Every finding on record at Serenity Bay Hospice 2, LLC

Based on clinical record reviews, home visit observations, and staff interviews it was determined the agency failed to ensure patient's medication profile was updated to reflect current medications at the time of the comprehensive assessment for one of three patients (P#) (P#6) observed during home visits. The findings include: 1. Review of the plan of care for P#6 who resides in a private home with the admission date of 4/22/22 revealed a diagnosis of Alzheimer's and type 2 diabetes mellitus. During a home visit observation on 6/14/22, at approximately 11:30 a.m., the surveyor compared P#6's current hospice agency medication profile dated 4/22/22, with the patient's home medications. The medications that patient is on at home are as follows: Docusate NA (stool softener) 100 mg capsule; one capsule by mouth twice daily. Metformin 500 mg once daily (used to control high blood sugar) Trazodone HC 50 mg once daily (antidepressant) Tylenol 650 mg as needed for pain. Review of the Hospice agency medication profile did not include the above-mentioned medications. The Hospice agency failed to ensure the medication profiles accurately reflected P#6's current medication regimen. During an interview with the Administrator on 6/15/22 at 12:30 p.m., the Administrator stated, medications are reviewed with the patient/caregiver at each visit and provided no evidence the medication profile had been updated to reflect the patient's current medication regimen.

Based on review of clinical records, it was determined that the interdisciplinary group failed to ensure that the comprehensive assessment update included documentation of the patient's progress toward the desired outcomes/goals specified in the plan of care and the patient's response to care for one of eight patients (P). (#5) sampled patients who were current hospice beneficiaries. Findings include: Review of the clinical record for P#5 revealed that patient was admitted to hospice on 7/20/21 with the diagnosis of muscle atrophy and cerebral vascular accident (CVA). The skilled nurse (SN) visit note dated 6/2/22, the SN documents that patient continued to be bedbound, and skin is high risk for breakdown, left hip has a small area with skin discoloration. Patient is incontinent of bowel and bladder. Skin Barrier cream to the skin as needed. however, the documentation of the interdisciplinary team's update of the comprehensive assessment for this patient lacked documentation regarding the patient's progress or lack of progress toward the desired outcomes/goals and the patient's response to skin care. During a record review meeting on 6/15/22, at 12:45 p.m., the Administrator stated, the SN notes are reviewed during IDG meetings, but IDG notes lacked documentation of updated status/assessment, intervention, and progress of patient's skin condition / complications.

Based on clinical record review, it was determined that the interdisciplinary group failed to ensure that the plan of care was followed for treatment and frequency of visits for the hospice aide and nurse was provided in accordance with the patient's plan of care for six of eleven patients(P) (#5 #6, #7. #8, #9, and #10) sampled patients who were current hospice beneficiaries. Findings include: 1. The interdisciplinary care plan review for patient #5 required the hospice aide to visit the patient two (2) times a week. The interdisciplinary care plan reviews dated 4/26, 5/10, 5/24/22 reflected that there were no changes in the visit frequency for the aide. The clinical record indicates the aide visited the patient one (1) time a week for the week of 5/1/22- 6/9/22, instead of 2 times as ordered. Additionally, the nurse was required to visit the patient one (1) time per week. The clinical record lacked documentation that the nurse visited the patient on the week of 5/29/22 resulting in unauthorized missed visits. . 2. The interdisciplinary care plan review for patient #6 required the nurse to visit the patient one (1) time a week. The interdisciplinary care plan reviews dated 4/26, 5/10, 5/24/22 reflected that there were no changes in the visit frequency for the nurse. Documentation of nurse visits revealed that the nurse did not visit the patient on the week of 5/22/22 and week of 6/5/22 resulting in unauthorized missed visits. 3. The interdisciplinary care plan review for patient #7 required the hospice nurse to visit the patient 1 time per week. The interdisciplinary care plan reviews dated 4/26, 5/10, 5/24/22 reflected that there were no changes in the visit frequency for the hospice nurse. Documentation of hospice nurse visits revealed that the nurse did not visit the patient during the week of 5/22/22, resulting in one unauthorized missed visit. 4. The interdisciplinary care plan review for patient #8 required the hospice nurse to visit the patient 1 time per week. The interdisciplinary care plan reviews on 5/25/22 and 6/7/22 reflected that there were no changes in the visit frequency for the hospice nurse. Documentation of hospice nurse visits revealed that the nurse did not visit the patient during the week of 6/5/22. Furthermore, there were two nurse visits were made on the week of 5/29/22, resulting in one unauthorized missed visit. 5. The interdisciplinary care plan review for patient #9 required the hospice nurse to visit the patient 1 time per week. The interdisciplinary care plan reviews dated 4/26, 5/10, 5/24/22 reflected that there were no changes in the visit frequency for the hospice nurse. Documentation of hospice nurse visits revealed that the nurse did not visit the patient during the week of 6/5/22, resulting in one unauthorized missed visit. 6. The interdisciplinary care plan review for patient #10 required the hospice nurse to visit the patient 1 time per week. The interdisciplinary care plan reviews dated 4/26, 5/10, 5/24/22 reflected that there were no changes in the visit frequency for the hospice nurse. Documentation of hospice nurse visits revealed that the nurse did not visit the patient during the week of 5/15/22. Furthermore, the plan of care required the aide to visit patient three times a week. Documentation of hospice aide visits revealed that aide did not visit the patient on the April 2022 and week of May 8, 15, 22 and week of 29, 2022 resulting in unauthorized missed visits. Additionally, the plan of care revealed that patient is on insulin Novolog 100 unit/ml 11 units three times daily and required the patient to check blood sugar three times daily. Nurse visit notes dated 5/6, 5/14, 5/28, and 6/4 did not document the if the blood sugar was monitored twice daily at home as ordered on the plan of care. The administrator confirmed during interview on 6/15/22 at 12:00 PM that surveyor was provided all available documentation of patient visits. It was also confirmed the hospice aide, and the nurse failed to follow the ordered visit frequency and the nurse did not document the blood sugars as ordered by the physician.

Based on personnel record review and staff interview it was determined the hospice failed to ensure licensed professional services were provided directly by health care professionals who meet the appropriate qualifications. Social work services must be based on the patient's psychosocial assessment and the patient's and family's needs and acceptance of these services for 10 of 10 patients (P) #1, #2, #3, 4, #5, #6, #7, and #8. The findings include: Review of the personnel file for Social Worker (SW) EE lacked evidence the employee was licensed as a Social Worker or professional counselor. During an interview on 6/15/22 , at 12:40 p.m., the Administrator confirmed the personnel record for Social Worker EE did not include evidence of a licensed clinical Social Worker to meet the professional counseling needs of patients and family members.

Based on review of personnel files and staff interviews, it was determined that the hospice failed to ensure that a Registered Nurse completed an initial and annual competency evaluation for two of two sampled Certified Nursing Assistants (CNA) DD and CNA HH. The findings include: The personnel records for CNA HH hired on 7/21/21, lacked documented evidence that a Registered Nurse had completed an initial competency evaluation of the aide's skills. The personnel records for CNA DD hired on 4/15/19 lacked documented evidence that a Registered Nurse had completed an annual competency evaluation of the aide's skills. During an interview on 6/15/22 , at 12:30 p.m., the Administrator confirmed the employee did not have the initial competency evaluation for employee HH and annual competencies for CNA DD.