Serenity Hospice, LLC

“Based on record review and interview, the Hospice Agency failed to conduct exercises to test their Emergency Preparedness Plan annually, which may be a community based full scale exercise or an individual facility based exercise. Findings include: Review of the Hospice Agency’s Emergency Preparedness Program indicated no evidence the Hospice Agency conducted testing of their Emergency Preparedness Plan by conducting an annual exercise as required. The last documented exercise was conducted on 8/16/21. During an interview on 4/10/24 at 2:00 P.M., the Executive Director said that the Hospice Agency has not conducted annual testing of their Emergency Preparedness Plan.”

“Based on record review and staff interviews, the Hospice Agency failed to follow the plan of care relative to the frequency of visits by Skilled Nursing and Hospice Aides, for 4 patients (HV#3, RR#1, RR#3 and RR#5), out of a total sample of 14 patients. Findings include: 3. Patient RR#1 was admitted to the hospice agency on 11/2023, with diagnosis of senile degeneration of brain. Review of the current physicians order for certification period (2/9/24-5/8/24), indicated orders for Hospice Aide 4 times a week for 14 weeks. Review of the clinical record indicated that the following services were not documented as being provided in accordance with the plan of care. -For the week of 2/18/24-2/24/24, only 3 Hospice Aide visits were conducted instead of 4 as ordered. -For the week of 2/25/24-3/2/24, only 3 Hospice Aide visits were conducted instead of 4 as ordered. -For the week of 3/3/24-3/9/24, only 2 Hospice Aide visits were conducted instead of 4 as ordered. -For the week of 3/10/24-3/16/24, only 3 Hospice Aide visits were conducted instead of 4 as ordered. -For the week of 3/17/24-3/23/24, only 3 Hospice Aide visits were conducted instead of 4 as ordered. 4. Patient HV #3 was admitted to the hospice agency on 11/2023, with a diagnosis of senile degeneration of brain. Review of the current physicians order for certification period (2/16/24-5/16/24), indicated orders for Skilled Nursing 2 times a week for 13 weeks and Hospice Aide 3 times a week for 13 weeks. Review of the clinical record indicated that the following services were not documented as being provided in accordance with the plan of care. -For the week of 2/18/24-2/24/24, only 1 Hospice Aide visits was conducted instead of 3 as ordered. -For the week of 3/3/24-3/9/24, only 2 Hospice Aide visits were conducted instead of 3 as ordered. -For the week of 3/31/24-4/6/24, only 1 Skilled Nursing visit was conducted instead of 2 as ordered. An interview was conducted with the Clinical Director on 4/10/24 at 2:15 P.M. She stated that after investigating, she felt that there was an error in the physician’s order and was not sure how the error occurred. 1. For Patient RR#3, the Agency failed to follow the plan of care relative to Hospice Aide visits. Patient RR#3 was admitted to the agency in 11/23 with a primary diagnosis of senile dementia of the brain. Review of the current physician orders for the certification period of 2/14/24 - 5/13/24, indicated orders for Hospice Aide services 4 times per week. Review of the clinical record indicated that the following services were not documented as being provided in accordance with the plan of care: - For the week of 2/25/24 - 3/2/24, only 3 Hospice Aide visits were conducted instead of the 4 as ordered. - For the week of 3/3/24 - 3/9/24, only 3 Hospice Aide visits were conducted instead of the 4 as ordered. - For the week of 3/10/24 - 3/16/24, only 3 Hospice Aide visits were conducted instead of the 4 as ordered. - For the week of 3/17/24 - 3/23/24, only 3 Hospice Aide visits were conducted instead of the 4 as ordered. - For the week of 3/24/24 - 3/30/24, only 3 Hospice Aide visits were conducted instead of the 4 as ordered. - For the week of 3/31/24 - 4/6/24, only 3 Hospice Aide visits were conducted instead of the 4 as ordered. 2. For RR#5, the Agency failed to follow the plan of care relative to skilled nursing visits. RR#5 was admitted to the Agency in 10/23 with a diagnosis of senile dementia. Review of the current physician orders for the certification period of 1/17/24 - 4/15/24, indicated orders for skilled nursing services 2 times a week. Review of the clinical record indicated that the following services were not documented as being provided in accordance with the plan of care: - For the week of 2/4/24 - 2/10/24, only 1 skilled nursing visit was conducted instead of the 2 that was ordered. - For the week of 3/24/24 - 3/30/24, only 1 skilled nursing visit was conducted instead of the 2 that was ordered. - For the week of 3/31/24 - 4/6/24, only 1 skilled nursing visit was conducted instead of the 2 that was ordered.”

“Based on record review and interview, the Hospice Agency failed to ensure that a Registered Nurse (RN) supervised the Hospice Aides at least every 14 days for 6 patients (HV#1, HV#3, RR#1, RR#3, RR#5 and RR#6) in a total sample of 14 patients. Findings include: 5. Patient RR #1 was admitted to the hospice agency on 11/2023, with a diagnosis of senile degeneration of brain. Review of the current physicians order for certification period (2/9/24-5/8/24), indicated orders for Hospice Aide 4 times a week for 14 weeks. Review of the clinical record indicated Hospice Aide visits were made 23 times from 2/9/24 through 4/9/24. There were only 1 documented Hospice Aide supervisory visits by the Registered Nurse for this period on 3/8/24, not every 14 days as required. 6. Patient HV #3 was admitted to the hospice agency on 11/2023, with a diagnosis of senile degeneration of brain. Review of the current physicians order for certification period (2/16/24-5/16/24), indicated orders for Hospice Aide 3 times a week for 14 weeks. Review of the clinical record indicated Hospice Aide visits were made 18 times from 2/16/24 through 4/9/24. There were only 3 documented Hospice Aide supervisory visit by the Registered Nurse for this period on 2/12/24, 3/13/24, and 3/26/24, not every 14 days as required. During an interview with the Clinical Director on 4/10/24 at 2:15 P.M., she said Hospice Aide supervisory visits are supposed to be conducted during each RN visit and was not sure why the supervisory visits were not documented. 1. Patient HV#1 was admitted to Hospice services in 1/2024 with a diagnosis of severe protein calorie malnutrition. The physician’s orders for the certification period of 1/12/24 - 4/9/24 indicated HV#1 was to receive Hospice Aide services 4 times a week. Review of the clinical record indicated Hospice Aide visits were made to HV#1 3 times per week from 1/15/24 - 4/6/24. There were no documented Hospice Aide supervisory visits conducted by the registered nurse (RN) for this period, which was to be every 14 days as required. 2. Patient RR#3 was admitted to Hospice services in 11/2023 with a diagnosis of senile degeneration of the brain. The physician’s orders for the certification period of 2/14/24 - 5/13/24 indicated RR#3 was to receive Hospice Aide services 4 times a week. Review of the clinical record indicated Hospice Aide visits were made to RR#3 4 times a week for the week of 2/18/24 - 2/24/24 and 3 times a week from 2/25/24 - 3/16/24. During this time period there were no documented Hospice Aide supervisory visits by the RN, which was to be every 14 days as required. 3. Patient RR#5 was admitted to Hospice services in 10/2023 with a diagnosis of senile dementia. The physician’s orders for the certification period of 1/17/24 - 4/14/24 indicated the RR#5 was to receive Hospice Aide services 4 times a week. Review of the clinical record indicated Hospice Aide visits were made to RR#5 4 times a week from 1/17/24 - 3/16/24. During this time period there were no documented Hospice Aide supervisory visits by the RN, which was to be every 14 days as required. 4. Patient RR#6 was admitted to Hospice services in 12/2023. The physician’s orders for the certification period of 12/29/23 - 3/27/24 indicated RR#6 was to receive Hospice Aide services 1 time a week. Review of the clinical record indicated Hospice Aide visits were made 1 time a week from 3/10/24 - 4/2/24. During this time period there were no documented Hospice Aide supervisory visits by the RN, which was to be every 14 days as required.”