Amavi Hospice and Palliative Care, LLC

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. 2 of 14 (14%) clinical records reviewed revealed that the agency did not ensure the initial comprehensive assessments were completed within five (5) calendar days after the election of hospice care. CLINICAL RECORD 1: The hospice benefit was elected on 04/06/2025. The clinical record lacked evidence of a psychosocial initial assessment no later than five (5) days after the election of hospice services. The initial nursing assessment was dated 04/06/2025, the initial psychosocial assessment was dated 04/12/2025 (6 days), and spiritual care was declined by the family on 04/06/2025. CLINICAL RECORD 8: The hospice benefit was elected on 04/23/2025. The clinical record lacked evidence of an initial spiritual assessment no later than five (5) days after the election of hospice services. The initial nursing assessment was dated 04/23/2025, the initial psychosocial assessment was dated 04/25/2025, and the initial spiritual assessment was completed on 04/29/2025 (6 days). During an interview with the Administrator (PERSONNEL RECORD 5) on 11/05/2025 she stated that they have done some education to the staff about documenting if the initial assessment visit is moved outside of the 5-day window. Specifically, if the patient/family/caregiver requests that the initial assessment is scheduled outside of the 5-day window, it is documented; those two must have just fallen through. However, they will be doing some additional education to remind the clinical staff of the process.”

“It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. 1 of 14 (7%) clinical records reviewed of patients that elected the hospice benefit revealed that the agency did not ensure that the initial bereavement assessment was completed as part of the initial comprehensive assessment and incorporated into the plan of care. CLINICAL RECORD 13: The hospice benefit was elected by the patient on 04/11/2025. The clinical record lacked evidence that an initial bereavement assessment was completed as part of the initial comprehensive assessment and incorporated into the plan of care. The initial nursing assessment was completed on 04/11/2025, the initial social work assessment was completed on 04/12/2025, spiritual services were declined on 04/11/2025, and the initial bereavement risk assessment was completed on 05/06/2025. During an interview with the Administrator/Bereavement Coordinator (PERSONNEL RECORD 5) on 11/05/2025 she stated she realized it had not been done as part of the initial comprehensive assessment and completed it as soon as it was identified. Also, she stated they have been working on the process and completing the initial bereavement risk assessment in a timely manner.”

“It is required that the documented number and scope of performance improvement projects conducted annually represent the needs of the hospice population served; represent the internal needs of the organization; and reflect the scope, complexity, and past performance of the hospice’s services and operations. This standard was not met as evidenced by document review and interview. Review of the QAPI program and activities revealed that the agency did not ensure that performance improvement projects were developed, implemented, or evaluated. There were no performance improvement projects documented in the agency evaluation for 2024 or 2023 and no current performance improvement projects in evidence. During an interview with the Administrator (PERSONNEL RECORD 4) on 11/05/2025, she stated that that she thought that they did have some performance improvement projects but they just switched out their binder to streamline its contents, however she does not know what happened to the performance improvement projects that she thought were present.”

“It is required that the documented number and scope of performance improvement projects conducted annually represent the needs of the hospice population served; represent the internal needs of the organization; and reflect the scope, complexity, and past performance of the hospice’s services and operations. Documentation of selected PI projects include: the reason for conducting the projects and measurable progress achieved. This standard was not met as evidenced by document review and interview. Review of the QAPI program and activities revealed that the agency did not ensure that performance improvement projects were documented inclusive of the reason for conducting the projects and measurable progress achieved. There were no performance improvement projects documented in the agency evaluation for 2024 or 2023 and no current performance improvement projects in evidence. During an interview with the Administrator (PERSONNEL RECORD 4) on 11/05/2025, she stated that that she thought that they did have some performance improvement projects but they just switched out their binder to streamline its contents, however she does not know what happened to the performance improvement projects that she thought were documented.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. 1 of 2 (50%) clinical records reviewed for patients that have been discharged revealed that the agency did not ensure that the attending physician was sent a copy of the hospice discharge summary. CLINICAL RECORD 14: The patient elected the hospice benefit on 03/29/2025 and transferred to another hospice on 05/01/2025. The clinical record review was absent evidence of the discharge summary being sent to the attending physician after discharge. During an interview with the Administrator (PERSONNEL RECORD 5) on 11/05/2025 she stated that she thought sending the information to the accepting agency was all that was required, but that she would do some education with the staff and they would send the discharge summary to the attending physician with all discharges.”