DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
441545 A. BUILDING __________
B. WING ______________ 		04/20/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
AVALON HOSPICE 2525 PERIMETER PLACE DRIVE, SUITE 105, NASHVILLE, TN, 37214
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0536      
40105 Based on agency policy review, medical record review, and interview, it was determined that the Hospice agency failed to manage wounds by not revising a plan of care to include the need for wound care (refer to L553), not ensuring wounds were measured, not ensuring patients had physician's orders for wound treatments, and not following physician's orders to obtain a wound culture (refer to L556). The cumulative effect of this systemic practice resulted in the agency's inability to ensure that the patient's wounds were assessed and measured to prevent worsening and failed to ensure care plans reflected the need for wound care and the Condition of Participation: Interdisciplinary group, care planning and coordination of services at 418.56 was not met.
L0553      
40105 Based on agency policy review, medical record review, and interview, the agency failed to update a plan of care to reflect the need for wound care for 1 patient (Patient #1) of 6 patients reviewed for wound care. The findings include: Review of the facility policy titled, "The Plan of Care," dated 8/2021, showed "...The plan of care will identify the patient's needs and services to meet those needs...It must state, in detail, the scope and frequency of services needed to meet the patients and family/caregiver's needs, goals, and outcome achievement...Any change in the patient's condition must result in a change in the plan of care, prior to implementation of the new service..." Record review showed Patient #1 was admitted to the agency on 11/23/2021 with diagnoses including Malignant Neoplasm of Sigmoid Colon, Malignant Neoplasm of Bone, Neoplasm Related Pain, Insomnia, and Dehydration. The patient passed away at his home on 12/28/2021. Review of Patient #1's Visit Note Report dated 12/20/2021, showed the patient had bruising and poor skin turgor to the extremities. Continued review showed "...Dressing changed on coccyx. Dressing had small amount of serosang [serosanguinous- drainage that contains blood] drainage. Area has bruising approximately 3" [inch] x [by] 3" with a tiny area of loose skin...mattress topper delivered..." Review of Patient #1's Visit Note Report dated 12/21/2021, showed the patient had poor skin turgor and had "...pulled off his dressing in the night..." Review of Patient #1's Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of Care Update Report dated 12/23/2021, showed no documentation of a wound or the need for wound dressings. During an interview on 4/20/2022 at 9:19 AM, the Regional Director of Clinical Operations confirmed there was no documentation of the wound on the IDG care plan update on 12/24/2021. He further confirmed if the wound had been identified on the 12/24/2021 IDG it could have been assessed, measured, and monitored for worsening. During an interview on 4/19/2022 at 12:55 PM, the Regional Director of Clinical Operations confirmed Patient #1's wound documented on the visit notes for 12/20/2022 and 12/21/2022, had not been added to the patient's plan of care.
L0556      
40105 Based on agency policy review, medical record review, and interview, the agency failed to obtain an order for a wound treatment for 1 patient (Patient #1), failed to obtain wound measurements per policy for 3 patients (Patients #1, #4, and #6), and failed to follow a physician's order to obtain a wound culture for 1 patient (Patient #6) of 6 patients reviewed for wounds. The findings include: Review of the facility policy titled, "Wound Assessment, Documentation and Clinical Oversight," dated 2/2022, showed "...Physician orders will be obtained for all wound treatments...Wound assessments will be performed...no less than once weekly. At least once weekly, the assessment will include wound measurements..." Record review showed Patient #1 was admitted to the agency on 11/23/2021 with diagnoses including Malignant Neoplasm of Sigmoid Colon, Malignant Neoplasm of Bone, Neoplasm Related Pain, Insomnia, and Dehydration. The patient passed away at his home on 12/28/2021. Review of Patient #1's Visit Note Report dated 11/23/2021, showed the patient had no pressure ulcers or wounds identified. Review of Patient #1's Hospice Certification and Plan of Care dated 11/23/2021-2/20/2022, showed "...A nursing plan of care will be established that meets the patients needs..." Review of Patient #1's Visit Note Report dated 11/29/2021, showed no wounds were identified. Review of Patient #1's Visit Note Report dated 12/1/2021, showed no wounds were identified. Review of Patient #1's Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of Care Update Report dated 12/1/2021, showed no documentation of a wound. Review of Patient #1's Visit Note Report dated 12/3/2021, showed no wounds were identified. Review of Patient #1's Visit Note Report dated 12/6/2021, showed no wounds were identified. Review of Patient #1's Supply Requisition Report dated 12/6/2021, showed the patient had been provided 4 inch x 4 inch island dressing (absorbent dressing with an adhesive backing, quantity of 5). Review of a Visit Note Report dated 12/8/2021, showed no wounds were identified. Review of Patient #1's IDG Comprehensive Assessment and Plan of Care Update Report dated 12/10/2021, showed the patient had received new orders since the last IDG meeting for barrier cream. There was no further documentation for the need for the barrier cream. There was no further documentation of location for it to be applied or the need for the island dressings. Review of Patient #1's Supply Requisition Report dated 12/14/2021, showed the patient had been provided optifoam sacral dressing (foam wound dressing that can absorb large amounts of fluid, quantity of 3). Review of Patient #1's Visit Note Report dated 12/15/2021, showed no wounds were identified. Review of Patient #1's Visit Note Report dated 12/20/2021, showed the patient had bruising and poor skin turgor to the extremities. Continued review showed "...Dressing changed on coccyx. Dressing had small amount of serosang [serosanguinous- drainage that contains blood] drainage. Area has bruising approximately 3" [inch] x [by] 3" with a tiny area of loose skin...mattress topper delivered..." There was no further documentation of the type of wound or wound measurements. Review of Patient #1's equipment delivery report dated 12/20/2021, showed the patient was delivered an alternating pressure pad for his bed. Review of Patient #1's Visit Note Report dated 12/21/2021, showed the patient had poor skin turgor and had "...pulled off his dressing in the night..." There was no further documentation of the wound type, location, or measurements. Review of Patient #1's Supply Requisition Report dated 12/21/2021, showed the patient had been provided barrier cream (quantity of 1), Optifoam non-border heel dressing (quantity of 2) , and 6 inch x6 inch bordered gauze (quantity of 4). Review of Patient #1's IDG Comprehensive Assessment and Plan of Care Update Report dated 12/23/2021, showed no documentation of a wound or the need for wound dressings. Review of Patient #1's Visit Note Report dated 12/24/2021, showed the patient had poor skin turgor. There was no documentation of the wound location, type of wound, wound measurements, or any treatment provided. Review of Patient #1's Visit Note Report dated 12/28/2021 at, showed the patient had poor skin turgor and bruising to the extremities. Further review showed the nurse had left the patients house at 5:47 PM. Review of a Visit Note Report dated 12/28/ 2021, showed the nurse had returned to Patient #1's home at 7:31 PM and the patient had deceased. Record review showed no Wound Record Report had been initiated for Patient #1 to include assessments of the wound or wound measurements. During a phone interview on 4/18/2022 at 3:00 PM, Registered Nurse (RN) #1 stated Patient #1's family member "...had stockpiles of everything...he was in his own bed...had an alternating air mattress and he refused to turn...he was a small thin person...had boxes of...dressings..." During an interview on 4/19/2022 at 8:48 AM, RN #1 stated did see Patient #1 on 12/20/2021 and changed a dressing on his coccyx. That was the first day she had seen the patient. RN #1 stated the family member had asked her to look at the wound, "...we cleaned it...can't remember what it looked like, but it wasn't horrible...he kept pulling the dressing off...I think it was just going to open up [not an open wound]...it must have been partially [open due to documentation of drainage]..." She was unsure if the wound was new or if there was an order to provide treatment "...I guess I was supposed to write an order...of course I should have [called the doctor to obtain a treatment order]...all that stuff was already there [dressings were in the home]..." During an interview on 4/19/2022 at 12:55 PM, the Regional Director of Clinical Operations, confirmed when a nurse identified a wound, the nurse should assess the wound and report to the physician to obtain for orders for wound care. He confirmed Patient #1 had a wound documented on the 12/20/2021 visit note but had no wound measurements and no physician's order had been obtained for wound treatment. During an interview on 4/20/2022 at 9:19 AM, the Regional Director of Clinical Operations, confirmed Patient #1's need for an island dressing on 12/6/2021 and an allyven dressing on 12/14/2021 should have been addressed in the IDG meetings on 12/10/2021 and 12/24/2021. He confirmed the nurse had documented that she had performed a wound dressing change on the 12/20/2021 visit note. He confirmed If the wound had been identified on the 12/24/2021 IDG meeting it could have been monitored for worsening. Record review showed Patient #4 was admitted to the agency on 3/4/2022 with diagnoses including Pneumonia Due to SARS-Associated Corona Virus and Dementia Without Behavioral Disturbance. Review of Patient #4's Hospice Certification and Plan of Care dated 3/4/2022-6/1/2022, showed "...Mupirocin 2% [antibiotic cream] topical ointment...3 times daily...prevent infection..." Review of Patient #4's Physician's order dated 3/22/2022, showed "...Change sacral dressing 3 times weekly..." Review of Patient #4's Visit Note Report dated 3/28/2022, showed "...Patient has sacral wound 2nd degree 5.5CM [centimeters] by 6CM with malodorous purulent drainage. Doctor notified and medication ordered. Dressing applied to wound..." Review of Patient #4's Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 4/15/2022, showed "...Patient had a 2nd degree wound on her sacral area measuring 5.5CM by 6 CM..." Further review showed "...4/8/2022...Mupirocin 2 % Topical Ointment...Apply to wound 3 times daily...Discontinued Meds...3/28/2022...DC [discontinued] Date...4/3/2022...Doxycycline [antibiotic]...100 MG [milligram] Capsule...Wound Infection..." Record review showed no Wound Record Report had been initiated for Patient #4 to include wound assessment or wound measurements. Wound measurements had not been obtained weekly. During an interview on 4/19/2022 at 12:55 PM, the Regional Director of Clinical Operations confirmed Patient #4 had a physician's order for a wound treatment to the sacrum. He confirmed the patient had no wound report to include weekly measurements. The Regional Director of Clinical Operations confirmed Patient #4's wound on her coccyx had been measured on the 3/28/2022 visit note and on the IDG update on 4/15/2022. He confirmed the wound had not been measured weekly. Record review showed Patient #6 was admitted to the agency on 1/20/2021 with diagnoses of Malignant Neoplasm of Unspecified Part of Bronchus or Lung, Malignant Neoplasm of Unspecified Female Breast, and Adult Failure to Thrive. Review of Patient #6's physician order dated 1/15/2022, showed "...Coccyx wound: 3 x per week cleanse with wound cleanser...Apply Betadine [skin disinfectant] to wound bed...Crush Nystatin [antifungal medication] tablet and sprinkle in wound bed...Apply therahoney [wound medication] to wound bed. Apply barrier cream [skin protectant] to surrounding skin. May use ABD [wound pad] pad for excessive drainage. Cover entire wound with adhesive dressing. Hospice nurse to do three times a week..." Review of Patient #6's Wound Record Report dated 1/15/2022-3/3/2022, showed the wound had been measured on 1/15/2022 with measurements of 4 cm (length) x 4 cm (width) x 1 cm (depth). The wound was measured on 1/18/2022 with measurements of 4 cm x 4 cm x 1 cm. The wound was measured on 1/24/2022 with measurements of 4 cm x 4 cm x 0.75 cm. The wound was measured on 2/12/2022 with measurements of 7 cm x 5 cm x 0.5 cm. No other measurements had been obtained Review of Patient #6's physician's order dated 1/20/2022, showed "...Culture coccyx wound next SNV [Skilled Nurse Visit]..." Review of Patient #6's Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 1/21/2022, showed "...Coccyx wound 3 x per week...Order Date 1/20/2022...culture coccyx wound next SNV..." Review of Patient #6's Coordination Note dated 1/22/2022, showed "...Wound assessed. Wound is a Stage 3 pressure ulcer. Wound care done...Obtained a specimen for wound cultures per MD [Medical Doctor] orders. Specimen taken to...lab..." Review of Patient #6's Coordination Note dated 1/22/2022, showed "...Received call from ...lab...specimen cannot be run as a swab was exposed and contaminated. MD notified and orders given to repeat culture next nurse visit..." Review of Patient #6's Coordination Note dated 1/24/2022 (the next skilled nurse visit), showed no documentation the wound culture had been obtained. Review of Patient #6's wound culture report dated 2/10/2022, showed the culture had been obtained on 2/10/2022 and the wound did show infection. Review of Patient #6's Coordination Note dated 2/13/2022, showed "...Wound assessed...wound has copious [large] amount of tan drainage with very foul odor..." Review of Patient #6's physicians order dated 2/13/2022, showed "...Doxycycline 100 MG....x 14 days...infection..." During an interview on 4/19/2022 at 12:55 PM, the Regional Director of Clinical Operations confirmed Patient #6's pressure wound had not been measured weekly. During an interview on 4/19/2022 at 2:51 PM, the Regional Director of Clinical Operations confirmed Patient #6 had a physician's order for a wound culture to be reobtained at the next skilled nurse visit (1/24/22), but the culture was not obtained until 2/10/2022. He stated the culture was obtained on 2/10/2022 and an antibiotic was started for a wound infection on 2/13/22. During an interview on 4/19/2022 at 3:12 PM, the Regional Director of Clinical Operations confirmed the initial culture had been obtained on 1/22/2022 but the specimen had been contaminated and the nurse had charted the culture would be obtained on the next nurse visit. Further interview confirmed the second wound culture was not obtained at the next skilled nurse visit on 1/24/22 as ordered. During an interview on 4/19/2022 at 4:19 PM, the MD stated the agency's delay in obtaining the wound culture may have caused the wound to worsen "...It could have its possible..." He stated the worsening of the pressure ulcer could have caused the patient harm "...I would assume they would have gotten it [the wound culture]..." He stated if he had been notified that the culture had not been obtained on 1/24/2022, he would have given an order to "...go ahead and start the antibiotic..." During an interview on 4/20/2022 at 10:26 AM, the Regional Director of Clinical Operations confirmed the patient had a face to face with the Nurse Practitioner (NP) on 2/18/2022, and the NP had documented the sacral wound was a stage 4 pressure wound (previously stage 3). He confirmed the physician's order was not followed timely to obtain the wound culture, there was no documentation the MD had been notified the culture had not been obtained on the 1/24/2022 visit, and the wound did increase in size from the 1/24/2022 measurement until the 2/12/2022 measurement.
L0559      
40105 Based on agency policy review, medical record review, and interview, it was determined the Hospice agency failed to ensure the Quality Assessment Performance Improvement program took a proactive approach and focused on the improvement of patient/family care and activities to improve patient outcomes. The QAPI program failed to analyze collected data to ensure measurable improvement in indicators related to the management of wounds (refer to L563). The cumulative effect of this systemic practice resulted in the agency's inability to ensure that the patient's wounds were assessed and measured to prevent worsening, physician orders were obtained for wound care, and to ensure physician's orders were followed, and failed to ensure care plans reflected the need for wound care and the Condition of Participation: Quality assessment and performance improvement (QAPI) at 418.58 was not met.
L0563      
40105 Based on agency policy review, medical record review, and interview the agency failed to ensure it developed a hospice-wide, effective, on-going and data driven performance improvement program which analyzed and assessed collected data in order to identify potential problems, and to ensure implementation of measures to improve processes and patient outcomes related to wound management. The findings include: Review of the agency policy titled, "Patient Focused Performance Improvement," dated 11/2020, showed "...As part of the hospice-wide QAPI [Quality Assessment and Performance Improvement] process, opportunities for improvement related to patient outcomes will be identified through...clinical/service record review...When an opportunity to improve performance is identified, a focused study (indicator) will be developed to measure and improve associated processes..." Review of the agency policy titled, "Improving Organizational Performance," dated 11/2020, showed "...Performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety, and will be incorporated into the program and process design and modifications...Data Collection an analysis...Creating and maintaining information systems and data management processes to support the collecting, managing and analyzing of data to improve performance..." Review of a Plan of Correction dated 8/10/2021, showed "...Nursing staff will be educated on...Wound Care and the Documentation Process...audit 10 patient records or 10% of daily census receiving wound care (whichever is greater) monthly beginning 9/6/2021 until threshold has been met to ensure that an RN [Registered Nurse] provides timely, continuous assessment of each patient's needs, specifically regarding wound care...Target Threshold=90%...When threshold has been met for 2 months, then may reduce audits to 10 records or 10% of daily census (whichever is greater) reviewed quarterly...ensure that the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions including complete orders for all drugs and treatments, with corrections/ amendments made as applicable..." Review of the agency's QAPI chart audit tool, undated, showed the charts were to be audited for "...ensure implementation of the POC [Plan of Care]...Ex. [example] RN not measuring wound at least weekly or assessing wound q [every] visit...There is evidence the updated plan of care includes information from the updated assessments and identifies progress toward outcomes/ goals...There is evidence that care/ services are provided based on ongoing assessments..." Review of the agency's QAPI Meeting Minutes dated 2/4/2022, showed "...Chart Audits...Overall Score for Comprehensive Chart Audits for the qtr [quarter]: 60%...Negative trends...IDG [Interdisciplinary Group] POC not updated to reflect current POC...MAR [Medication Administration Record] not up to date...treatments...Plan to address negative trends for Comprehensive Chart audits (an overall score of less than 80% will require a PIP [Performance Improvement Plan]..." During an interview on 4/20/2022 at 10:26 AM, the Regional Director of Clinical Operations the agency had been performing monthly chart audits related to wound care. He stated the chart audits had been part of a plan of corrections from a previous survey. He stated the facility had been cited for wounds not being assessed with every nurse visit or not being measured. He confirmed he had been aware in 1/2022 that not all wounds were being measured from a chart audit he had performed in 12/2021. The Regional Director of Clinical Operations confirmed the plan of correction had not been effective to prevent future occurrences. During an interview on 4/20/2022 at 10:55 AM, the Regional Director of Clinical Operations as a result of the chart audits being performed the agency had found patients wounds had not been assessed or measured. He stated he had sent the Director and email in 1/2022 with copy of the 12/2021 audits. The Regional Director of Clinical Operations stated the Director had then left the agency in 2/2022 and he had not followed up with the Director prior to him leaving to see if he (the Previous Director) had taken any action to correct the identified concerns. He stated the chart audits were to be continued indefinitely until the agency reached a 90% threshold and maintained that for 2 months. He stated the agency had currently not reached that goal and audits are ongoing. The Regional Director of Clinical Operations stated the QAPI audits for 2/2022 had a chart audit score of 60% with a threshold of 80%. He confirmed a score of less than 80% required a PIP to be implemented but the agency had not developed a PIP. The Regional Director of Clinical Operations confirmed the agency's QAPI program should have identified the agency's the quality deficiency.