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

Upon patient record review, 1 of 5 (Patient #2) 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 2 no evidence of identified bleeding precautions on care plan, patient is taking Eliquis.

Upon patient record review, 1 of 5 (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 4 order 10/30/24 for initial SC eval. 11/1/24 SC order states 2 times a month. 11/13/24 SC order states 2 times a month. SC visits completed on 11/1/24, 11/8/24, 11/14/24 which is a total of 3 visits for the month of November.

Upon patient record review, 1 of 5 (Patient #5) 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. Patient 5 initial order 11/2/24 for SW eval. Order on 11/5/24 for SW 1x month effective 11/2/24. SW visits on 11/5/24 and 11/13/24.

Upon patient record review, 7 of 19 (Patients #3,#5,#8,#9,#10,#11,#14) 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 medication profile contained Biofreeze topical gel no area defined for administration. Corrected on site. Patient 5: The medication profile contained Lidocaine topical patches no area defined for administration. The facility and hospice medication profiles did not match for Haldol with the facility identifying patient had an order for scheduled daily tablets and PRN daily tablets that were not on the hospice profile. Corrected on site. Patient 8: The medication profile contained polyethylene glycol oral powder with no instructions to mix with a diluent and duplicative oxygen listings. Corrected on site. Patient 9: The medication profile contained Miralax oral powder with no instructions to mix with a diluent and had oxygen on the medication profile in error. Corrected on site. Patient 10: The facility medication profile contained Milk of Magnesia which was not on the hospice profile. Corrected on site. Patient 11: The medication profile contained diclofenac topical gel, lidocaine topical patch, and methyl salicylate-menthol topical cream with no areas defined for administration. Corrected on site. Patient 14: The medication profile contained oxygen with no delivery method and polyethylene glycol oral powder with no instructions to mix with a diluent. Corrected on site.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 10 of 19 (Patients #1,#2,#3,#6,#7,#9,#10,#12,#13,#14) 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 1,3,7,9,10,12,14: The medical records contained nursing documentation upon admission identifying the patients were a high risk for falls. There was no evidence of problems, goals, and interventions related to fall safety included in the plan of care. Corrected on site. Patient 2: The medical records contained nursing documentation upon admission identifying the patient was a high risk for falls and aspiration due to dysphagia. There was no evidence of problems, goals, and interventions related to fall safety and dysphagia included in the plan of care. Corrected on site. Patient 6: The medical records contained nursing documentation upon admission identifying the patients were a high risk for falls. There was no evidence of problems, goals, and interventions related to fall safety included in the plan of care. The care plan also contained active problems, goals, and interventions related to spiritual care services to be provided by the chaplain in error due to patient declining services. Corrected on site. Patient 13: The medical records contained nursing documentation upon admission identifying the patient was a high risk for falls and constipation. There was no evidence of problems, goals, and interventions related to fall safety and constipation. The care plan also contained an active problem of cardiac dysfunction without goals and interventions. Corrected on site.

Upon patient record review, 6 of 19 (Patients #3,#5,#8,#9,#11,#14) 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 medical record contained an order for Biofreeze topical gel with no area defined for administration. Corrected on site. Patient 5: The medical record contained an order for Lidocaine topical patches with no area defined for administration. Corrected on site. Patient 8: The medical record contained an order for polyethylene glycol oral powder with no instructions to mix with a diluent. Corrected on site. Patient 9: The medical record contained an order for Miralax oral powder with no instructions to mix with a diluent. Corrected on site. Patient 11: The medical record contained orders for diclofenac topical gel, lidocaine topical patch, and methyl salicylate-menthol topical cream with no areas defined for administration. Corrected on site. Patient 14: The medical record contained an order for oxygen with no delivery method and polyethylene glycol oral powder with no instructions to mix with a diluent. Corrected on site.

Upon patient record review, 7 of 19 (Patients #2,#4,#6,#7,#8,#10,#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 2: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair, hospital bed, and over bed table. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 4: The medical record contained nursing documentation upon admission identifying patient use of a cane and walker. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 6: The medical record contained nursing documentation upon admission identifying patient use of a cane. There was no evidence of an order for the cane included in the plan of care. Corrected on site. Patient 7,8,10: The medical records contained nursing documentation upon admission identifying patient use of a walker. There was no evidence of orders for the walker included in the plans of care. Corrected on site. Patient 12: The medical record contained nursing documentation upon admission identifying patient use of a commode. There was no evidence of an order for the commode included in the plan of care. Corrected on site.

Upon patient record review, 1 of 19 (Patient #6) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient 6: There was no evidence of collaboration with the attending physician for updates to the plan of care between 4/17/24 and 9/19/24.

Upon patient record review, 2 of 19 (Patients #1,#11) 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 1: The plan of care included active psychosocial problems, goals, and interventions to be completed by the social worker despite services discontinued with last visit 5/28/24. Corrected on site. Patient 11: The plan of care included active psychosocial problems, goals, and interventions to be completed by the social worker despite services discontinued per order 6/12/24. Corrected on site.

Upon patient record review, 1 of 19 (Patient #11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 11: The medical record contained nursing documentation 9/16/24 identifying the RN removed an indwelling catheter and allowed trial of patient to not have catheter in place without a physician's order.

Upon patient record review 1 of 19 (Patient #6) 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 6: There was no evidence of an aide supervisory visit between 8/5/24 and 8/23/24.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The agency volunteer utilization rate was 4.7% for 2023.

Upon patient client record review, 1 of 13 (Patient #13) 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 13: The medical record contained an election form identifying the patient elected to receive the Notification of Hospice Non-Covered Items on admission 8/7/24. There was no evidence the information was provided until 8/14/24, outside the 5 day timeframe allowable.

Upon patient record review, 2 of 13 (Patient #2,9) 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. Patient #2 RN visit on 12/14/21 documented taking Pepto-Bismol. No evidence of Pepto-Bismol on medication profile. Patient #9 Medication profile included Oxygen 2-5L, no evidence of route of administration.

Upon patient record review, 5 of 13 (Patient #1,4,7,8,12) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component completed or completed timely. Patient #1 Admitted on 9/14/21 and Bereavement Risk Assessment completed on 9/20/21. Patient #4 Admitted on 5/6/21 and Bereavement Risk Assessment completed on 6/1/21. Patient #7 Admitted on 7/29/21 and Bereavement Risk Assessment completed on 9/8/21. Patient #8 and #12 No evidence Bereavement Risk Assessment was completed.

Upon patient record review, 1 of 13 (Patient #9) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient #9 No evidence of medication teaching for the following medications: Aricept, Docusate, Glycopyrrolate, Albuterol, Lorazepam, Miralax, Morphine, Mucinex, Namenda, Oxygen, Tolterodine, Trelegy Ellipta.

Upon patient record review, 2 of 13 (Patient #2,13) 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 RN visit on 12/14/21 documented taking Pepto-Bismol. No evidence of an order for Pepto-Bismol. Patient #13 RN visits on 9/13/21, 9/17/21, 9/20/21, 9/24/21 documented 16FR foley in place. No evidence of order for Foley.

Upon patient record review, 2 of 13 (Patient #10, 13) 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 #10 and #13 with orders for Oxygen. No evidence of DME and supplies related to the Oxygen orders.

Upon patient record review, 5 of 10 applicable (Patient #1,2,8,12,13) did not have evidence in the patient record that hospice aide assignments and duties include the task to be provided and the frequency of those tasks. Patient #1 Identified as high fall risk, no evidence of fall precautions on aide care plan. Aide care plan included hair care every visit and cleanse hair weekly as one task making it difficult to determine exactly which task the aide completed on each visit. Aide care plan included for the task of turn and position every visit to pre-medicate as needed to help ease discomfort. Patient was in a SNF and this reportedly is meant for aide to check with facility nurse about pre-medicating as needed prior to aide care. This was unclear. Patient #2 Identified as high fall risk and on oxygen, no evidence of fall precaution or oxygen precautions on aide care plan. Patient #8 Aide care plan dated 1/22/22 included shower and bed bath every visit. Patient #12 Aide care plan dated 5/28/21 included shower and bed bath every visit. Patient #13 Aide care plan included partial sponge bath and shower every visit.

Upon patient record review 4 of 10 applicable (Patient #1,5,11,12) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #1 Aide visit on 1/24/22 with surveyor, the aide dressed patient. No evidence of dressing patient on aide care plan. Patient #5 Aide care plan denoted to document BM every visit. No evidence of documentation of BM on 12/10/21 HHA visit. Aide care plan denoted weight documented q month. No evidence of weight for the month of December. Patient #11 Aide care plan included shampoo weekly. Aide visits on 9/1/21, 9/3/21, 9/8/21, 9/10/21, 9/14/21, 9/17/21, 9/22/21, 9/24/21 documented shampoo performed. Patient #12 Aide care plan included shampoo weekly. Aide visits on 5/24/21, 5/27/21, 6/1/21, 6/4/21 documented shampoo performed.