Every finding on record at Serenity Home Hospice LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 1 of 9 (11%) clinical records reviewed revealed that the hospice did not ensure that the comprehensive assessment included a complete review of the patient's current prescription medications. Clinical Record 2: The patient elected the hospice benefit on 8/8/2023. The Skilled Nurse (SN) visit note dated 8/8/2023 documented the patient was using Ativan for anxiety. The updated drug profile dated 9/27/2023 did not include Ativan. The Skilled Nurse (SN) visit note dated 8/16/2023 documented the patient was using Colace for constipation. The drug profile dated 9/27/2023 did not include Colace. The Skilled Nurse (SN) visit note dated 9/3/2023 documented the patient was using Calmoseptine medicated ointment to coccyx. The drug profile dated 9/27/2023 did not include Calmoseptine. The Skilled Nurse (SN) visit note dated 9/23/2023 documented the patient was using Zofran for nausea. The drug profile dated 9/27/2023 did not include Zofran. The Administrator, Director of Nursing/Alternate Administrator, Registered Nurse/Alternate Director of Nursing stated in an interview on 12/22/2023 that the drug profile was not updated.

It is required that a hospice aide provides services 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 1 (100%) clinical record reviewed of a patient receiving aide services, it was revealed that the agency did not ensure the hospice aide followed the plan of care as ordered. Clinical Record 2: The aide care plan created 10/11/2023 for aide services 3 times a week assigned the task for shower 2 times a week and shampoo hair 2 times a week. The aide documented a shower 3 times a week and shampoo hair 3 times a week for assigned task 10/11/2023 through 12/15/2023, and a complete bed bath and application of allevyn dressing to coccyx 3 times a week. Complete bed bath and application of allevyn dressing to coccyx were not assigned on aide care plan for visits performed 10/11/2023 through 12/15/2023. Administrator, Director of Nursing/Alternate Administrator, Registered Nurse/Alternate Director of Nursing stated in an interview on 12/22/2023 that the aide did not follow the plan of care as ordered.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency. This standard was not met as evidenced by interview, document review, and personnel record review. In 4 of 9 (44%) personnel records reviewed it was revealed that the hospice did not ensure adherence to the agency orientation policy. Document 2: Policy HR.015 (no date) stated in part, "[Agency name] provides an orientation program intended to ensure that all newly hired and reassigned employees have the training and competency necessary to perform their jobs effectively. 6. Documentation of the successful completion of the orientation program is retained in the employee's personnel record." Personnel Record 3: The MSW/Bereavement Coordinator (BC) was hired on 7/3/23. The record lacked evidence of an initial skills competency for the BC role. Personnel Record 4: The Chaplain/Bereavement Coordinator (BC) was hired on 11/26/23. The record lacked evidence of an initial skills competency for the Chaplain and BC roles. Personnel Record 5: The Director of Nursing/Alternate Administrator/Registered Nurse was hired on 3/1/23. The record lacked evidence of an initial skills competency for the Registered Nurse role. Personnel Record 9: The Medical Director/Owner was hired on 7/1/22. The record lacked evidence of an initial skills competency for the Medical Director role. The Administrator, Director of Nursing/Alternate Administrator, and Registered Nurse/Alternate Director of Nursing stated in an interview on 12/22/2023 that the initial skills and competencies were not assessed.