Every finding on record at Serenity Hospice and Palliative Care, Inc.

Upon personnel record review, 1 of 12 (Personnel # 8) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel # 8) Review of personnel employee did not have evidence of competency assessment of communication skill, the ability to read.

Upon client record review, 3 of 14 (Patients # 10, 11, 12) did not have evidence that the discharge summary includes all required information. Patient # 10) The discharge summary sent to the attending did not show evidence the latest discharge orders, current POC, D/C orders, instructions, medication profile and allergies. Patient # 11) The discharge summary sent to the attending did not show evidence the latest discharge orders, current POC, D/C orders, instructions, medication profile and allergies. Patient # 12) The discharge summary sent to the attending did not show evidence the latest discharge orders, current POC, D/C orders, instructions, medication profile and allergies.

Observed in Emergency Management Session. The surveyor noted the Emergency Operation’s Plan did not describe the patient population served by the organization or the extent to which additional populations may be cared for during an emergency. This was evidenced by the organization was not able to produce documentation at the time of survey. This was confirmed with the CEO.

Observed in Emergency Management Session. The surveyor noted the Emergency Operation’s Plan did not describe how state and federally designated health care professionals would be incorporated into the staffing strategy for addressing a surge in needs during an emergency as evidenced by the organization was not able to produce this documentation. This was confirmed with the CEO.

Observed in Emergency Management Session. The surveyor noted as part of its communication plan, the organization did not maintain the names and contact information of staff, physician volunteers, and other response partners contracted entities as evidenced by the communication plan did not include the contact information for the contracted entities (DME, pharmacy, SNF), staff, volunteers and physician. This was confirmed with the CEO.

Observed in Emergency Management Session. The surveyor noted the organization did not determine what its role would be in the community response plan as evidenced by the organization did not have written documentation of its role in the community response plan. This was confirmed with the CEO.

Observed in Record Review. In 1 of 5 patient records reviewed, the assessment did not include the severity of the symptom. In RR #2, the surveyor noted the chaplain and medical social worker identified the patient as having depression; however, the assessment did not include the severity of the symptom. This was confirmed with the administrator/DPCS.

Observed in Record Review. In 2 of 5 patient records reviewed, the plan of care was not based on the patient's goals and the time frames required to meet those goals. In HV #2, the surveyor noted the plan of care goals did not include a time frame on the initial plan of care. This was confirmed with the administrator/DPCS. In RR #1, the surveyor noted the plan of care goal section had a checkbox for each goal; however, the plan of care had no goals checked and therefore the plan of care had not goals identified for the patient. This was confirmed with the administrator/DPCS.

Observed in Record Review. In 3 of 5 patient records reviewed, the plan of care did not include interventions to manage pain and symptoms. In HV #1, the surveyor noted the patient was identified at risk for skin breakdown; however, the plan of care did not include interventions to address this identified need. This was confirmed with the administrator/DPCS. In HV #2, the surveyor noted the patient was identified as having shortness of breath; however, the plan of care did not include interventions to address this identified need in first certification period. This was confirmed with the administrator/DPCS. In RR #2, the surveyor noted the patient was identified as having depression and dysphagia; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the administrator/DPCS.

Observed in Record Review. In 2 of 5 patient records reviewed, the plan of care did not include drugs and treatment necessary to meet the needs of the patient. In HV #2, the surveyor noted the plan of care goal indicated blood sugar between 60 - 180; however, the plan of care did not include the frequency of blood sugar monitoring. This was confirmed with the administrator/DPCS. In RR #2, the surveyor noted the plan of care indicated duoneb 1 unit dose; however, did not specify the dosage of the medication. This was confirmed with the administrator/DPCS.

Observed in Record Review. In 1 of 5 patient records reviewed, the organization did not provide care, treatment or services according to the patient's individual plan of care. In HV #1, the surveyor noted the plan of care indicated the skilled nurse was to educate on the administration and side effects of all medications. The patient was started on four new medications (metoprolol, aspirin, atorvastatin and amlodipine); however, there was no documentation of education provided on these new medications. This was confirmed with the administrator/DPCS.

Observed in Individual Tracer. In 1 of 3 home visits conducted, the organization did not use standard precautions to reduce the risk of infection. In HV #3, the surveyor noted the aide entered their bag to retrieve equipment without performing hand hygiene upon arrival. This was discussed with the DPCS/administrator.

Observed in Record Review. In 1 of 2 patient records reviewed where the patient received aide services, the registered nurse did not prepare written patient care instructions for the hospice aide. In HV #3, the surveyor noted the patient required a shower chair; however, the aide plan of care did not include this written instruction. This was confirmed with the administrator/DPCS.

Observed in Record Review. In 5 of 5 patient records reviewed, all entries were not appropriately authenticated and dated in accordance with hospice policy and currently accepted standards of practice. In HV #1, the surveyor noted the chaplain coordination note did not include the date when the chaplain signed the note. In addition, the medical social worker did not authenticate the COVID 19 screening assessment document as evidenced by there was no signature on the document. This was confirmed with the administrator/DPCS. In HV #2, HV #3, RR #1 and RR #2, the surveyor noted the medical social worker did not authenticate the COVID 19 screening assessment document as evidenced by there was no signature on the document. This was confirmed with the administrator/DPCS.

Observed in Record Review. In 3 of 5 patient records reviewed, the organization did not protect against unauthorized alteration. In HV #3, the surveyor noted the plan of care was typed with handwritten checkmarks; however, these checkmarks were not dated and initialed as to when they were amended as required by the organization's policy Information Confidentiality, Security and Data Integrity. In addition, the first IDG note was typed with hand written checkmarks without date and initial of amendment. This was confirmed with the administrator/DPCS. In RR #1, the surveyor noted the discharge summary and plan of care were typed and had hand written entries added; however, the skilled nurse did not follow their policy for amending the record to include the date and initial of the amended entry. This was confirmed with the administrator/DPCS. In RR #2, the surveyor noted the plan of care and the oxygen safety assessment was typed with handwritten documentation; however, the skilled nurse did not follow their policy for amending the record to include the date and initial of the amended entry. This was confirmed with the administrator/DPCS.

Observed in Record Review. In 1 of 5 patient records reviewed, the hospice did not provide services in accordance with rules and regulations. In HV #2, the surveyor noted the hospice election of benefit form indicated Diabetes Mellitus Type 2 was not covered; however, the organization did not specify on the form that metformin would not be covered under the benefit. This was confirmed with the CEO.