Every finding on record at Hospice of Serene Care Inc

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.

Upon patient record review, 6 of 14 (Patient #1,2,3,4,5,and 6) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 1: There is no evidence of imminence of death in the comprehensive assessment completed at SOC on 7/01/25. Patient 2: There is no evidence of imminence of death in the comprehensive assessment completed at SOC on 04/30/25. Patient 3: There is no evidence of imminence of death in the comprehensive assessment completed at SOC on 09/11/25. Patient 4: There is no evidence of imminence of death in the comprehensive assessment completed at SOC on 09/02/25. Patient 5: There is no evidence of imminence of death in the comprehensive assessment completed at SOC on 07/29/25. Patient 6: There is no evidence of imminence of death in the comprehensive assessment completed at SOC on 07/27/25.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1: There is an order on the medication list for Depakote 250 mg twice daily on Agency medication list and 125mg twice daily on the facility medication list. COS with medication reconciliation.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments Patient 1: There is an order on the agency POC 09/24/25 for Depakote 250 mg twice daily and the ALF facility POC contains an order for 125mg twice daily on the facility POC. Corrected on site with medication reconciliation.

Upon observation 1 of 3 home visits, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 3: During home visit, the SN is observed reaching into the clean area of the nursing bag with dirty gloved hands without removing gloves and performing hand hygiene prior to reaching into nursing bag.

Upon patient record review, 3 of 14 (Patient # 2, 5, and 6) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 2: The Aide POC gives options of choice for aide to place bed rails up with either one, two or partial bed rails. Aide documentation on 9/26 indicates use of all options for siderails. COS with updates to Aide POC. Patient 5: The Aide POC on 7/29/25 gives options of choice for aide to dress patient in street clothes or Pajamas every day. Aide documentation on 10/9 indicates use of both options. COS with updates to Aide POC. Patient 6: The Aide POC 0n 7/29/25 gives options of choice for aide for placing bed rails up with either one or two bed rails. Aide documentation on 9/26 indicates use of both options for siderails. COS with updates to Aide POC.

Upon patient client record review, 5 of 14 (Patient # 1, 2, 4, 8, and 9) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 1: The LVN documentation on 9/10/25 SN documents in narrative referring to patient as "pot and opt" which are not approved medical abbreviations for patient according to agency policy. COS with updates to documentation. Patient 2: The LVN visit on 9/27 and RN visit on 9/02/25 are not signed and dated in the visit notes and Aide visit notes are not signed and dated from 9/1/25- 9/29/25. COS with approval of visits by DPCS. Patient 4: Recertification comprehensive assessment SN visit notes on 9/1/25 are not signed and dated and RN visit notes from 10/7/25-10/12/25 are not signed and dated, MSW visit note on 10/9/25 and LVN visit notes from 9/30/25-10/11/25 are not signed and dated. COS with approval of visits by DPCS. Patient 8: The RN visit note on 9/30/25 are not signed and dated. Visit notes are corrected on site by DPCS. Patient 9: The RN visit on 10/13/25 and 10/08/25 are not signed and dated. COS with approval by DPCS.

Upon inpatient contract review, 1 of 4 (Citrus Nursing Center contract) did not have evidence that the hospice retains responsibility for ensuring that the training of personnel who will be providing the patient's care in the inpatient facility has been provided and that a description of the training and the names of those giving the training are documented.

Upon inpatient contract review, 1 of 4 (Citrus Nursing Center contract) did not have evidence of a method for verifying that the requirements for ACHC standard HSP1-8B and CFR 418.108c (1)-418.108c(5)are met. JCAHO and CHAP standards are listed for compliance on written agreement with Citrus Nursing Center.