Every finding on record at Serenity Hospice, LLC

Observed in HR File Review. In 2 of 9 HR files reviewed, the organization failed to document ongoing emergency management training for its volunteers. During tracer activities for Competence Assessment, the Hospice Nurse Surveyor observed HR file #7 and #8 ( both volunteers) did not have documentation of emergency management training at least annually per organizational policy. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 1 of 17 patient records reviewed, the organization failed to assess and reassess according to policy. During record review for HOSRRHV#3, the patient had a coccyx wound had not been assessed for 3 1/2 weeks. It was assessed once noticed but was not assessed until it was inactivated 3 1/2 weeks later. The organizational policy stated the wound would be assessed at least weekly. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 6 of 14 patient records reviewed, the organization failed to complete all necessary initial comprehensive assessments during the required timeframe. During record review for HOSRRHV#3, HOSRRNHV#4, HOSRRNHV#5 and HOSRRNHV#6, HOSRRBR#1 and HOSRRBR#2, the patient's initial bereavement assessments were not completed at all or were not completed timely. For example in HOSRRHV#3, the bereavement assessment was completed one month late. In HOSRRNHV#4, the bereavement assessment was completed two months late. In HOSRRNHV#5, the bereavement assessment was not documented by survey date. In HOSRRNHV#6, the bereavement assessment was approximately two months late. In HOSRRBR#1 and HOSRRBR#2, both records the initial bereavement assessment was completed two months late. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 10 of 10 patient records reviewed, the organization failed to plan the patient's care. During record review for all records, the Hospice Nurse Surveyor observed the goals on the plan of care did not contain timeframes required to meet those goals. For example in HOSRRHV#1, the plan of care had a goal of having an acceptable level of pain of 4/10 ongoing with no measurable timeframe to meet that goal. The SW had a goal of decreasing anxiety and depression with no measurable timeframe. In HOSRRHV#2, the patient had a colostomy for many years and had managed it himself. He had a hospice goal of will have proper care of pt ostomy by end of life. The timeframe was not individualized or measurable. In HOSRRHV#3, the patient had a goal for control of constipation with the target date being ongoing which was not measurable. In HOSRRNHV#1, the patient had a goal of to have funeral arrangements in place with no goal date. In HOSRRNHV#2, the patient had a goal of decrease fear and anxiety throughout the dying process and end of life journey. The goal date of throughout the dying process and end of life journey was not individualized. In HOSRRNHV#3, the patient had a goal of will have funeral arrangements in place with no goal date. In HOSRRNHV#4, the patient had a goal of will verbalize understanding of skin care practices to preserve skin integrity on an on going basis throughout the end of life journey. The patient had been on service for over a year and this goal was not updated with a individualized timeframe. In HOSRRNHV#5, the patient had a goal of pt to achieve optimal pain relief throughout end of life journey. The patient had been on service for 10 months and this goal timeframe was not individualized or updated to reflect current patient needs. In HOSRRNHV#6, the patient had a goal of Pt will report an understanding of causes and treatment of anxiety within 2 weeks. This goal was entered one year prior to survey and the timeframe was not updated to reflect current patient needs. In HOSRRNHV#7, the patient had a goal of Pt/ CG will understand the purpose of advanced directives within 4 weeks. This goal was added 4 months prior to survey and the goal timeframe was not updated. This was verified and discussed with the Hospice Leadership Team.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to plan the patient's care. During record review for HOSRRNHV#6, the Hospice Nurse Surveyor observed the organization had orders for oxygen for the patient but there was no route included. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Tracer Activities. The organization failed to use data analysis results to identify improvement opportunities. During tracer activities for Data Management, the Hospice Nurse Surveyor observed the organization had not identified or documented process improvement opportunities for 2023 or 2024. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Tracer Activities. The organization failed to improve compliance with hand hygiene. During tracer activities for Data Management, the Hospice Nurse Surveyor observed the organization had been collecting hand hygiene data and had a goal for hand hygiene of 100% but had not documented analysis of the data to assess compliance. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Tracer Activities. The organization failed to provide day to day administrative or direct patient care in an amount that equaled at least 5%. During tracer activities for Volunteer Services, the Hospice Nurse Surveyor observed the volunteer percentage for 2024 was 3.69%. For the current year the percentage continues to average less than 5%. This was discussed and reviewed with the Hospice Leadership Team.

Observed in HR File Review. In 2 of 9 HR files reviewed, the organization failed to document orientation for volunteers. During tracer activities for Competence Assessment, the Hospice Nurse Surveyor observed HR file #7 and #8 ( both volunteers) did not have documentation of orientation to the organization or to the policies. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Patient Home. In 1 of 1 home visits conducted, where a medication reconciliation was completed, the organization failed to maintain a complete and accurate record. During home visit HOSRRHV#1, the Hospice Nurse Surveyor observed the RN did a medication reconciliation according to policy but the medication list in the home, the one in the EMR and the patient bottles did not match. The patient had been on service for 4 weeks. For example the patient was no longer taking the Ferrous Sulfate. But she was taking Women's vitamin, Healthy eyes supplement, Prevagen, Kidney support supplement, Valacyclor, Trazadone, Fish oil, Melatonin, Buspirone, Memantine and Rosuvastatin which were not included in the EMR. This was verified and discussed with the Hospice Leadership Team.

Observed in Emergency Management Session. During the emergency management session discussion and the competency assessment it was noted that the organization failed to document initial training in emergency preparedness policies and procedures upon hire, nor did they have documentation of annual training as required by policy. During discussion with Administrator it was noted that the organization was utilizing a virtual training forum however this platform was generic emergency preparedness training and not specific to the organizations plan and policy and procedures. This observation was reviewed with the Administrator.

Observed in Tracer Activities. during review of the organization's admission packet and patient handbook it was noted that the organization failed to inform and distribute written information to the patient concerning its policies on advance directives. The organization's packet included a description of Nevada state law, however their policy on advance directives was omitted. This observation was reviewed with the Administrator and the Director of Nursing.

Observed in Record Review. In 3 of 11 patient records reviewed, The organization did not ensure that hospice conducted and documented a patient-specific comprehensive assessment to include an initial bereavement assessment that identified the patient’s family factors that may impact their ability to cope with the patient's death. For example: upon review of HV#1, RR#5, RR#4 it was noted that a initial bereavement risk assessment was not documented in the record. This observation was reviewed with the Director of Nursing.

Observed in Leadership Session. Upon discussion with the Director of Nursing it was noted that because the MSW position was vacated in May and organization is currently without a MSW, there had been no social worker to attend the last 3 IDG meetings prior to survey. Further it was noted that the Spiritual Counselor position was vacant in November 2021 and IDG in late November did not have a Spiritual Counselor in attendance. The Director of Nursing noted that the RN was currently completing the Social Worker summary as part of the IDG meeting, and completed the Counselor summary while that position was vacant. This observation was further discussed with the Administrator.

Observed in Tracer Activities. upon review of the organizations admission packet and patient handbook it was noted that there was a lack of an individualized emergency plan, and there was no information provided on pain management. This observation was reviewed with the Administrator and the Director of Nursing. Observed in Record Review. In 2 of 11 patient records reviewed, The organization failed to ensure that the patient and the primary care giver received education and training as related to the patient's ordered wound care. For example: upon review of RR#4 the patient had a stage 4 wound and documentation in the record noted that the facility staff was providing wound care. There was no indication in the record at the facility staff was provided education and training on the wound care ordered for the patient. Similar lack of education and training on the wound care ordered was also noted in RR#5. These observations were reviewed with the Director of Nursing.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization failed to develop a individualized written plan of care that reflected the patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The goals established were not specific and measurable, and lacked interventions to ensure progress to goals. For example: In HV#1 the goal for neuro status stated patient/caregiver verbalize understanding to report any altered mental status or incidence of confusion with the only intervention of assessed sensory/neurological status. The goal for cardiopulmonary stated Patient exhibits reduction/relief of any cardiopulmonary symptoms with the only intervention of assessed cardiovascular system. The patient was noted to be at risk for falls however this was not reflected on the care plan. The patient was on oxygen and the use of oxygen and oxygen safety were not reflected in the plan of care. In RR#4 the goal for pain was Pain is currently managed at a level acceptable to patient with an intervention of evaluated effectiveness of pain control measures. For the care plan for skin integrity the goal stated patient/caregiver verbalize and demonstrate understanding of skin breakdown and the intervention of assess skin for s/s of breakdown as well as preventive measures does not address making progress to the goal. In review of HV#2 the nutritional care plan has an intervention but no goal. In RR#11the patient had a chest tube and a colostomy yet neither of these were reflected in the plan of care. Similar findings can be noted throughout all records reviewed. These observations were reviewed with the Administrator and the Director of Nursing.

Observed in Record Review. In 3 of 11 patient records reviewed, the organization failed to ensure that the patient's plan of care included all drugs and treatments necessary for the palliation and management of the patient's terminal illness. For example: upon review of HV#1 and RR#4 it was noted that the patient's were receiving oxygen therapy however there were no orders for oxygen noted on the clinical record. Further on review of RR#11 it was noted in the documentation that the patient had a chest tube, however there were no orders noted on the record for the functioning and care of the chest tube. These observations were reviewed with the Director of Nursing.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to ensure that the care and services were provided in accordance with the plan of care. For example: during the home observation for HV#1 the hospice aide plan of care included a covid screening which upon discussion with the aide she noted that she did not do covid screenings with the patient. Further, the patient was assigned oral care to be performed every visit yet this task was not performed nor did the patient refuse the task. Shaving was assigned weekly and not provided yet the patient was not asked if he wanted a shave. The aide applied lotion to the patient's entire body, however the plan of care notes to apply skin protectant to bony prominences, but no task of apply lotion was assigned. These observations were reviewed with the Administrator and the Director of Nursing.

Observed in Data Session. Upon review of the data management program and QAPI summaries it was noted that the organization was not comparing internal data over time to compare levels of performance, patterns, trends and variations. Each quarter the QAPI summary contained data solely for the quarter reporting and did not compare data over time. This observation was reviewed with the Administrator, DON, and other organization leadership.

Observed in Patient Home. In 1 of 3 home visits conducted, The organization failed to ensure the accepted standards of practice to prevent the transmission of infections and communicable diseases were carried out per policy. For example: during the home observation for HV#1 the aide was noted to apply double gloves to perform the patient's bath. When providing peri care the aide performed care to the patient's front, then removed the first layer of gloves, and continued to perform care perineal care to the patient's rear, without performing hand hygiene. This double glove method was not in accordance with the organizations hand hygiene policy. This observation was reviewed with the Administrator and the Director of Nursing.

Observed in Tracer Activities. Upon discussion with the Director of Nursing it was noted that the organization was currently without a MSW to provide Medical Social Services a core service for approximately 4 weeks. The organization is actively recruiting a MSW replacement and per the Director of Nursing the nursing staff is assessing for social service needs yet an MSW is currently unavailable. Further in discussion with the Director of Nursing during record reviews it was discovered that the organization was without a spiritual counselor from November to December 2021. Patient's admitted during this time period were not offered counseling services, and spiritual counseling services were discontinued for existing patients. These observations were reviewed with the Administrator and the Director of Nursing.

Observed in Tracer Activities. During the bereavement program review with the Bereavement Coordinator and the Administrator it was noted that the organization lacked an organized program for the provision of bereavement services. Upon discussion of the current status of the bereavement program with the bereavement coordinator he noted that when he began with the organization in December of 2021 there was no formal program in place. Since that time he began to develop a spreadsheet of bereaved family contacts but when the office transitioned over to the Traditions Health system all data was lost and he had to begin gathering bereaved information again. He noted that he currently has 30 contacts on the bereavement program yet admits that the number should be much higher estimating that the number should be likely double the current or more. The Bereavement Coordinator was unable to articulate the process for developing the bereavement plan of care nor was able to provide samples of all correspondence to be mailed to the bereaved. These observations were reviewed with the Administrator and the Bereavement Coordinator.

Observed in Patient Home. In 2 of 11 patient records reviewed, the organization failed to ensure that the RN provided written patient care instructions for the hospice aide related to the patient's oxygen. For example: upon review of the aide plan of care and home observation of HV#1 it was noted that the patient was on continuous oxygen. The aide removed that patient's nasal cannula while washing the patient's face, however there were no written instructions noted on the plan of care to instruct the aide whether to remove O2 for bathing or to leave in place. Example 2: In RR#7 the Aide was assigned by the RN to obtain vital signs, and the aide consistently documented that task has already been completed. Upon discussion with the Director of Nursing the hospice aides at this organization do not take vital signs. These observations were reviewed with the Administrator and the Director of Nursing.

Observed in Leadership Session. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: - §418.100, 418.64, and 418.56

Observed in Tracer Activities. In 4 of 6 HR files reviewed, With the exception of the CNA, the HR files for the Chaplain, DON, Administrator, and Medical Director, lack any documentation of orientation to the organization policy and procedures, their job duties, and the emergency management plan. This observation was reviewed with the Administrator.

Observed in Competency Session. In 3 of 6 HR files reviewed, the organization failed to ensure that the skills and competencies of staff upon hire and document with orientation. For example: the was no documented initial competency assessment noted in the HR file for the Chaplain/Volunteer Coordinator/Bereavement Coordinator, Administrator, and Medical Director. These observations were reviewed with the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to ensure that the medication profile as part of the medical record contained information to reflect the patient's care, treatment, and services. For example: during the home observation for HV#2 during the medication reconciliation, it was noted that the medication profile in the record and the profile in the patient home included ondansetron, however this medication could not be located in the patient home, and the patient noted she was not taking the medication. This observation was reviewed with the Administrator and the Director of Nursing.

Observed in Record Review. For the record review with a live discharge, RR#11, the organization failed to ensure that a written discharge summary was completed and the attending physician was informed of its availability. This observation was reviewed with the Director of Nursing.

Observed in Record Review. In 1 of 11 patient records reviewed, The hospice did not ensure that the patient caregivers ability to demonstrate proficiency of the wound care being provided to the patient. For example: in RR#4 the patient was receiving dressing changes for a wound. The skilled nurse indicated in the record that the facility staff was providing the wound care however there is no documentation noting the facility staff's demonstration of proficiency to provide the wound care in a safe manner as ordered. This observation was reviewed with the Director of Nursing.

Observed in Record Review. In 2 of 11 patient records reviewed, the hospice plan of care failed to identify the care and services that were needed and specifically identify which provider was responsible for performing the respective functions. FOr example: upon review of RR#4 the patient resided in a nursing home and was ordered wound care and had a foley catheter. The plan of care did not specifically identify whether the hospice or the facility staff was responsible for the wound and foley care. In RR#10 the patient care plan specified that the patient was to receive blood glucose monitoring. The patient resided in a nursing home but the plan of care did not specify who was responsible for the blood glucose monitoring. These observations were reviewed with the Director of Nursing.

Observed in Leadership Session. During review of the organization's CLIA certificate of waiver, it was noted that the individual named on the certificate was not updated after that named clinician left the organization. Upon discussion with the Administrator concerning the named clinician, he stated that it was a former medical director that had been gone from the organization for approximately a year, however the CLIA certificate has not been updated as of date of survey.