Every finding on record at Serenity Hospice Care of Upstate LLC

It is required that the patient’s pain is assessed as part of a comprehensive assessment. Assessment of pain in children and adolescents is conducted with consideration of age and neurocognitive development. The documented assessment of the patient’s pain includes history of pain and its treatment, both pharmacological and non-pharmacological, use of a standardized pain assessment tool appropriate to the patient’s developmental and cognitive status, characteristics of the pain, including location, frequency, and intensity, how pain impacts the patient’s ability to engage in usual activities and function (e.g., appetite, sleeping) and the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed revealed that the agency did not ensure the documented assessment of the patient’s pain included the patient's and family's goals for pain management. Clinical Record 2: The patient elected the hospice benefit on 11/07/2024 with diagnoses of moderate calorie malnutrition, diabetes mellitus, dementia, and multiple falls. The comprehensive assessment dated 11/07/2024 include documentation that the patient’s pain level was 0 upon admission and included documentation that pain was an active problem for the patient. The assessment included documentation that the patient was treated for pain with Acetaminophen twice daily, Hydrocodone-Acetaminophen 5/325mg every eight hours as need, and Ibuprofen 400mg every six hours as needed for pain. The pain goal documented on the assessment was to evaluate the patient's pain at each visit for the patient’s acceptable level of pain tolerance, but the goal did not include what the patient considered an acceptable level of pain. During an interview on 03/06/2025, the Director of Clinical Services stated that the patient was not having pain at the time of admission.

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 observation and interview. In 3 of 3 (100%) home visit observations, the agency did not ensure the medication profile was updated at the time of the comprehensive assessment, when new medications are added, and/or when changes are made to existing medications. Home Visit 1: The patient elected the hospice benefit on 11/18/2024 with diagnoses of senile degeneration of the brain, Alzheimer's disease, schizophrenia, type 2 diabetes mellitus, hypertension, and cerebrovascular disease. The patient resided in a skilled nursing facility [SNF]. During the home visit observation on 03/04/2025 with the Certified Nurse Assistant (CNA) (Personnel Record 1), a medication review was completed by comparing the hospice medication profile to the SNF medication list. The SNF medication list included artificial tears, one drop to both eyes every six hours as needed (effective 02/12/2025). The hospice medication profile did not include artificial tears. During an interview on 03/05/2025, the Director of Clinical Services stated that they had missed the order when checking the facility orders. The SNF medication list also included Milk of Magnesia (MOM) 30 ml daily as needed for constipation (effective 01/06/2025). The hospice medication profile included MOM 30 ml one dose effective 12/20/2024. The hospice medication profile was not updated with the patient’s current medications. Home Visit 2: The patient elected the hospice benefit on 11/07/2024 with diagnoses of moderate calorie malnutrition, diabetes mellitus, dementia, and multiple falls. The patient resided in a SNF. During the home visit observation on 03/05/2025, a medication review was completed by comparing the hospice medication profile to the SNF medication list. The SNF medication list included Fast Freeze Roll to lower back every shift (effective 04/15/2024), and Famotidine 20mg twice daily. The hospice medication profile did not include Fast Freeze Roll and Famotidine. During an interview on 03/05/2025, the Director of Clinical Services stated that they had missed the orders when checking the facility orders. The SNF medication list also included Ativan 2mg per ml, give 0.25ml every hour as needed for agitation. The hospice medication profile included Ativan 0.25mg every hour and as needed for agitation. The SNF medication list included Clonidine 0.1mg every eight hours as needed for systolic blood pressure (SBP) greater than 170 or diastolic blood pressure (DBP) greater than 105. The hospice medication profile included Clonidine with instructions to give for SBP greater than 170 OR DBP less than 105. The SNF medication list included Melatonin 3mg at bedtime for sleep. The hospice medication profile included Melatonin 3mg at bedtime for sleep as needed. The hospice medication profile was not updated with the patient’s current medications. Home Visit 3: The patient elected the hospice benefit on 11/07/2024 with diagnosis of protein calorie malnutrition. During the home visit observation on 03/05/2025, a medication review was completed by comparing the hospice medication profile to the patient’s current home medications. The patient’s current home medications included Tramadol 50 mg every eight hours as needed for pain (effective 12/13/2024). The hospice medication profile did not include Tramadol. During an interview and record review on 03/05/2025, the Director of Clinical Services stated, after review of the orders in the clinical record, that the medication had not been discontinued but was inactivated and therefore removed from the active medications and was likely an EMR [electronic medical record] glitch as the medication was still active.

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 clinical record review and interview. In 2 of 7 (29%) clinical record reviewed, the agency did not ensure the individualized written plan of care Identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected the hospice benefit on 11/18/2024 with diagnoses of senile degeneration of the brain, Alzheimer's disease, schizophrenia, type 2 diabetes mellitus, hypertension, and cerebrovascular disease. The comprehensive assessment dated 11/18/2024 included documentation that the patient’s primary diagnosis was senile degeneration of the brain and assessment findings that included a 15.3% weight loss in the last five months, bedbound status, incontinence of bowel and bladder habits, and a scab to the patient's left heel. The plan of care dated 11/18/2024 to 02/15/2025 did not include planned interventions for prevention of skin breakdown based on the patient’s risk factors documented in the comprehensive assessment, including weight loss, bedbound status, and incontinence of bowel and bladder. Clinical Record 2: The patient elected the hospice benefit on 11/07/2024 with diagnoses of moderate calorie malnutrition, diabetes mellitus, dementia, and multiple falls. The comprehensive assessment dated 11/07/2024 included documentation that the patient had a diagnosis of protein calorie malnutrition and was a high nutritional risk. The plan of care dated 11/04/2024 to 02/04/2025 did not include planned interventions based on the patient’s identified nutritional risk. During an interview and record review on 03/05/2025, the Director of Clinical Services stated that the problem should have been added to the care plan, but she overlooked it and the electronic medical record software that they were using was causing many issues.

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, observation, and interview. In 1 of 3 (33%) clinical record reviews with aide services provided, the agency did not ensure the Hospice Aide reported changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a Registered Nurse. Clinical Record 1/Home Visit 1: During the home visit observation on 03/04/2025 with the Certified Nurse Assistant (CNA) (Personnel Record 1). The CNA was observed to ask the patient if he/she had pain. The patient responded that he/she had pain in the legs and that it burned with urination. The Hospice Aide did not document in the aide visit note dated 03/04/2025 that the patient had complained of leg pain and burning with urination and there was no documented evidence in the clinical record that the CNA had reported the patient’s complaints to the Registered Nurse. During an interview and review of findings on 03/05/2025, the Director of Clinical Services stated that she did not receive a report of the patient's pain or burning with urination from the CNA.

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 5 of 6 (83%) clinical record reviews for patients that reside in a skilled nursing facility, the agency did not ensure 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 1: The patient elected the hospice benefit on 11/18/2024 with diagnoses of senile degeneration of the brain, Alzheimer's disease, schizophrenia, type 2 diabetes mellitus, hypertension, and cerebrovascular disease. The patient resided in a skilled nursing facility [SNF]. The hospice plan of care dated 11/18/2024 to 02/15/2025 identified the care and services needed for the patient but did not specify which provider was responsible for performing the functions that were agreed upon and included in the plan of care. Clinical Record 2: The patient elected the hospice benefit on 11/07/2024 with diagnoses of moderate calorie malnutrition, diabetes mellitus, dementia, and multiple falls. The patient resided in a SNF. The hospice plan of care dated 11/07/2024 to 02/04/2025 identified the care and services needed for the patient but did not specify which provider was responsible for performing the functions that were agreed upon and included in the plan of care. Clinical Record 4: The patient elected the hospice benefit on 10/29/2024 with diagnoses of paroxysmal atrial fibrillation, protein calorie malnutrition, chronic kidney disease, and dementia. The patient resided in a skilled nursing facility [SNF]. The hospice plan of care dated 10/29/2024 to 01/26/2025 identified the care and services needed for the patient but did not specify which provider was responsible for performing the functions that were agreed upon and included in the plan of care. Clinical Record 5: The patient elected the hospice benefit on 10/31/2024 with diagnoses of protein calories malnutrition and dementia. The patient resided in a SNF. The hospice plan of care dated 10/31/2024 to 01/28/2025 identified the care and services needed for the patient but did not specify which provider was responsible for performing the functions that were agreed upon and included in the plan of care. Clinical Record 6: The patient elected the hospice benefit on 11/06/2024 with diagnoses of protein calorie malnutrition, carotid artery stenosis, diverticulitis, hypertension, and post hip fracture. The patient resided in a SNF. The hospice plan of care dated 11/06/2024 to 02/03/2025 identified the care and services needed for the patient but did not specify which provider was responsible for performing the functions that were agreed upon and included in the plan of care. Clinical Record 7: The patient elected the hospice benefit on 11/12/2024. The patient resided in a SNF. The hospice plan of care dated 11/12/2024 to 02/09/2025 identified the care and services needed for the patient but did not specify which provider was responsible for performing the functions that were agreed upon and included in the plan of care. During an interview and record review on 03/06/2025, the Administer and the Director of Clinical Services stated the focus had been on the medications and not all the tasks and a plan would be put into place to ensure the care plan integration.