Ava Hospice Care Inc.

“Based on record review, interviews, and policy review the Hospice agency failed to ensure pain was adequately addressed for one of 15 sampled patients (Patient (P)5) and wound care was addressed for two of 15 sampled patients (P3 and P5). The failure to manage pain and symptoms promptly and effectively has the potential to have an impact on the hospice experience for both the patient and family/caregiver.Findings include: 1. Review of P5’s Start of Care (SOC) “POC/IDG [Plan of Care (POC)/Interdisciplinary Group (IDG)] Review” located in the “POC” tab in the electronic medical record (EMR) dated 01/08/26, revealed, “admitted to hospice care with primary diagnosis of senile degeneration of the brain and diabetes mellitus … Inspection of the right foot revealed necrosis [death of body tissue] affecting approximately 50% [percent] of the area. The affected tissue has a foul odor and is tender upon manipulation.” Review of the patient goals in the POC revealed, “Goal: Bring down pain to < [less than] 3” The POC did not include interventions for wound care.Review of P5’s “Discharge Summary” located in the “Discharge” tab in the EMR dated 01/23/26 revealed, “Pt. [patient] goals were partially met as evidenced by comfortable [sic] during care … patient is transferred to another hospice per family request.”Telephone interview with P5’s Power of Attorney (POA) on 04/01/26 at 10:00 AM, revealed the POA called the hospice agency because P5 was “screaming” due to experiencing abdominal pain. The POA thought it might be related to the ordered twice a day morphine and was concerned because P5 had a history of abdominal bleed in the past. The POA stated the agency told the POA P5 was probably constipated and to give as needed (PRN) medication for constipation. The POA stated a nurse did not come out to assess P5 after the phone call to the agency. The POA had previously requested evening hospice aide services to assist with transferring P5 to bed. The POA stated that on two occasions hospice aides arrived before the requested time and when told what was needed stated they could not accommodate the request because they were not available at that time. The POA called the Veterans Administration (VA) asking for a transfer to another hospice.During an interview on 04/01/26 at 1:45 PM, when asked why a complaint was not completed for P5, Case Manager (CM)2 stated, “I didn’t think it was a complaint but rather the family had unrealistic expectations and didn’t understand the patient was just constipated.” CM2 confirmed the agency was not providing wound care or a wound care specialist consulted. On 04/01/26 at 4:15 PM, CM2 produced a form labelled “Complaints and Grievances Report Log Year 2026.” The form had columns labelled, “Problem, Type of Incident, Date/Time of Incident, Location, Reported To, Action Taken, and Outcome.” The form did not identify a patient name in any of the columns. Only four lines are completed, and it is possible to discern that the four “incidents” involve P5. The four incidents show the following:1. 01/09/26 “Refused CNA … Action Taken … Replaced CNA” 2. 01/10/26 at 10:30 PM “c/o [complaining of] pain … Action Taken …Notified MD with order …Outcome … pt is hallucinating.”3. 01/11/26 at 6:04 PM “uncomfortable due to pain … Hold morphine due to agitation … Outcome … Less agitated.”4. 01/22/26 … “Complains of pain … D/C [discontinue] morphine … Outcome … D/C morphine.”Review of P5’s “Visit Note RN [Registered Nurse]” located in the “Visit Notes” tab in the EMR dated 01/11/26 at 4:00 PM revealed, “Patient states pain was at a 6 [pain scale 1-10] but appeared uncomfortable during time of assessment. Patient receiving morphine and oxycodone for pain … Bowels: Active in all quadrants, ABD [abdomen] soft and non-tender to palpation … Right foot has necrotic tissue present on approximately half of the surface of patient’s foot. Patient reports increased pain during assessment after removing sock from feet to inspect. Foot was malodorous, tender to touch, and skin was black in appearance. Patient requires assistance with transfers due to pain in right foot. Goes from wheelchair to recliner. Care giver requesting for patient’s bed to arrive by the weekend.”Review of P5’s Visit Note RN” located in the “Visit Notes” tab dated 01/22/26 at 10:30 AM, indicated “pain was controlled and report as level 4.” There is no indication in this note that morphine was discontinued. Section labeled “Integumentary – skin” indicated there are no wounds.There are no visit notes indicating that either of the Case Managers (CM1 and CM2) visited P5’s home.2. Review of P3’s POC located in the “POC” tab in the EMR dated 3/13/25 revealed, “Stage 2 sacral pressure ulcer and pressure injuries on both heels.” The POC did not include treatment orders for the sacral pressure ulcer or injuries on both heels.During an interview on 04/01/25, CM2 confirmed there were no orders for wound care to the stage 2 pressure ulcer but stated that booties were applied for the pressure ulcer injuries on both heels. Review of the hospice agency’s policy titled, “Complaint Resolution,” dated June 2019, revealed, “A patient complaint may be formal or informal and in writing or verbal. The complaint may be made by the patient or patient representative … Hospice will investigate complaints made by a patient, patient’s family or guardian regarding treatment or care that is (or fails to be) furnished.”Review of the undated hospice agency’s policy titled, “Hospice Wound Care Policy” revealed, “All wound care must follow the individualized Plan of Care, reflect the patient’s goals and prognosis, and use the least burdensome interventions necessary to manage pain, odor, educate and skin integrity … Care Planning: RN updates the Plan of Care with wound type, goals, dressing orders, frequency, comfort measures, and caregiver involvement.””

“Based on record review and interview, the Hospice agency failed to develop an individualized Plan of Care (POC) for 15 of 15 patients (Patient (P)1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15). This failure had the potential to affect the care and services received by all patients receiving hospice care from the agency. Findings include: 1. Review of P1’s initial “POC/IDG Review” (Plan of Care (POC)/Interdisciplinary Group (IDG)) dated 01/26/26, located in the “POC” tab in the electronic medical record (EMR), revealed a primary diagnosis of malignant neoplasm (cancerous tumor) of the pelvis. Secondary diagnosis included chronic obstructive pulmonary disease (COPD-a progressive lung disease that limits airflow and causes breathing difficulties). Review of P1’s “Discharge Summary” dated 02/01/26, located in the “Discharge” tab in the EMR, revealed P1’s family member called 911 because P1 was having breathing difficulty. P1 was subsequently admitted to the hospital with a diagnosis of pneumonia and discharged from hospice care.Review of P1’s “Orders” on the POC included the following:a. DASH diet (designed to lower blood pressure by restricting certain foods and limiting salt).b. May apply skin barrier cream or ointment daily as needed for skin breakdown prevention.c. Skilled Nurse (SN) may suction as needed.d. Oxygen via nasal cannula at 2 liters per minute for shortness of breath. May titrate up to 5 liters per minute as needed.e. SN visit once per week.f. Social Worker (SW): Initial assessment and as needed.g. Spiritual Counselor (SC): Initial assessment and as needed.h. Volunteer: Offered and declined. 2. Review of P2’s initial POC dated 05/20/25, located in the “POC” tab in the EMR, revealed a diagnosis of COPD. Review of P2’s “Discharge Summary” dated 09/04/25, located in the “Discharge” tab in the EMR, revealed P2 was “Discharged with Cause” after P2 contacted the office requesting discharge and stated, “hospice is not beneficial for me.” The “Discharge Summary” revealed P2 expressed they primarily needed an electric wheelchair and that Medicare conveyed that they would not qualify while receiving hospice care. Review of P2’s “Orders” on the POC included the following:a. DASH dietb. May apply skin barrier cream or ointment daily as needed for skin breakdown prevention.c. SN may suction as needed.d. Oxygen via nasal cannula at 2 liters per minute for shortness of breath. May titrate up to 5 liters per minute as needed.e. SN visit once per week.f. SW: Initial assessment and as needed.g. SC: Initial assessment and as needed.h. Volunteer: Offered and declined.i. Health aide: Three times per week.3. Review of P3’s initial POC dated 03/13/25, located in the “POC” tab in the EMR revealed a diagnosis of atrial fibrillation (a common type of irregular heart rhythm) and a stage two sacral pressure ulcer.Review of P3’s “Visit Notes” section in the EMR revealed P3 died on 10/07/25.Review of P3’s “Orders” on the POC included the following:a. DASH dietb. May apply skin barrier cream or ointment daily as needed for skin breakdown prevention.c. SN may suction as needed.d. Oxygen via nasal cannula at 2 liters per minute for shortness of breath. May titrate up to 5 liters per minute as needed.e. SN visit once per week.f. SW: Initial assessment and as needed.g. SC: Initial assessment and as needed.h. Volunteer: Offered and declined.P3’s POC did not include physician orders for treatment of the stage two pressure ulcer.4. Review of P4’s initial POC dated 01/16/26, located in the “POC” tab in the EMR revealed a diagnosis of malignant neoplasm of bone and cartilage.Review of P4’s “Visit Notes” section in the EMR revealed P4 died on 1/17/26.Review of P4’s “Orders” on the POC included the following:a. DASH dietb. May apply skin barrier cream or ointment daily as needed for skin breakdown prevention.c. SN may suction as needed.d. Oxygen via nasal cannula at 2 liters per minute for shortness of breath. May titrate up to 5 liters per minute as needed.e. SN visit once per week.f. SW: Initial assessment and as needed.g. SC: Initial assessment and as needed.h. Volunteer: Offered and declined.5. Review of P5’s initial POC dated 01/08/26, located in the “POC” tab in the EMR revealed a diagnosis of senile degeneration of brain and diabetes with diabetic peripheral angiopathy with gangrene. Review of the section of the POC labelled “IDG Discussion/Updated Comprehensive Assessment Review” dated 01/08/26, revealed, “Inspection of the right foot revealed necrosis affecting approximately 50% of the area. The affected tissue has a foul odor and is tender to manipulation. The patient has experienced unintentional weight loss greater than 10% over the past several months. Oral intake remains poor due to dysphagia.”Review of P5’s “Discharge Summary” dated 01/23/26, located in the “Discharge” tab in the EMR revealed P5 was transferred to another hospice agency.Review of P5’s “Orders” on the POC included the following:a. DASH dietb. May apply skin barrier cream or ointment daily as needed for skin breakdown prevention.c. SN may suction as needed.d. Oxygen via nasal cannula at 2 liters per minute for shortness of breath. May titrate up to 5 liters per minute as needed.e. SN visit once per week.f. SW: Initial assessment and as needed.g. SC: Initial assessment and as needed.h. Volunteer: Offered and declinedP5’s POC did not include wound care orders or a dysphagia diet.6. Review of P6’s initial POC dated 01/31/26, located in the “POC” tab in the EMR revealed a diagnosis of stage 4 colon cancer.Review of P6’s “Discharge Summary” dated 02/02/26, located in the “Discharge” tab of the EMR revealed “Discharged with Cause.”During an interview on 03/30/26, Case Manager (CM2) stated P6 was discharged because the patient and family decided to seek further treatment.Review of P6’s “Orders” on the POC included the following:a. DASH dietb. May apply skin barrier cream or ointment daily as needed for skin breakdown prevention.c. SN may suction as needed.d. Oxygen via nasal cannula at 2 liters per minute for shortness of breath. May titrate up to 5 liters per minute as needed.e. SN visit once per week.f. SC: Initial assessment and as needed.g. Volunteer: Offered and declined7. Review of P7’s initial POC dated 04/18/25, located in the “POC” tab in the EMR revealed a diagnosis of heart failure, hyperlipidemia (high cholesterol), and essential hypertension.Review of P7’s “Orders” on the POC included the following:a. DASH dietb. May apply skin barrier cream or ointment daily as needed for skin breakdown prevention.c. SN may suction as needed.d. Oxygen via nasal cannula at 2 liters per minute for shortness of breath. May titrate up to 5 liters per minute as needed.e. SN visit once per week.f. SW: Initial assessment and as needed.g. SC: Initial assessment and as needed.h. Volunteer: Offered and declinedi. Health aide: three time per week.8. Review of P8’s initial POC dated 02/26/25, located in the “POC” tab in the EMR revealed a diagnosis of senile degeneration of brain, difficulty walking, and muscle weakness.Review of P8’s “Orders” on the POC included the following:a. DASH dietb. May apply skin barrier cream or ointment daily as needed for skin breakdown prevention.c. SN may suction as needed.d. Oxygen via nasal cannula at 2 liters per minute for shortness of breath. May titrate up to 5 liters per minute as needed.e. SN visit once per week.f. SW: Initial assessment and as needed.g. Health aide: three times per weekh. Volunteer: Offered and declinedi. SC: Initial assessment and as needed.9. Review of P9’s initial POC dated 01/10/25, located in the “POC” tab in the EMR revealed a diagnosis of unspecified dementia, atrial fibrillation, nutritional anemia, and obstructive and reflux uropathy (blockage in the urinary tract preventing normal urine flow.) Review of P9’s “Orders” on the initial POC included the following:a. DASH dietb. May apply skin barrier cream or ointment daily as needed for skin breakdown prevention.c. SN may suction as needed.d. Oxygen via nasal cannula at 2 liters per minute for shortness of breath. May titrate up to 5 liters per minute as needed.e. SN visit once per week.f. SW: Initial assessment and as needed.g. Health aide: three times per weekh. Volunteer: Offered and declinedi. SC: Initial assessment and as needed.The POC did include foley catheter orders in addition to the above.10 Review of P10’s initial POC dated 01/05/26, located in the “POC” tab in the EMR revealed diagnosis of atherosclerotic heart disease (progressive condition caused by buildup of fats, cholesterol, and plaque in the lining of arteries) and hypertension.Review of P10’s “Orders” on the initial POC included the following:a. DASH dietb. May apply skin barrier cream or ointment daily as needed for skin breakdown prevention.c. SN may suction as needed.d. Oxygen via nasal cannula at 2 liters per minute for shortness of breath. May titrate up to 5 liters per minute as needed.e. SN visit once per week.f. SW: Initial assessment and as needed.g. Volunteer: Offered and declinedh. SC: Initial assessment and as needed.11. Review of P11’s initial POC dated 02/05/26, located in the “POC” tab in the EMR, revealed a diagnosis of Parkinsons disease.Review of P11’s “Orders” on the initial POC included the following:a. DASH dietb. May apply skin barrier cream or ointment daily as needed for skin breakdown prevention.c. SN may suction as needed.d. Oxygen via nasal cannula at 2 liters per minute for shortness of breath. May titrate up to 5 liters per minute as needed.e. SN visit once per week.f. SW: Initial assessment and as needed.g. Volunteer: Offered and declinedh. SC: Initial assessment and as needed.i. Health aides: three times a week.12. Review of P12’s initial POC dated 03/19/26, located in the “POC” tab in the EMR, revealed a diagnosis of COPD.Review of P12’s “Orders” on the initial POC included the following:a. DASH dietb. May apply skin barrier cream or ointment daily as needed for skin breakdown prevention.c. SN may suction as needed.d. Oxygen via nasal cannula at 2 liters per minute for shortness of breath. May titrate up to 5 liters per minute as needed.e. SN visit once per week.f. SW: Initial assessment and as needed.g. Volunteer: Offered and declinedh. SC: Initial assessment and as needed.i. Health aide: three times a week.13. Review of P13’s initial POC dated 02/23/34, located in the “POC” tab in the EMR, revealed a diagnosis of COPD and dementia. Review of P13’s “Orders” on the initial POC included the following:a. DASH dietb. May apply skin barrier cream or ointment daily as needed for skin breakdown prevention.c. SN may suction as needed.d. Oxygen via nasal cannula at 2 liters per minute for shortness of breath. May titrate up to 5 liters per minute as needed.e. SN visit once per week.f. SW: Initial assessment and as needed.g. Volunteer: Offered and declinedh. SC: Initial assessment and as needed.i. Health aide: three times a week.14. Review of P14’s initial POC dated 08/04/25, located in the “POC” tab in the EMR, revealed a diagnosis of COPD and acute respiratory failure.Review of P14’s “Orders” on the initial POC included the following:a. DASH dietb. May apply skin barrier cream or ointment daily as needed for skin breakdown prevention.c. SN may suction as needed.d. Oxygen via nasal cannula at 2 liters per minute for shortness of breath. May titrate up to 5 liters per minute as needed.e. SN visit once per week.f. SW: Initial assessment and as needed.g. Volunteer: Offered and declinedh. SC: Initial assessment and as needed.15. Review of P15’s initial POC dated 02/01/26, located in the “POC” tab in the EMR, revealed a diagnosis of hypertensive heart disease with heart failure and atrial fibrillation.Review of P15’s “Discharge” documentation dated 02/25/26, revealed P15 with discharged with noncompliance with required interventions.Review of P15’s “Orders” on the initial POC included the following:a. DASH dietb. May apply skin barrier cream or ointment daily as needed for skin breakdown prevention.c. SN may suction as needed.d. Oxygen via nasal cannula at 2 liters per minute for shortness of breath. May titrate up to 5 liters per minute as needed.e. SN visit once per week.f. SW: Initial assessment and as needed.g. Volunteer: Offered and declinedh. SC: Initial assessment and as needed.During chart reviews noted that SC and SW consistently visit the patient at the SOC and at recertification. Neither the SC nor SW saw any of the patients at any other time. During an interview on 03/31/26 at 9:45 AM, the SC stated, “Seeing the patients for recertification is just their [the agency] standard.” The SC confirmed that the patient visits were not based on the assessment completed within five days of admission for hospice care but that it was the agency’s standard practice for the SC to visit on admit and at recertification.During an interview on 04/01/26 at 2:30 PM, the Director of Nursing (DON) generated the POCs and stated, “they are mostly generated from the initial nursing assessment”. The DON agreed that the POCs were not individualized and stated the POCs tend to have much of the same wording. The DON stated it was not required to have nursing visits based on the individual assessment of the patients’ needs because the nurses were assigned one-time a week visits and the as needed visits would cover any other visits the patient might need. When asked about the SC and SW only seeing patients at the start of care and at recertification, the DON stated, “that’s how it works out.” Review of the hospice agency’s policy titled, “IDG Care Planning Process,” dated January 2020, revealed, “The Hospice IDG develops a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs … The IDG works together to meet the physical, medical, psychosocial, emotional and spiritual needs of the hospice patients and families facing terminal illness and bereavement … All care and services furnished to patients and their families follows an individualized written plan of care established by the IDG in collaboration with the attending physician (if any), the patient or representative and the primary caregiver in accordance with the patient’s needs.””