Every finding on record at Serenity Hospice Care, LLC

Based on a review of policy titled “The Interdisciplinary Plan of Care,” record review, and staff and family interviews, it was determined that the agency failed to provide care to the patient in accordance with the plan of care for one patient (P) (P2) of five sampled patients. --- Findings included: Review of an undated policy titled “The Interdisciplinary Plan of Care,” No. 9-017 revealed the following:“Policy:The care provided to the patient must be in accordance with the plan of care.Procedure:10. Any change in the patient’s condition must result in a change in the plan of care, prior to implementation of the new service.14. Care provided to the patient will be in accordance with the plan of care.” Clinical record for P2 failed to reveal documentation of wound care according to Plan of Care. Chart review for P2 failed to reveal order for UNNA boot (a specialized, non-elastic compression bandage, containing zinc oxide and calamine). Review of clinical record revealed coordination notes report dated 01/07/2026 with nurse documentation stating, “Skin tear covered with ointment and a bandage.”Coordination notes report dated 01/23/2026 revealed “RN cleaned site, applied Neosporin, and applied a new bandage.Coordination notes report dated 01/26/2026 revealed “informed pt and son, pt will need to UNNA boot applied to extremity.”Coordination notes report dated 02/02/2026 revealed “writer cleansed the wound using wound cleanser. No dressing was on her leg when I arrived.”Coordination noted dated 02/03/2026 revealed “both areas cleaned with wound cleanser, pat dry applied UNNA boot to extremity. Instructed to keep BLLE elevated, and not to remove UNNA boot will be changed in one week.” On 03/25/2026 at 10:20 AM, a phone interview was conducted with License Practical Nurse (LPN) who recalled making multiple visits to see P2, and recalled providing wound care, The LPN stated that the patient needed a UNNA boot and that the agency did not have the supplies for the UNNA boot. The LPN stated the agency had to order the supplies. The LPN stated that the family of P2 bought the supplies for the boot. The LPN was unable to confirm if pictures or measurements were taken of the wounds and stated she could not remember what doctor she notified of the wounds and UNNA boot order. The LPN could not confirm putting in an order for the UNNA boot. An in-person interview was conducted on 03/25/2026 at 11:00 AM with the Area Vice President who confirmed that wound measurements were documented only once for P2 on the visit dated 02/02/2026. Area Vice President also agreed that there was no order for a UNNA boot for P2.

Based on review of policy titled “Ongoing Comprehensive Assessment,” review of records, family and staff interviews, it was determined the agency failed to ensure that care and services were provided in accordance with the plan of care for one patient (P) (P2) of five sampled patients. Specifically, the agency failed to obtain Partial Thromboplastin Time /International Normalized Ratio (PTT/INR-test that measures how fast a blood sample forms a clot) every Wednesday as ordered. --- Findings included: Review of an undated policy titled” Ongoing Comprehensive Assessment,” No. 1-016, revealed the following:“Procedure:1. During each home visit, the Registered Nurse or other discipline will evaluate the patient according to the care plan problems identified during the initial assessment and thereafter the comprehensive assessment.2. The nurse will assess each patient on each visit for:     O. Compliance with treatments and medication regime5. Based upon the findings of the assessment, change/verbal orders will be obtained as needed and forwarded to the physician for signature.6. The physician will be notified to verify any changes in medications, including over-the -counter medications, and treatments/ interventions that require physician approval.” Review of records for P2 revealed a start of care (SOC) date of 10/31/2025, and discharge date of 02/08/2026. Review of records revealed a Hospice certification and Plan of Care dated 10/31/2025 with an order for hospice nurse to obtain Partial Prothrombin Time and International Normalized Ratio PTT/INR lab every Wednesday.  Review of plan of care update dated 01/13/2026 revealed an order for hospice nurse to obtain PTT/INR every Wednesday. An in-person interview was conducted on 03/25/2026 at 11:00 AM with the Area Vice President who confirmed that there was an order in P2 chart for PTT/INR to be drawn  every Wednesday. The Area Vice President also stated that she was only able to confirm the PTT/INR being checked two times and provided copies of the test results of first lab result dated 11/14/2025 and second on 01/26/2026. Additional weekly lab reports for Wednesday’s were not received prior to exit of survey.

Based on policies and procedures, record reviews, staff and family interviews, it was determined the agency’s governing body failed to ensure care provided had physician orders for one patient (P) (P2) of five sampled patients and the governing body failed to ensure nursing services were provided as ordered by the physician for one patient (P2) of five sampled patients. --- Findings included: Cross refer to L0545 relating to care plansCross refer to L0555 relating to Coordination of Services

It is required that each patient’s individualized written plan of care: reflects patient and family goals; [and] identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the patient's plan of care identified planned interventions based on problems identified in the comprehensive assessments. Clinical Record 3: The patient elected hospice care on 03/15/2024 with a diagnosis of senile degeneration of the brain. The skilled nursing (SN) recertification assessment dated 10/22/2024 documented that the patient was using oxygen continuously at 3 liters (L) per nasal cannula (NC). The plan of care orders dated 11/01/2024 for the certification period dated 11/10/2024 through 01/08/2025 did not document planned interventions and goals addressing the patient's use of oxygen. Clinical Record 14: The patient, a 13-year-old male, was admitted to hospice services on 01/16/2025 with the diagnosis of acute lymphoblastic leukemia. The SN's initial comprehensive assessment dated 01/16/2025 documented that the patient complained of severe fatigue. The plan of care did not document interventions and goals to address the patient's complaints of fatigue. The Manager of Compliance and Regulations confirmed findings after clinical record reviews on 02/11/2025.

It is required that each patient’s individualized written plan of care measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by document review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the patient's plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 14: The patient, a 13-year-old male, was admitted to hospice services on 01/16/2025 with the diagnosis of acute lymphoblastic leukemia. The SN's initial assessment documented the patient's severe pain. The plan of care dated 01/16/2025 through 04/15/2025 documented the patient's goal: "caregiver will demonstrate adequate knowledge of pain management." The goal did not document measurable outcomes or parameters to measure the patient's pain level. In an interview on 02/11/2025, the Manager of Compliance and Regulations confirmed that the plan of care did not include measurable outcomes.

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 following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the patient's plan of care included drugs and treatments necessary to meet the patient's needs. Clinical Record 6: The patient elected hospice care on 01/19/2023 with a diagnosis of chronic obstructive pulmonary disease (COPD). The patient resided in a skilled nursing facility (SNF). The skilled nursing (SN) recertification assessment dated 12/22/2024 documented, "recurrent stage 3 pressure ulcer to left hip, pressure ulcer being managed by the facility wound care team." The plan of care dated 12/24/2024 did not include documentation of orders for wound care or orders for the SNF to manage the wound care. Clinical Record 14: The patient, a 13-year-old male, was admitted to hospice services on 01/16/2025 with the diagnosis of acute lymphoblastic leukemia. The SN's initial comprehensive assessment dated 01/16/2025 documented, "Left chest port accessed with dressing intact with dried blood underdressing... the patient would be seen tomorrow for labs and possible transfusion." The plan of care did not document interventions or orders to address the port. Clinical Record 15: The patient elected hospice care on 09/10/2024 with a diagnosis of cerebral infarction. An SN recertification assessment dated 11/25/2024 documented that the patient required a Foley catheter, which was in place, and a G-tube for tube feedings. The plan of care ordered: "The hospice nurse to provide instructions/ reinforcement related to urinary incontinence," Isosource tube feedings, and medication routes per gastrostomy tube (G-tube). The plan of care dated 12/14/2024 through 03/13/2024 did not document orders or interventions for the care and maintenance of the Foley catheter or the G-tube. During a joint record review and interview on 02/11/2025, the Manager of Compliance and Regulation confirmed the finding and reported that the nurse forgot to push the orders through on the recertification plan of care. The Manager of Compliance and Regulations confirmed findings after chart reviews on 02/11/2025.

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 an 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 5 of 11 (45%) clinical records reviewed of patients receiving Hospice Aide services, the agency did not ensure that the Hospice Aide received patient care instructions that addressed all of the patient's needs. Clinical Record 2: The patient elected hospice care on 05/12/2023 with a diagnosis of heart disease. The patient resided in a skilled nursing facility (SNF). The skilled nursing (SN) visit notes and SN assessment dated 02/10/2025 documented that the patient was a high fall risk and required a Hoyer lift. The plan of care dated 01/01/2025 through 03/01/2025 ordered HA services "1w1, 2w8" and documented equipment that included Mobility Aids -(Hoyer). The HA care plan, last updated on 10/23/2024, documented fall precautions, wheelchair-bound, and transfer assistance. The HA documented "DONE or complete" for fall precautions, wheelchair-bound, and transfer assistance for each visit, as noted on the care plan. The HA care plan did not document using the Hoyer lift for transfers. Clinical Record 6: The patient elected hospice care on 01/19/2023 with a diagnosis of chronic obstructive pulmonary disease (COPD). The patient resided in a SNF. The SN assessment dated 12/22/2024 documented that the patient had a stage 3 pressure ulcer and was bedbound. The HA care plans dated 10/28/2024 and updated 01/19/2024 assigned the HA the relevant task of providing a shower (the SNF had a special shower for bedbound patients) every visit but did not provide any direction to the HA related to the left hip area and how to manage the dressing should it become wet or soiled during the shower. Clinical Record 8: The patient elected hospice care on 01/13/2025 with a diagnosis of hemiplegia following a cerebral vascular accident. The SN assessment dated 01/13/2025 documented that the patient had a gastrostomy tube (G-tube), a Foley catheter, and a stage 2 pressure ulcer on their "bottom." The HA care plan dated 01/13/2025 and updated 01/15/2025 assigned the HA the relevant task of bed bath. The HA care plan did not include documentation of instructions for the HA related to the care of the Foley catheter during personal care or the G-tube and wound dressings should they become soiled or dislodged during the bedbath. Clinical Record 12: The patient elected hospice care on 02/03/2025 with a diagnosis of malignant neoplasm of the laryngeal cartilage. The plan of care ordered HA services "1w1,1w12." The SN assessment dated 02/03/2025 documented that the patient had a new tracheostomy and a peg tube and was dependent on 5 liters (L) of oxygen per nasal cannula (NC). The HA care plan created by the RN on 02/03/2025 and updated on 02/04/2025 assigned the HA the relevant task of a bedbath. The HA care plan did not provide the HA with instructions related to the care of the percutaneous endoscopic gastrostomy (PEG) tube and the tracheostomy dressings should they become soiled or dislodged during the bedbath. The HA care plan did not provide instructions for the patient's use of oxygen during the bedbath. Clinical Record 13: The patient elected hospice care on 12/13/2024 with a diagnosis of memory deficit following a cerebral infarct. The plan of care ordered HA services "2w2, 3w7." The SN assessment and plan of care dated 12/13/2024 ordered oxygen as needed (PRN) and documented that the patient was on fall and oxygen precautions. The HA care plan documented by the RN dated 12/13/2024 assigned the HA the relevant task of bedbath. The HA care plan did not provide the HA with instructions on the patient's use of oxygen or fall precautions during personal care. During an interview on 02/13/2025, the Manager of Compliance and Regulations confirmed the findings.

It is required that the hospice is responsible for providing all hospice services to the residents/hospice patients including: ongoing assessment, monitoring, care planning, coordination, and provision of care by the hospice Interdisciplinary Group (IDG). This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed of patients residing in a skilled nursing facility (SNF), the agency did not ensure that the hospice was responsible for the ongoing assessment, monitoring, care planning, coordination, and provision of care by the hospice IDG. Clinical Record 6: The patient was elected hospice care on 01/19/2023 with a diagnosis of chronic obstructive pulmonary disease (COPD). The patient resided in a long-term care facility. The skilled nursing (SN) assessment dated 12/22/2024 documented that the patient had a stage 3 pressure ulcer on the left hip: "Pressure ulcer being managed by the facility wound care team." A clinical record review revealed no evidence that the hospice IDG directed, coordinated, or supervised the patient's wound care. The clinical record did not include documentation of descriptions of the wound. The plan of care did not include orders or interventions for the pressure wound. After a joint review of the clinical record on 02/11/2025, the Manager of Compliance and Regulations confirmed the findings and agreed that the plan of care should include orders for wound management.

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/IID representatives. 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 clinical record review and interview. In 1 of 5 (20%) clinical records reviewed of patients residing in a skilled nursing facility (SNF), the agency did not ensure that the hospice plan of care identified the care and services that were needed and specified which provider was responsible for performing the functions that were agreed upon and included in the plan of care. Clinical Record 6: The patient was elected hospice care on 01/19/2023 with a diagnosis of chronic obstructive pulmonary disease (COPD). The patient resided in a long-term care facility. The skilled nursing (SN) assessment dated 12/22/2024 documented that the patient had a stage 3 pressure ulcer on the left hip: "Pressure ulcer being managed by the facility wound care team." The plan of care dated 12/24/2025 for the certification period 01/08/2025 through 03/08/2025 contained no orders for wound care or treatment of the stage 3 pressure ulcer. The plan of care contained one intervention: "prescribed medications will be administered by hospice/facility staff." The plan of care did not document if the SNF or hospice was responsible for administering the patient's medications or managing the pressure ulcer. After a joint review of the clinical record on 02/11/2025, the Manager of Compliance and Regulations confirmed the findings and the need for the plan of care to specify the responsibilities of care of services.

It is required that the hospice has a written Patient Bill of Rights and Responsibilities (Bill of Rights). The patient has the right to be informed of his or her rights and responsibilities, and the hospice defines, protects, and promotes the exercise of these rights. This standard was not met as evidenced by clinical record review and interview. 10 of 13 (77%) clinical records revealed that the informed consent, including patient rights did not contain the appropriate information about the hospice. Clinical record #49282 was reviewed and identified the patient elected the hospice benefit on 1/27/2022. The Informed Consent, including Patient Rights, did not contain the legal name of the hospice. A telephone call to the family on 3/24/2020, to inquired about the name of the hospice from which the patient was receiving care, revealed a name other then the legal name of the agency. Clinical record #12432 was reviewed and identified the patient elected the hospice benefit on 12/15/2021. The Informed Consent, including Patient Rights, did not contain the legal name of the hospice. Clinical record #97359 was reviewed and identified the patient elected the hospice benefit on 8/25/2021. The Informed Consent, including Patient Rights, did not contain the legal name of the hospice. Clinical record # 29831 was reviewed and identified the patient elected the hospice benefit on 2/7/202. The Informed Consent, including Patient Rights, did not contain the legal name of the hospice. Clinical record #20810 was reviewed and identified the patient elected the hospice benefit on 12/17/2021. The Informed Consent, including Patient Rights, did not contain the legal name of the hospice. Clinical record #14517 was reviewed and identified the patient elected the hospice benefit on 9/15/2021. The Informed Consent, including Patient Rights, did not contain the legal name of the hospice. Clinical record #31041 was reviewed and identified the patient elected the hospice benefit on 8/11/2021. The Informed Consent, including Patient Rights, did not contain the legal name of the hospice. Clinical record #47315 was reviewed and identified the patient elected the hospice benefit on 3/10/2022. The Informed Consent, including Patient Rights, did not contain the legal name of the hospice. Clinical record #85230 was reviewed and identified the patient elected the hospice benefit on 9/2/2021. The Informed Consent, including Patient Rights, did not contain the legal name of the hospice. Clinical record #78535 was reviewed and identified the patient elected the hospice benefit on 10/22/2021. The Informed Consent, including Patient Rights, did not contain the legal name of the hospice. In an interview with the Director of Operations and the Director of Accreditation and Regulatory Compliance, it was stated that the hospice was acquired on June 23, 2021. The consents were updated with the brand name of the new company at that time. The new patient consent information did not contain the legal name of the hospice.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid/MediCal-certified facility, the hospice forwards to the receiving facility a copy of: The hospice discharge summary described in HCDT 41.I; and The patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. 1 of 2 (50%) applicable clinical records reviewed of patients that discharged or revoked the hospice benefit revealed the hospice did not ensure that a discharge summary was sent to the receiving facility. Clinical Record #31041 was reviewed and identified that the patient was discharged on 11/11/2021. There is no documentation that the discharge summary was sent to the receiving facility. The Director of Operations and The Director of Accreditation and Regulatory Compliance were interviewed on 3/23/2022 and stated that a plan of correction had already been created to correct this deficient practice.