Every finding on record at Serene Hospice LLC

Upon patient record review 14 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14: There was no evidence that the comprehensive psychosocial or spiritual assessment was completed by any discipline.

Upon patient record review, 4 of 14 (Patient #1,2,6,9) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1 - The medication profile showed patient is taking aspirin as a blood thinner. There was no evidence of problems, goals, or interventions related to the bleeding risk of the medication. Patient #2 - The medication profile showed patient is taking aspirin as a blood thinner. There was no evidence of problems, goals, or interventions related to the bleeding risk of the medication. Patient #6 - The medication profile showed patient is taking metformin for diabetes management. Diabetes is also listed as a related diagnosis. There was no evidence of problems, goals, or interventions related to the endocrine system. Patient #9 - The medication profile showed patient is taking metformin for diabetes management. Diabetes is also listed as a related diagnosis. There was no evidence of problems, goals, or interventions related to the endocrine system.

Upon patient record review, 5 of 14 (Patient #1,2,6,7,8) 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 equipment and supply needs. Patient #1 - The medication profile listed Duoneb via nebulizer. The nebulizer machine and it's supplies were not listed on patient's plan of care. Patient #2 - The medication profile listed Duoneb via nebulizer. The nebulizer machine and it's supplies were not listed on patient's plan of care. Patient #6 - The medication profile listed oxygen 2L via nasal cannula prn. The nursing comprehensive and subsequent nursing assessments included patient was experiencing incontinence. The plan of care did not include oxygen or incontinent supplies. Patient #7 - The medication profile listed Duoneb via nebulizer and oxygen at 2L prn. There was no evidence of a nebulizer machine and oxygen concentrator and it's supplies were listed on the plan of care. Patient #8 - The medication profile listed Duoneb via nebulizer and oxygen at 2L prn. There was no evidence of a nebulizer machine and oxygen concentrator and it's supplies were listed on the plan of care.

Upon client record review, 11 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1,2,3,4,5,6,7,8,9,10,12: The initial plan of care for all patients listed a frequency order for both MSW and Spiritual Care as one visit per month with two prn visits. There was no evidence in the medical records that these visits were completed. There was also no evidence of frequency order change or discontinue until the recertification order in the subsequent benefit period for all listed patients.

Upon observation, there was not evidence the Emergency Plan communication plan includes an alternate means for communicating with hospice's employees. Corrected on site.

Upon patient record review, 1 of 11 (Patient #11) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and notes the patient's progress towards outcome/goals from the plan of care. Patient #11: The record indicated that the patient was actively dying and was placed on continuous level of care from 7/11/21-7/16/21. There was not evidence that 'continuous care' and 'imminence of death' were added to the care plan with individualized goals and interventions. An IDG that was held on 7/12/21 indicated 'no problems found' for these 2 areas.

Upon client record review, 3 of 11 (Patient #2,#6,#8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: The record indicated that phone visits were conducted by the spiritual care counselor on 6/25/22 and 6/30/22 without evidence that telehealth was a part of the plan of care. Patient #6: The record indicated that a phone visit was conducted by the spiritual care counselor on 6/30/22 without evidence that telehealth was a part of the plan of care. The visit frequency for the spiritual care counselor was 1x/month and 2 prn. There was not evidence of a visit during the month of July. The visit frequency for the social worker was 1x/month and 2 prn. There was not evidence of a visit during the month of July. Patient #8 Beginning with the IDT dated 3/28/22 and ending at the end of the certification period (6/17/22), the visit frequency for the spiritual care counselor and the social worker were both 1x/month and 1-2 prn. There was not evidence of visits for either discipline during this period.

Upon patient record review, 1 of 1 applicable (Patient #11) did not have evidence the hospice offers bereavement counseling that includes: • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery. There was not evidence of goals in the bereavement plan of care.

Upon patient record review, 1 of 1 applicable (Patient #11) did not have evidence in the patient record that hospice aide assignments and duties are: • Written patient care instructions for a hospice aide, prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 and includes all reportable indicators. Patient #11: The record indicated for the aide to take blood pressure, temperature, pulse and respirations at every visit. There was not evidence that reportable parameters were included in the aide plan of care.

Upon patient record review, 1 of 11 (Patient #11) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #11: There was not evidence that the certification of terminal illness was signed and dated by the medical director.

Upon patient client record review, 11 of 11 records (Patients #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11) 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. Patients #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11: Documentation in the record, including verbal orders, visit notes and certification of terminal illness did not contain evidence of the staff members credentials after their electronically signed signature. This included the RN, LVN, SW, SCC, Aide and Physician. Patient #1: The nurse narrative documentation on 7/5/22 indicated, 'informed patient to call Special Care Hospice 24/7 for any medical concerns.' The agency name is Serene Hospice. Patient #4: The nurse narrative documentation on 7/6/22, 7/13/22, 7/20/22, and 7/27/22 indicated, 'informed patient to call Special Care Hospice 24/7 for any medical concerns.' The agency name is Serene Hospice.

Upon client record review, 1 of 1 applicable (Patient #10) did not have evidence that the discharge summary includes all required information. There was not evidence that the discharge summary included • A summary of the patient's stay, including treatments, symptoms and pain management • The patient's current plan of care • The patient's latest physician orders • Any other documentation that will assist in post-discharge continuity of care

Upon client record review, 11 of 11 records (Patient #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. There was not evidence of acknowledgement of receipt of the policy for managing controlled substances.

Upon policy and procedure review, there was not evidence that the policy contained: • A process by which personnel may request an exemption from the personnel COVID-19 vaccination requirements based on an applicable federal law. • A process for tracking and securely documenting information provided by those personnel who have requested, and for whom the Hospice has granted, an exemption from the personnel COVID-19 vaccination requirements. • A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines, and which supports personnel requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable state and local laws, and for further ensuring that such documentation contains: • All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the personnel member to receive and the recognized clinical reasons for the contraindications; and • A statement by the authenticating practitioner recommending that the personnel member be exempted from the Hospice's COVID-19 vaccination requirements for personnel based on the recognized clinical contraindications. • A process for ensuring the tracking and secure documentation of the vaccination status of personnel for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment. Corrected on site.