Every finding on record at Serenity Hospice Care, 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 following, 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 measures 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 4 of 19 (21%) clinical records reviewed and home visits observed, the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient's current medications. CLINICAL RECORD 7/HOME VISIT 1: The patient elected hospice care on 06/27/2024 with a primary diagnosis of senile degeneration of the brain. The patient resided in a skilled nursing facility (SNF). During the home visit with the Chaplain [Personnel Record 7] on 11/18/2025, the hospice medication profile printed on 11/17/2025 and the SNF medication profile were reviewed. The hospice medication profile documented acetaminophen 500 mg tablet, administer one (1) tablet every 6 hours as needed for mild pain or fever (dated 11/15/2024); allopurinol 300 mg tablet, give one (1) tablet by mouth daily as needed (dated 06/28/2024); anti-diarrheal (loperamide) 2 mg capsule, give two (2) caps/tabs by mouth after 1st loose stool, followed by one (1) cap/tab by mouth after each loose stool up to 6 tabs daily (dated 10/24/2024); duloxetine 40 mg capsule delayed release, one (1) capsule daily, dated 11/21/2024; polyethylene glycol 3350 17 gm/dose oral powder, mix 17 gm powder (one capful) with 6-8 oz fluids and drink daily as needed for constipation, dated 06/28/2024; and Senna Lax 8.6 mg tablet, take one (1) tablet by mouth daily, dated 09/10/2024. The SNF medication profile did not document acetaminophen, allopurinol, anti-diarrheal (loperamide), polyethylene glycol, or Senna. The SNF nurse verified that acetaminophen, allopurinol, anti-diarrheal (loperamide), polyethylene glycol, and Senna. CLINICAL RECORD 9/HOME VISIT 3: The patient elected hospice care on 05/02/2025 with a primary diagnosis of chronic obstructive pulmonary disease (COPD). During the home visit with the Certified Nurse Aide (HA) [Personnel Record 8] on 11/19/2025, the patient's home medications and hospice medication profile were reviewed. The patient's home medications included pantoprazole sodium dr 20 mg, take one (1) tablet daily; benzonate 100 mg capsule, take one (1) capsule three times a day (dated 07/25/2023); potassium chloride ER 10 mEq tablet, take one (1) tablet daily (dated 11/04/2024); Centrum Woman's Vitamin, take one (1) tablet daily; and acidophilus probiotic 100 million organisms, take two (2) capsules twice a day. All of the patient's prescription bottles had older dates. The patient stated that the new medications were put in the smaller bottles to fit them all in the container where the medications are kept. The hospice medication profile printed on 11/17/2025 documented magnesium gluconate 12.5 mg magnesium (250 mg) tablet, take one (1) tablet by mouth at bedtime (dated 06/19/2025), and omeprazole 20 mg capsule, delayed-release, take one (1) capsule daily (dated 05/05/2025). The patient stated that the magnesium gluconate was taken a few times and then stopped due to not working, that pantoprazole has been taken for two (2) years instead of omeprazole, Centrum Women's Vitamin has been taken for two months, and the acidophilus probiotics has been taken for several years. CLINICAL RECORD 10/HOME VISIT 4: The patient elected hospice care on 01/12/2023 with a diagnosis of diffuse large B-cell lymphoma. The patient resided in an assisted living facility (ALF) since 04/2025. During the home visit with the Medical Social Worker [Personnel Record 6] on 11/19/2025, the patient's home medications and the hospice medication profile printed on 11/17/2025 were compared. The hospice medication profile documented Midodrine 2.5 mg tablet, 5 mg orally as needed for severe hypotension (dated 01/16/2023). The ALF med tech reported that Midodrine was not documented on the ALF active or discontinued medications. CLINICAL RECORD 15: The patient elected hospice care on 08/21/2025 with a diagnosis of senile degeneration of the brain. The medication profile was reviewed on 11/19/2025. A clinical record review revealed a coordination note dated 11/05/2025 at 2:44 AM documenting, "Son called. Confirmed he is on contact list. Also confirmed date of birth (DOB). He reports this morning (patient) woke him around 230 (patient) is banging on the table in the kitchen. (Patient) is agitated. He placed the lorazepam cream about 30 minutes ago. So far it is not effective. He applied 4 clicks of the medication to the skin. He also has the lorazepam intensol 0.25 ml. When he gives (patient) is very drowsy. He did not administer this medication. He is requesting patient to receive a shot to help... sleep. Advised him will have a nurse come assess and assist with patient symptom needs...” The physician's order dated 10/29/2025 ordered, "change lorazepam to scheduled TID (three times a day) and Q4HR PRN (every 4 hours as needed). Add lorazepam cream for emergency use when patient refuses oral medication." The medication profile reviewed on 11/19/2025 did not include documentation of lorazepam cream or lorazepam intensol as active or discontinued medications to date. During a joint record review and interview on 11/20/2025, the Manager of Accreditation and Regulatory Compliance confirmed that there was no documented evidence that the medications were reconciled when new medication was added, or changes made to existing medications.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any), the patient or patient representative, and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the Registered Nurse member of the IDG coordinated care, continuously assessed the patient’s and family’s needs, and implemented the interdisciplinary plan of care established by the hospice IDG. CLINICAL RECORD 15: The patient elected hospice care on 08/21/2025. On 10/28/2025, the Registered Nurse (RN) and Medical Social Worker (MSW) visited the patient at the patient's home together. The RN Coordination Note dated 10/28/2025 documented, “Upon arrival, (emergency medical services) EMS and law enforcement in the patient's yard. Sheriff’s deputy in yard advised nurse that (son), PCG (primary caregiver) had called 911 d/t (due to) patient taking too many pills. EMS was in home evaluating patient. Patient sitting in recliner with eyes open upon nurse arrival. (Vital signs) VS were stable per EMS, and patient was at baseline of pleasantly confused. (Son) reported that the Synthroid bottle had 8-9 pills in it earlier, but now only had 2. Discussed using a pill planner and patient agreed. Nurse filled pill planner with available medications. Updated (son), POA [power of attorney] about visit. Per (POA), patient (pt) had 2 Synthroid when he had spoken to (the patient) the day before. (POA) does not believe patient took too many pills, patient requires assistance with all ADLs except feeding…” The MSW Coordinaton Note dated 10/28/2025 documented, “SW (social worker) met with pt and cg for routine visit. Pt alert and oriented to self. Pt hard of hearing. EMTS present upon SW arrival as pt had taken multiple thyroid pills by accident. RNCM (Registered Nurse Case Manager) also present. SW assessed pt for changes in mental health. Pt alert and able to communicate clearly. SW and RN provided education about medication management. RN filled pill planner. SW assessed for other needs." The Triage After Hours Coordination Note dated 10/28/2025 at 9:57:00 PM, documented, "Son of (patient) calling because (patient) is yelling and anxious and very agitated. (Patient) has lorazepam but will not take it for (son). (Son) has called EMS to help get (patient) calm…. 10/28/2025 10:12:00 PM Called LPNOC (Licensed Practical Nurse on call). Gave report. (LPNOC) asked for us to call (the LPNOC) when the patient pings. Let (LPNOC) know I will email RNCM, (LPNOC), and the office to update… 10/28/2025 10:33:00 transferred (POA), another son, with POA. He says (the patient) has been combative and fighting. EMS is there, and they do not know what to do with (the patient). (The patient) is obsessed with getting (patient's) thyroid pill.... (Patient's) MAR and the medications in (the patient's) home do not match in form, but (the patient) has lorazepam in the home…Also educated that there is (lorazepam (Ativan), diphenhydramine (Benadryl), haloperidol (Haldol) (“ABH”)) ABH cream that can take the edge off…, but the doctor would have to order it. He says they are trying to get through until January, when he can take (the patient) to a facility near his home.” The Triage After Hours Coordination Note dated 10/31/2025 at 5:57:00 PM, documented, "(son) CG states patient is supposed to be going to respite and he needs to find out when and where (patient) is going? 10/31/2025 6:08:00 OB call to (SW), who states (SW) will call on call SW for branch to see if (SW) can get some answers as to when/where patient is supposed to go and will f/u with son.” The Non-Clinical Phone Call Coordination Note entered on 10/31/2025 at 6:33:00, documented, “SWOC (social worker on call) needing to speak with region (number) SWOC regarding respite stay for pt… 10/31/2025 6:41:00 connected to SWOC…” The Interdisciplinary Group (IDG) Meeting dated 10/31/2025, documented, "Social Worker note: SW met with pt and cg for routine visit. Pt is agitated easily and cg fatigue combined with cg mental health concerns creates volatile environment for pt and cg. RN, SW, and DO (Director of Operations) discussed with cg and POA options such as medication and respite assist. Cg unwilling to utilize medication. POA agreed to take pt to his home for a few days to provide relief to cg after cg refused respite." The Non-Clinical Phone Call (Customer Relations Team Leader) Coordination Note dated 11/02/2025 at 4:14:00 PM, documented, “Son calling. The patient is in the background agitated and yelling, and he is saying (the patient) may need to be placed somewhere because they are unable to take care of (patient) due to her behavior. Transferred to (nurse) in triage.” The Triage After Hours Coordination Note dated 11/02/2025 at 4:15:00 PM, documented, "Son came to pick pt up, and pt is screaming and combative. Pt is uncontrollable and family is unable to give any medications to calm patient down. CG deny the need for nurse visit as the patient was starting to settle towards end of call. Cg reports he will call office in the morning to come up with a plan for pt… Follow-up comment entered by (registered nurse) on 11/04/2025 Lengthy conversations with POA and nurses/MSW as well as CS (Clinical Supervisor) and AVP (Area Vice President) about care and needs.” There was a Triage After Hours Coordination Note entered on 11/03/2025 at 6:06:00 AM, that stated in part, "Family member (son) states he gave patient Ativan last evening and (the patient) slept until about 5 am and now (the patient) is awake, screaming. States they were not able to move the patient yesterday to another family member’s home, and he cannot take care of (the patient). States he has anxiety, and he cannot handle taking care of (the patient). Asked if he had tried to give patient more Ativan, and he states no because patient will not take the pills. States someone was supposed to be looking into finding somewhere for patient to go. Placed on hold and transferred to an on-call nurse.” The Triage After Hours Coordination Noted entered on 11/05/2025 at 2:44:00 AM, documented, "Son called….He reports this morning (the patient) woke him around 230 (The patient) is banging on the table in the kitchen. (The patient) is agitated. He placed the lorazepam cream about 30 minutes ago. So far, it is not effective. He applied 4 clicks of the medication to the skin. He also has the lorazepam intensol 0.25 ml. When he gives (the patient) is very drowsy. He did not administer this medication. He is requesting patient to receive a shot to help (patient) sleep. Advised him will have a nurse come assess and assist with patient symptom needs. He is also asking about respite as patient is becoming too difficult to care for….” The On Call RN Coordination Noted dated 11/05/2025 at 6:59:27, documented, “Received call from triage that pt son called reporting pt was screaming and beating on the table at 3 AM and he is not able to calm her down. Medications on med list do not match medications pt son is saying are in home. Request for nurse to come out and give pt a shot and take (the patient) to placement. Nurse called (POA) per report to inquire about situation. He is unaware, and states he went out to cut grass and clean up Monday and (son) was in home, pulled a gun on him so he is not going over there any more states (Son) and patient are “nuts” and they both need mental health help. Nurse called (son), and he stated he cannot calm pt down. He has not given the liquid Ativan since yesterday afternoon. Nurse told him he will have to give that to (the patient) to keep (patient) calm. Explained we cannot give patient a shot, and I cannot find placement for pt at 3 am…” The CS Annotation Coordination note dated 11/05/2025 at 11:49 AM, documented, "AVP and CS discussed care and safety issues with QA (quality assurance) Director about patient’s home environment this morning. Discussed the POA son and son that is physically at the home taking care of the patient not being the same person… (POA) states that he and (son) did argue on Monday and that he has pulled a gun on him in the recent past. It was suggested that we discharge patient from care for cause related to safety issues for staff. (CS) will plan to follow up with our MSW as well as (POA)." The CS Annotation Coordination Note dated 11/05/2025 at 11:59 AM, documented, "(CS) just got off the phone with (POA). …(POA) and (CS) discussed the need to discharge (the patient) for cause due to the risk of safety to our staff under the current living conditions. He said that he understands because he knows that his brother is unhinged and is not sure of his own safety when he goes to try to take care of the (patient)." The RN Hospice Discharge – No Visit Made note dated 11/05/2025, documented that the patient was discharged for cause. A clinical record review revealed no documented evidence that the RN made in-person visits after 10/28/2025 to continue assessing the patient and family needs. There was no documented evidence that the RN followed up with the patient or the sons after the triage calls requesting assistance with symptom management and placement. There was no documented evidence that the RN coordinated care with the full IDG, including collaboration with the Medical Director and/or Hospice Physician, and the patient or patient representative to meet the patient’s needs. During a joint record review and interview on 11/20/2025, the Manager of Accreditation and Regulatory Compliance confirmed that the clinical record lacked evidence of agency-initiated follow-up by the RN or other members of the IDG. The Manager of Accreditation and Regulatory Compliance agreed that the agency did not ensure that the RN coordinated care with the IDG, including the Medical Director or Hospice Physician, and continuously assessed the patient's needs. Before the exit conference, the patient’s clinical record was updated with late entries regarding the incident and subsequent discharge.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 18 (6%) clinical records reviewed of patients receiving Hospice Aide (HA) services, the hospice did not ensure that the HA received written patient care instructions to meet the patient's needs. CLINICAL RECORD 14: The patient elected hospice care on 02/08/2024 with a primary diagnosis of senile degeneration of the brain. The patient resided in a skilled nursing facility (SNF). The HA care plan dated 07/21/2025 assigned the HA the tasks, "Bathing (Bed) every visit, Bathing (shower) Monday, Wednesday, Friday." The care plan did not provide the HA with clear instructions regarding the type of bath the patient was to receive. During a joint review of the record and an interview on 11/20/2025, the Manager of Accreditation and Regulatory Compliance agreed that the instructions on the HA care plan were not specific.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 2 of 18 (11%) clinical records reviewed for patients who received Hospice Aide (HA) services, the agency did not ensure that the HA notified the Registered Nurse of changes in the patient’s needs. CLINICAL RECORD 14: The patient elected hospice care on 02/08/2024 with a diagnosis of senile degeneration of the brain. The patient resided in an assisted living facility (ALF). The HA care plan dated 07/21/2025 assigned the HA the tasks of "Bathing (Bed) every visit and Bathing (shower) Monday, Wednesday, Friday." The Hospice Aide visit notes dated 10/01/2025, 10/02/2025, 10/03/2025, 10/06/2025, 10/07/2025, 10/08/2025, 10/09/2025, 10/10/2025, 10/13/2025, 10/14/2025, 10/15/2025, 10/16/2025, 10/17/2025, 10/20/2025, 10/21/2025, 10/23/2025, 10/24/2025, 10/27/2025, 10/28/2025, 10/29/2025, 10/30/2025, and 10/31/2025 documented that the HA provided a bed bath and shower during each visit. There was no documented evidence that the registered nurse was contacted on which task to complete. CLINICAL RECORD 15: The patient elected hospice care on 08/21/2025 with a diagnosis of senile degeneration of the brain. The Hospice Aide care plan dated 08/28/2025 assigned the HA the relevant tasks: walker; assist to bedside commode; assist to toilet; bathing (shower); dressing; hair care; provide incontinence care; change linens; offer fluids; socialization; notify RN of any skin changes, bowel/bladder concerns, or safety issues; oxygen safety; report pain to nurse; review wound alert. The HA visit note dated 10/14/2025 documented "pt refused" for assist to toilet; assist to bedside commode; hair care; dressing; bathing (shower); provide incontinence care; offer fluids; change linens; socialization; and safety. There was no evidence that the HA notified the Registered Nurse (RN) of changes to the HA care plan. During a joint clinical record review and interview on 11/20/2025, the Manager of Accreditation and Regulatory Compliance confirmed that the HA documentation lacked notification to the Registered Nurse of the changes in the care plan.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 2 of 18 (11%) clinical records that had aide services reviewed revealed that the agency did not that the registered nurse did not make an on-site supervisory visit to the patient’s home no less frequently than every 14 days and assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. CLINICAL RECORD 1: The patient elected hospice care on 03/12/2025 with a diagnosis of alcoholic cirrhosis of the liver without ascites. The patient resided in an assisted living facility (ALF). The HA's first visit was dated 03/14/2025. Registered Nurse visits were documented on 07/23/2025, 07/29/2025, 07/31/2025, 08/04/2025, 08/07/2025, 08/15/2025, 08/18/2025, 08/26/2025, 08/28/2025, 09/09/2025, 09/11/2025, 09/17/2025, 09/19/2025, and 09/24/2025. A clinical record review revealed no evidence that a Registered Nurse made an on-site supervisory visit from 07/21/2025 through 09/01/2025 and 09/09/2025 through 09/29/2025. CLINICAL RECORD 14: The patient elected hospice care on 02/08/2024 with a primary diagnosis of senile degeneration of the brain. The patient resided in a skilled nursing facility (SNF). The HA care plan dated 07/21/2025 assigned the HA the tasks, "Bathing (Bed) every visit, Bathing (shower) Monday, Wednesday, Friday." The Hospice Aide visit notes dated 10/01/2025, 10/02/2025, 10/03/2025, 10/06/2025, 10/07/2025, 10/08/2025, 10/09/2025, 10/10/2025, 10/13/2025, 10/14/2025, 10/15/2025, 10/16/2025, 10/17/2025, 10/20/2025, 10/21/2025, 10/23/2025, 10/24/2025, 10/27/2025, 10/28/2025, 10/29/2025, 10/30/2025, and 10/31/2025 documented giving the patient both a bed bath and shower during each visit. There was no documented evidence that the Registered Nurse was contacted on which task to complete. The RN Hospice Subsequent Visit notes dated 10/06/2025, 10/13/2025, 10/22/2025, 11/05/2025, 11/13/2025, 11/20/2025 documented, "Supervisory functions: Does the aide follow the plan of care? Yes. Any changes to the plan of care? No." There was no documented evidence that the RN assessed the quality of care and services provided by the HA to ensure that services ordered by the Interdisciplinary Group (IDG) meet the patient’s needs. During a joint clinical record review and interview on 11/20/2025, the Manager of Accreditation and Regulatory Compliance confirmed that the RN did not make on-site supervisory visits every 14 days or assess the quality of care and services provided by the HA, and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s needs.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the organization did not ensure the patient’s clinical record included physician’s orders to meet the patient's care needs. CLINICAL RECORD 15: The physician's order dated 10/29/2025 ordered, "Change lorazepam to scheduled TID [three times a day] and Q4HR PRN [every 4 hours as needed]. Add lorazepam cream for emergency use when the patient refuses oral medication." The order did not document the strength, dose, or frequency of administration of the lorezapam cream. During a joint review of the record and an interview on 11/20/2025, the Manager of Accreditation and Regulatory Compliance agreed that the physician’s orders did not include the medication's strength, the dose to be given, or the frequency.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: hospice election form. This standard was not met as evidenced by clinical record review, document review, interview, and observation. Agency policy # 1-031 "Provision of Care to Residents of SNF/NF or ICF/IID" (not dated) stated in part, "7. The organization will provide the SNF/NF or ICF/IID the following information specific to each patient: B. Hospice election form and Advanced Directives." In 1 of 1 (100%) home visits observed and clinical records reviewed of a patient residing in a skilled nursing facility (SNF), the organization did not ensure the Interdisciplinary Group (IDG) provided the SNF with the hospice election form. HOME VISIT 1/CLINICAL RECORD 7: The patient ELECTED HOSPICE CARE ON 06/27/2024. Upon reviewing the hospice documents at the SNF, there was no documented evidence that the agency provided a copy of the patient's hospice election form. During a joint clinical record review, document review, and interview on 11/18/2025, the Manager of Accreditation and Regulatory Compliance confirmed that the agency did not provide the facility with the hospice election form.

It is required that the written Patient Bill of Rights includes the right to receive effective pain management and symptom control from the hospice for conditions related to the terminal illness. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 13 (8%) records reviewed revealed the agency did not ensure the patient's right to receive effective pain management and symptom control. Clinical Record 3: The 12/15/2022 registered nurse (RN) visit note stated the patient was complaining of burning with urination. On 12/15/2022, the RN documented she notified the patient’s physician who ordered a urinalysis with culture and sensitivity. On 12/16/2022, the RN documented that the urine specimen was collected and transported to the lab. Four days later on 12/22/2022, the RN documented the patient continued to report urinary urgency and frequency, but the RN did not reference the UA result from the specimen that was collected on 12/16/2022 in her documentation. In a delayed entry in the clinical record on 12/28/2022, the RN stated the 12/16/2022 UA report was uploaded into the patient’s record with a fax received date of 12/28/2022. The medication profile was updated to reflect a new medication order for Ampicillin 500 mg oral three times a day for 1 week, with a start date of 12/28/2022. There was a span of 12 days from the date the RN transported the urine specimen to the lab on 12/16/2022 until the patient began taking the Ampicillin on 12/28/2022. Additionally, documentation in the 01/05/2023 RN recertification assessment and the 01/12/2023 RN visit note stated the patient continued to report burning with urination. There was no documentation regarding assessment of medication compliance or effectiveness of the Ampicillin, and no communication with the physician regarding ongoing symptoms. The documentation in the clinical record included a missed visit entry for a 01/15/2022 nursing visit. On 01/20/2023 a physician’s order was entered for Nitrofurantoin 100mg orally twice daily for 7 days and per the RN visit note documentation, the caregiver was "educated." On 01/23/2023, the RN entered a coordination note which stated the patient’s caregiver had called to let the agency know the medication had not yet been delivered. The RN responded to the caregiver that she had left a voice mail and text message on 01/20/2023, stating the medication would need to be picked up at the pharmacy. A 01/24/2023 coordination note entered by the RN stated the caregiver had picked up the medication and was providing it to the patient as directed. There was a span of 18 days from the date the patient reported continued burning with urination on 01/5/2023 and 01/24/2023, the date the patient’s caregiver picked up the 2nd antibiotic Nitrofurantoin and started providing it to the patient as directed. During the 01/26/2023 RN home visit, the caregiver stated the patient reported burning with urination had decreased. The patient first reported burning with urination on 12/15/22 and reported a decrease in symptoms on 01/26/2023, a span of 42 days. In an interview on 01/26/2023, the agency Director of Accreditation stated the agency was unable to provide additional evidence of timely follow-up with lab results and symptoms presented and subsequent assessment and coordination of medication effectiveness.

It is required that 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 a review of clinical records, document reviews, interviews and observations. 1 of 13 (8%) records reviewed revealed the agency did not ensure that the medication profile was updated when changes were made to an existing medication. Clinical Record 1: The 1/10/2023 Hospice plan of care (POC) and the current medication profile indicated, “Oxygen 2-5 Liters continuous via nasal cannula.” The 12/27/2022 renewal Certification of Terminal Illness (CTI) indicated, “Oxygen in the home for prn use.” The 01/16/2023 registered nurse assessment indicated, “patient on room air.” During the home visit on 01/15/2023, the patient was observed on room air and the caregiver stated the patient only utilizes oxygen when short of breath. The Medication Profile Policy (Policy no.2-004) stated in part, "The medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications." In an interview on 01/25/2023, the agency Director of Accreditation indicated the oxygen use was incorrect on the medication profile and the Hospice POC and had been corrected.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by review of records, documents, and interview with the leadership team which revealed the following issues with the development and implementation of patients’ interdisciplinary care plans: Failure to provide coordination of care and to ensure continuous assessment of patient and family needs and ensure implementation of the interdisciplinary plan of care [HCPC.19.I/L540]; Failure of the hospice Interdisciplinary Group to ensure Hospice care and services were provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician [HCPC.19.I/L543]; Failure of the Interdisciplinary Group to ensure each patient’s individualized written plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments [HCPC.21.I/L545]; Failure to ensure that the plan of care included a detailed statement of the frequency of services needed to meet specific patient and family needs [HCPC.21.I/L547]; Failure to ensure the plan of care included treatments necessary to meet the needs of the patient [HCPC.21.I/L549]; and Failure of the agency to provide care in accordance with the Patient’s Bill of Rights to ensure the patient received effective pain management and symptom control [HPFC.2.D/L512]. The cumulative effect of these deficiencies could negatively impact the organization’s ability to develop, update, and implement plans of care to ensure services are provided that will meet the care needs of patients.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; and ensure implementation of the interdisciplinary plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 13 (8%) records reviewed revealed the agency did not ensure coordination of care and continuous assessment of the patient’s needs. Clinical Record 3: The 12/15/2022 registered nurse (RN) visit note documentation stated the patient was complaining of burning with urination. The physician was notified per RN visit note documentation on 12/15/2022 and ordered a urinalysis with culture and sensitivity which was documented as completed and transported to the lab on 12/16/2022. The 12/22/2022 RN visit documentation stated the patient complained of urgency and frequency with urination but did not reference laboratory (lab) results from lab collected on 12/16/2022. On 12/28/2022 delayed entry documentation entered by the RN stated, “For '15/16', results sent to physician and order obtained and entered for Ampicillin 500mg oral three times a day for 1 week, patient caregiver was notified.” The medication profile was updated to reflect the new medication order with a start date of 12/28/2022. Lab results were uploaded into the patient record with a fax received date of 12/28/2022. The 01/05/2023 recertification assessment and the 01/12/2023 visit note entered by the RN stated patient had burning with urination and there was no documentation regarding medication compliance/effectiveness or communication with the physician. There was a missed visit entry for a nursing visit on 01/15/2023. A 01/20/2023 physician order was entered for Nitrofurantoin 100mg orally twice daily for 7 days and the caregiver was educated per RN visit note. A 01/23/2023 coordination note entered by the RN stated the caregiver had called to let the agency know the medication had not yet been delivered to which the nurse responded that a voice message and text message was left for the caregiver on 01/20/2023 stating the medication would need to be picked up at the pharmacy. A coordination note entered by the RN on 01/24/23 stated the caregiver had picked up the medication and was providing it to the patient as directed. During the home visit on 01/26/2023 the caregiver stated the patient had started the antibiotics and reported burning with urination had decreased. In an interview on 01/26/2023, the agency Director of Accreditation stated the agency was unable to provide additional evidence of timely follow-up with lab results and symptoms presented and subsequent assessment and coordination of medication effectiveness.

It is required that Hospice care and services provided to patients and families follow the individualized plan of care established by: The hospice IDG in collaboration with the attending physician (if any); the patient or patient representative; and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 13 (15%) records reviewed revealed the agency did not ensure services were provided per the Hospice plan of care (POC). Clinical Record 8: The 01/02/2023 Hospice plan of care (POC) included a Chaplain visit frequency of 1week1; 1 every 4 week 8. There was no evidence that a Chaplain visit was made and there was no missed visit documentation prior to the 01/16/2023 Chaplain visit note. Clinical Record 13: The patient was admitted to Hospice on 10/28/22 with a diagnosis of Congestive Heart Failure. A Physical Therapy (PT) evaluation was ordered on 11/08/2022 and the patient revoked the Hospice Benefit on 01/04/2023. There was no evidence that the PT evaluation was provided as of the date of the revocation on 01/14/2023. In an interview on 01/27/2023, the agency's Director of Accreditation stated the associated orders and visits were reviewed and there was no additional documentation to confirm that the visits were provided as ordered on the Hospice POC.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 13 (15%) records reviewed revealed the agency did not ensure the plan of care included planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 7: The 12/22/2022 Hospice plan of care (POC) included a diagnosis of Diabetes and SN to report a pattern of blood glucose >300mg/dl. The 12/22/2022 registered nurse (RN) start of care (SOC) assessment stated the caregiver performed fingerstick blood sugar checks twice weekly. The 01/17/2023 RN visit note stated the patient does not get fingerstick blood sugar checks but did have a Hemoglobin A1C check with his last physician appointment. There were no interventions related to blood sugar check frequency on the Hospice POC to date. Clinical Record 8: The 11/03/2022 Hospice POC included a diagnosis of Diabetes. The 11/03/2022 RN SOC assessment stated the caregiver performs fingerstick blood sugar checks as needed. The 12/22/2022 RN visit note stated the patient performs fingerstick blood sugar checks daily. There were no interventions related to blood sugar check frequency on the Hospice POC to date. In an interview on 01/26/2023, the agency Director of Accreditation confirmed there were no interventions related to diabetic monitoring on the Hospice POC. She further stated the Hospice POC has since been updated.

It is required that each patient’s individualized written plan of care: includes a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 13 (8%) records reviewed revealed the agency did not ensure that a detailed scope and frequency was included on the hospice plan of care (POC) for services provided. Clinical Record 5: The 12/20/2022 Hospice POC did not include orders for a social work visit frequency. The 12/16/2022, 12/30/2022, and 01/13/2023 interdisciplinary team meeting notes entered by the social worker included an active problem related to coping with associated interventions and goals on the updated Hospice POC. In an interview on 01/26/2023, the agency Director of Accreditation stated/confirmed the Hospice POC did not have a visit frequency for the social worker and that this has since been corrected.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 13 (15%) records reviewed revealed the agency did not ensure that the hospice plan of care (POC) included treatments necessary to meet the needs of the patient. Clinical Record 12: The 08/19/2022 registered nurse start of care visit documentation indicated the patient had a urostomy and the Hospice nurse would change the urostomy bag two times per week. There were no orders on the 08/19/2022 Hospice POC to date regarding urostomy care. Clinical Record 13: The 10/28/2022 registered nurse start of care visit documentation indicated the patient had a Stage II sacral decubitus with orders for calmosyn and manuka honey dressing changes. There were no orders on the 10/28/2022 Hospice POC to date regarding decubitus wound care. In an interview on 1/27/2023, the agency Director of Accreditation stated there no treatment order for the needs identified in the associated nursing assessment documentation.

It is required that bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 2 (50%) clinical records reviewed with the provision of bereavement services revealed the agency did not ensure a bereavement plan of care was developed to address the needs of the bereaved. Clinical Record 10: The patient expired on 11/15/2022. A post death bereavement assessment was documented at time of death as well education on and agreement of the family member to receive bereavement services. There was no documented evidence of a bereavement plan of care in the clinical record to date. In an interview on 01/26/2023, the agency Director of Accreditation reviewed the clinical record and confirmed there was no bereavement plan of care in place. This was subsequently corrected. In addition, she stated the family member of the patient had been identified as low risk at the time of death and per agency low-risk care plan a post card had already been mailed and documentation had since been entered to reflect the bereavement care that was provided.

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 a review of clinical records and interviews. 5 of 9 (56%) clinical records reviewed in which aide services were provided revealed the agency did not ensure the aide provided visits and services included in the aide plan of care. Clinical Record 4: The 11/25/2022 aide plan of care (POC) created by the registered nurse (RN) described a task frequency of weekly for shampoo and linen change. The aide visit documentation dated 01/17/2023, 01/18/2023, 01/19/2023 and 01/20/2023 describe completion of linen change each visit as well as the completion of shampoo with the exception of the visit dated 01/19/2023. Clinical Record 5: The 06/29/2022 aide POC created by the RN described a task frequency of weekly for nail care, shower and linen change. The aide's visit note documentation described these tasks were completed every visit from 12/21/2022 to 01/24/2923 with the associated aide visit frequency of 4 week 1, 5 week 9, effective 12/20/2022. Clinical Record 9: The 10/29/2022 aide POC created by the RN described a task frequency of nail care weekly and linen care twice weekly. The aide's visit note documentation indicated these tasks were completed every visit with the associated aide visit frequency of 5 x week for 10/31/2022-11/18/2022. In addition, there were only 4 documented aide visits for the week of 10/31/2022 however, the aide visit frequency on the 10/29/2022 hospice POC was 5 x week. Clinical Record 12: The 08/19/2022 aide POC created by the RN indicated a task frequency of weekly for nail care, shampoo, shave and linen care. The aide's visit note documentation indicated these tasks were completed every visit with the associated aide visit frequency of 2 x week effective 10/06/2022. Clinical Record 13: The 10/28/2022 aide POC created by the RN indicated a task frequency of linen change twice weekly. The hospice aide's visit note documentation indicated these tasks were completed every visit for the week of 12/05/2022 with the associated aide visit frequency of 5 x week per the 10/28/2022 hospice POC. The agency Director of Accreditation reviewed the aide visit documentation and in an interview on 01/16/2023, stated the aide did not provide care as directed on the aide care plan.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives and the hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 1 (100%) record reviewed in which services were provided for a patient in a SNF revealed the agency did not ensure that there was clear delineation of which provider was responsible for performing the functions that were agreed upon and included in the plan of care. Clinical Record 9: The 10/29/2022 Hospice plan of care wound care order read as follows: "Hospice nurse and caregiver to perform wound care to stage II sacral pressure wound utilizing clean technique - cleanse with wound cleanser, apply calmosyn cream, cover with non-adherent dressing and secure with medipore tape. Change daily and as needed if becomes soiled or dislodgement. Instruct caregiver on wound care." The wound care order does not provide specific direction regarding which provider should perform wound care on each day. In an interview on 01/26/2023, the agency Director of Accreditation acknowledged that the wound care order did not include specific provider instructions regarding provision of the daily wound care.