer Coordinator as she was unaware that recruitment and retention activities were supposed to be tracked and documented.

Observed in Leadership Session. the surveyor noted during review of the governing body minutes for 2021, 2022, and 2023 that the governing body minutes did not reflect approval of the frequency and detail of the data collection for the quality assessment and improvement program..

Observed in Leadership Session. during review of the governing minutes and documents related to the QAPI program and further confirmed in discussion with the leadership team the agency had not conducted a program evaluation for 2021 and had not finalized the program evaluation for 2022 as the first quarter of 2023. This was verified with the Alternate Agency Administrator.

Observed in Individual Tracer. In 1 of 2 patient records reviewed, the bereavement coordinator did not ensure that bereavement services reflected the needs of the bereaved. During review of the BR#2 record the post bereavement assessment indicated that the survivor was at moderate risk due to extreme dependency, sense of hopelessness, multiple losses prior to this of a father and sibling, and exhaustion. The care plan options for moderate risk included increased frequency of telephone calls which the coordinator did not choose. The coordinator contacted the bereaved at six months at which time the bereaved stated that it has been a struggle for him over the past four or five months. During the surveyor's interview with the Bereavement Counselor the counselor stated that the bereaved may have benefitted from earlier contact.