Every finding on record at Serenity Hospice Care Provider, Inc.

Upon patient record review 8 of 10 (Patients #1, 2, 3, 4, 5, 6, 7, 9) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #1: There was no evidence of an initial psychosocial assessment completed. MSW was declined at admission, however, the nursing assessment did not include the required elements of an initial psychosocial assessment. Patient #2: The RN initial states that social worker and spiritual care were declined. The initial nursing assessment did not include the required elements of an initial psychosocial assessment. The initial nursing assessment also did not include elements of the spiritual care initial assessment. Although an initial bereavement assessment was completed by the social worker, it did not meet all components of the psychosocial initial assessment. Patient #3: The RN initial states that spiritual care was declined. The initial nursing assessment did not include the required elements of an initial spiritual care initial assessment, including but not limited to spiritual beliefs and rituals, as well as the nature and scope of spiritual concerns and needs. Patient #4,5,6,7,9: The RN initial states that social worker and spiritual care were declined. The initial nursing assessment did not include the required elements of an initial psychosocial assessment including but not limited to the mental health component, the social component, as well as the environmental and economic components.. The initial nursing assessment also did not include elements of the spiritual care initial assessment including but not limited to spiritual beliefs and rituals, as well as the nature and scope of spiritual concerns and needs. Although an initial bereavement assessment was completed by the social worker, it did not meet all components of the psychosocial initial assessment.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #1: There was no evidence that the comprehensive assessment included an initial bereavement assessment.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 6 of 14 (Patients #2, 3, 4, 5, 6, 7) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #2: The RN visited on 05/22/25. The patient was complaining of continued hematuria. On 05/23/25, an antibiotic was ordered to start via phone. There was no evidence of a further follow up call or visit to the patient until 05/29/25. On 06/18/25, the patient complained of possible UTI symptoms. On 06/19/25, the RN called the patient with orders to start an antibiotic. There is no evidence of follow up call or visit until 06/26/25. Patient #3: On 07/03/25, the patient was seen by a nurse with complaints of UTI symptoms and "uncontrolled pain". An antibiotic and Norco were called in. There is no evidence of a follow up call or visit until 07/09/25. During the visit on 07/09/25, patient still complaining of a pain of 4. POC states pain is to be maintained below 3. There is no evidence of a follow up call or visit until 07/18/25. Patient #4: Upon admission patient found to have a "Left heel wound". There was not a full skin assessment completed including measurements. There is no evidence of measurements and full assessment of the Left heel on any subsequent visits. On 07/15/25, the patient was found to have a stage 2 sacral wound. There was no evidence of measurements taken of the wound upon discovery or subsequently, no wound assessment with measurements. Patient #5: On 05/09/25, patient called and experiencing multiple nosebleeds. Order received from doctor to hold Eliquis. There is no evidence of follow up call of visit for 5 days. On 05/14/25, there was a call from the patient stating that nosebleeds had stopped, but she was coughing up blood clots - visit made the next day on 05/15/25. On 06/17/25, call from patient that she was feeling lightheaded and her heart rate was 49. She expressed she had a pacemaker and it was set at 70. There is no evidence of a visit made for complaint. On 07/10/25, patient prescribed Azithromycin for a sinus infection. No evidence of a follow up call or visit until 07/15/25. Patient #6: On 06/25/25, patient was seen. She had fallen on 06/20/25 without injury. Patient was having increased pain and daily scheduled narcotic was initiated. There is no evidence of a follow up call or visit until 07/03/25. Patient #7: On 05/23/25, Patient called and complained of severe pain and requested to go to the VA ER for treatment. Daily scheduled narcotic started, however, no visit made. No evidence of visit or phone call to patient until 05/27/25. On 07/08/25, during visit, wife stated she was concerned that the patient "had a stroke last night". No evidence of a follow up call or visit until 07/22/25.

Upon patient record review, 2 of 14 (Patients #2, 4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2: The patient has a wound to her Left Calf. The wound care order reads, "cleanse with Betadine solution, pat dry with 4x4 gauze. Apply hydrogel. Cover with non adherent dressing. Wrap with Kerlix and secure with tape. Dressing daily and prn. There is no evidence of who will change the dressing on what days or a reason for prn dressing changes. Patient #4: The patient has a wound to the sacral area. The wound care order reads, "cleanse with wound cleanser. Pat dry. Apply Zinc oxide ointment and cover with a foam dressing. Change every other day and prn. This order does not contain evidence of why a prn dressing change wound be required.

Upon patient record review, 1 of 14 (Patients #6) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #6: The patient had 3 falls documented between 03/25/25 and 06/25/25. The Environmental/Safety POC was not updated.

Upon patient record review, 1 of 14 (Patient #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: The patient has a wound to her left calf. The wound care order reads, "cleanse with betadine solution, pat dry with 4x4 gauze. Apply hydrogel. Cover with non adherent dressing. Wrap with Kerlix and secure with tape. Dressing daily and prn. During the home visit, the LVN cleansed the wound with normal saline rather than betadine solution. The LVN applied triple antibiotic cream to wound rather than the hydrogel that was ordered.

Upon patient record review 1 of 14 (Patient #6) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #6: On 03/23/25, the daughter called and stated "I thought hospice provided emotional support and symptom management" She stated she was struggling and feeling like the hospice was just "drugging" patient. Although Administrator was contacted and SN visit was made later that night and subsequent days following on 3/24, 3/25, and 3/27, there is no evidence that social work or spiritual care was offered. On 03/24/25, it is documented by the nurse, "daughter appears to be experiencing psychosocial distress". There is no evidence of offering a social work or spiritual visit.

Upon observation, there was no evidence the hospice measures, analyzes, and tracks quality indicators, including adverse patient events and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations. Patient #6: There was a complaint by the daughter on 03/23/25. Although there is documentation in the record of the complaint, there was not an incident report created of the complaint and it was not mentioned in the quarterly QAPI.

Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient's clinical record in confidential manner. Patient #9: There is a documented medication error in the record dated 05/29/25. Within the report it states that the medications were ordered for another patient though delivered to patient #9. The report lists the name of the patient that was supposed to get the medication and for what reasons. This is represents a break in HIPAA as the record cannot contain health information or names of other patients on service.

Upon observation and home visits 3 of 3 (Patient #1,2,3), there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. Patient #1,2,3 During home visits there was no evidence that the policies and procedures on the management of controlled drugs were provided to the patient/family/caregiver.

Observed in Patient Home. In 3 of 3 home visits conducted, it was noted that the state of California advance directive information was provided to patients in their home folders, but the organization’s policy was not. This was reviewed with the Administrator, Assistant DPCS and other staff.

Observed in Record Review. In 6 of 11 patient records reviewed, the surveyor noted that initial social work and/or spiritual comprehensive assessments were not completed within five days of the election of the hospice benefit in the records of HV#1, HV#2, RR#1, RR#2, RR#3, RR#4 as required by policy and law. This was reviewed with the Administrator, DPCS, Assistant DPCS and other staff.

Observed in Record Review. In 9 of 11 patient records reviewed, the surveyor found that assessment documentation was missing or incomplete. In the records of HV#1, HV#2, RR#1, RR#2, RR#3, RR#4, RR#5, RR#6, and RR#8 comprehensive spiritual assessments were not documented and/or bereavement assessment tools were blank, did not include supporting narrative notes, or were not completed. was reviewed with the Administrator, DPCS, Assistant DPCS and other staff.

Observed in Record Review. In 4 of 11 patient records reviewed, an RN did not document the completion of a comprehensive re-assessment every 15 days in the records of HV#2, HV#3, RR#5, and RR#8 as required by policy and law. This was reviewed with the Administrator, DPCS, Assistant DPCS and other staff. Observed in Record Review. In 4 of 11 patient records reviewed, an RN did not document the completion of a comprehensive re-assessment every 15 days in the records of HV#2, HV#3, RR#5, and RR#8 as required by policy and law. This was reviewed with the Administrator, DPCS, Assistant DPCS and other staff.

Observed in Record Review. In 9 of 11 patient records reviewed, the organization did not provide the patient with care, treatment, or services according to his or her individualized plan of care. During review of the records for HV#1, HV#2, HV#3, RR#1, RR#2, RR#5, RR#6, RR#7, and RR#8 the surveyor noted that there were either missed or additional visits by various disciplines, however, there were no change of frequency orders or documentation to support why visits did not match the ordered frequencies. This was reviewed with the Administrator, DPCS, Assistant DPCS and other staff.staff. Observed in Record Review. In the record of RR#2 the following order for a Stage III sacrococcygeal wound was noted. Clean with wound cleanser, pat dry, apply Medi honey gel, collagen, calcium alginate, and cover with silicone bordered foam dressing. Wound care provided by a SN did not follow the order. In several notes the following wound care was documented. Cleansed with normal saline, pat dry, apply saintly ointment to wound bed with a gauze and cover with foam dressing. This was reviewed with the Administrator, DPCS, Assistant DPCS and other staff. This was reviewed with the Administrator, DPCS, Assistant DPCS and other staff. Observed in Record Review. In the record of RR#2 the surveyor found that measurements of a Stage III sacrococcygeal wound had not been documented since admission two months earlier. This was reviewed with the Administrator, DPCS, Assistant DPCS and other staff.

Observed in Patient Home. hospice staff failed to perform hand hygiene in accordance with their Hand Hygiene policy. During HV#1 the MSW did not perform hand hygiene at the beginning of his visit. This was reviewed with the Administrator, Assistant DPCS and other staff.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to ensure the hospice aide was supervised to assess the quality of care and services provided no less frequently than every 14 days in the records of HV#2 and HV#3. This was reviewed with the Administrator, DPCS, Assistant DPCS and other staff.

Observed in Document Review. The Governing Body did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: - §418.100, §418.54. This was reviewed with the Administrator, Assistant DPCS and other staff.