Every finding on record at Serenity Hospice Homes LLC

Upon patient record review 2 of 6 (Patient #1,#2) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient#1: The patient was admitted on 11/14/23. The record indicated that the spiritual assessment was completed on 11/21/23. Patient#2: The patient was admitted on 11/14/23. The record indicated that the spiritual assessment was completed on 11/24/23.

Upon patient record review, 2 of 6 (Patient #1,#3) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient#1: The medication profile indicated Polyethylene Glycol 17 Gm daily PO daily without evidence of a diluent. Corrected on site. Patient#3: The medication profile indicated Acetaminophen 500mg PO 3 tablets daily for pain. Acetaminophen 650mg rectal suppository every 4 hours PRN pain/fever. There was no parameters for fever or maximum daily dose listed. Corrected onsite.

Upon patient record review, 2 of 6 (Patient #1,#3) 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#1: The record indicated Polyethylene Glycol 17 Gm daily PO daily without evidence of a diluent. Corrected on site. Patient#3: The record indicated Acetaminophen 500mg PO 3 tablets daily for pain. Acetaminophen 650mg rectal suppository every 4 hours PRN pain/fever. There was no parameters for fever or maximum daily dose listed. Corrected onsite.

Upon patient record review, 1 of 6 (Patient #6) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient#6: There was no evidence of a bereavement risk assessment or bereavement plan of care. Patient died 12/5/23, Chaplain made a bereavement visit on 12/6/23. There was no evidence of a follow-up bereavement care plan (re: frequency of calls, sending cards and letters, etc).

Upon patient record review 1 of 6 (Patient #3) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient#3: The aide plan of care indicated for nail care to be done at each visit. The record indicated that the task was not performed on 11/07/23, 11/20/23, 12/08/23, and 12/11/23. Also, the aide plan of care indicated for mouthcare to be done at each visit. The record indicated that the task was not performed on 12/15/23.

Upon client record review, 1 of 6 (Patient #4) did not have evidence that the discharge summary includes all required information. Patient#4: The initial discharge summary that was sent to the hospice agency receiving patient did not contain: The transfer order, the patient's current plan of care, patient's latest physician orders, and documentation of wound care provided by the customer that would assist in post-discharge continuity of care.

Upon personnel record review, 3 of 13 (Personnel #10,#11,#12) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at renewal or in accordance with specific state practice act requirements.

Upon personnel record review, 1 of 13 (Personnel #12) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions.

Upon personnel record review, 1 of 13 (Personnel #11) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions.

Upon personnel record review, 1 of 13 (Personnel #10 ) did not have evidence all Physical Therapy Services are provided by a qualified licensed Physical Therapist (PT) in accordance with the state's Physical Therapy Practice Act and the hospice's policies and procedures and/or job descriptions.

Upon personnel record review, 3 of 13 (Personnel #10,#11,#12) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records.