Every finding on record at Serenity Hospice of Utah LLC

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. 1 of 13 (8%) clinical records reviewed, the agency did not ensure that an initial comprehensive assessment was completed no later than five (5) calendar days after the election of hospice care Clinical Record 12: The patient elected hospice care on 8/2/2023. The Medical Social Worker (MSW) communication note dated 8/6/2023 documented, "Assessment date pushed back." The electronic medical record (EMR) schedule was documented as "rescheduled for later in the week." As of 8/10/2023, no further MSW assessment was completed. A review of the clinical record revealed no documented reason for the postponement of the assessment or documentation indicating the patient requested the MSW assessment be postponed. A documented missed visit dated 8/6/23 marked the reason for the missed visit as "Other" with no explanation. During an interview on 8/10/23, the Director of Clinical Services confirmed that the MSW assessment was not completed, and there was no documentation indicating that the patient refused. 1 of 13 (8%) of clinical records reviewed the agency did not ensure that the comprehensive assessment within 5 days after hospice election.

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. 12 of 13 (92%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included an initial bereavement assessment. Clinical Record 1: The patient elected hospice care on 6/22/23. A clinical record review revealed no evidence that the comprehensive assessment included documentation of an initial bereavement assessment. Clinical Record 2: The patient elected hospice care on 6/30/23. A clinical record review revealed no evidence that the comprehensive assessment included documentation of an initial bereavement assessment. Clinical Record 3: The patient elected hospice care on 7/2/23. A clinical record review revealed no evidence that the comprehensive assessment included documentation of an initial bereavement assessment. Clinical Record 4: The patient elected hospice care on 7/4/23. A clinical record review revealed no evidence that the comprehensive assessment included documentation of an initial bereavement assessment. Clinical Record 5: The patient elected hospice care on 7/6/23. A clinical record review revealed no evidence that the comprehensive assessment included documentation of an initial bereavement assessment. Clinical Record 6: The patient elected hospice care on 7/8/23. A clinical record review revealed no evidence that the comprehensive assessment included documentation of an initial bereavement assessment. Clinical Record 7: The patient elected hospice care on 7/11/23. A clinical record review revealed no evidence that the comprehensive assessment included documentation of an initial bereavement assessment. Clinical Record 8: The patient elected hospice care on 7/13/23. A clinical record review revealed no evidence that the comprehensive assessment included documentation of an initial bereavement assessment. Clinical Record 9: The patient elected hospice care on 7/14/23. A clinical record review revealed no evidence that the comprehensive assessment included documentation of an initial bereavement assessment. Clinical Record 10: The patient elected hospice care on 8/1/23. A clinical record review revealed no evidence that the comprehensive assessment included documentation of an initial bereavement assessment. Clinical Record 11: The patient elected hospice care on 8/2/23. A clinical record review revealed no evidence that the comprehensive assessment included documentation of an initial bereavement assessment. Clinical Record 12: The patient elected hospice care on 8/2/23. A clinical record review revealed no evidence that the comprehensive assessment included documentation of an initial bereavement assessment. During an interview on 8/9/23, the Chaplain/Bereavement Coordinator stated, "I complete an initial Bereavement Assessment on the day of the event or the day after...The day of the event is the day of the death...No we don't do a Bereavement interview within the first five days of care." During an interview on 8/9/23, the Director of Clinical Services confirmed the finding and stated, "No, we didn't know to assess bereavement from admission...We have always done the initial bereavement assessment at the time of death...We will start doing now." 12 of 13 (92%) of records reviewed the agency did not ensure that the comprehensive assessment included an initial bereavement assessment.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. 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. 1 of 13 (8%) clinical records reviewed of patients receiving hospice aide services, the agency did not ensure that the hospice aide care plan provided clear and accurate information for the hospice aide. Clinical Record 1: The patient elected hospice care on 06/22/2023. The initial comprehensive assessment completed by the Registered Nurse (RN) dated 06/22/2023 documented the patient had a Foley catheter inserted on the day of the hospice admission, 06/22/2023. The plan of care dated 6/22/2023 ordered "Foley catheter 16 Fr. 20 ml balloon. Change q month." The Hospice Aide care plan dated 6/22/2023 read, " Catheter care: External QV." A review of the clinical record revealed no evidence the patient had an external catheter and no specific instructions to the hospice aide regarding Foley catheter care. During an interview on 8/8/23, the Director of Clinical Services confirmed the hospice aide care plan was incorrect and stated, "Oh no, I must have fat-fingered that." 1 of 13 (8%) of clinical records reviewed with aide services, the agency did not ensure that the aide care plan provided clear and accurate information for the aide.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. This standard was not met as evidenced by clinical record review and interview. 1 of 1 (100%) clinical record review of a patient discharged from hospice services to a facility, the agency did not ensure that the facility received a discharge summary with the required components. Clinical Record 10: The patient elected hospice care on 08/01/2023 and was discharged from the hospice on 8/7/2023 after a fall. A discharge summary was completed and sent to the receiving facility and physician on 08/07/2023. A clinical record review revealed the discharge summary did not include documentation of a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. The discharge summary documented only why the patient was discharged from hospice services. During an interview on 8/10/2023, the Director of Clinical Services stated, "I didn't know all of that was required." 1 of 1 (100%) of patients discharged and admitted to a facility, the agency did not ensure that the facility received a discharge summary with the required components.