Serenity Hospice Care

Plan Based on All Hazards Risk Assessment (42 CFR 418.113(a)(1))

“Observed in Emergency Management Session. The organization failed to conduct a hazard vulnerability analysis utilizing an all-hazards approach as evidenced by the hazard vulnerability analysis did not include emerging infectious diseases, this was observed and validated by the Administrator and DON”

Rule E0006. Standard-level.

Development of EP Policies and Procedures (42 CFR 418.113(b))

“Observed in Emergency Management Session. The organization failed to review and makes necessary updates based on after-action reports or opportunities for improvement to the following items every two years as evidenced by not completing an after action report following community and table top drill, this was observed and validated by the Administrator and DON”

Rule E0013. Standard-level.

Policies/Procedures for Medical Documentation (42 CFR 418.113(b)(3))

Rule E0023. Standard-level.

Initial & comprehensive assessment of patient (42 CFR 418.54)

“Observed in Record Review. In 10 of 10 patient records reviewed, The organization failed to document in writing the need for volunteer services to offer support or respite to the patient, family, or other caregivers during the comprehensive assessment in RRHV#1, RRHV#2, RRHV#3, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, RRNHV#5, RRNHV#6 and RRNHV#7, this was observed and validated by the Administrator and DON”

Rule L0520. Standard-level.

Timeframe for completion of assessment (42 CFR 418.54(b))

“Observed in Record Review. In 1 of 10 patient records reviewed, The organization failed to assess the patient and the patient’s condition according to defined time frames as evidenced in RRNHV#7: Spiritual support not completed within 5 days and no documentation as to why, this was validated by the LVN and DON”

Rule L0523. Standard-level.

Content of plan of care (42 CFR 418.56(c)(2))

“Observed in Record Review. In 1 of 10 patient records reviewed, The organization failed when using external resources to meet the patient’s needs, coordinates the patient’s care, treatment or services in accordance with orders or prescriptions as evidenced in RRNHV#5:Wound Care Experts PA sees patient weekly for wound care, this information is not on the POC, this was validated by the LVN and DON”

Rule L0547. Standard-level.

Executive responsibilities (42 CFR 418.58(e)(1))

“Observed in Data Session. The organization failed to establish priorities for performance improvement as evidenced by the QAPI program, failed to address DME, pharmacy, bereavement, contracted or volunteer services, this was observed and validated by the Administrator and DON”

Rule L0574. Standard-level.

Counseling services (42 CFR 418.64(d)(1)(iv))

“Observed in Record Review. In 2 of 2 patient records reviewed, The hospice failed to develop a bereavement plan of care that specifies the type of bereavement services to be offered and the frequency of service delivery as evidenced in RRBR#1 and RRBR#2, the bereavement risk assessment indicated that the bereaved was at a high risk and moderate risk respectively, yet the only interventions planned were to send a standard series of mailings with no indication of other proposed interventions, this was observed and validated by the Administrator and DON”

Rule L0596. Standard-level.

Hospice aide assignments and duties (42 CFR 418.76(g)(1))

“Observed in Record Review. In 2 of 10 patient records reviewed, A registered nurse who is a member of the interdisciplinary group and is responsible for hospice aide supervision failed to add all required written patient care instructions for the hospice aide as evidenced in RRHV#1 and RRNHV#5 : HHA assignment did not specify precautions related to wound care, this was observed and validated by the Patient Care Coordinator and DON”

Rule L0625. Standard-level.

Training (42 CFR 418.100(g)(2))

“Observed in Individual Tracer. In 1 of 9 HR files reviewed, The organization failed to provide hospice orientation to contracted including relevant policies and procedures as evidenced in HR#9: contracted physical therapist did not receive orientation on hospice philosophy or policies, this was validated by the DON”

Rule L0662. Standard-level.

Training (42 CFR 418.100(g)(3))

“Observed in HR File Review. In 1 of 8 HR files reviewed, The organization failed to define the competencies of volunteers who provide patient care, treatment, or services as evidenced in HR#7, their was no competency completed for the volunteer, this was validated by the DON”

Rule L0663. Standard-level.

Authentication (42 CFR 418.104(b))

Rule L0679. Standard-level.

Coordination of services (42 CFR 418.112(e)(3)(i))

“Observed in Patient Home. In 3 of 3 home visits conducted, The organization failed to provide the patient’s most recent hospice plan of care at the board and care facility as evidenced in RRHV#1: the last POC was dated 4 weeks ago and previous one was 13 weeks. In RRHV#2: last POC was 4 weeks ago and previous one was 6 weeks, and RRHV#3: the last POC updated in home folder was 4 weeks ago, this was observed by the LVN and validated by the DON”

Rule L0781. Standard-level.