Every finding on record at Serenity Hospice Care, LLC

It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. This standard was not met as evidenced by clinical record review. In 1 of 27 (4%) records reviewed, it was revealed that the agency did not ensure that an assessment of the patient's and family's spiritual needs was completed. Clinical Record 1: The patient was admitted on 6/24/23 and died on 6/30/23. The patient declined chaplain services as noted in the assessment done on 6/24/23. There was no documentation that an assessment of the patient and family's spiritual needs was performed by the nurse or the social worker.

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. 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. In 7 of 7 (100%) records reviewed of patients who resided in a skilled facility, it was revealed that the plans of care identified care and services needed but did not include which provider was responsible for performing the functions that were agreed upon and included in the plan of care. Clinical Record 3: The patient was admitted on 5/4/23 with a diagnosis of Lung Cancer. The plans of care (POC) dated 5/9/23, 5/23/23, 6/8/23, 6/22/23 and 7/6/23 identified the care and services needed but did not specify which provider was responsible for performing the functions that were agreed upon in the plan of care. The patient died on 7/11/23. Clinical Record 4: The patient was admitted on 4/17/23 with a diagnosis of Senile Degeneration of the Brain. The plans of care dated 5/2/23,5/16/23,5/30/23 and 6/13/23 identified the care and services needed but did not specify which provider was responsible for performing the functions that were agreed upon in the plan of care. The patient died on 6/19/23. Clinical Record 8: The patient was admitted on 12/21/21 with a diagnosis of Senile Degeneration of the Brain. The plans of care dated 7/27/23 and 8/10/23 did identify the care and services needed but did not specify which provider was responsible for performing the functions that were agreed upon in the plan of care. Clinical Record 9: The patient was admitted on 4/30/23 with a diagnosis of Lung Cancer. The plans of care dated 7/27/23 and 8/10/23 did identify the care and services needed but did not specify which provider was responsible for performing the functions that were agreed upon in the plan of care. Clinical Record 10: The patient was admitted on 11/22/22 with a diagnosis of Heart Failure. The plans of care dated 7/27/23 and 8/10/23 did identify the care and services needed but did not specify which provider was responsible for performing the functions that were agreed upon in the plan of care. Clinical Record 12: The patient was admitted on 12/20/21 with a diagnosis of Senile Degeneration of the Brain. The plans of care dated 7/27/23 and 8/10/23 did identify the care and services needed but did not specify which provider was responsible for performing the functions that were agreed upon in the plan of care. Clinical Record 13: The patient was admitted on 3/22/23 with a diagnosis of Protein Calorie Malnutrition. The plans of care dated 7/27/23 and 8/10/23 did identify the care and services needed but did not specify which provider was responsible for performing the functions that were agreed upon in the plan of care.