Every finding on record at Cristela Flores Serenity Hospice Dba Serenity Hospice LLC

Observed in Record Review. In 2 of 2 patient records reviewed, it was noted that the POC goals did not have time frames for achieving goals. For example, in records 1 and 2 the documented goals did not contain any time frames. The goals are not individualized, such as Optimal sleep/rest for patient. Optimal spiritual/emotional support to patient and all involved in care. Patient/caregiver adequately informed on pain control measures. This was confirmed with the Alternate Administrator present.

Observed in Tracer Activities. During discussion with Asst Administrator and review of records it was noted that there was no plan in place or education having been done for goals for volunteers providing patient services. There are currently no patients receiving volunteer services so unable to assess records.

Observed in Tracer Activities. During review of PI systems it was found that there was no data collected for volunteers, bereavement, or DME. This was confirmed by the asst Administrator.

Observed in Tracer Activities. During PI review the asst Administrator reported a process and surveyor viewed a spreadsheet showing data over time including hand hygiene and patient satisfaction. They have not yet started collecting the data. This was confirmed with the asst. Administrator.

Observed in Tracer Activities. During the Data session it was noted that the hospice had identified one performance improvement project, Communicable disease that was being conducted, but did not document the reasons for conducting the project or the measurable progress achieved on it. This was confirmed with the alternate administrator present.

Observed in Tracer Activities. Volunteer systems tracer was conducted with the Asst. Administrator. There was no documentation of efforts to recruit and retain volunteers. This was confirmed by the Asst. Admin.

Observed in Tracer Visit. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by condition level deficiencies at 418.56, and 418.58.

Observed in Record Review. There is now a form for documenting volunteers orientation but no orientation has been done for the volunteers. This was confirmed by the asst Administrator.

Observed in Emergency Management Session. During the Emergency Management session it was noted that the written comprehensive emergency management program did not include exercises and testing - Disaster recovery - Program evaluation. This was confirmed with the Alternate Administrator present.

Observed in HR File Review. In 6 of 7 HR files reviewed, it was noted that ongoing emergency management training was not done every 2 years. For example the HR files for the LVN, HHA/Volunteer, MSW, spiritual counselor, Medical Director and Alternate Administrator did not have documentation of ongoing emergency management training every 2 years. This was confirmed with the Alternate Administrator present.

Observed in Emergency Management Session. During the Emergency Management session it was noted that the organization did not test its plan in any of the last 2 years. The Alternate Administrator present had printed copies of actual events from the news that had taken place in the area in a binder and there were blank Corridor group event evaluation forms in the binder, but nothing had been documented.

Observed in Record Review. In 2 of 10 patient records reviewed, it was noted that the initial bereavement assessment was not documented. For example, in records RRNHV#6 and #7 there was no documentation of the initial bereavement assessment. This was discussed with the Alternate Administrator and Alternate DON.

Observed in Record Review. In 2 of 2 patient records reviewed, for bereavement care it was noted that an assessment at death was not done to assess bereavement risk in order to inform the decisions made by the IDG. For example in records RRBR#1 and #2 it was noted that there was a list of items to complete over a 12 month time frame, but no documentation of a post death assessment. This was confirmed with the Bereavement Coordinator present.

Observed in Record Review. In 10 of 10 patient records reviewed, it was noted that the POC goals did not have time frames for achieving goals. For example, in records RRHV#1 to #3 and RRNHV#1 to #7 the documented goals did not contain any time frames. The goals are not individualized, such as Optimal sleep/rest for patient. Optimal spiritual/emotional support to patient and all involved in care. Patient/caregiver adequately informed on pain control measures. This was confirmed with the Alternate Administrator present.

Observed in Record Review. In 1 of 1 patient records reviewed, that included volunteer services it was noted that the plan of care did not include all services needed for palliation. For example, In record RRHV#2 the POC did not include any goals or interventions for the volunteer visits. This was confirmed with the Alternate Administrator present.

Observed in Record Review. In 4 of 10 patient records reviewed, it was noted that care was not provided according to hospice plan of care. For example in record RRHV#1 and RRNHV#1, #2 and #3 the plan of care skilled nurse frequency was one visit per week. However, in RRHV#1 6 weeks in the past 3 months there was no documentation of a visit and in RRNHV#1 and #3 3 weeks in the past 2 months there was no documentation of a visit. This was confirmed with the Alternate Administrator present.

Observed in Data Session. During the Data session it was noted that the hospice's QAPI program failed to address DME, pharmacy, bereavement and volunteer services. This was confirmed with the Alternate Administrator present.

Observed in Data Session. During Data session it was noted that the hospice did not collect data for volunteer services, bereavement, or DME and as a result was unable to demonstrate improvement in the related indicators. This was confirmed with the Alternate Administrator present.

Observed in Data Session. During the Data session it was noted that the organization collected patient satisfaction and hand hygiene data, however the data was not compiled in a manner it could be analyzed or used to identify performance trends or variances. This was confirmed with the Alternate Administrator present.

Observed in Data Session. During the Data session it was noted that the hospice had identified one performance improvement project, Communicable disease that was being conducted, but did not document the reasons for conducting the project or the measurable progress achieved on it. This was confirmed with the alternate administrator present.

Observed in Data Session. During the Data session it was noted that there was no data collection to evaluate hand hygiene compliance. The Alternate Administrator present stated that hand hygiene compliance was evaluated twice a year, once during a joint visit and once in the office. There was no data available for hand hygiene compliance for 2024 and 2023.

Observed in Record Review. In 2 of 2 patient records reviewed, for bereavement care it was noted that there was no documented bereavement plan of care. For example, in records RRBR#1 and #2 the paper sheet titled Bereavement POC for each patient did not include any goals or interventions, it was a to do list with dates for mailings. They did not include specific, individualized interventions, and the timing and frequency were the same exactly for all patients. This was confirmed with the Bereavement Coordinator present.

Observed in Record Review. In 1 of 3 patient records reviewed, that included aide services it was noted that the hospice aide supervision was not done every 14 days. For example in record RRHV#1 documentation of aide supervision was missing 3 times in the past 2 months. This was confirmed with the Alternate Administrator present.

Observed in Tracer Activities. During the Volunteer program session it was noted that the organization stated that they could not recruit volunteers since COVID there was no documentation to support any recruitment or retention activities. This was discussed with the Volunteer Coordinator.

Observed in Tracer Activities. During the Volunteer program discussion it was noted that the cost savings achieved did not include the positions occupied by volunteers. The cost savings was based on hours collected 100% for paid employees working as volunteers in the same position that they were paid to work. For example, the aide is seeing a patient daily to empty a foley catheter bag and volunteers on Saturday to do the same and the office manager volunteers time to make charts in the office. This was discussed with the Alternate Administrator.

Observed in Record Review. In 1 of 1 patient records reviewed, that included volunteer services it was noted that the documented volunteer hours were done by paid staff and when factored out the organization did not meet the required 5%. During discussion with the Alternate Administrator about the roles the staff had while working as 'volunteers' revealed the roles were the same as when they were paid to work. For example record RRHV#2 the HHA is seeing the patient daily to empty a foley catheter bag and volunteers on Saturday to do the same. The Alternate Administrator sees patient on the weekend to assist in the home the same as during the paid week. This was discussed with the Alternate Administrator.

Observed in Data Session. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by 418.56, 418.78, and 418.58.

Observed in Tracer Activities. During the Volunteer program discussion, it was noted that the hospice recorded 5 volunteers. However, they were all paid employees of the hospice whose volunteer activities were the same as their paid activities. For example, the aide was seeing a patient daily to empty a foley catheter bag and volunteered on Saturdays to do the same and the office manager volunteers time to make charts in the office. This was discussed with the Alternate Administrator.

Observed in HR File Review. In 2 of 2 HR files reviewed, for employees who also acted as volunteers it was noted that the organization had not documented the orientation of the volunteers. For example, the aide and alternate administrator also worked as volunteers for the organization and there was no documentation of orientation for the volunteer position. This was confirmed with the Alternate Administrator present.

Observed in Record Review. In 1 of 10 patient records reviewed, it was noted that a physician's certification of terminal illness statement was not filed in the patient record. For example record RRHV#2 there was no initial CTI documentation. Verbal attestation was included in record 8 days after SOC. This was confirmed with the Alternate Administrator present.

Observed in Record Review. In 1 of 2 patient records reviewed, for a hospice live discharge patient, it was noted that the discharge summary was not sent to the next health care professional responsible for providing care and services. For example, in record RRDC#2 it stated Patient's daughter called stating that patient will be moving to a new facility and has a in-house hospice and was wanting to use there services. A revocation was signed and a discharge summary completed, However it was not sent to the new hospice. This was confirmed with the Alternate Administrator present.

Observed in Patient Home. In 3 of 3 home visits conducted, that included oxygen in the home, it was noted that the organization did not provide education related to the oxygen equipment. For example, during visit RRHV#1 there were 3 E tanks in the home and 2 were free standing unsecured. Upon questioning the daughter related to oxygen safety she did not recall receiving education. During visit RRHV#2 there were 3 E tanks in the home and 2 were free standing unsecured. The RN conducting the visit worked with the unsecured tank's valve, however did not address the safety of unsecured E tank. During visit RRHV#3 the Etank was on a cart, but placed in the corner of an enclosed closet. The LVN present did not educate related to proper oxygen tank storage.

Observed in Record Review. In 1 of 11 patient records reviewed, it was noted that the organization did not ensure that a pain assessment that included its defined criteria was completed. For example, a review of the medical record for RR#1 revealed that the physician member of the interdisciplinary team documented the patient's history of back pain and the use of opioid medication for relief of symptoms. The start of care comprehensive pain assessment did not include the following information: Pain location, quality, patterns of radiation, and character; Alleviating and aggravating factors; Pain management history, including medication history, presence of common barriers to reporting pain and using analgesics, past interventions and response, and manner of expressing pain; Effects of pain, these include impact on daily life, function, sleep, appetite, relationships with others, emotions, and concentration. Secondary symptoms related to pain, such as nausea, vomiting, respiratory distress, or nutritional compromise. This observation was reviewed with the Administrator and the Director of Nursing.

Observed in Record Review. In 1 of 11 patient records reviewed, it was noted that the organization did not ensure the plan of care included all required information. For example, a review of the medical record for RR#8 revealed that, during week#1 of the second benefit period the patient experienced a fall. The plan of care was not updated with interventions to maintain patient safety and strategies to prevent injury. This observation was reviewed with the Administrator, and the Director of Nursing.