Every finding on record at Serene Meadows Hospice, LLC

Based on record review and interview, the hospice agency failed to accurately reflect effective pain and symptom control on the comprehensive assessments. In three (Records 2, 5, 6) of three active records reviewed of patients who were admitted to hospice services with symptoms of pain, the agency did not provide accurate, complete comprehensive pain assessments. This failure put patients at risk of not receiving effective pain relief. Findings include: CLIENT RECORD #2: Record review of the "Initial Comprehensive Assessment" for Cl #2, dated 07/09/21, revealed a soc of 7/09/21, and a terminal diagnosis of Unspecified Diastolic Congestive Heart Failure." Under "Pain Screening," the assessment read in part, "Was the patient screened for pain? Yes; ...Did the patient have pain? Yes; Current Pain Intensity: 3-tolerable; Pain Severity: 1-mild; ...Past Week Pain Intensity Level (Worst): 3-tolerable; ...Past Week Pain Intensity (Best): 3-tolerable; Current Pain Regimen: Oxycodone. Record review of the "IPOC" for Cl #2, dated 07/09/21, revealed the cl problem of "Alteration in comfort related to pain. Risk for increased pain due to non-compliance with prescribed pain regimen, including overuse or underuse." The "Goals" for this problem was "Patient will report pain using a standardized pain scale, establish a self-identified pain goal, and report/demonstrate that pain is managed at or below this level. Patient self-identified pain goal is 4- Completed by: Ongoing. Conduct and document a comprehensive pain assessment, using a standardized assessment tool, including location, quality, intensity, aggravating/alleviating factors, and associated symptoms." Record review of the "IDT POC" (CPOC Update/Comprehensive Assessment Update) dated 07/14/21, revealed in part, "Physical Comfort/Pain: Pain average @ 3, Pain location: Back." Under "Outcomes: Pain control goal is 3; Compliance with med regime; Symptoms managed." No documentation of a complete comprehensive pain assessment was found. Record review of the "IDT POC" dated 07/14/21, revealed in part, "Physical Comfort/Pain: Pain managed with oxycodone." No documentation of a comprehensive pain assessment was found. CLIENT RECORD #5 Record review of the "Initial Comprehensive Assessment" for Cl #5, dated 05/28/21, revealed a soc of 05/28/21, a terminal diagnosis of Cerebrovascular Disease, and comorbidities of Right Hemiplegia, Occlusive and Stenotic Bilateral Carotid Arteries, Seizures, and Chronic Kidney Disease Stage 3. The "Pain Screening" read in part, "Was the patient screened for pain? Yes; Did the patient have pain? Unable to Communicate, Pain Assessment in Advanced Dementia (PAINAD) Scale: No Pain; ...Pain Severity: None; Is pain an active problem for the patient? (Not answered); Type of Pain Scale Used: Staff Observation (PAINAD)." Medication Assessment read in part, "Pantoprazole 40 mg oral delayed release tablet, 40 mg oral daily, gastritis ...." Under Scheduled Opiod, "Was a scheduled opiod initiated or continued? No." Under PRN Opiod, "Was a PRN opiod initiated or continued? No." No prn pain medication was found. Record review of the "IPOC" for Cl #5, dated 05/28/21, revealed the cl problem of "Risk for undertreated pain secondary to inability to verbalize pain." The "Goal" for this problem was "Patient will report pain using a standardized pain scale, establish a self-identified pain goal, and report/demonstrate that pain is managed at or below this level. Patient self-identified pain goal is 2/10- Completed by: Ongoing." Record review of the "IDG Summary (CPOC Update)/Comprehensive Assessment Update" for Cl #5, dated 06/02/21 and 06/16/21, revealed in part, "Continue POC: Current plan of care effective for Symptom Management." No documentation was found on these CPOCs regarding the cl's problem of "Risk for undertreated pain." No documentation of a comprehensive pain assessment was found. Record review of the "IDT POC" (CPOC Update/Comprehensive Assessment Update) dated 07/14/21, revealed in part, "Physical Comfort/Pain: Pain average @ 2, Pain location: Gen (General). Under "Outcomes: Pain control goal is 3; Compliance with med regime; Symptoms managed." No documentation of a comprehensive pain assessment was found. CLIENT RECORD #6 Record review of the "Initial Comprehensive Assessment" for Cl #6, dated 06/07/21, revealed that Cl #6 had a terminal diagnosis of Alzheimer's Dementia and comorbidities of Dysphagia, Essential Hypertension, and Osteoarthritis. Under "Pain Screening" the assessment read in part, "Was the patient screened for pain? Yes; Did the patient have pain? Unable to Communicate; Pain Assessment in Advanced Dementia (PAINAD) Scale: No Pain; Pain Severity: None; Type of Pain Scale Used: Staff Observation (PAINAD)." Under Fall Assessment, "Pain affecting level of function- Pain often affects an individual's desire or ability to move or pain can be a factor in depression or compliance with safety recommendations. Under Medication Assessment, "Tramadol 50 mg oral tid prn, three times daily as needed, (for) pain, start date 06/07/21. There was no comprehensive pain assessment documented which demonstrated the cl's historical pain management. No question was documented by the nurse, regarding when the last Tramadol was taken, or if she had been taking Tramadol to keep her pain at a 0. Record review of the "IPOC" for Cl #6, dated 06/07/21, revealed no documentation of the awareness of the cl's potential problem of pain related to the Osteoarthritis. Record review of the "IDG Summary (CPOC Update)/Comprehensive Assessment Update" for Cl #6, dated 06/16/21 and 06/30/21, revealed in part, "Pain assessed using PAINAD Scale, 0." No documentation of a comprehensive pain assessment was found. Record review of the "IDT POC" (CPOC Update/Comprehensive Assessment Update) dated 07/14/21 and 07/28/21, revealed under "Physical Comfort/Pain: N/A" was checked. No documentation of a comprehensive pain assessment was found. In an interview with the Adm and DON, on 10/19/21 at approximately 11:45 am, the findings above were reviewed and discussed. The Adm and DON agreed that the documentation did not show complete, accurate comprehensive pain assessments.

Based on review of personnel records and interview, the agency failed to maintain documentation of successful competency testing on a hospice aide providing aide service to hospice patients, that demonstrated federal regulations were met, in one (Hospice Aide C) of one hospice aide record reviewed. This failure could result in the provision of unsafe or incompetent care to agency patients. Findings include: Personnel Record Employee C: Record review of the employee roster included a listing for Employee C as a CNA (Certified Nurse's Aide) with a hire date of 03/16/19. Record review of the personnel record of CNA C contained a "Hospice Aide Skill's Competency Checklist" (form dated 2013), dated "8-20-18" on the top right of the page. The competency checklist showed under Partial Baths, only "Shower" was circled, dated "8-20(18)" and marked "Satisfactory." Under Shampoos, only "Tub(-shower)" (with shower written in) was circled, dated "8/20" and marked Satisfactory. The checklist was signed by RN D and dated "8-25(18)." In an interview with the Adm, and the DON, on 10/20/21 at approximately 11:45 am, the competency evaluation was reviewed. The DON agreed that the aide competency evaluation had not been documented correctly.