Every finding on record at Serenity Hospice, 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. This standard was not met as evidenced by observation and interview. In 2 of 4 (50%) home visit observations, the agency did not ensure the drug profile contained the patient's current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. Home Visit 1: The patient elected the hospice benefit on 09/06/2023 for the diagnosis of leukemia. The patient resided in a skilled nursing facility (SNF). During the home visit observation with the Hospice Aide (HA) (Personnel Record 7), a copy of the facility's medication administration record (MAR) was compared to the hospice medication profile. The facility had the following medications listed that were not on the hospice medication profile, Milk of Magnesia 30 ml every 12 hours dated 01/01/2024, Probiotic 1 capsule daily dated 05/30/2024. The hospice medication profile had the following medications that were not listed on the facility MAR, Robitussin DM every 6 hours as needed dated 09/13/2023, Cosopt eye drops twice daily date 12/19/2023, Senna S twice daily dated 03/14/2024, and Glycopyrrolate three times daily as needed dated 04/20/2024. Home Visit 2: The patient elected the hospice benefit on 11/17/2023 for the diagnosis of Parkinson's disease. The patient resided in a SNF. During the home visit observation with the Licensed Vocational Nurse (LPN) (Personnel Record 10), a copy of the facility's MAR was compared to the hospice medication profile. The facility had the following medications listed that were not on the hospice medication profile, Bisacodyl 5 mg daily dated 11/23/2023, Lasix 20 mg daily dated 11/23/2023, Prosource 30 ml daily dated 11/30/2023, Benadryl 25 mg every 6 hours as needed dated 12/29/2023, Coreg 6.25 mg two times daily dated 11/24/2023 vs hospice had Coreg 1 time a day, Norco every 6 hours as needed dated 11/23/2023 vs hospice had every 6 hours scheduled. The hospice had the following medication listed that were not on the facility MAR, Bisacodyl 10 mg suppository as needed dated 03/15/2024. During an interview and joint record review on 06/05/2024, the Director of Patient Care Services and the Quality Coordinator confirmed there were differences in the drug profiles.

It is required that the comprehensive assessment includes an initial bereavement assessment of 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. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure an initial bereavement assessment was completed. Clinical Record 13: The patient elected the hospice benefit on 04/29/2024 for the diagnosis of chronic obstructive pulmonary disease. Clinical record review revealed no documented evidence that an initial bereavement assessment was completed. Clinical Record 14: The patient elected the hospice benefit on 05/07/2024 for the diagnosis of malignant neoplasm of the lung. Clinical record review revealed no documented evidence that an initial bereavement assessment was completed. Clinical Record 15: The patient elected the hospice benefit on 12/22/2023 for the diagnosis of Parkinson's disease. Clinical record review revealed no documented evidence that an initial bereavement assessment was completed. During an interview and joint record review on 06/05/2024, the Director of Patient Care Services and the Quality Coordinator confirmed the clinical records did not contain initial bereavement assessments.

It is required that the 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). This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure hospice care and services provided to patients followed the individualized plan of care. Clinical Record 1: The patient elected the hospice benefit on 09/06/2023 for the diagnosis of leukemia. The initial plan of care included an order for skilled nurse visit frequency of 1-3 visits per week. Clinical record review revealed skilled nursing visits were not documented for the weeks of 12/03/2023, 01/14/2024, and 02/05/2024. The clinical record contained no documented reason for the missed nursing visits. Clinical Record 2: The patient elected the hospice benefit on 11/17/2023 for the diagnosis of Parkinson's disease. The initial plan of care included an order for skilled nurse frequency of visits, 1-3 visits per week. Clinical record review revealed a skilled nursing visit was not documented for the week of 12/10/2024 and the clinical record contained no documented reason for the missed visit. Clinical Record 10: The patient elected the hospice benefit on 01/28/2024 for the diagnosis of malignant neoplasm of the skin. The initial plan of care included an order for skilled nurse frequency of visits 2-4 visits per week. Clinical record review revealed during the week 05/13/2024 only one visit was documented on 05/15/2024. The clinical record contained no documented reason for the missed visit(s). During an interview and joint record review on 06/05/2024, the Director of Patient Care Services and the Quality Coordinator confirmed visits had not been documented or performed as ordered in the plans of care.

It is required that the bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 2 of 3 (67%) clinical records reviewed with bereavement services, the agency did not ensure bereavement services reflected the needs of the bereaved per a bereavement plan of care. Clinical Record 17: The patient elected the hospice benefit on 03/21/2024 for the diagnosis of pulmonary fibrosis. The patient died on 03/24/2024. The clinical record contained no documented evidence that a bereavement plan of care had not been established. Clinical Record 18: The patient elected the hospice benefit on 02/14/2024 for the diagnosis of heart disease. The patient died on 05/07/2024. The clinical record contained no documented evidence of a post-death bereavement assessment or that a bereavement plan of care had not been established. During an interview and joint record review on 06/05/2024, the Director of Patient Care Services and the Quality Coordinator confirmed that bereavement services were not outlined in plans of care.

It is required that written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 8 of 14 (57%) clinical records reviewed with hospice aide services accepted, the agency did not ensure the Registered Nurse (RN) provided patient-specific care instructions for the hospice aide. Clinical Record 1: The patient elected the hospice benefit on 09/06/2023 for the diagnosis of leukemia. The initial nursing assessment dated 09/06/2023 included documentation that the patient had periods of "Requires supplemental oxygen at 2 liters per minute continuously." The hospice aide care plan dated 09/06/2023 assigned the aide the tasks of bed bath and shampooing hair but did not provide specific instructions to the aide related to the patient’s use of oxygen during tasks. Clinical Record 2: The patient elected the hospice benefit on 11/17/2023 for the diagnosis of Parkinson's disease. The initial nursing assessment dated 11/17/2023 included documentation that the patient had "a wound to coccyx and wounds to left toes." The hospice aide care plan dated 11/17/2023 assigned the aide the tasks of bed bath and visualize condition of skin and report to RN, but the aide care plan did not notify the aide of the patient’s wounds. The aide care plan did not provide specific instructions to the aide related to caring for the wounds and wound dressings while providing care to the patient. Clinical Record 3: The patient elected the hospice benefit on 12/25/2023 for the diagnosis of cerebral infarction. The initial nursing assessment dated 12/25/2023 included documentation that the patient is prescribed Keppra 1000 mg seizures. The nursing assessment dated 02/26/2024 included documentation that the patient had an "upper right back wound." A nursing assessment dated 05/08/2024 included documentation of "right buttocks wound." The nursing assessment dated 05/15/2024 included documentation of "right buttock pressure ulcer with hydrocolloid dressing." The hospice aide care plan dated 12/25/2023 assigned the aide the tasks of bed bath, incontinent care and visualize condition of skin every visit and report to RN. The aide care plan did not include notification of seizure precautions and did not provide specific instructions to the aide related to caring for the wound and wound dressing while providing care to the patient. Clinical Record 6: The patient elected the hospice benefit on 05/22/2024 for the diagnosis of cerebral infarction. The initial nursing assessment dated 05/22/2024 included documentation that the patient had "multiple wounds, pressure sores to coccyx, right heel and left second finger." The hospice aide care plan dated 05/22/2024 assigned the aide the tasks of bed bath and visualize condition of skin and report to RN. The aide care plan did not notify the aide of the patient’s wounds and did not provide specific instructions to the aide related to caring for the wound and wound dressing while providing care to the patient. Clinical Record 8: The patient elected the hospice benefit on 01/10/2024 for the diagnosis of malignant neoplasm of the tongue. The initial nursing assessment dated 01/10/2024 included documentation that the patient had a G-tube [gastrostomy tube]. The hospice aide care plans dated 03/15/2024 and 04/11/2024 assigned the aide the tasks of bed bath and visualize condition of skin and report to RN. The aide care plans did not notify the aide of the patient’s G-tube and did not include specific instructions related to G-Tube care while providing care to the patient. Clinical Record 10: The patient elected the hospice benefit on 01/28/2024 for the diagnosis of malignant neoplasm of the skin. A physician order dated 01/28/2024 noted "skin tears bilateral arms cover with foam dressing." The hospice aide care plan dated 01/28/2024 assigned the aide the care tasks of shower and visualize condition of skin and report to RN. The aide care plan did not notify the aide of the patient’s wounds and did not provide specific instructions to the aide related to caring for the wound and wound dressing while providing care to the patient. Clinical Record 11: The patient elected the hospice benefit on 03/14/2024 for the diagnosis of Alzheimer's disease. The hospice aide care plan dated 3/14/2024 identified that the aide was tasked with giving the patient a bath but did not specify which type of bath: shower, bed bath, partial bed bath or shower chair. Clinical Record 18: The patient elected the hospice benefit on 02/14/2024 for the diagnosis of heart disease. The hospice aide care plan dated 04/29/2024 assigned the aide the tasks of bed bath and shampooing. The aide care plan notified the aide that the patient was on oxygen at 4 LPM [liters per minute] continuously but did not provide specific instructions to the aide related to the patient’s use of oxygen during tasks. During an interview and joint record review on 06/05/2024, the Director of Patient Care Services and the Quality Coordinator confirmed the hospice aide care plans did not contain specific instructions to the aide related to the patient’s care task assigned.

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 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 7 of 10 (70%) clinical records reviewed with recertification, the agency did not ensure the recertification of the terminal illness was completed by the physician no later than two calendar days after the first day of the benefit period and no more than 15 days before the next benefit period. Clinical Record 1: The patient elected the hospice benefit on 09/06/2023 for the diagnosis of leukemia. Clinical record review revealed the fourth benefit period started on 05/03/2024 and the recertification of terminal illness was signed by the hospice Medical Director on 05/06/2024, 3 days after the start of the benefit period and 1 day outstanding. Clinical Record 2: The patient elected the hospice benefit on 11/17/2023 for the diagnosis of Parkinson's disease. Clinical record review revealed the second benefit period started on 02/15/2024 and the recertification of terminal illness was signed by the hospice Medical Director on 02/19/2024, 4 days after the start of the benefit period and 2 days outstanding. Clinical Record 3: The patient elected the hospice benefit on 12/25/2023 for the diagnosis of cerebral infarction. Clinical record review revealed the fifth benefit period started on 04/02/2024 and the recertification of terminal illness was signed by the hospice Medical Director on 04/10/2024, 8 days after the start of the benefit period and 6 days outstanding. The sixth benefit period started on 06/01/2024 and the recertification of terminal illness was not signed by the hospice Medical Director, as of the date of record review on 06/05/2024, 4 days after the start of the benefit period and 2 days outstanding. Clinical Record 5: The patient elected the hospice benefit on 07/29/2023. Clinical record review revealed the second benefit period started on 10/27/2023 and the recertification of terminal illness was signed by the hospice Medical Director on 10/30/2023, 3 days after the start of the benefit period and 1 day outstanding. The third benefit period started on 01/25/2024 and was signed by the hospice Medical Director on 01/29/2024, 4 days after the start of the benefit period and 2 days outstanding. The fourth benefit period started on 03/25/2024 and was signed by the hospice Medical Director on 04/07/2024, 13 days after the start of the benefit period and 11 days outstanding. The fifth benefit period started on 05/24/2024 and was signed by the hospice Medical Director on 05/28/2024, 4 days after the start of the benefit period and 2 days outstanding. Clinical Record 7: The patient elected the hospice benefit on 12/29/2023 for the diagnosis of chronic obstructive pulmonary disease. Clinical record review revealed the second benefit period started on 03/28/2024 and the recertification of terminal illness was signed by the hospice Medical Director on 04/07/2024, 10 days after the start of the benefit period and 8 days outstanding. Clinical Record 8: The patient elected the hospice benefit on 01/10/2024 for the diagnosis of malignant neoplasm of the tongue. Clinical record review revealed the second benefit period started on 04/09/2024 and the recertification of terminal illness was signed by the hospice Medical Director on 05/01/2024, 24 days after the start of the benefit period and 22 days outstanding. Clinical Record 15: The patient elected the hospice benefit on 12/22/2023 for the diagnosis of Parkinson's disease. Clinical record review revealed the eleventh benefit period started on 04/20/2024 and the recertification of terminal illness was signed by the hospice Medical Director on 04/23/2024, 3 days after the start of the benefit period and 1 day outstanding. During an interview and joint record review on 06/05/2024, the Director of Patient Care Services and the Quality Coordinator confirmed the recertifications had not been signed by the Medical Director within the 2-day time frame.