Every finding on record at Serenity Point Hospice LLC

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 11 of 14 (79%) clinical records reviewed it was revealed that the agency did not ensure that the hospice interdisciplinary group (IDG) completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. Clinical Record 1: The patient elected the hospice benefit on 12/08/2023. The record lacked evidence that a Chaplain initial assessment was completed no later than 5 calendar days after the election of hospice care, or supportive documentation that the patient/family requested a delay for the Chaplain visit. The Chaplain initial assessment was completed on 12/14/2023 which was one (1) day late. Clinical Record 2: The patient elected the hospice benefit on 07/11/2023. The record lacked evidence that a Chaplain initial assessment was completed, or supportive documentation that the patient/family refused Chaplain services no later than 5 calendar days after the election of hospice care. Clinical Record 3: The patient elected the hospice benefit on 03/19/2024. The record lacked evidence that the Chaplain and the Social Worker initial assessments, or the supportive documentation that the patient/family refused the Chaplain and the Social Worker services within 5 calendar days after the election of hospice care. Clinical Record 4: The patient elected the hospice benefit on 07/25/2023. The record lacked evidence that the Chaplain initial assessment was completed, or supportive documentation that the patient/family refused Chaplain services no later than 5 calendar days after the election of hospice care. Clinical Record 5: The patient elected the hospice benefit on 07/27/2023. The record lacked evidence that a Chaplain initial assessment was completed no later than 5 calendar days after the election of hospice care, or supportive documentation that the patient/family requested a delay for the Chaplain visit. The Chaplain initial assessment was completed on 08/11/2023. Clinical Record 6: The patient elected the hospice benefit on 11/29/2023. The record lacked evidence that the Chaplain initial assessment was completed, or supportive documentation that the patient/family refused Chaplain services no later than 5 calendar days after the election of hospice care. Clinical Record 9: The patient elected the hospice benefit on 04/17/2024. The record lacked evidence that the Chaplain initial assessment was completed, or supportive documentation that the patient/family refused Chaplain services no later than 5 calendar days after the election of hospice care. Clinical Record 10: The patient elected the hospice benefit on 04/23/2024. The record lacked evidence that the Chaplain initial assessment was completed, or supportive documentation that the patient/family refused Chaplain services no later than 5 calendar days after the election of hospice care. Clinical Record 12: The patient elected the hospice benefit on 04/22/2024. The record lacked evidence that the Chaplain initial assessment was completed, or supportive documentation that the patient/family refused Chaplain services no later than 5 calendar days after the election of hospice care. Clinical Record 13: The patient elected the hospice benefit on 03/13/2024. The record lacked evidence that the Chaplain and the Social Worker initial assessments, or the supportive documentation that the patient/family refused the Chaplain and the Social Worker services no later than 5 calendar days after the election of hospice care. Clinical Record 14: The patient elected the hospice benefit on 04/04/2024. The record lacked evidence that the Chaplain and the Social Worker initial assessments, or the supportive documentation that the patient/family refused the Chaplain and the Social Worker services no later than 5 calendar days after the election of hospice care. The Chief Executive Officer and Administrator/Alternate Director of Nursing/Volunteer Coordinator stated in an interview on 05/02/2024 that the agency did not ensure that the hospice interdisciplinary group (IDG) completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. This standard was not met as evidenced by clinical record review and interview. In 14 of 14 (100%) clinical records reviewed it was revealed that the agency did not ensure that an initial bereavement assessment was completed for the patient's family and other individuals, as part of the comprehensive assessment. Clinical Record 1: The patient elected the hospice benefit on 12/08/2023. The record lacked evidence of an initial bereavement assessment having been completed for the patient's family and other individuals as part of the comprehensive assessment. Clinical Record 2: The patient elected the hospice benefit on 07/11/2023. The record lacked evidence of an initial bereavement assessment having been completed for the patient's family and other individuals as part of the comprehensive assessment. Clinical Record 3: The patient elected the hospice benefit on 03/19/2024. The record lacked evidence of an initial bereavement assessment having been completed for the patient's family and other individuals as part of the comprehensive assessment. Clinical Record 4: The patient elected the hospice benefit on 07/25/2923. The record lacked evidence of an initial bereavement assessment having been completed for the patient's family and other individuals as part of the comprehensive assessment. Clinical Record 5: The patient elected the hospice benefit on 07/27/2023. The record lacked evidence of an initial bereavement assessment having been completed for the patient's family and other individuals as part of the comprehensive assessment. Clinical Record 6: The patient elected the hospice benefit on 11/29/2023. The record lacked evidence of an initial bereavement assessment having been completed for the patient's family and other individuals as part of the comprehensive assessment. Clinical Record 7: The patient elected the hospice benefit on 06/23/2023. The record lacked evidence of an initial bereavement assessment having been completed for the patient's family and other individuals as part of the comprehensive assessment. Clinical Record 8: The patient elected the hospice benefit on 02/19/2024. The record lacked evidence of an initial bereavement assessment having been completed for the patient's family and other individuals as part of the comprehensive assessment. Clinical Record 9: The patient elected the hospice benefit on 04/17/2024. The record lacked evidence of an initial bereavement assessment having been completed for the patient's family and other individuals as part of the comprehensive assessment. Clinical Record 10: The patient elected the hospice benefit on 04/23/2024. The record lacked evidence of an initial bereavement assessment having been completed for the patient's family and other individuals as part of the comprehensive assessment. Clinical Record 11: The patient elected the hospice benefit on 12/20/2023. The record lacked evidence of an initial bereavement assessment having been completed for the patient's family and other individuals as part of the comprehensive assessment. Clinical Record 12: The patient elected the hospice benefit on 04/22/2024. The record lacked evidence of an initial bereavement assessment having been completed for the patient's family and other individuals as part of the comprehensive assessment. Clinical Record 13: The patient elected the hospice benefit on 03/13/2024. The record lacked evidence of an initial bereavement assessment having been completed for the patient's family and other individuals as part of the comprehensive assessment. Clinical Record 14: The patient elected the hospice benefit on 04/04/2024. The record lacked evidence of an initial bereavement assessment having been completed for the patient's family and other individuals as part of the comprehensive assessment. The Chief Executive Officer and Administrator/Alternate Director of Nursing/Volunteer Coordinator stated in an interview on 05/02/2024 that the agency did not ensure that an initial bereavement assessment was completed for the patient's family and other individuals, as part of the comprehensive assessment.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered, and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) bereavement records reviewed for patients discharged due to death revealed the agency did not ensure a post-death bereavement assessment and plan of care (POC) was completed for the bereaved. Clinical Record 4: The patient expired on 12/03/2023. The record lacked evidence of a completed post-death bereavement assessment and POC. Post-death, there was evidence of a sympathy card and other mailings that provided grief support to the family. Clinical Record 5: The patient expired on 08/28/2023. The record lacked evidence of a completed post-death bereavement assessment and POC for the survivor(s). Post-death, there was evidence of a sympathy card and other mailings that provided grief support to the family. The Chief Executive Officer and Administrator/Alternate Director of Nursing/Volunteer Coordinator stated in an interview on 05/02/2024 that the agency did not ensure a post-death bereavement assessment and plan of care (POC) was completed for the survivor(s).

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed for patients that elected hospice aide services it was revealed that the agency did not ensure the hospice aide care plan prepared by the registered nurse (RN) included the specifics for the aide tasks ordered. Clinical Record 3: The aide care plan dated 03/19/2024 lacked evidence of specific clear directions for the aide. The tasks for Bathing ordered included: "Bed bath" and "Shower". During joint clinical record review on 05/01/2024, the Alternate DON stated that she ordered both types of bathing so the aide can choose whichever was best for the patient on any given day. She stated, "Sometimes the patient wants a shower, and sometimes a bed bath." The Chief Executive Officer and Administrator/Alternate Director of Nursing/Volunteer Coordinator stated in an interview on 05/02/2024 that the agency did not ensure the hospice aide care plan prepared by the RN included the specific bath type.

It is required that a hospice aide provides services that are Included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 5 of 13 (38%) clinical records reviewed of patients that elected hospice aide services it was revealed that the agency did not ensure the hospice aide provided services included in the plan of care (POC). Clinical Record 4: The aide POC dated 07/25/23 ordered the task: "Shower with chair" every visit. The aid visit note dated 11/21/2023 stated the aide completed a "Bed bath". Clinical Record 6: The aide POC dated 11/29/2023 ordered the task: "Weight" two times per week. The aide visit notes dated 02/27/2024 and 03/01/2024 lacked documentation of the patient's weight. An explanation as to why the patient was not weighed at each visit was not provided. Clinical Record 7: The aide POC dated 06/23/2023 ordered the task: "Shower with chair" every visit. The aide visit note dated 08/08/2023 stated the aide completed a "Bed bath". Clinical Record 11: The aide POC dated 04/18/2024 ordered the task: "Shower with Chair" every visit. The aide visit note dated 04/19/2024 lacked evidence that the task "Shower with Chair" was completed. An explanation as to why the patient was not bathed, as ordered, during the visit was not provided. Clinical Record 14: The aide POC dated 04/04/2024 ordered the task: "Shower" every visit. The aide visit notes dated 4/5/24 and 4/18/24 stated the aide completed a "Shower with chair". The Chief Executive Officer and Administrator/Alternate Director of Nursing/Volunteer Coordinator stated in an interview on 05/02/2024 that the agency did not ensure the hospice aide provided the services included on the aide POC.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 3 of 12 (25%) clinical records reviewed of patients that elected hospice aide services it was revealed that the agency did not ensure the hospice aide reported changes in the patient's medical needs as related to the plan of care (POC) to the registered nurse (RN). Clinical Record 4: The aide POC dated 07/25/23 ordered the task: "Shower with chair" every visit. The aid visit note dated 11/21/2023 stated the aide completed a "Bed bath". The record lacked evidence of the aide having reported the changes in the patient's medical needs as related to the POC to the RN. Clinical Record 7: The aide POC dated 06/23/2023 ordered the task: "Shower with chair" every visit. The aide visit note dated 08/08/2023 stated the aide completed a "Bed bath". The record lacked evidence of the aide having reported the changes in the patient's medical needs as related to the POC to the RN. Clinical Record 11: The aide POC dated 04/18/2024 ordered the task: "Shower with chair" every visit. The aide visit note dated 04/19/2024 lacked evidence of a "Shower with chair" having been completed; no bathing task was completed at this aide visit. The record lacked evidence of the aide having reported the changes in the patient's medical needs as related to the POC to the RN. The Chief Executive Officer and Administrator/Alternate Director of Nursing/Volunteer Coordinator stated in an interview on 05/02/2024 that the agency did not ensure the hospice aide documented reported changes in the patient's medical needs as related to the POC to the RN.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed of a patient that transferred to a facility, it was revealed the agency did not ensure a copy of the hospice discharge summary was forwarded to the receiving facility. Clinical Record 6: The patient elected the hospice benefit on 11/29/2023. The family elected to revoke the hospice benefit on 03/27/2024 to pursue aggressive treatment. The record lacked evidence that the agency forwarded a copy of the hospice discharge summary to the receiving facility (hospital). The Chief Executive Officer and Administrator/Alternate Director of Nursing/Volunteer Coordinator stated in an interview on 05/02/2024 that the agency did not ensure that the agency forwarded a copy of the hospice discharge summary to the receiving facility.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients that were discharged or revoked the hospice benefit and went to a facility, it was revealed that the agency did not ensure a copy of the hospice discharge summary was forwarded to the patient's attending physician. Clinical Record 6: The patient elected the hospice benefit on 11/29/2023. The family elected to revoke the hospice benefit on 03/27/2024 to pursue aggressive treatment. The record lacked evidence that the agency forwarded a copy of the hospice discharge summary to the patient's attending physician. Clinical Record 7: The patient elected the hospice benefit on 06/23/2023. The patient was discharged from hospice services due to no longer being terminally ill on 08/11/2023. Per the Unattended Discharge Note dated 08/11/2023, the former patient's attending physician agreed to take the patient back on his service. The record lacked evidence that the agency forwarded a copy of the hospice discharge summary to the patient's attending physician. The Chief Executive Officer and Administrator/Alternate Director of Nursing/Volunteer Coordinator stated in an interview on 05/02/2024 that the agency did not ensure a copy of the hospice discharge summary was forwarded to the patient's attending physician.

Based on observation, document review and interview, it was determined the Hospice failed to comply with the Condition of Participation, 42 CFR 418.100, Organization Environment. --- Findings Include: 1. The Governing Body failed to ensure the Administrator followed Hospice Policy and Procedure for the proper disposal of controlled substances (L651)

Based on observation, document review and interview, it was determined the Governing Body and Administrator failed to oversee that Hospice Policy and Procedure for the disposal of controlled substances was followed. --- Findings include: 1. An observational tour of the Hospice medication and supply storage area was conducted on 2/7/24 at approximately 1:00 PM. During the tour, the Director of Nursing (DON) opened the locked medication refrigeratorand the following medications were found inside: - Hydromorphone 2 mg/ tab, 28.5 tabs remaining of 30 - Compazine 10 mg/ tab, 29 tabs remaining of (unlabeled) - Morphine 100mg/5 ml (20mg/1ml), 18.5ml remaining of 30ml ordered - Morphine 100mg/5ml (20mg/1ml), 23.5 ml remaining of 30ml ordered - Tramadol 50mg/tab, 102 tabs remaining of 240 ordered - Lorazepam 2mg/ml, sealed - Cyclobenzaprine 5mg/ tab, 57 tabs remaining of 60 ordered 2. On 2/7/24 at 2:15 PM, the Policy titled, ";Medication Disposal" (undated) was reviewed. The policy notes, ";Procedure.......2. Disposal of controlled substances: Mixing prescription drugs with an undesirablesubstance, such as used coffee grounds or kitty litter, and putting them in impermeable, non-prescript containers, such as empty cans or sealable bags, will further ensure the drugs are not diverted....."3. On 2/7/24 during the observational tour an interview was conducted with DON and Chief Executive Officer (CEO). DON stated, [Name of Admin] instructed us to bring the controlled substances back to the facility todispose of within 72 hours, but that didnt always happen. Our policy is to destroy them on site, or the family or facility will destroy them." CEO, ";We should never have controlled substances in our stock. We are partnered with the area pharmacies so that if staff need to fill a prescription, they can 24 hours a day. I was not even aware these medications were in the refrigerator or that we had an issue. The Director of Nursing is the only staff member with access to the refrigerator."

Based on observation, document review and interview, it was determined the Hospice failed to comply with the Condition of Participation, 42 CFR 418.106, Drugs and biologicals and durable medical equipment. --- 1. The Hospice agency failed to ensure medications were disposed of per policy (L694) 2. The Hospice agency failed to ensure a medication discrepancy was investigated immediately (L700)

A. Based on observation, record review and interview, it was determined for seven of seven controlled substances the facility failed to ensure medications were disposed of per policy. B. Based on document review and interview, it was determined for five of five patients (Pt #2, Pt #7, Pt #8, Pt #9, Pt #10) whose medications were stored at the Hospice Agency office, the facility failed to ensure that the record indicated the appropriate disposition of the controlled substances --- Findings include: A.1. An observational tour of the Hospice medication and supply storage area was conducted on 2/7/24 at approximately 1:00 PM. During the tour, the Director of Nursing (DON) opened the locked medication refrigerator and the following medications were found inside: - Hydromorphone 2 mg/ tab, 28.5 tabs remaining of 30 tabs ordered - Compazine 10 mg/ tab, 29 tabs remaining of (unlabeled) - Morphine 100mg/5 ml (20mg/1ml), 18.5ml remaining of 30ml ordered - Morphine 100mg/5ml (20mg/1ml), 23.5 ml remaining of 30ml ordered - Tramadol 50mg/tab, 102 tabs remaining of 240 ordered - Lorazepam 2mg/ml, sealed - Cyclobenzaprine 5mg/ tab, 57 tabs remaining of 60 ordered 2. On 2/7/24 at 2:15 PM, the Policy titled, ";Medication Disposal" (undated) was reviewed. The policy notes, ";Procedure.......2. Disposal of controlled substances: Mixing prescription drugs with an undesirable substance, such as used coffee grounds or kitty litter, and putting them in impermeable, non-prescript containers, such as empty cans or sealable bags, will further ensure the drugs are not diverted....." 3. On 2/7/24 during the observational tour an interview was conducted with DON and CEO. DON stated, ";[Name of Admin] instructed us to bring the controlled substances back to the facility to dispose of within 72 hours but that didnt always happen. Our policy is to destroy them on site, or the family or facility will destroy them." CEO stated, ";We should never have controlled substances in our stock. We are partnered with the area pharmacies so that if staff need to fill a prescription, they can 24 hours a day. I was not even aware these medications were in the refrigerator or that we had an issue. The Director of Nursing is the only staff member with access to the refrigerator." B. 1. On 2/7/24 at approximately 1:00 PM, an observational tour of the Hospice medication and supply storage area was conducted with CEO and DON. During the tour, DON opened the locked medication refrigerator and the following medication were found inside: - Hydromorphone 2 mg/ tab, 28.5 tabs remaining of 30 tabs ordered (prescribed for Pt #7). - Lorazepam 2mg/ml, sealed (prescribed for Pt #10 – who expired on 12/15/24). - Cyclobenzaprine 5mg/ tab, 57 tabs remaining of 60 ordered (prescribed for Pt #11 who expired 2/19/23). 2. Pt #2s record was reviewed. Pt #2s record indicated Pt #2 expired on 11/27/23 at 1:34 AM. The death visit note completed by ADMIN included, ";Hospice Staff Disposed of Medications... Person who disposed medications [Name of ADMIN], Person Who Witnessed Disposal: [Name of DON]" The note indicated the medications disposed of were Morphine 20mg/ml 24 ml (disposed) and Ativan 2mg/ml 23.5ml (disposed) which both were disposed of in cat litter. 3. Pt #7s record was reviewed. Pt #7s record indicated Pt #7 expired on 11/12/23 at 8:45 AM. The death visit note completed by ADMIN included, ";Hospice Staff Disposed of Medications... Person who disposed medications [Name of ADMIN], Person Who Witnessed Disposal: [Name of DON]" The note indicated the medications disposed of were Morphine 20mg/ml 18.5 ml (disposed) and Ativan 2mg/ml 12ml (disposed) which both were disposed of in cat litter. 4. Pt #10s record was reviewed. Pt #10s record indicated Pt #10 expired 12/15/23 at 11:18AM. The death visit was conducted by Hospice Physician (E #6). The note stated, ";Facility Staff to Dispose Medications." Pt #10s Ativan was found in the locked medication refrigerator during the observational tour. 5. An interview was conducted on 2/7/24 at approximately 11:45 AM with CEO. CEO stated, "I was not even aware there were issues before this incident came to light. (Name of ADMIN and DON] were not following policy and were not destroying the medications per the policy even though it was charted that they were." 6. During the survey on 02/08/24 the CEO presented the following medications that were turned over by ADMIN on 02/08/24: - Morphine 20mg/ml – 30ml dispensed - 26 ml (for Pt #8) - Oxycodone 5mg – 60 tabs dispensed on 11/17/23, 4 remaining (for Pt #8) - Ativan 2mg/ml 30ml dispensed, 25ml remaining (for pt # 8). When CEO presented the medication, CEO stated, ";I just asked [Name of ADMIN and DON if they had any other medications. [Name of ADMIN] went to [Name of ADMIN]s car and returned with these medications." 7. Pt #8's record was reviewed. Pt #8s record indicated Pt #8 expired 11/26/23 at 10:00AM. The death visit was conducted by Hospice RN (E #9). The note stated, ";Instructed Family/Caregiver on Disposal of Medications." The note indicated the medications disposed of were Morphine 20mg/ml 26 ml (disposed) and Ativan 2mg/ml 15ml (disposed) which both were disposed of in cat litter. The medications were not disposed of and presented to the surveyors.

Based on document review and interview, it was determined for one of one medication discrepancy events the facility failed to ensure the discrepancy was investigated immediately. --- Findings include: 1. On 2/7/24 at approximately 10:30 am the Patient/Employee Incident Report Form regarding pt #1 was reviewed. Under ";Incident investigation:" the form notes, ";On Thursday Dec 7, 2023, [name of DON] disclosed to [name of CEO] that, on a shift changes for pt # 1, 12/2/2023, [name of Administrator] stated, I had to heavy hand him per the families request. [name of CEO] asked [name of DON] what she meant by that statement, [name of DON] continued to explain that the narcotic count would be off. [name of DON] said, the narc count was off by about 20 doses. [name of DON] said, the longer I sat there and stewed on it the more worried I became that the facility nurse would find out and blame me. She then decided to go to her car and get an old bottle of Pt #2s Morphine and poured out the remaining medication in his bottle into the bottle for pt #1. She said it brought the narc count to only 3 doses short. [Name of DON] became tearful and stated ";I promised myself I would never jeopardize my morals or my license for the sake of anyone else. I hate myself for letting [name of administrator] put me in this situation and even more that I compromised my license." 2. An interview was conducted on 2/7/24 at approximately 11:45 am with CEO. CEO stated, "; I was not even aware there were issues before this incident came to light. This incident was reported to me on 12/7/23 and I immediately started our investigation after being informed. DON should have immediately informed me on 12/3/23 of her findings so that we could have initiated the investigation at that time."