Every finding on record at Serenity Hospice and Home

Observed in Record Review. In 2 of 13 patient records reviewed, it was noted that the organization did not ensure initial assessments by members of the interdisciplinary group included all required information. For example, a review of the medical record for RR#3, and RR#6, revealed that the spiritual assessment section of the initial comprehensive assessment did not include cultural or religious practices that may affect care. Example #2: A review of the medical record for RR#6, revealed that an initial bereavement risk assessment was not documented. This observation was reviewed with the Education Manager / Compliance Officer.

Observed in Record Review. In 2 of 13 patient records reviewed, it was noted that the review and revision of the plan of care did not include all required elements. For example, a review of the medical record for HV#2 revealed that during week 6 of the 3rd benefit period, the clinician documented the presence of a stage 2 pressure ulcer at the buttocks. The plan of care was not updated with interventions for wound care management, and a goal statement to evaluate the effectiveness of wound care interventions. Example #2: A review of the medical record for RR#1 revealed that during week 11 of the 1st benefit period the patient experienced multiple falls, the plan of care was not updated with interventions to maintain patient safety, strategies to prevent injury, and a goal statement to evaluate response to care, treatment and services related to fall prevention interventions. This observation was reviewed with the Education Manager / Compliance Officer.

Observed in Record Review. In 1 of 13 patient records reviewed, it was noted that the organization did not ensure plan of care elements were implemented as planned. For example, a review of the medical record for RR#3, revealed that the plan of care specified Hospice Aide visit frequency as 1 time per week. There was no documented evidence that a Hospice Aide visit was completed during week 2 of services. This observation was reviewed with the Education Manager / Compliance Officer.

Observed in Building Tour. During the building tour the following items were resting on the sprinkler pipes: coiled conduit, and insulated duct piping. This observation was reviewed with the Maintenance Manager. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. During the building tour the surveyor noted vent tubing penetrated the ceiling. A smoke barrier gap greater than 1/8 inch was noted between the vent tubing and the ceiling. A sprinkler detection system was noted in the soiled utility room. This observation was reviewed with the Maintenance Manager. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.