Serenity Hospice Services, LLC

“Based on record reviews and interview, the agency failed to ensure the medical social worker (MSW) completed the psychosocial assessment within 5 calendar days after the election of hospice services for 1 (Patient #17) of 19 (Patient #1-Patient #19) sampled patients. Findings: Review of Patient #17s record revealed Patient #17s caregiver signed the election of hospice services on 01/04/2024. Further review revealed Patient #17s psychosocial assessment was not completed until 01/18/2024. In an interview on 01/10/2025 at 11:42 a.m., S2Assistant Director of Nursing (ADON) indicated the agency did not have the psychosocial assessment completed within 5 days of election as required.”

“Based on record reviews and interviews, the agency failed to ensure an initial bereavement assessment was completed for 3 (Patient #4, Patient #8, and Patient #18) of 19 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #15, Patient #16, Patient #17, Patient #18, and Patient #19) sampled patients reviewed for initial bereavement requirements. Findings: Patient #4 Review of Patient #4s record revealed Patient #4 was admitted to the agency on 11/08/2024. Further review revealed no documented evidence, and the agency presented no documented evidence, an initial bereavement assessment was completed. In an interview on 01/10/2025 at 10:33 a.m., S2Assistant Director of Nursing (ADON) indicated Patient #4 did not have an initial bereavement assessment completed. Patient #8 Review of Patient #8s record revealed Patient #8 was admitted to the agency on 04/26/2024. Further review revealed no documented evidence, and the agency presented no documented evidence, an initial bereavement assessment was completed. In an interview on 01/10/2025 at 10:40 a.m., S2ADON indicated Patient #8 did have an initial bereavement assessment completed. Patient #18 Review of Patient #18s record revealed Patient #18 was admitted to the agency on 03/22/2024. Further review revealed no documented evidence, and the agency presented no documented evidence, an initial bereavement assessment was completed. In an interview on 01/10/2025 at 11:45 a.m., S2ADON indicated Patient #18 did not have an initial bereavement assessment completed.”

“Based on record reviews and interviews, the agency failed to ensure care needs were communicated to ensure services were received timely for 3 (Patient #6, Patient #7, and Patient #16) of 19 (Patient #1-Patient #19) sampled patients reviewed for coordination of care. Findings: Patient #6 Review of Patient #6s Patient Communication Note dated 12/23/2024 revealed, in part, the on-call nurse received a phone call from Patient #6s caregiver that Patient #6 had increased pain and was currently on Fentanyl (narcotic pain medication used to treat severe pain) 12.5 microgram (mcg) patch. Further review revealed S11Medical Director was contacted and an order to increase Fentanyl patch to 25 mcg patch every 72 hours was obtained. Review of Patient #6s record revealed no documented evidence, and the agency did not present any documented evidence, a skilled nurse assessment or phone call had been made to follow-up on the effectiveness of the increase in Fentanyl until 12/26/2024. In an interview on 01/10/2025 at 11:54 a.m., S2ADON indicated due to Patient #6s increase in pain and change in Fentanyl dosage, a skilled nurse visit should have been made within 24 hours. Patient #7 Review of Patient #7s Patient Communication Note dated 12/09/2024 at 2:19 a.m. revealed, in part, Patient #7s caregiver called and reported Patient #7 was tired and short of breath. Further review revealed Patient #7s caregiver was educated on comfort measures and the case manager would be updated via the on-call report that Patient #7 needed a skilled nurse visit today. Review of Patient #7s Patient Communication Note dated 12/09/2024 at 7:56 p.m. revealed, in part, Patient #7 complained of shortness of breath. There was no documented evidence, and the agency presented no documented evidence, a skilled nurse was informed of the need for a skilled nurse visit on 12/09/2024, and/or a skilled nurse visit was made between the on-call communication on 12/09/2024 and 12/10/2024. In an interview on 01/10/2025 at 11:56 a.m., S2ADON indicated the agency did not have documented evidence the skilled nurse assessed Patient #7 prior to 12/10/2024 for shortness of breath. Patient #16 Review of Patient #16s Plan of Care for the certification period of 02/19/2024 through 05/18/2024 revealed no documented evidence, and the agency presented no documented evidence, of a request for hospice aide services. Review of Patient #16s Missed Visit Form for the Aide Care Visit dated 02/19/2024 revealed family provided care due to the hospice aide was out sick. Review of Patient #16s Registered Nurse Skilled Nursing Visit dated 02/29/2024 revealed, in part, Patient #16s caregiver had complained about her hospice aide and asked for her not to return. Further review revealed Patient #16s caregivers were requesting a new aide. Review of Patient #16s record revealed no documented evidence, and the agency presented no documented evidence, the agency had scheduled a hospice aide during the certification period of 02/19/2024 through 05/18/2024. In an interview on 01/10/2025 at 11:49 a.m., S2ADON indicated the agency did not have documentation of when the hospice aide was requested or the agencys coordination to provide hospice aide care.”

“Based on record reviews and interviews, the agency failed to ensure care was provided per the patients plan of care for 3 (Patient #6, Patient #7, and Patient #18) of 19 (Patient #1-Paitent #19) sampled patients reviewed for care provided per the plan of care. Findings: Patient #6 Review of Patient #6s Plan of Care for the certification period of 12/03/2024 through 03/02/2025 revealed Patient #6 was to receive skilled nursing services twice a week. Review of Patient #6s record revealed the only skilled nurse visit completed for the week of 12/22/2024 through 12/28/2024 was documented on 12/26/2024. There was no documented evidence, and the agency presented no documented evidence, a second skilled nurse visit was completed for the week of 12/22/2024 through 12/26/2024. In an interview on 01/10/2025 at 11:54 a.m., S2Assistant Director of Nursing (ADON) indicated the agency had no documented evidence a second skilled nurse visit was completed as required. Patient #7 Review of Patient #7s Plan of Care for the certification period of 11/26/2024 through 02/23/2025 revealed, in part, the skilled nurse was to assess Patient #7s oxygen saturation as ordered. Review of Patient #7s Communication Note on 12/09/2024 revealed Patient #7s caregiver had called the agency on-call nurse about Patient #7 being short of breath. Further review revealed a skilled nurse was to see Patient #7 in the morning. Review of Patient #7s Skilled Nurses Note dated 12/10/2024 revealed no documented evidence, and the agency presented no documented evidence, an oxygen saturation was obtained on Patient #7. In an interview on 01/10/2025 at 11:56 a.m., S2ADON indicated the skilled nurse did not obtain an oxygen saturation on 12/10/2024 per Patient #7s plan of care, and should have. Patient #18 Review of Patient #18s Plan of Care for the certification period of 03/22/2024 through 05/17/2024 revealed the medical social worker (MSW) was to provide services once a month. Review of Patient #18s record revealed no documented evidence, and the agency presented no documented evidence, Patient #18 received MSW services for the month of April 2024. In an interview on 01/10/2025 at 11:45 a.m., S2ADON indicated the agency had no documented evidence Patient #18 received MSW services per the plan of care for the month of April 2024.”

“Based on record review and interview, the agency failed to ensure an agency-wide surveillance of patient infections was completed for 3 (Patient #1, Patient #5, and Patient #8) of 9 (Patient #1, Patient #2, Patient #5, Patient #8, Patient #11, Patient #13, Patient #14, Patient #15, and Patient #18) sampled patients reviewed for infection surveillance. Findings: Patient #1 Review of Patient #1s Patient Communication Note dated 12/20/2024 revealed Patient #1 had a swollen and reddened left ankle/foot with possible cellulitis. Further review revealed S11Medical Director was notified and Patient #1 was prescribed Keflex (antibiotic medication used to treat infections). Review of Patient #1s Registered Nurse (RN) Skilled Nursing Visit Note dated 12/23/2024 revealed, in part, Patient #1 had severe left lower extremity pain, with swelling, and possible cellulitis. Further review revealed S11Medical Director was notified and Patient #1 was prescribed Clindamycin (antibiotic medication used to treat infections) 300 milligrams (mg) three times a day. Patient #5 Review of Patient #5s Medication Profile revealed Patient #5 was prescribed Clindamycin on 12/05/2024. Patient #8 Review of Patient #8s RN Skilled Nurse Visit Note dated 07/11/2024 revealed, in part, Patient #8 had strong smelling concentrated urine. Further review revealed Patient #8s physician was contacted and prescribed prophylactic antibiotics. Review of Patient #8s RN Skilled Nurse Visit Note dated 09/05/2024 revealed, in part, Patient #8 had a possible urinary tract infection. Further review revealed Patient #8s physician ordered Bactrim (antibiotic medication used to treat infections). Review of Patient #8s RN Skilled Nurse Visit Note dated 12/10/2024 revealed, in part, Patient #8s urine had a strong odor to her urine. Further review revealed Patient #8s physician had ordered Bactrim. Review of the agencys Infection Control Log for 2024 revealed the following infections were not captured on the Infection Control Log: Patient #1s Clindamycin prescribed on 12/20/2024 and Keflex prescribed on 12/23/2024; Patient #5s Clindamycin prescribed on 12/05/2024; and, Patient #8s Bactrim prescribed on 07/12/2024, 09/03/2024, and 12/05/2024. In an interview on 01/09/2025 at 3:01 p.m., S2Assistant Director of Nursing (ADON) indicated the process for the agencys infection control program was that anytime a patient had signs and symptoms of infection and was prescribed a new antibiotic or antiviral medication, then the nurse was to initiate an infection control report and then follow-up with the patient until the infection was resolved. S2ADON indicated the reports then would be complied into the agencys Infection Control Log which the agency used to identify trends and any need for further education or intervention. S2ADON indicated the skilled nurses had not completed infection control reports for the above mentioned patients; therefore, the above mentioned patients infections were not in the agencys surveillance of infections documentation. In an interview on 01/09/2025 at 3:02 p.m., S1Administrator/Director of Nursing indicated the agency did not track and trend the above mentioned infections as required.”

“Based on record reviews and interviews, the agency failed to: 1. Ensure the registered nurse (RN) assessed the patient as stable and predictable prior to delegating care to a licensed practical nurse (LPN) (Patient #7 and Patient #12); and, 2. Ensure the skilled nurse measured the wounds weekly to evaluate for wound healing (Patient #4, Patient #11, and Patient #17). This deficient practice was identified for 5 (Patient #4, Patient #7, Patient #11, Patient #12, Patient #17) of 19 (Patient #1-Patient #19) sampled patients reviewed for care and services. Findings: 1. Review of Louisiana Administrative Code Chapter 37 Nursing Practice revealed, in part, the registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient’s health care problems prior to delegating nursing care. This assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required. Patient #7 Review of Patient #7s record revealed Patient #7s election of hospice services was signed on 11/26/2024. Further review revealed the first skilled nurse visit was made by the LPN on 11/26/2024, and initial RN assessment was not made until 11/27/2024. There was no documented evidence, and the agency was unable to present any documented evidence, a RN had assessed and deemed Patient #7 as stable and predictable prior to delegating care of Patient #7 to the LPN. In an interview on 01/10/2025 at 11:56 a.m., S2Assistant Director of Nursing (ADON) indicated the agency had no documented evidence a RN assessed Patient #7 as stable and predictable prior to delegating care of Patient #7 to the LPN. Patient #12 Review of Patient #12s record revealed Patient #12s election of hospice services was signed on 12/19/2024. Further review revealed the first skilled nurse visit was made by the LPN on 12/19/2024, and the initial RN assessment was not made until 12/20/2024. There was no documented evidence, and the agency was unable to present any documented evidence, a RN assessed and deemed Patient #12s condition as stable and predictable prior to delegating Patient #12s care to the LPN. In an interview on 01/10/2025 at 11:50 a.m., S2ADON indicated the agency had no documented evidence of a RN assessed Patient #12s condition as stable and predictable prior to delegating Patient #12s care to the LPN. 2. Review of the Wound Ostomy and Continence Nurses Society’s Guidelines revealed assessment and documentation of wound status, which included comprehensive clinical data demonstrating evidence of progress in healing or failure to heal. Comprehensive wound assessment included: dimensions and depth; presence, location and depth of any sinus tracts or undermining areas; status and characteristics of the wound bed; volume, color, and odor of exudates; evidence of infection in surrounding tissues. Further review revealed when recorded over time this information can be used to track the progress of wound healing. Patient #4 Review of Patient #4s RN Skilled Nursing Visit Note dated 12/12/2024 revealed, in part, Patient #4 had a stage I (reddened area caused by prolonged pressure which did not turn white when skin was pressed) pressure to the center of buttocks. Further review revealed no documented evidence Patient #4s stage I pressure ulcer to the center of buttocks had been measured. Review of Patient #4s RN Skilled Nursing Visit Notes dated 12/16/2024, 12/19/2024, 12/23/2024, 12/16/2024, and 12/30/2024 revealed Patient #4 with a stage I pressure ulcer to the center of buttock; however, no measurements were documented. In an interview on 01/10/2025 at 10:33 a.m., S2ADON indicated the agency had no documented evidence Patient #4s center of buttock wound was measured as required. Patient #11 Review of Patient #11s RN Initial Assessment dated 10/22/2024 revealed, in part, Patient #11 was assessed as having an excoriation to the buttock. Further review revealed no documented evidence, and the agency did not present any documented evidence, of wound care measurements had been obtained. Review of Patient #11s RN Skilled Nursing Visit Note dated 10/25/2024 revealed, in part, Patient #11 was assessed as having a stage one pressure ulcer to center upper buttock. Further review revealed no documented evidence, and the agency did not present any documented evidence, of wound care measurements had been obtained. Review of Patient #11s RN Skilled Nursing Visit Note dated 10/29/2024 revealed Patient #11 had an open stage II (open area of the skin caused by pressure) pressure ulcer with no measurements obtained. Review of Patient #11s RN Skilled Nursing Visit Notes dated 11/01/2024, 11/05/2025, 11/08/2024, 11/12/2024, 11/15/2024, 11/19/2024, 11/22/2024, 11/26/2024, 12/03/2024, 12/06/2024, 12/10/2024, 12/13/2024, 12/14/2024, 12/17/2024, 12/20/2024, 12/23/2024, and 12/27/2024 revealed no documented evidence, and the agency did not present any documented evidence, Patient #11s center upper buttock wound was measured. In an interview on 01/10/2025 at 10:44 a.m., S2ADON indicated the agency had no documented evidence Patient #11s center buttock wound was measured for the above mentioned timeframe. Patient #17 Review of Patient #17s RN Skilled Nursing Visit Note dated 01/09/2024 revealed, in part, Patient #17 had developed an area of stage one breakdown on the buttock. Further review revealed no documented evidence, and the agency presented no documented evidence, the stage one breakdown was measured. Review of Patient #17s Skilled Nursing Visit Notes dated 01/12/2024, 01/17/2024, 01/19/2024, 01/22/2024, 01/25/2024, and 01/27/2024 revealed no documented evidence, and the agency presented no documented evidence, that the skilled nursing staff had measured Patient #17s buttock wound for the above mentioned timeframes. In an interview on 01/10/2025 at 11:42 a.m., S2ADON indicated the agency had no documented evidence Patient #17s buttock wound was measured weekly for the above mentioned timeframes.”

“Based on record reviews and interviews, the agency failed to ensure a registered nurse made an on-site visit to the patients home every 14 days to assess care and services provided by the hospice aide for 4 (Patient #2, Patient #13, Patient #15, and Patient #17) of 15 (Patient #1, Patient #2, Patient #3, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #15, Patient #17, and Patient #19) sampled patients who received hospice aide services. Findings: Patient #2 Review of Patient #2s Plan of Care for the certification period of 11/14/2024 through 01/12/2025 revealed, in part, Patient #2 was to have hospice aide services once a week, and skilled nursing services once a week. There was no documented evidence and the agency did not present any documented evidence that a registered nurse made an on-site visit to assess care and services provided by the hospice aide for the time period of 11/14/2024 through 12/22/2024 for Patient #2. In an interview on 01/01/2025 at 10:29 a.m., S2ADON indicated the indicated a registered nurse did not conduct an in-person visit to assess care and services provided by the hospice aide at Patient #2s residence as required for the above mentioned certification period. Patient #13 Review of Patient #13s Plan of Care for the certification period of 11/20/2024 through 02/17/2025 revealed, in part, Patient #13 was to have hospice aide services three times a week, and skilled nursing services once a week. Review of Patient #13s record revealed Patient #13 received hospice aide services three times a week during the certification period of 11/20/2024 through 01/0/06/2025. There was no documented evidence and the agency did not present any documented evidence that a registered nurse made an on-site visit to assess care and services provided by the hospice aide for the time period of 11/20/2024 through 01/0/06/2025 for Patient #13. In an interview on 01/10/2025 at 10:46 a.m., S2ADON indicated the agency had no documented evidence a registered conducted an in-person visit to assess care and services provided by the hospice aide at Patient #13s residence for the above mentioned certification period Patient #15 Review of Patient #15s Plan of Care for the certification period of 10/28/2024 through 11/15/2024 revealed, in part, Patient #15 was to have hospice aide services three times a week, and skilled nursing services once a week. Review of Patient #15s record revealed Patient #15 received hospice aide services three times a week from 10/28/2024 through 11/20/2024. Further review revealed there was no documented evidence and the agency did not present any documented evidence that a registered nurse conducted an on-site visit to assess care and services provided by the hospice aide for the time period of 11/01/2024 through 11/26/2024 for Patient #15. In an interview on 01/10/2025 at 10:52 a.m., S2ADON indicated a registered nurse did not conduct an in-person visit to assess care and services provided by the hospice aide at Patient #15s residence as required for the above mentioned certification period. Patient #17 Review of Patient #17s Plan of Care for the certification period of 12/31/2023 through 02/04/2024 revealed, in part, Patient #17 was to receive hospice aide services three times a week, and skilled nursing services twice a week. Review of Patient #17s record revealed Patient #17 received hospice aide services three times a week from 12/31/2023 through 02/04/2024. Further review revealed there was no documented evidence and the agency did not present any documented evidence that a registered nurse conducted an on-site visit to assess care and services provided by the hospice aide for the time period of 12/31/2024 through 02/04/2024 for Patient #17. In an interview on 01/10/2025 at 11:42 a.m., S2ADON indicated a registered did not conduct an in-person visit to assess care and services provided by the hospice aide at Resident #17s residence as required for the above mentioned certification period.”