Every finding on record at Serene Hospice Care, Inc.

It is required that the hospice provides nursing care under the supervision of a Registered Nurse. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure nursing care and services were under the supervision of a Registered Nurse (RN). Clinical Record 6: The patient elected the hospice benefit on 01/31/2022 with a terminal diagnosis of cerebral stoke syndrome. Clinical record review revealed no documented evidence of Licensed Vocational Nurse (LVN) supervisory visits by the RN from 01/31/2022 to 03/15/2022 and 03/17/2022 to 12/19/2022. Clinical Record 10: The patient elected the hospice benefit on 01/11/2023 with a terminal diagnosis of colon cancer. Clinical record review revealed no documented evidence of LVN supervisory visits by the RN from 01/11/2023 to 07/06/2023. During an interview on 12/14/2023, the Administrator and the Director of Patient Care Services confirmed the clinical records did not include documented supervisory visits. In 2 of 9 (22%) clinical records reviewed in which a licensed vocational/practical nurse (LPN/LVN) provided services revealed that a registered nurse (RN) did not perform LPN/LVN supervisory visits.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by document review, clinical record review, and interview. In 4 of 4 (100%) clinical records reviewed with patient death, the agency did not ensure bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Agency policy 9-023 Bereavement Services, revised 1/2020, stated in part, "After a death has occurred, the bereavement assessment will be updated. Within 2 weeks after the death of a patient, a sympathy card will be sent to the bereaved. After 3 weeks, a bereavement letter with be sent to the bereaved. Within 3-5 weeks after the patient's death, a bereavement assessment will be completed by the bereavement counselor." Clinical Record 8: The patient elected the hospice benefit on 09/26/2023 with a terminal diagnosis of kidney failure. The patient's death was dated 09/27/2023. The clinical record contained no documented evidence of a post death bereavement assessment or a bereavement plan of care. Clinical Record 11: The patient elected the hospice benefit on 04/23/2023 with a terminal diagnosis of lung cancer. The patient's death was dated 04/25/2023. The clinical record contained no documented evidence of a post death bereavement assessment or a bereavement plan of care. Clinical Record 12: The patient elected the hospice benefit on 03/03/2023 with a terminal diagnosis of prostate cancer. The patient's death was dated 04/04/2023. The clinical record contained no documented evidence of a post death bereavement assessment or a bereavement plan of care. Clinical Record 14: The patient elected the hospice benefit on 03/08/2023 with a terminal diagnosis of end stage renal disease. The patient's death was dated 03/11/2023. The clinical record contained no documented evidence of a post death bereavement assessment or a bereavement plan of care. During an interview on 12/14/2023, the Administrator and the Director of Patient Care Services confirmed this finding and stated that she did not know why the bereavement coordinator was not documenting as they all were at the patient's homes to support the families and bring them flowers. In 4 of 4 (100%) clinical records reviewed of patients who expired revealed the hospice did not ensure a completed post death bereavement plan of care.

It is required that a hospice aide provides services that are ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 10 (10%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aide provided services as ordered in the plan of care. Clinical Record 6: The patient elected the hospice benefit on 01/31/2022 with a terminal diagnosis of cerebral stoke syndrome. The hospice aide plan of care dated 02/01/2022, assigned the aide to provide visits twice a week. Clinical record review revealed starting the week of 02/07/2022, the hospice aide provided visits three times a week. There was no documented evidence in the clinical record that aide visits had been ordered three times a week. During an interview on 12/14/2023, the Administrator and the Director of Patient Care Services confirmed the record did not include an order for aide visit frequency three times a week. In 2 of 10 (20%) clinical records reviewed in which a hospice aide (HA) provided services revealed that the care provided by the HA was not consistent with the HA plan of care.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 1 of 10 (10%) clinical records reviewed with hospice aide (HA) services provided, the agency did not ensure the Registered Nurse (RN) performed supervisory visits of the hospice aide. Clinical Record 10: The patient elected the hospice benefit on 01/11/2023 with a terminal diagnosis of colon cancer. The clinical record contained no documented evidence of HA supervisory visits at least every 14 days as required at the end of the public health emergency on 05/11/2023 through 07/06/2023. During an interview on 12/14/2023, the Administrator and the Director of Patient Care Services confirmed supervisory visits were not documented in the clinical record. In 2 of 10 (20%) clinical records reviewed in which a hospice aide (HA) provided services, revealed that a registered nurse (RN) did not perform HA supervisory visits.

It is required that if a patient revokes the election of hospice care or is discharged from hospice (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed with patient revocation, the agency did not ensure a copy of the discharge summary was forwarded to the patient’s attending physician. Clinical Record 6: The patient elected the hospice benefit on 01/31/2022 with a terminal diagnosis of cerebral stoke syndrome and revoked hospice care on 12/19/2022. The clinical record contained no documented evidence that a discharge summary was forwarded to the patient's attending physician. During an interview on 12/14/2023, the Administrator and the Director of Patient Care Services confirmed the clinical record did not include documentation that a discharge summary was sent to the physician. In 1 of 2 (50%) clinical records reviewed in which a patient revoked the election of hospice care or was discharged revealed the hospice did not ensure that a copy of the discharge summary was forwarded to the patient’s attending physician.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care or to the patient’s community attending physician upon hospice discharge includes at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed with a discharge summary required, the agency did not ensure that the information provided to the receiving facility contained a summary of the patient's hospice stay. Clinical Record 6: The patient elected the hospice benefit on 01/31/2022 with a terminal diagnosis of cerebral stoke syndrome. The patient revoked hospice care on 12/19/2022. The discharge summary did not include documentation of a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. Clinical Record 7: The patient elected the hospice benefit on 11/21/2022 with a terminal diagnosis of heart disease. The patient was transferred to another hospice on 10/23/2023. The discharge summary did not include documentation of a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. During an interview on 12/14/2023, the Administrator and the Director of Patient Care Services confirmed the discharge summaries did not include a summary of the patient’s hospice stay. In 2 of 5 (40%) clinical record reviewed in which a discharge summary was required revealed the hospice did not ensure that the information provided to the receiving facility contained a summary of the patient's hospice stay.

Observed in Record Review. In 2 of 2 patient records reviewed, It was found on review of 01122209-629 RRBR#1 and 0092213-652 RRBR#2 that bereavement assessments post death were not documented. This was verified by the DON.

Observed in Regulatory Review. It was found in review of HV#1 record review that the Chaplain did not document the initial assessment with in 5 days of admission. He documneted the assessment 9/5/2023 and the patient was admitted 7/24/23. This was verified with the DON.

Observed in Individual Tracer. In 2 of 2 home visits conducted, It was observed on HV#2 that the RN asked the care giver what medications was she giving to the patient . The nurse did not have a copy or access to the current medication profile so she could not do a proper medication reconciliation. Observed in Individual Tracer. It was found on HV#1 in a SNF that the medication profiles for the hospice and the SNF did not match. The hospice medication profile was missing 4 medications that the SNF was administering to the patient. The medications were Acetaminophen, Multi vitamin, MiraLAX and Ascorbic acid. This was verified with the SNF charge nurse and the Hospice CEO.

Observed in Record Review. In 2 of 6 patient records reviewed, It was found on review of HV#1 record review that and IDT was held 7/26/2023 when patient was admitted however there was no further documentation of an IDT as of 9/ 8/2023. This was verified with the DON. Observed in Record Review. In 5 of 6 patient records reviewed, It was found on HV#3 record review that IDG was documented on 4/13/2023 and not again until 8/25/2023. This was verified with the DON Observed in Record Review. In 4 of 6 patient records reviewed, It was found in RRNHV#3 that there was no documentation of IDG from 4/13/2023 to 9/8/2023. Observed in Record Review. In 2 of 6 tracers conducted, It was found on review of HV#2 record review that IDT was not performed every 15 days. Patient admitted 1/10/2023 IDTs were done 4/13/2023 and the next was 8/25/2023. This was verified with the DON. Observed in Record Review. It was found on review of RRNHV#1 that IDTs were not documented every 15 days. On review of the record DT was documented on 4/13/23 and not documented until 9/8/2023 This was verified with the DON.

Observed in Individual Tracer. During HV# 2 it was observed that the nurse performing wound care did not cleanse her hands after removal of gloves. The nurse also did not change her gloves when she was cleaning two separate wounds. She only changed her gloves when she placed the new dressings on both wounds. She also did not cleanse her hands after removal of gloves. This was verified with the CEO. During the visit the nurse placed her cloth back pack on the floor.

Observed in Surveyor review but corrected onsite pending acceptable Evidence of Standards Compliance. In 2 of 2 patient records reviewed, It was found on review of RRBR#1 and RRBR#2 that there was no evidence of a bereavement care plan. This was verified with the DON.

Observed in Document Review. In review of recruitment activities it was found that recruitment activities are not being documented. While the organization stated that they had tried to recruit there was no documentation to support their statements

Observed in Document Review. It was found in review of the volunteer program that volunteers did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff. This was verified with the Volunteer coordinator. Average of 4.5 for the last two years.

Observed in Leadership Session. For hospices that elect to use The Joint Commission deemed status option: A qualified administrator appointed by and reporting to the governing body is responsible for the day-to-day operations of the hospice.

Observed in Individual Tracer. It was found on HV#3 that oxygen storage was inappropriate. A back up tank was found in the closet of the patients room. This was verified with the CEO.

Observed in HR File Review. It was found on review of personnel files that an RN license was not verified at the time it expired which was December 31 2022. Organization verified the license on site today.