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 measurements 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 1 of 14 (7%) clinical records reviewed, the agency did not ensure the medication profile was updated when new medications were ordered. Clinical Record 12: The patient elected the hospice benefit on 12/26/2022 with a terminal diagnosis of Parkinson’s disease. The Skilled Nurse documented on the nursing visit note dated 09/12/2023, "called [physician] to request Fentanyl patch and Atropine." The skilled nurse visit note dated 09/13/2023 included documentation that the "Patient just received Fentanyl patch 25mg, q 72 hrs. As per cg [caregiver] patch just got delivered with Atropine drops." Clinical record review revealed the medication profile dated 09/11/2023 to 09/16/2023 contained no documented evidence that the medication profile was updated to include Fentanyl and Atropine. During joint record review and interview on 01/25/2024, the Alternate Director of Nursing confirmed that medications were not updated on the medication profile.

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 4 of 14 (29%) clinical records reviewed, the agency did not ensure hospice care and services followed the individualized plan of care. Clinical Record 6: The patient elected the hospice benefit on 07/21/2023, with terminal diagnosis of Alzheimer’s disease. The plan of care dated 07/21/2023 included an order for Medical Social Worker [MSW] visits once per month and PRN [as needed]. The MSW visit note dated 08/22/2023 included documentation that the MSW was "Unable to complete due to hazardous road conditions attributed to Tropical Storm." The clinical record contained no documented evidence of other attempts to schedule a MSW visit for August and no documented evidence that the physician was notified or ordered a change in visit frequency. During a joint record review and interview on 01/24/2024, the Director of Nursing confirmed that the record lacked evidence that Medical Social Worker services were provided according to the plan of care. Clinical Record 3: The patient elected the hospice benefit on 01/27/2022 with a terminal diagnosis of senile degeneration of the brain. The initial plan of care dated 01/27/2022 and the recertification plan of care dated 03/08/2022 included an order for "Chaplain frequency 1-2 times per month for three months." Clinical record review revealed no documented evidence of a Chaplain visit for March 2022, and no evidence that the physician was notified or ordered a change in visit frequency. Clinical Record 5: The patient elected the hospice benefit on 02/23/2023 with a terminal diagnosis of Alzheimer’s disease. The plan of care dated 02/24/2023 included an order for "Chaplain frequency once a month for three months." Clinical record review revealed no documented evidence of a Chaplain visit for May, and no evidence that the physician was notified or ordered a change in visit frequency. Clinical Record 13: The patient elected the hospice benefit on 12/26/2022 with a terminal diagnosis of Parkinson’s disease. The plan of care dated 12/26/2022 included an order for "Chaplain frequency once monthly for three months." Review of the IDT [intradisciplinary team] meeting documents and updates to the plan of care dated 04/04/2023 and 04/18/2023 included documentation that stated, "Chaplain frequency once a month and as needed." Clinical record review revealed no documented evidence of a Chaplain visit for February and April, and no evidence that the physician was notified or ordered a change in visit frequency. During joint record reviews and interview on 01/25/2024, the Alternate Director of Nursing confirmed that the records lacked evidence that the Chaplain provided services according to the plan of care.

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 8 of 11 (73%) clinical records reviewed, the hospice did not ensure the individualized written plan of care included planned interventions and goals based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected the hospice benefit on 03/28/2022 with a terminal diagnosis of Alzheimer’s disease. The plan of care dated 03/28/2022 included an order for the Chaplain visit frequency as once a month. The Chaplain documented on the visit note dated 04/29/2022 patient concerns with lack of self-worth and unfinished business. The plan of care did not include spiritual problems, goals, and interventions. Clinical Record 2: The patient elected the hospice benefit on 06/12/2023 with a terminal diagnosis of chronic kidney disease. The plan of care dated 06/12/2023 included an order for the Chaplain visit frequency as once a month. The Chaplain documented on the visit notes dated 07/18/2023, 08/21/2023, and 09/22/2023 the patient had concerns related to unfinished business and salvation. The plan of care did not include spiritual problems, goals, and interventions. Clinical Record 3: The patient elected the hospice benefit on 01/27/2022 with a terminal diagnosis of senile degeneration of the brain. The plan of care dated 01/27/2023 included an order for the Chaplain visit frequency as once a month. The Chaplain documented on the visit notes dated 02/26/2022, 04/20/2022, 05/06/2022, and 06/15/2022 the patient had concerns with lack of self-worth, relationship issues, and/or abandonment by others. The plan of care did not include spiritual problems, goals, and interventions. Clinical Record 5: The patient elected the hospice benefit on 02/23/2023 with a terminal diagnosis of Alzheimer’s disease. The plan of care dated 02/23/2023 included an order for the Chaplain visit frequency as once a month. The Chaplain documented on the visit notes dated 03/27/2023, 04/24/2023, and 06/01/2023 the patient had concerns with lack of self-worth, abandonment by others, unfinished business, and/or alienation from God. The plan of care did not include spiritual problems, goals, and interventions. Clinical Record 6: The patient elected the hospice benefit on 07/21/2023, with terminal diagnosis of Alzheimer’s disease. The plan of care dated 07/21/2023 included an order for the Chaplain visit frequency as once a month. The Chaplain documented on the comprehensive assessment dated 07/22/2023 the patient had concerns with a lack of support and on the visit note dated 08/16/2023 the patient had concerns with a lack of self-worth and abandonment by others. The plan of care did not include spiritual problems, goals, and interventions. Clinical Record 7: The patient elected the hospice benefit on 01/14/2023, with a terminal diagnosis of Alzheimer’s disease. The plan of care dated 07/21/2023 included an order for the Chaplain visit frequency as once a month. The Chaplain documented in the comprehensive assessment dated 01/18/2023 the patient had concerns with a lack of support and family/marital issues. The plan of care did not include spiritual problems, goals, and interventions. Clinical Record 9: The patient elected the hospice benefit on 11/16/2021 with a terminal diagnosis of cerebral infarct. The plan of care dated 11/16/2021 included an order for the Chaplain visit frequency as once a month. The Chaplain documented on the visit notes dated 12/09/2021, 01/06/2022, 02/06/2022, and 03/04/2022 that the patient had concerns with lack of self-worth and/or unfinished business. The plan of care did not include spiritual problems, goals, and interventions. Clinical Record 13: The patient elected the hospice benefit on 12/26/2022 with a terminal diagnosis of Parkinson’s disease. The plan of care dated 12/12/2022 included an order for the Chaplain visit frequency as once a month. The Chaplain documented on the visit note dated 03/03/2023 the patient had concerns with a lack of self-worth and/or alienation from God. The plan of care did not include spiritual problems, goals, and interventions. During a joint review of the records and an interview on 01/24/2024, the Director of Nursing agreed there was no documented evidence that the plans of care included problems, goals, and interventions for the problems identified in the Chaplain assessments.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed, the hospice did not ensure the hospice medical director or physician-designee provided written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Clinical Record 2: The patient elected the hospice benefit on 06/12/2023 with a terminal diagnosis of chronic kidney disease. Clinical record review revealed no documented evidence that the physician completed the recertification of terminal illness for the patient’s third benefit period starting 12/09/2023. Clinical Record 3: The patient elected the hospice benefit on 01/27/2022 with a terminal diagnosis of senile degeneration of the brain. Clinical record review revealed no documented evidence that the physician completed the recertification of terminal illness for the patient’s twelfth benefit period starting 11/28/2023. Clinical Record 5: The patient elected the hospice benefit on 02/23/2023 with a terminal diagnosis of Alzheimer’s disease. Clinical record review revealed no documented evidence that the physician completed the recertification of terminal illness for the patient’s fourth benefit period starting 10/22/2023 and fifth benefit period starting 12/21/2023. During joint review of the records and interview on 01/24/2024, the Director of Nursing agreed there was no documented evidence the recertifications were completed.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) clinical records reviewed with patient transfer/discharge, the agency did not ensure the discharge summary was sent to the receiving Medicare/Medicaid certified facility. Clinical Record 6: The patient elected the hospice benefit on 07/21/2023, with terminal diagnosis of Alzheimer’s disease. The patient's care was transferred to another hospice provider on 09/11/2023. Clinical record review revealed no documented evidence that the discharge summary was sent to the receiving facility. During joint record review and interview on 01/24/2024, the Director of Nursing confirmed that the record lacked evidence that the discharge summary was sent to the receiving Medicare/Medicaid-certified facility.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient's record if requested. This standard was not met as evidenced by clinical record review and interview. In 3 of 4 (75%) clinical records reviewed with patient discharge, the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. Clinical Record 7: The patient elected the hospice benefit on 01/14/2023, with a terminal diagnosis of Alzheimer’s disease. Clinical record review revealed no documented evidence that the discharge summary dated 03/03/2023 was sent to the patient’s attending physician. Clinical Record 8: The patient elected the hospice benefit on 01/10/2023 with a terminal diagnosis of congestive heart failure. Clinical record review revealed no documented evidence that the discharge summary dated 03/03/2023 was sent to the patient’s attending physician. Clinical Record 9: The patient elected the hospice benefit on 11/16/2021 with a terminal diagnosis of cerebral infarct. Clinical record review revealed no documented evidence that the discharge summary dated 05/08/2023 was sent to the patient’s attending physician. During joint record review and interview on 01/24/2024, the Director of Nursing confirmed that the records lacked evidence that the discharge summary was forwarded to the patient’s attending physician.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 3 of 4 (75%) clinical records reviewed with patient discharge, the agency did not ensure the discharge summary included a summary of the patient's hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. Clinical Record 6: The patient elected the hospice benefit on 07/21/2023, with terminal diagnosis of Alzheimer’s disease. Clinical record review revealed the discharge summary dated 09/11/2023 lacked a summary of the patient's hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. Clinical Record 7: The patient elected the hospice benefit on 01/14/2023, with a terminal diagnosis of Alzheimer’s disease. Clinical record review revealed the discharge summary dated 03/03/2023 lacked a summary of the patient's hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. Clinical Record 8: The patient elected the hospice benefit on 01/10/2023 with a terminal diagnosis of congestive heart failure. The discharge summary dated 3/3/2023 lacked a summary of the patient's hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. During a joint record review and interview on 01/24/2024, the Director of Nursing confirmed that the records lacked evidence that the discharge summary included a summary of the patient's hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician.