Amavi Home Health and Hospice Care Services, Inc.

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over the counter (OTC) drugs, supplements, herbal remedies and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 3 (67%) home visit observations, the agency did not ensure medications were reviewed and the drug profiled was updated. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 11/11/2023 for the diagnosis of senile degeneration of the brain. During the home visit observation, medications were reconciled between the medication list from the nursing facility and the hospice medication profile. The facility list contained the following medications not listed in the hospice medication profile: Melatonin 5 mg, ordered 08/18/2023; Seroquel 25 mg, ordered 08/28/2023, and Carafate 1 gram, ordered 11/10/2023. Clinical Record 2/Home Visit 2: The patient elected the hospice benefit on 09/21/2023 for the diagnosis of Parkinson’s disease. During the home visit observation, medications were reconciled between the medication list from the nursing facility and the hospice medication profile. The facility list contained the following medications not listed in the hospice medication profile: Docusate 100 mg, ordered 09/22/2023. The facility list did not contain the following medications from the hospice medication profile: Ativan 1 mg, ordered 10/3/2023 and Melatonin 3 mg, ordered 03/22/2024. During an interview and joint record review on 04/10/2024, the Administrator/President and the Director of Patient Care Services confirmed the medication lists from the facility and the hospice had not been reconciled.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient’s condition requires. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the individualized plan of care was reviewed, revised, and updated as frequently as the patient’s condition required. Clinical Record 4: The patient elected the hospice benefit on 12/08/2023 for the diagnosis of Huntington’s disease. The problem, interventions, and goals for the patient “imminently dying” were added to the plan of care on 12/11/2023. The clinical record was reviewed on 04/10/2024 and did not include documentation that the patient’s status was imminently dying. The plan of care had not been updated to reflect the patient’s change in status. During an interview and joint record review on 04/10/2024, the Administrator/President and the Director of Patient Care Services stated that when the patient was admitted they believed the patient to be imminently dying but the plan of care had not been updated when the patient’s condition stabilized.”

“It is required that the hospice provides spiritual counseling. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed with spiritual counseling services provided, the agency did not ensure that spiritual counseling services were provided as ordered on the plan of care based on the patient and family beliefs and acceptance of services. Clinical Record 1: The patient elected the hospice benefit on 11/11/2023 for the diagnosis of senile degeneration of the brain. The Spiritual Counselor documented on the initial visit note dated 11/13/2023 “Spoke to patient’s daughter and [patient] requested I visit patient as often as possible, and [patient] is VERY religious.” The plan of care included an order for spiritual care visit frequency of twice a month starting in November 2023. A spiritual care visit was documented on 01/02/2024 and the next spiritual care visit was dated 03/12/2024. There has not been another spiritual care visit documented since 03/12/2024, as of the date of record review on 04/10/2024. The clinical record lacked documentation of missed spiritual care visits for a January 2024 visit, 2 visits for February 2024, and a missed visit for March 2024. During an interview and joint record review on 04/10/2024, the Administrator/President and the Director of Patient Care Services confirmed the plan of care had orders for twice monthly visit frequency and an order to discontinue the visits had not been written. The clinical record did not include reasons for the missed visits.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN (Registered Nurse) who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 13 (15%) clinical records reviewed with aide services provided, the agency did not ensure the hospice Registered Nurse provided the Hospice Aide with patient specific written instructions. Clinical Record 13: The patient elected the hospice benefit on 09/26/2023 for the diagnosis of acute on chronic respiratory failure. The initial nursing assessment dated 09/26/2023 identified a “Stage II pressure ulcer on the right elbow covered with foam dressing.” The hospice aide care plan dated 09/26/2023 assigned the aide the tasks of bed bath and dressing the patient. The aide care plan did not notify the aide of the wound and did not provide the aide with instructions on how to care for the wound/wound dressing while providing the assigned tasks of bed bath and dressing the patient. Clinical Record 14: The patient elected the hospice benefit on 06/12/2023 for the diagnosis of chronic obstructive pulmonary disease. The comprehensive nursing assessment dated 07/24/2023 included documentation of a “wound on the coccyx covered with 4x4 Mepilex.” The hospice aide care plan dated 07/26/2023 assigned the aide the tasks of bed bath and peri care. The aide care plan did not notify the aide of the wound and did not provide the aide with instructions on how to care for the wound/wound dressing while providing the bed bath and peri care. During an interview and joint record review on 04/10/2024, the Administrator/President and the Director of Patient Care Services confirmed the hospice aide care plans did not contain notification of the wounds or specific instructions for the aide.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review, observation, and interview. In 3 of 13 (23%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Hospice Aide followed the plan of care. Clinical Record 2/Home Visit 2: The patient elected the hospice benefit on 09/21/2023 for the diagnosis of Parkinson’s disease. The aide care plan dated 09/21/2023 assigned the aide the tasks of bathing the patient in a shower chair and peri care. During the home visit observation with the Hospice Aide (staff 7), the aide was observed to provide a bed bath, shampoo, and changing the patient’s linens. The aide care plan did not assign the tasks of shampoo and changing linens and the bath type assigned was shower with a shower chair. The Hospice Aide did not provide cares as ordered on the aide care plan. Clinical Record 7: The patient elected the hospice benefit on 03/14/2024 for the diagnosis of senile degeneration of the brain. The hospice aide care plan dated 03/14/2024 assigned the aide the tasks of bed bath and shampoo. The Hospice Aide documented on the aide visit note dated 03/29/2024 the task of bed bath and shampoo were not checked off as completed. The Hospice Aide did not provide care as ordered on the aide care plan. Clinical Record 10: The patient elected the hospice benefit on 02/06/2024 for the diagnosis of senile degeneration of the brain. The aide care plan dated 02/06/2024 assigned the aide the tasks of shower with shower chair, dress, and shampoo. The Hospice Aide documented on the aide visit note dated 02/09/2024 the tasks of shower chair, shampoo, and dress were not checked off as completed. The Hospice Aide did not provide care as ordered on the aide care plan. During an interview and joint record review on 04/10/2024, the Administrator/President and the Director of Patient Care Services confirmed the aide had not completed the tasks as assigned in the aide care plans.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 3 of 13 (23%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Hospice Aide reported changes to the Registered Nurse. Clinical Record 1: The patient elected the hospice benefit on 11/11/2023 for the diagnosis of senile degeneration of the brain. The aide care plan dated 11/11/2023 assigned the aide the tasks of showering and peri care. The Hospice Aide documented on the aide visit note date 03/19/2024 “Patient had been cleaned already” and the tasks were not checked off as being completed. The Hospice Aide documented on the aide visit note dated 03/21/2024 “Patient declined visit” and the tasks were not checked off as being completed. Clinical record review revealed no documented evidence that the Hospice Aide reported tasks not completed to the Registered Nurse. Clinical Record 3: The patient elected the hospice benefit on 03/06/2024 for the diagnosis of malignant neoplasm of the bronchus or lung. The aide care plan dated 03/06/2024 assigned the aide the tasks of showering and shampooing. The Hospice Aide documented on the aide visit note dated 03/13/2024 “Patient declined visit” and the tasks were not checked off as being completed. Clinical record review revealed no documented evidence that the Hospice Aide reported tasks not completed to the Registered Nurse. Clinical Record 12: The patient elected the hospice benefit on 06/05/2023 for the diagnosis of malignant neoplasm of the female breast. The aide care plan dated 06/05/2023 assigned the aide the tasks of shower and shampooing. The Hospice Aide documented on the aide visit note dated 06/14/2023 “Patient refused care today” and the tasks were not checked off as being completed. Clinical record review revealed no documented evidence that the Hospice Aide reported tasks not completed to the Registered Nurse. During an interview and joint record review on 04/10/2024, the Administrator/President and the Director of Patient Care Services confirmed the clinical records did not include documentation that the Hospice Aide reported changes to the Registered Nurse.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, personnel record review, and interview. In 1 of 8 (12%) personnel records reviewed, the agency did not ensure the skills and competencies of individuals providing care were assessed. Agency policy 3-003 Competency Assessment, dated April 2021, stated in part, “The competence of all organization clinical personnel (employed, contract, or volunteer) will be assessed during orientation, during the probationary period, periodically throughout the course of the year, and during the annual performance evaluation. Competency assessments will be completed at least 1 time per year using a competency skills performance checklist.” Personnel Record 1: Hospice Medical Director date of hire 07/07/2022. Personnel record review revealed no documented evidence of competency assessment when the Medical Director provided direct clinical care by completing face-to-face visits. During an interview and joint record review on 04/10/2024, the Administrator/President and the Director of Patient Care Services confirmed the skills and competencies of the Medical Director had not been assessed.”