Every finding on record at Serenity Hospice Care

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 1,2,3,4,5,6,7,8,9,10: There is no evidence in the patient record that the RN compressive assessment takes into consideration the imminence of death.

Upon patient record review, 4 of 14 (Patient #2,4,7,10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 2: On the home visit the acetaminophen 500mg tablet 3xday as needed for pain, patient does not have this medication in the home and caregiver states it has been discontinued, there is no discontinue order on the medication profile. Patient has Miralax oral powder 17gm on the hospice medication profile, this medication is not in the home and has not been discontinued on the hospice medication profile. Corrected on site. Patient 4: The medication profile list Acetaminophen 500mg oral tablet every 6 hours prn and Acetaminophen rectal suppository 650mg every 6 hours as needed, the entry does not include a maximum dose of 4000 mg daily. Corrected on site. Patient 7: The medication profile list Acetaminophen oral tablet 325mg 2 tabs every 6 hours as needed and Acetaminophen rectal suppository 650mg every 6 hours as needed, the entry does not include a maximum dose of 4000 mg daily. Corrected on site. Patient 10: The medication profile list Acetaminophen 500mg tab one by mouth every 4 hours as needed and Acetaminophen rectal suppository 650mg every 6 hours as needed for pain, the entry does not include a maximum dose of 4000 mg daily. Corrected on site.

Upon patient record review, 3 of 14 (Patient #4,7,10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 4: On the plan of care there is an order for Acetaminophen 500mg oral tablet every 6 hours prn and Acetaminophen rectal suppository 650mg every 6 hours as needed, the entry does not include a maximum dose of 4000 mg daily. Corrected on site. In addition, there is documentation “ISC to be performed 4-5x/day to be performed by caregivers”, there are no orders on how to perform intermittent self catheterization Patient 7: On the plan of care there is an order for Acetaminophen oral tablet 325mg 2 tabs every 6 hours as needed and Acetaminophen rectal suppository 650mg every 6 hours as needed, the entry does not include a maximum dose of 4000 mg daily. Corrected on site. Patient 10: On the plan of care there is an order for Acetaminophen 500mg tab one by mouth every 4 hours as needed and Acetaminophen rectal suppository 650mg every 6 hours as needed for pain, the entry does not include a maximum dose of 4000 mg daily. Corrected on site.

Upon patient record review, 2 of 14 (Patient #4,9) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 4: In the patient record there is documentation “ISC to be performed 4-5x/day to be performed by caregivers”, there are no supplies listed for self catheterization on the plan of care. Corrected on site. Patient 9: On 4/23/25 the RN documented that the patient has a wheeled walker. This equipment is not on the DME list on the plan of care. Corrected on site.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 4: In the RN comprehensive assessment 04/4/24 there is documentation, "patient needs ISC which he is unable to do", ISC is not an approved abbreviation.

Upon patient record review, 1 of 6 (Patient #2) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 2: An order dated 5/16/2022 included Oxygen 2L/M PRN, Instructions admin 2-5L via N/C , Oxygen 2-4L via N/CPRN anxiety. There was no evidence of a medication profile with O2. Corrected on site.

Upon patient record review, 4 of 6 (Patient #1, 2, 4, 5) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patients 1, 2, 4, 5 plan of care included SN 1-4x per week and 3 prn. Orders are not individualized to the patient specific need.

Upon patient record review, 1 of 6 (Patient #2) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 2: Care plan dated 5/16/2022 included Oxygen 2L/M PRN, Instructions admin 2-5L via N/C, Oxygen 2-4L via N/CPRN anxiety. Corrected on site.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 2; Home visit with LPN, used gloves during pt care, reached into pocket with dirty gloves to retrieve sanitizer wipes and cleansed all equipment, placing it back into clean space of bag, without changing gloves.

Upon patient record review, 3 of 4 applicable (Patients #1, #2, #5) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patients 1, 2, 5: In the SOC RN assessment the patient is identified as high fall risk. There is no evidence in the HHA POC of fall risk precautions. Corrected on site for 1 and 2.

Upon patient client record review, 1 of 6 (Patient #1) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 1: There were 2 Written certifications with narrative not appropriately dated. Certification signed 3/30/2022 for cert period of 5/29/2022-7/227/2022 (intended for Cert period of 3/30/2022-5/28/2022), and Written certification singed 5/30/2022 for cert period of 7/28/2022- 9/25/2022 (intended for cert period of 5/29/2022- 7/27/2022). Corrected on site.

Upon client record review, 6 of 6 (Patient #1, #2, #3, #4, #5, #6) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patients 1, 2, 3, 4, 5, 6: There was no documentation or evidence in the client record that the written policies and procedures for managing controlled drugs was provided and discussed.

Upon personnel record review, 1 of 4 applicable records (Personnel #9) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel 9: MD did not have evidence of a criminal background check.