Every finding on record at Serenity One Hospice and Palliative Care Lllc

Based on review of the Hospice's Emergency Preparedness Plan and staff interview, it was determined the Hospice failed to review and update its Emergency Plan and policies biannually. This has the potential to affect all Pts. who receive services from the Hospice. --- Findings include: 1. The Hospice's Emergency Preparedness Plan dated 01/22/16 was reviewed on 02/28/24 at 3:15 PM. This plan was titled "Emergency Management Plan." The plan/policy lacked documentation it was reviewed after 2016. 2. During an interview with the Administrator/QAPI/RN Coordinator on 02/29/24 at 9:30 AM, the above finding was confirmed.

Based on review of the Hospice's Emergency Preparedness Plan and staff interview, it was determined the Hospice failed to ensure the Emergency Preparedness Plan was based on a facility and community risk assessment, utilizing an all-hazards approach. This has the potential to affect all Pts. served by the Hospice. --- Findings include: 1. The Hospice's Emergency Preparedness Plan dated 01/22/16 was reviewed on 02/28/24 at 3:15 PM. The Plan lacked a facility and community-based risk assessment, using an all-hazards approach. 2. During an interview with the Administrator/QAPI/RN Coordinator on 02/29/24 at 9:30 AM, the above finding was confirmed.

Based on a review of the Hospice's Emergency Preparedness Program and Plan and staff interview, it was determined the Hospice failed to ensure the required community exercises were conducted bi-annually to ensure the effectiveness of the Hospice's Emergency Preparedness Plan. This has the potential to affect all Pts. receiving Home Health Care services. --- Findings Include: 1. The Hospice's Emergency Preparedness Plan dated 01/22/16 was reviewed on 02/28/24 at 3:15 PM. The Plan lacked documentation the Hospice conducted testing of emergency preparedness procedures biannually. The Hospice was unable to provide documentation that full-scale individual or community exercises were conducted for the year 2022. 2. During an interview with the Administrator/QAPI/RN Coordinator on 02/29/24 at 9:30 AM, it was confirmed the Hospice failed to conduct a full-scale community or individual based testing of its Emergency Plan for the year 2022.

Based on the Clinical record review and Staff interview, it was determined in 4 of 14 (Pts. # 4, 2, 9 and 12) records reviewed the Hospice failed to ensure the comprehensive assessments were completed within 5 calendar days after the election. --- 3. Pt. #9 was admitted to Hospice services on 12/22/23 with the diagnosis of Cerebral Atherosclerosis. The clinical record was reviewed on 02/27/24 and contained the Election of Hospice Benefit dated 12/22/23. The record contained documentation that the Chaplain made initial contact with the family on 12/28/23 (6 days after the Election of Hospice). The record lacked documentation the Chaplain initiated or attempted to conduct the spiritual assessment within 5 days. Findings include: 1. Pt. #4 was admitted to Hospice services on 01/03/24 with diagnosis of Cerebral Atherosclerosis. The clinical record was reviewed on 02/27/24 and lacked the comprehensive assessment by the Chaplain until 01/16/24. During the interview with the Chaplain, it was stated he was out of town when the Pt. was admitted. 2. Pt. #2 was admitted to Hospice services on 11/21/23 with diagnosis of Cerebral Atherosclerosis. The clinical record was reviewed on 02/28/24. The record included an initial comprehensive assessment completed by the Nurse dated 11/21/23. The initial spiritual care and assessment was completed by the Chaplain on 11/28/23 (7 days from admission). The initial Social assessment was completed by the Social Worker on 11/28/23 (7 days from admission). 4. Pt. #12 was admitted to Hospice services on 02/17/23 with diagnosis of Malignant Neoplasm of Lower third of esophagus. The clinical record was reviewed on 02/27/24. The record included an initial comprehensive assessment completed by the Nurse dated 02/17/23, and by the Social worker dated 02/21/23. The initial spiritual care and assessment was completed by the Chaplain on 02/24/23 (7 days from admission). 5. During interviews with the Administrator/QAPI/RN Coordinator on 02/28/24 at 10:00 AM and 4:00 PM, and on 02/29/24 from 9:30 AM to 10:50 AM, the Administrator/QAPI/RN Coordinator confirmed the above findings.

Based on the Clinical record review and Staff interview, it was determined in 8 of 14 (Pts. # 1, 8, 9, 11, 13, 10, 12 and 14) records reviewed the Hospice failed to ensure the staff followed the POC. --- Findings include: 1. Pt. #1 was admitted to Hospice services on 02/04/24 with diagnosis of Cerebral Atherosclerosis. The clinical record was reviewed on 02/27/24. The POC required weekly Aide visits. The record lacked the Aide visit during the week of 01/14/24. 2. Patient #8 was admitted to Hospice services on 11/06/23 with diagnosis of Other Sequelae of Cerebral Infarction. The clinical record was reviewed on 02/27/24. The POC required weekly RN visits. The record lacked the RN visit during the week of 11/19/23. The POC also required weekly Aide visits. The record lacked the Aide visit during the week of 11/19/23. 4. Pt. #11 was admitted to Hospice services on 04/06/23 with the primary diagnosis of Cerebral Atherosclerosis. The clinical record was reviewed on 02/28/24. The record included documentation of the initial POC which included a visit frequency indicating Pt. #11 was to receive Hospice Aide services "1 visit weekly 5 PRN visits every 30 days effective 04/06/2023." The record lacked documentation that any Hospice Aide visits were provided. 5. Pt. #13 was admitted to Hospice services on 12/07/23 with the primary diagnosis of Alzheimers Disease. The clinical record was reviewed on 02/28/24. The record included documentation of the initial POC which included visit frequency indicating Pt. #11 was to receive Hospice Aide services 3 visits weekly 3 PRN visits every 30 days effective 12/07/2023." The record lacked documentation of 2 visits for the week of 12/03/23 to 12/09/23 and lacked documentation of visits for the weeks of 12/10/23 to 12/16/23 and 12/17/23 to 12/23/23. 6. Pt. #10 was admitted to Hospice services with Diagnosis of Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 02/27/24. The POC effective 12/20/23 to 03/18/24, which contained Physicians order: Hospice Aide 2 visits weekly, 5 PRN visits every 30 days. The record lacked documentation the Hospice Aide provided any service for weeks of 12/20/20 to 12/23/23 and 12/24/23 to 12/25/23. 7. Pt. #12 was admitted to Hospice services on 02/17/23 with diagnosis of Malignant Neoplasm of Lower third of esophagus. The clinical record was reviewed on 02/27/24. The clinical record was reviewed on 02/27/24. The POC effective 02/17/23 to 05/17/23, which contained Physicians order: Hospice Aide 1 visit weekly. The record contained a Hospice Aide visit dated 03/01/23. The record lacked documentation that the Hospice Aide provided any service for weeks of 02/17/23 to 02/18/23, 02/19/23 to 02/25/23 and 03/05/23 to 03/11/23. 8. Pt. #14 was admitted to Hospice services with Diagnosis of Cerebral Atherosclerosis. The clinical record was reviewed on 02/28/24. The POC effective 10/05/23 to 01/02/24, which contained Physicians order: Hospice Aide 2 visits weekly. The record lacked documentation that the Hospice Aide provided any services for weeks of 10/05/23 to 10/07/23, 10/08/23 to 10/14/23, 10/15/23 to 10/21/23, 10/22/23 to 10/28/23 and 10/29/23 to 11/04/23. The record lacked documentation that Hospice Aide visits were provided and, lacked documentation why these visits were missed or that the RN Coordinator was notified. 9. During interviews with the Administrator/QAPI/RN Coordinator on 02/28/24 at 10:00 AM and 4:00 PM and on 02/29/24 from 9:30 AM to 10:50 AM, the Administrator/QAPI/ RN Coordinator, the above findings were confirmed. 3. Pt. #9 was admitted to Hospice services on 12/22/23 with the diagnosis of Cerebral Atherosclerosis. The clinical record was reviewed on 02/27/24 and contained the POC for the certification period of 12/22/23 to 3/20/24 which required the RN to provide service: "1 visit(s) weekly 5 PRN visit(s) every 30 day(s) effective 12/22/2023". The record lacked documentation the RN provided service during the week of 12/24/23 to 12/30/23.

Based on review of the Governing Board minutes and Staff interview, it was determined the Hospice failed to ensure the details of the QAPI program were approved by the governing body. --- Findings include: 1. The Governing Board minutes and Hospice QAPI program were reviewed on 02/28/24 at 10:00 AM. The minutes lacked documentation that the Governing Board met to approve the data collection frequency and details of the QAPI program. 2. During the interview with the Administrator/QAPI/RN Coordinator, on 02/28/24 at 10:30 AM, the findings were confirmed.

Based on review of the Governing Board minutes and Staff interview, it was determined the Hospice failed to ensure the annual evaluation of the QAPI program. --- Findings include: 1. The Governing Board minutes and Hospice QAPI program was reviewed on 02/28/24 at 10:00 AM and lacked the annual evaluation. During the interview with the Administrator it was stated the last Governing Body meeting were in 2017. 2. During the interview with the Administrator/QAPI/RN Coordinator, on 02/28/24 at 10:30 AM, the findings were confirmed.

Based on review of the QAPI program documents and Staff interview, it was determined the Hospice failed to ensure the licensed staff participated in the QAPI program. --- Findings include: 1. The Hospice QAPI program was reviewed on 02/28/24 at 9:30 AM and lacked documentation that the licensed staff (MSW and Chaplain) participated in the QAPI program. 2. During the interview with the Administrator/QA/PI/RN Coordinator, on 02/28/24 at 10:30 AM, the findings were confirmed.

Based on a review of clinical records, Hospice policy and staff interview, it was determined in 1 of 2 (Pt. #14) closed records reviewed for bereavement, the Hospice failed to ensure that on-going bereavement counseling was provided as required. --- Findings include: 1. Pt. #14 was admitted to Hospice services on 10/05/23 with diagnosis of Cerebral Atherosclerosis. The clinical record was reviewed on 02/28/24. The clinical record documented that Pt. #14 expired on 11/06/23. The record include documentation that the family/caregiver was sent a bereavement card on 11/08/23, and bereavement support provided by phone on 11/09/23. The bereavement note dated 11/09/23 indicated continued support might be beneficial to family. The record lacked documentation that family/caregiver refused services or that further bereavement counseling was provided after 11/09/23. 2. The Hospice Policy titled: Plan of Care Bereavement Program, was reviewed on 02/29/24and required : "....The bereavement program takes a minimum of 13 months following death of the patient unless refused by the family members...." 3. During an interview with the Bereavement Coordinator on 02/28/24 at 10:00 AM and with the Administrator/QAPI/RN Coordinator on 02/29/24 at 9:15 AM, both confirmed the above findings.

Based on a review of personnel records, Hospice policy and staff interview, it was determined in 4 of 4 employees (Employee #1, 5, 6 and 7) employed more than 3 years, the Hospice Administrator and/or Governing Body failed to ensure performance evaluations were conducted every 3 years. --- Findings include: 1. The personnel records were reviewed on 02/28/24. The files lacked the following personnel requirements: Employee #1. Date of hire 01/22/16. Lacked a performance evaluation in 2020, 2021, 2022 and 2023. Employee #5. Date of hire 07/23/20. Lacked a performance evaluation in 2021, 2022 and 2023. Employee #6. Date of hire 03/17/17. Lacked a performance evaluation in 2020, 2021, 2022 and 2023. Employee #7. Date of hire 02/03/20. Lacked a performance evaluation in 2021, 2022 and 2023. 2. The Hospice policy titled; ";Employee Performance Evaluation" was reviewed on 02/28/24. The policy included: ";...1. The employee performance evaluation shall be conducted every three years at the first quarter of the year..." 3. The Hospice policy titled; ";Personnel File – 201 File" was reviewed on 02/28/24 at 11:10 AM. The policy included: ";...8. Performance appraisals / improvement program records a. Job performance and standards..." 4. During an interview with the Administrator/QAPI/RN Coordinator and Pt. Care Coordinator on 02/28/24 at 11:40 AM, both confirmed the employees failed to receive a performance evaluation every 3 years.

Based on a review of clinical records and staff interview, it was determined for 2 of 2 (Pts. #12 and 11) patient records reviewed wherein a discharge summary was required, the Hospice failed to ensure the discharge summary included all the requirements. --- 2. Pt. #11 was admitted for Hospice services on 04/06/23 with diagnosis of Cerebral Atherosclerosis. The clinical record was reviewed on 2/28/24 and included documentation that Pt. #11 was discharged from Hospice on 04/18/23 for discharge for a cause - transfer to a Home Health Agency. The discharge summary lacked documentation of a summary of the patients stay, including treatments, symptoms, pain, POC and Physicians orders. 3. During an interview with the Administrator/QAPI/RN Coordinator on 02/29/24 at 9:30 AM, the above findings were confirmed. Findings include: Pt. #12 was admitted to Hospice services on 02/17/23 with diagnosis of Malignant Neoplasm of Lower third of esophagus. The clinical record was reviewed on 02/27/24. The SN note dated 03/08/23, indicated the Pt. was discharged from hospice care for not being eligible, CA Esophageal evaluated as non terminal CA in remission as per hospital physician. An undated discharge summary documented care level change for Pt #12 – ";Discharge – No longer appropriate" and lacked a summary of the patients stay including: treatments, symptoms, pain, POC and Physician's orders.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed, the agency did not ensure that the patient’s individualized written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 2: The patient elected the hospice benefit on 11/21/2023, with a primary hospice diagnosis of Cerebral Atherosclerosis. The patient's comorbid conditions identified during admission included cerebrovascular accident with right hemiplegia and dysphagia. A review of the clinical record for benefit period 9 (BP#9), dated 11/21/2023 through 01/19/2024, and benefit period 10 (BP#10), dated 01/20/2024 through 03/19/2024, revealed the initial nursing assessment completed by the Registered Nurse (RN) dated 11/21/2023 documented, “pt coughs with thin liquids and pt tends to pocket foods, needs prompting to swallow." The plans of care for BP#9 and BP#10 did not include documentation of problems, goals, or planned interventions to address the patient's symptoms of dysphagia. Clinical Record 3: The patient elected the hospice benefit on 01/03/2024, with a primary hospice diagnosis of Cerebral Atherosclerosis. The patient's comorbid conditions identified during admission included dysphagia, which was identified on admission. A review of the clinical record for benefit period 1 (BP#1) dated 01/03/2024 through 04/01/2024 revealed the initial nursing assessment completed by the RN dated 01/03/2024 documented, "pt has cough with crackles" and “pt on aspiration precautions diagnosed with dysphagia." The plan of care for BP#1 did not include documentation of problems, goals, or planned interventions to address the patient's respiratory or dysphagia symptoms. Clinical Record 8: The patient elected the hospice benefit on 08/29/2023 with a primary hospice diagnosis of Cardiomyopathy, Unspecified. The patient's comorbid conditions identified during admission included acute onset chronic heart failure, coronary artery disease, and ischemic cardiomyopathy. A review of the clinical record for benefit period 1 (BP#1) dated 08/29/2023 through 10/06/2023 revealed the initial nursing assessment completed by the RN dated 08/29/2023 documented “breathing with accessory muscles on room air, denies shortness of breath” and “mild dyspnea.” The plan of care for BP#1 did not include documentation of problems, goals, or planned interventions to address the patient's cardiopulmonary symptoms. During a joint clinical record review on 02/20/2024, the Director of Clinical Services (DCS) confirmed that the plans of care did not include all problems, goals, and interventions to address the patient's symptoms and problems identified.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene. This standard was not met as evidenced by document review, interview, and observation. In 1 of 3 (33%) home visits observed, the agency did not ensure that personnel performed hand hygiene when indicated by the agency's policy. Agency policy "Standard Precautions-Hand Hygiene" (dated 01/22/2016) stated in relevant parts, "Policy; Indications for Hand Hygiene, always perform hand hygiene in the following situations: *After contact with blood, body fluid or excretions, *After glove removal." Home Visit 1: During the home visit with the Hospice Aide (HA) [Personnel Record 8] on 02/21/2024. The Hospice Aide was observed twice during care of the patient doffing their gloves and donning new gloves without first performing hand hygiene. Once after removing the patient's soiled brief and once before accessing clean supplies. During an interview on 01/22/2024, the Director of Clinical Services (DCS) confirmed that the HA [Personnel Record 8] did not follow standard precautions and established agency policy for hand hygiene.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 9 (11%) personnel records reviewed, the agency did not ensure that the skills and competencies of all individuals providing care were assessed per agency policy. Agency policy #HR 004.06 "Competency Evaluation Program" stated in relevant parts; "The Competency Evaluation Program applies to all members of the Interdisciplinary Staff involved in the provision of patient care...The competency Evaluation Program shall be conducted every three years at the first quarter of the year." Personnel Record 5: The Social Worker was hired on 07/23/2020. A personnel record review revealed an initial competency assessment was conducted on 08/23/2020. There was no evidence competency was evaluated every three years per the policy. During an interview, the Administrator/Director of Clinical Services confirmed that the Social Worker had no documented competency evaluation since the initial one on 08/23/2020 and should have completed it in the first quarter of 2023 per the agency policy.