Every finding on record at Serenity Palliative Care and Hospice LLC

Upon patient record review, 3 of 19 (Patient #3, #4,#16) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #3: The SNF has an order for O2 for comfort dated 4/4/2023; this order is not from the Hospice and not included on hospice medication profile. Corrected on site Patient #4: On home visit medication reconciliation review found Hospice profile listed Glycopyrrolate 1mg tablet PO Q6hrs for terminal secretions. This medication is not on the SNF orders/medication record. The SNF has an order for Ondansetron HCL 4mg Q 6 hrs. PO PRN N&V dated 12/15/2024; this order is not from Hospice and not included on hospice medication profile. Corrected on site. Patient #16: Medication profile dated 1/31/2024 included Diclofenac 1% topical apply TID, no evidence of indication or area to apply, and Polyethylene glycol 17GM Po, no evidence of a diluent.

Upon patient record review, 12 of 19 (Patient #1,#3,#4,#5,#6,#7,#8,#11,#16,#17,#18,#19) 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 #1: On SN SOC identified dysphagia and at risk for aspiration and no funeral plan in place. No evidence on POC of risk of aspiration or need for funeral planning. Corrected on site. Patient #3,#4: On SN SOC identified at risk for falls, no evidence on POC of risk for falls. Corrected on site. Patient #5: On SN SOC identified risk of aspiration (aspiration pneumonia episodes x 2), no evidence on POC for risk of aspiration. Corrected on site. Patient #6: On SOC no funeral home identified, no evidence on POC for funeral planning. Corrected on site. Patient #7: On SN SOC identified risk of aspiration and using O2. No evidence on POC for risk of aspiration and problem/goals/interventions for O2 use. Corrected on site. Patient #8: On SN SOC identified dysphagia at risk for aspiration. No evidence on POC for risk of aspiration. Corrected on site. Patient #11:On SN SOC identified g-tube. No evidence on care plan for problem/goals/interventions for G-tube. Corrected on site. Patient #16: On SN SOC identified dysphagia. No evidence on POC for risk of aspiration. Patient #17: On SN SOC identified dysphagia with history of aspiration. No evidence on POC for risk of aspiration. Patient #18: On SN SOC identified dysphagia. No evidence on POC for risk of aspiration. Patient #19: On SN SOC identified dysphagia and taking Eliquis. No evidence on POC for risk of aspiration and bleeding.

Upon patient record review, 3 of 19 (Patient #3,#4,#16) 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 #3: The SNF has an order for O2 for comfort dated 4/4/2023; this order is not from the Hospice and not included on hospice records or POC. Corrected on site . Patient #4: The SNF has an order for Ondansetron HCL 4mg Q 6 hrs. PO PRN N&V dated 12/15/2024; this order is not from Hospice and not included on hospice records or POC. Corrected on site Patient #16: Order dated 1/31/2024 included Diclofenac 1% topical apply TID, no evidence of indication or area to apply, and Polyethylene glycol 17GM Po, no evidence of a diluent.

Upon patient record review, 10 of 19 (Patient #1,#5,#7,#8,#9,#14,#15,#16,#17,#19) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: SN found on SOC pt. at risk for falls, seizures and aspiration, no evidence on aide assignment/POC for risk/precautions of aspiration. seizures and falls. Corrected on site. Patient #5: SN found on SOC pt. at risk for aspiration, no evidence on aide assignment/POC for risk/precautions of aspiration. Corrected on site. Patient #7: SN found on SOC pt. at risk for aspiration, no evidence on aide assignment/POC for aspiration precautions. Corrected on site. Patient #8: SN found on SOC pt. at risk for aspiration, no evidence on aide assignment/POC for aspiration precautions . Corrected on site. Patient #9: SN found on SOC pt. at risk for falls, no evidence on aide assignment/POC for fall precautions. Corrected on site. Patient #14: SN found on SOC pt. at risk for falls, no evidence on aide assignment/POC for fall precautions. Corrected on site. Patient #15: SN found on SOC pt. at risk for falls, no evidence on aide assignment/POC for fall precautions. Patient #16: SN found on SOC pt. at risk for falls and aspiration, no evidence on aide assignment/POC for fall and aspiration precautions . Patient #17: SN found on SOC pt. at risk for falls and aspiration, no evidence on aide assignment/POC for fall and aspiration precautions . Patient #19: SN found on SOC pt. at risk for aspiration and on Eliquis at risk for bleeding, no evidence on aide assignment/POC for aspiration and bleeding precautions.

Upon patient record review 3 of 19 (Patient #2,#11,#12) 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 #2: Aide visit order dated 12/1/2024 1x week, then resume 2x week. No evidence of a visit or missed aide visit for week of 12/1/2024. Patient #11: Aide visit order for 12/15/2024 1x week, no evidence of an aide visit or missed visit week of 12/15/24. Patient #12: Aide visit order for weeks 12/22/2024 and 12/29/2024 1x week. Week of 12/22/2024 two visits made on 12/23 and 12/27/2024. Week of 12/29/2024 two visits made 12/30/24 and 1/3/2025.Order for 1/5/2025 3x week, one visit made on 1/10/2025 without evidence of missed visits.

Upon patient record review 2 of 19 (Patient #10,#14) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #10. Aide supervisory visits documented 12/2/2024 and 1/13/2025, no evidence of supervisory visit every 14 days to assess the quality of care and services provided by the hospice aide. Patient #14. Aide supervisory visits documented 12/8/2024 and 1/3/2025, no evidence of supervisory visit every 14 days to assess the quality of care and services provided by the hospice aide.

Upon client record review, 1 of 19 (Patient #15) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #15: Revoked and transferred to hospital for hip surgery after a fall while on service. No evidence of a transfer summary sent to hospital.

Upon patient record review, 4 of 19 (Patient #1,#2,#3,#4) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice's 24-hour on-call system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient Patients #1, #2,#3,#4: No evidence in SNF record of Hospice election form.

Upon client record review, 5 of 13 (Patients #3, #4, #7, #8 and #11) did not have evidence that the IDG ensured that the care and services were provided in accordance with the plan of care. Patient #3: A Physician order was written for a Music Evaluation to be conducted during the week of 12/12/2021. As of the Survey, the evaluation has not yet been completed. Patient #4: The Recertification dated 12/7/2021 had a Physician order for monthly foley catheter changes. There was no documentation to indicate the foley had been changed in the month of December. Patient #7: On the Initial Plan of Care, a Physician order was noted for monthly foley catheter changes using a 14 French/10cc. On 12/7/2021, the Nurse documented a foley change using a 18 French foley. Patient #8: On 10/18/2021, the RN documented placing a Coude catheter. There was no Physician order for the coude catheter. Patient #11: On the Initial Plan of Care, a Physician order was noted for monthly foley changes. There was no documentation to indicate the foley was changed in the month of December.

Upon patient record review, 3 of 12 applicable (Patients #1, #2 and #9 ) did not have evidence in the patient record that hospice aide assignments and duties include the tasks to be provided and the frequency of those tasks including precautions. Patient #1: Had a history of seizures and falls. There was no seizure and fall precautions listed on the Aide Care Plan. Patient #2: Had a history of falls. There was no fall precautions listed on the Aide Care Plan. Patient #9: At the start of care, the RN directed the Aide to allow the patient the choice to shower or receive a bed bath due to the patient being cognitively aware. On 1/14/2022, the RN documented, patient ..."lethargic and difficulty to rouse." On 1/20/2022, the RN documented, patient "forgetful, confused and lethargic". On 1/23/2022, the RN documented, patient ..."comatose and unresponsive..." There was no documentation to indicate the Aide Care Plan had been changed to reflect the patient's decline and current cognitive abilities.

Upon patient record review 2 of 12 applicable (Patients #3 and #9) did not have documented evidence that a hospice aide provided services that were ordered by the IDG and included in the plan of care. Patient #3: The Aide Care Plan dated 11/5/2021, directed the Aide to notify the RN if the patient went longer then 3 days before having a bowel movement. During the Aide visit conducted on 12/21/2021, the Aide documented the last bowel movement was 12/17/2021 (4 days). The Aide failed to notify the RN of the finding. Patient #9: On 11/17/2020, the Aide documented ..."ROM provided to left lower extremity, left upper extremity, right lower extremity and right upper extremity. Based on the Aide Care Plan dated 9/18/2021, the RN had not directed the Aide to perform those tasks.

Upon patient client record review, 4 of 13 (Patients #1, #2, #3 and #4) did not have evidence that all entries were legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Review of the Agency's Policy titled, "Clinical Service/Data Collection (2-6) stated ..."Entries into the clinical/service record will be completed within 24 hours of the provision of service to patient. Patient #1: RN visits that were conducted on 12/30/2021 and 1/18/2022, were not completed until 1/25/2022. A Chaplain visit conducted on 1/13/2022 was not completed until 1/19/2022. Patient #2: A Volunteer visit that was conducted on 12/21/2021, was not completed until 12/30/2021. Patient #3: A RN visit that was conducted on 11/10/2021, was not completed until 11/20/2021. An Aide visit conducted on 11/25/2021, was not completed until 12/2/2021. A Social Work visit conducted on 11/29/2021 was not completed until 12/6/2021. Patient #4: A RN visit that was conducted on 1/13/2022, was not completed until 1/19/2022.