Every finding on record at Seasons Hospice & Palliative Care of Pinellas County, LLC

Observed in Record Review. In 1 of 2 discharge records reviewed, it was noted that the organization did not ensure the Notice of Medicare Non-coverage was provided when required. For example, a review of the medical record for RRDC#1, revealed no documented evidence that when the patient was discharged for extended prognosis, the Notice of Medicare Non-Coverage was provided to the patient or the patient’s representative. This observation was reviewed with agency leadership.

Observed in Record Review. In 2 of 24 patient records reviewed, it was noted that the organization did not ensure that patient specific comprehensive assessments included all required information. For example, during a review of the medical record for HosRRHV#3, the clinician documented the presence of a unstageable wound at the patient’s left buttocks. The comprehensive assessment did not include a wound assessment. The clinician documented in response to the wound assessed trigger – “No, not ordered this visit”. A subsequent review of two skilled nurse visits completed in the following 6 day period also revealed that a wound assessment was not completed. Example #2: A review of the medical record for RRHV#5, revealed that the comprehensive assessment completed at the time of recertification for the 7th benefit period did not include a falls risk assessment. In response to the assessment trigger - [Indicate other reason a fall assessment was not completed] - the clinician documented Patient is already a fall risk. This observation was reviewed with agency leadership.

Observed in Record Review. A review of 4 of 24 medical records revealed that the organization did not ensure that the comprehensive assessment update included all required information. For example, during a review of the medical record for RRHV#1, it was noted that the comprehensive assessment update completed during week three of services, did not include information about the patient’s progress toward desired outcomes and goals of care, treatment. Example #2: During a review of the medical record for RRHV#3, the following information was noted: Care Plan Problem – Risk for Aspiration; Goal statement – Patient, Family, Caregiver, Facility will demonstrate interventions to minimize aspiration risk and maximize safety at each visit throughout the certification period. The comprehensive assessment update completed during week three of services, did not include information about the patient’s progress toward desired outcomes and goals of care, treatment related to the patient’s risk for aspiration. Example #3: A review of RRHV#5, revealed that since a goal statement related to the patient’s terminal illness diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery w/o Angina Pectoris was not established; the requirement to ensure the updated comprehensive assessment included the patient's progress toward goals and outcomes related to Atherosclerotic Heart Disease of Native Coronary Artery w/o Angina Pectoris was not documented. Example #4: A review of the RRNHV#1, revealed that since a goal statement related to the patient’s terminal illness diagnosis of Alzheimer’s disease with early onset, the patient’s risk for falls, and the patient’s nutritional needs; the requirement to ensure the updated comprehensive assessment included the patient’s progress toward goals and outcomes related to Alzheimer’s disease with early onset, the patient’s risk for falls, and the patient’s nutritional needs was not documented, This observation was reviewed with agency leadership.

Observed in Record Review. In 2 of 24 patient records reviewed, it was noted that the organization did not ensure the plan of care goals included outcome measures for specific care activities. For example, a review of the medical record for RRHV#5, revealed that the patient’s terminal illness diagnosis was Atherosclerotic Heart Disease of Native Coronary Artery w/o Angina Pectoris The plan of care did not include a goal statement to evaluate the response to care, treatment, and services related to the treatment of Atherosclerotic Heart Disease of Native Coronary Artery w/o Angina Pectoris.Example #2: A review of the medical record for RRNHV#1, revealed that the patient’s terminal illness diagnosis was Alzheimer's Disease with early onset. The clinician documented the following assessment information: Patient has had increased confusion, decreased mobility, and assistance needed for adls where she was close to independent prior. Patient has lost 40 in the past six months. The plan of care did not include a goal statement to address care, treatment and services related to the terminal illness diagnosis, the patient's risk for falls, and the patient's nutritional needs. This observation was reviewed with agency leadership.

Observed in Record Review. In 2 of 24 patient records reviewed, it was noted that the organization did not ensure the plan of care goals included outcome measures for specific care activities. For example, a review of the medical record for RRHV#5, revealed that the patient’s terminal illness diagnosis was Atherosclerotic Heart Disease of Native Coronary Artery w/o Angina Pectoris. The plan of care did not include interventions to address the care, treatment, and services related to Atherosclerotic Heart Disease of Native Coronary Artery w/o Angina Pectoris. Example #2: A review of the medical record for RRNHV#1, revealed that the patient’s terminal illness diagnosis was Alzheimer's Disease with early onset. The clinician documented the following assessment information: Patient has had increased confusion, decreased mobility, and assistance needed for adls where she was close to independent prior. Patient has lost 40 in the past six months. The plan of care did not include interventions to address care, treatment and services related to the terminal illness diagnosis, the patient's risk for falls, and the patient's nutritional needs. This observation was reviewed with agency leadership.

Observed in Individual Tracer. In 1 of 3 patient records, for patients receiving hospice aide services, it was noted that the organization did not ensure the Hospice Aide assignment sheet included all applicable precautions for patient care activity. For example, a review of the Hospice Aide assignment sheet for RRHV#4, revealed that a need for bleeding precautions during patient care activities was not identified. This observation was reviewed with agency leadership.

Observed in Building Tour. The 1 hour fire barrier near the nurse station above the cross corridor doors, had a scab patch and a 2 inch hole above a conduit through the fire barrier. This was verified by the director of business operations and the director of property management. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy: Observed in Building Tour. The fire wall above the ceiling at the cross corridor 90 minute fire rated doors located between the hospice family dining room and the adjacent nursing home (separate and distinct occupancy) does not exist. This was verified by the Director of Business Operations.The one hour fire barrier at the occupancy separation near room 315, above the cross corridor doors had two penetrations not sealed. This was verified by the Oak Manor facilities team. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy:

Observed in Document Review. The fire sprinkler system inspection reports completed in 2024 and 2025 (to date) did not include a NFPA standard(s) referenced for the activity. This was verified by the director of business operations and the contracted vendor Oak Manor Director of facilities. The fire alarm system inspection reports completed in 2024 and 2025 (to date) did not include a NFPA standard(s) referenced for the activity. This was verified by the director of business operations and the contracted vendor Oak Manor Director of facilities. Observed in Document Review. The fire sprinkler system inspection reports completed in 2024 and 2025 (to date) did not include a NFPA standard(s) referenced for the activity. This was verified by the director of business operations and the contracted vendor Oak Manor Director of facilities. The fire alarm system inspection reports completed in 2024 and 2025 (to date) did not include a NFPA standard(s) referenced for the activity. This was verified by the director of business operations and the contracted vendor Oak Manor Director of facilities.

Observed in Individual Tracer. In 2 of 5 home visits conducted, The organization did not implement infection prevention and control activities when doing the following: Cleaning and performing disinfection of medical supplies and devices. During home visits 1and 2 the nurse disinfected the equipment used to take vital signs with Sani-wipes. The items were placed back in the nursing bag with no dry time. The manufacturer's guidelines state that Sani-wipes require a 2 minute dry time. This was confirmed by the Director of Clinical Services. Observed in Individual Tracer. The organization did not implement its infection prevention and control activities. During home visit 1 it was observed that the nurse did not cleanse her hands after doffing gloves and before entering the nursing bag according to policy. This was confirmed by the Director of Clinical Operations.

Observed in Tracer Activities. Volunteer staff did not provide administrative or direct care in an amount that equals 5% of the total of patient care hours of all paid hospice employees and contract staff. During the volunteer session, it was reported that the hours for volunteers were 3% for the past year. This was confirmed by the Director of Clinical Services.

Observed in Record Review. In 2 of 22 patient records reviewed, All entries in the patient record were not legible, clear, complete, and appropriately authenticated and dated in accordance with the organization’s policy and currently accepted standards of practice. During review of records 6 and 12 it was noted that the certifications of terminal illness were not signed within 48 hours according to organization policy. For example, the certification in record 6 was dated 3 months prior and had not yet been signed. This was verified by the Executive Director.

Observed in Record Review. In 2 of 2 patient records reviewed, The hospice did not inform the attending physician of the availability of a discharge summary. The discharge summary was not provided to the physician upon the physician’s request and includes the patient's medical and health status at the time of discharge. During review of bereavement records 21 and 22 it was noted that there was no documentation of the discharge summary being offered or provided to the physician. This was confirmed by the Executive Director.