Serenity Hospice

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

“Observed in Tracer Activities. During discussion with Asst Administrator and review of records it was noted that there was no plan in place or education having been done for goals for volunteers providing patient services. There are currently no patients receiving volunteer services so unable to assess records.”

Rule L0547. Condition-level.

Governing body and administrator (42 CFR 418.100(b))

“Observed in Tracer Visit. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by condition level deficiencies at 418.56, and 418.58.”

Rule L0651. Condition-level.

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

“Observed in Record Review. In 2 of 2 patient records reviewed, it was noted that the POC goals did not have time frames for achieving goals. For example, in records 1 and 2 the documented goals did not contain any time frames. The goals are not individualized, such as Optimal sleep/rest for patient. Optimal spiritual/emotional support to patient and all involved in care. Patient/caregiver adequately informed on pain control measures. This was confirmed with the Alternate Administrator present.”

Rule L0545. Standard-level.

Program scope (42 CFR 418.58(a)(1))

“Observed in Tracer Activities. During review of PI systems it was found that there was no data collected for volunteers, bereavement, or DME. This was confirmed by the asst Administrator.”

Rule L0561. Standard-level.

Program data (42 CFR 418.58(b)(2)(ii))

“Observed in Tracer Activities. During PI review the asst Administrator reported a process and surveyor viewed a spreadsheet showing data over time including hand hygiene and patient satisfaction. They have not yet started collecting the data. This was confirmed with the asst. Administrator.”

Rule L0564. Standard-level.

Performance improvement projects (42 CFR 418.58(d)(2))

“Observed in Tracer Activities. During the Data session it was noted that the hospice had identified one performance improvement project, Communicable disease that was being conducted, but did not document the reasons for conducting the project or the measurable progress achieved on it. This was confirmed with the alternate administrator present.”

Rule L0573. Standard-level.

Recruiting and retaining (42 CFR 418.78(c))

“Observed in Tracer Activities. Volunteer systems tracer was conducted with the Asst. Administrator. There was no documentation of efforts to recruit and retain volunteers. This was confirmed by the Asst. Admin.”

Rule L0645. Standard-level.

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

“Observed in Record Review. There is now a form for documenting volunteers orientation but no orientation has been done for the volunteers. This was confirmed by the asst Administrator.”

Rule L0662. Standard-level.

Quality assessment & performance improvement (42 CFR 418.58)

“Observed in Data Session. During the Data session it was noted that the hospice’s QAPI program failed to address DME, pharmacy, bereavement and volunteer services. This was confirmed with the Alternate Administrator present.”

Rule L0559. Condition-level.

Governing body and administrator (42 CFR 418.100(b))

“Observed in Data Session. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by 418.56, 418.78, and 418.58.”

Rule L0651. Condition-level.

Establishment of the Emergency Program (EP) (42 CFR 418.113)

“Observed in Emergency Management Session. During the Emergency Management session it was noted that the written comprehensive emergency management program did not include exercises and testing - Disaster recovery - Program evaluation. This was confirmed with the Alternate Administrator present.”

Rule E0001. Standard-level.

EP Training Program (42 CFR 418.113(d)(1)(iii))

“Observed in HR File Review. In 6 of 7 HR files reviewed, it was noted that ongoing emergency management training was not done every 2 years. For example the HR files for the LVN, HHA/Volunteer, MSW, spiritual counselor, Medical Director and Alternate Administrator did not have documentation of ongoing emergency management training every 2 years. This was confirmed with the Alternate Administrator present.”

Rule E0037. Standard-level.

EP Testing Requirements (42 CFR 418.113(d)(2))

“Observed in Emergency Management Session. During the Emergency Management session it was noted that the organization did not test its plan in any of the last 2 years. The Alternate Administrator present had printed copies of actual events from the news that had taken place in the area in a binder and there were blank Corridor group event evaluation forms in the binder, but nothing had been documented.”

Rule E0039. Standard-level.

Content of comprehensive assessment (42 CFR 418.54(c)(7))

“Observed in Record Review. In 2 of 10 patient records reviewed, it was noted that the initial bereavement assessment was not documented. For example, in records RRNHV#6 and #7 there was no documentation of the initial bereavement assessment. This was discussed with the Alternate Administrator and Alternate DON.”

Rule L0531. Standard-level.

Content of comprehensive assessment (42 CFR 418.54(c)(8))

“Observed in Record Review. In 2 of 2 patient records reviewed, for bereavement care it was noted that an assessment at death was not done to assess bereavement risk in order to inform the decisions made by the IDG. For example in records RRBR#1 and #2 it was noted that there was a list of items to complete over a 12 month time frame, but no documentation of a post death assessment. This was confirmed with the Bereavement Coordinator present.”

Rule L0532. Standard-level.

Plan of care (42 CFR 418.56(b ))

“Observed in Record Review. In 10 of 10 patient records reviewed, it was noted that the POC goals did not have time frames for achieving goals. For example, in records RRHV#1 to #3 and RRNHV#1 to #7 the documented goals did not contain any time frames. The goals are not individualized, such as Optimal sleep/rest for patient. Optimal spiritual/emotional support to patient and all involved in care. Patient/caregiver adequately informed on pain control measures. This was confirmed with the Alternate Administrator present.”

Rule L0543. Standard-level.

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

“Observed in Record Review. In 1 of 1 patient records reviewed, that included volunteer services it was noted that the plan of care did not include all services needed for palliation. For example, In record RRHV#2 the POC did not include any goals or interventions for the volunteer visits. This was confirmed with the Alternate Administrator present.”

Rule L0547. Standard-level.

Coordination of services (42 CFR 418.56(e)(2))

Rule L0555. Standard-level.

Program scope (42 CFR 418.58(a)(1))

“Observed in Data Session. During Data session it was noted that the hospice did not collect data for volunteer services, bereavement, or DME and as a result was unable to demonstrate improvement in the related indicators. This was confirmed with the Alternate Administrator present.”

Rule L0561. Standard-level.

Program data (42 CFR 418.58(b)(2)(ii))

“Observed in Data Session. During the Data session it was noted that the organization collected patient satisfaction and hand hygiene data, however the data was not compiled in a manner it could be analyzed or used to identify performance trends or variances. This was confirmed with the Alternate Administrator present.”

Rule L0564. Standard-level.

Performance improvement projects (42 CFR 418.58(d)(2))

“Observed in Data Session. During the Data session it was noted that the hospice had identified one performance improvement project, Communicable disease that was being conducted, but did not document the reasons for conducting the project or the measurable progress achieved on it. This was confirmed with the alternate administrator present.”

Rule L0573. Standard-level.

Control (42 CFR 418.60(b)(2)(ii))

“Observed in Data Session. During the Data session it was noted that there was no data collection to evaluate hand hygiene compliance. The Alternate Administrator present stated that hand hygiene compliance was evaluated twice a year, once during a joint visit and once in the office. There was no data available for hand hygiene compliance for 2024 and 2023.”

Rule L0581. Standard-level.

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

“Observed in Record Review. In 2 of 2 patient records reviewed, for bereavement care it was noted that there was no documented bereavement plan of care. For example, in records RRBR#1 and #2 the paper sheet titled Bereavement POC for each patient did not include any goals or interventions, it was a to do list with dates for mailings. They did not include specific, individualized interventions, and the timing and frequency were the same exactly for all patients. This was confirmed with the Bereavement Coordinator present.”

Rule L0596. Standard-level.

Supervision of hospice aides (42 CFR 418.76(h)(1)(i))

“Observed in Record Review. In 1 of 3 patient records reviewed, that included aide services it was noted that the hospice aide supervision was not done every 14 days. For example in record RRHV#1 documentation of aide supervision was missing 3 times in the past 2 months. This was confirmed with the Alternate Administrator present.”

Rule L0629. Standard-level.

Recruiting and retaining (42 CFR 418.78(c))

“Observed in Tracer Activities. During the Volunteer program session it was noted that the organization stated that they could not recruit volunteers since COVID there was no documentation to support any recruitment or retention activities. This was discussed with the Volunteer Coordinator.”

Rule L0645. Standard-level.

Cost saving (42 CFR 418.78(d)(1))

Rule L0646. Standard-level.

Level of activity (42 CFR 418.78(e))

Rule L0647. Standard-level.

Services (42 CFR 418.100(c)(1)(v))

“Observed in Tracer Activities. During the Volunteer program discussion, it was noted that the hospice recorded 5 volunteers. However, they were all paid employees of the hospice whose volunteer activities were the same as their paid activities. For example, the aide was seeing a patient daily to empty a foley catheter bag and volunteered on Saturdays to do the same and the office manager volunteers time to make charts in the office. This was discussed with the Alternate Administrator.”

Rule L0652. Standard-level.

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

“Observed in HR File Review. In 2 of 2 HR files reviewed, for employees who also acted as volunteers it was noted that the organization had not documented the orientation of the volunteers. For example, the aide and alternate administrator also worked as volunteers for the organization and there was no documentation of orientation for the volunteer position. This was confirmed with the Alternate Administrator present.”

Rule L0662. Standard-level.

Content (42 CFR 418.104(a)(5))

“Observed in Record Review. In 1 of 10 patient records reviewed, it was noted that a physician’s certification of terminal illness statement was not filed in the patient record. For example record RRHV#2 there was no initial CTI documentation. Verbal attestation was included in record 8 days after SOC. This was confirmed with the Alternate Administrator present.”

Rule L0676. Standard-level.

Discharge or transfer of care (42 CFR 418.104(e)(1)(i))

Rule L0682. Standard-level.

Use and mintenance of equipment and supplies (42 CFR 418.106(f)(2))

Rule L0702. Standard-level.