Every finding on record at Serenity Hospice Services Inc

Upon patient record review, 2 of 5 (Patient #1, 2) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 1, 2: Both patients were admitted for hospice services on 03.20.2023; the comprehensive initial assessment was completed by the RN as required on admission. However, the RN has not made another visit to date to these patients to update the comprehensive assessment and determine the patients' response to care/progress toward care plan goals. Of note, the LPN has seen these patients weekly on 03.30.2023 and 04.06.2023 (and during the survey on 04.13.2023) in accordance with the SN discipline orders to provide necessary care.

Upon patient record review and direct observation during the home visit, 1 of 5 (Patient #2) 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 treatment order that indicates the use of an oxygen concentrator via trach for patient comfort; this order is inaccurate and incomplete. The patient is utilizing the humidifier attachment of the concentrator only (no O2 flow) via the trach collar continuously for comfort to keep the trach moist. (corrected onsite)