Every finding on record at Serenity Palliative Care and Hospice, LLC

Upon patient record review, 5 of 19 (Patients #1,#3,#4,#9,#12) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 1: The medication profile contained diclofenac topical gel with no area defined for administration, and morphine with conflicting instructions for frequency of every 4 hours PRN and hourly PRN. Patient 3: The medication profile contained loperamide listed twice with differing instructions and max doses. Patient 4: The medication profile contained ondansetron with conflicting instructions for frequency of every 6 hours PRN and every 4 hours PRN. Patient 9,12: The medication profile contained morphine with conflicting instructions for frequency of every 4 hours PRN and hourly PRN.

Upon patient record review, 1 of 19 (Patient #3) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 3: The medical record contained nursing documentation since admission identifying patient has dysphagia requiring pureed diet. There was no evidence of problems, goals, and interventions included in the plan of care.

Upon patient record review, 1 of 19 (Patient #5) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 5: The current order for social work visit frequencies stated one time in March and then to continue as PRN for months going forward. There was no evidence of developing a schedule to anticipate needs or discontinue services if scheduled visits were not needed.

Upon patient record review, 6 of 19 (Patients #1,#3,#4,#6,#9,#12) 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 1: The medical record contained orders for diclofenac topical gel with no area defined for administration, and morphine with conflicting instructions for frequency of every 4 hours PRN and hourly PRN. Patient 3: The medical record contained two loperamide orders with differing instructions and max doses. Patient 4: The medical record contained an order for ondansetron with conflicting instructions for frequency of every 6 hours PRN and every 4 hours PRN. Patient 6: The medical record contained nursing documentation upon recertification assessment 4/8/26 identifying patient use of a bi-pap. There was no evidence of an order for bi-pap parameters and settings included in the plan of care. Patients 9,12: The medical records contained orders for morphine with conflicting instructions for frequency of every 4 hours PRN and hourly PRN.

Upon patient record review, 3 of 19 (Patients #3,#7,#12) 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 equipment and supply needs. Patient 3: The medical record contained nursing documentation 4/13/26 and 4/16/26 identifying patient use of a Hoyer lift for transfers. There was no evidence of an order for the DME included in the plan of care. Patient 7: The medical record contained nursing documentation since admission identifying patient use of bedrails and a shower chair. There was no evidence of orders for the DME included in the plan of care. Patient 12: The medical record contained nursing documentation since admission identifying patient use of a shower chair. There was no evidence of an order for the DME included in the plan of care.

Upon patient record review, 3 of 19 (Patients #4,#6,#7) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 4,7: The plan of care included current problems, goals, and interventions to be completed by a massage therapist. There was no evidence the plan of care was updated to remove the care planning after discontinuation of massage therapy 12/22/25. Patient 6: The plan of care included current problems, goals, and interventions to be completed by a massage therapist, chaplain, and social worker. There was no evidence the plan of care was updated to remove the care planning after discontinuation of those services 3/16/26.

Upon patient record review 1 of 19 (Patient #14) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 14: The medical record contained an order for aide visits twice weekly. There was no evidence of a second visit completed the week of 3/29/26. The aide documented the visit was not completed 3/31/26 because they ran out of time to complete.

Upon personnel record review, 1 of 15 (Personnel #15) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records.

Upon patient record review 2 of 19 (Patient #1,14) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 1: Spiritual assessment completed late. Patient was admitted on 03/29/2023, assessment completed on 04/04/2023. Patient 14: Spiritual assessment completed late. Patient was admitted on 02/4/2023, assessment completed on 02/10/2023.

Upon client record review, 3 of 19 (Patient #5, 7, 12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patients 5: One wound present but had not received weekly measurements. Wounds were being assessed weekly but not measured weekly, which is the agencies policy. Patient 7: Two wounds present but had not received weekly measurements. Wounds were being assessed weekly but not measured weekly, which is the agencies policy. Last wound measurement occurred at the time of admission by admitting nurse. Patient 12: Three wounds present but had not received weekly measurements. Wounds were being assessed weekly but not measured weekly, which is the agencies policy.

Upon patient client record review, 1 of 19 (Patient #11) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 11: Elected to receive 'Notice of non-covered items list" No evidence that patient ever received the list. There is a coordination note on the chart where the nurse stated that the POA verbalized that he did want the list of non-covered items. The agency has a policy in for when that happens. Agency is to get a "retraction of request for notice of non-covered items" form signed by the patient or POA. No evidence that the form was ever signed or uploaded to the chart.

Upon client record review, 3 of 19 (Patient #4,8,11) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patients 4: One wounds present but had not received weekly measurements. Wounds were being assessed weekly but not measured weekly, which is the agencies policy. Patient 8: Two wounds present but had not received weekly measurements. Wounds were being assessed weekly but not measured weekly, which is the agencies policy. Patient 11: Three wounds present but had not received weekly measurements. Wounds were being assessed weekly but not measured weekly, which is the agencies policy. Last wound measurement occurred at the time of admission by admitting nurse.