Serenity Hospice

“Based on record review and interview, the agency failed to include an updated plan of care in the clinical record for 1 of 4 patient records (Pt #1) for which records were reviewed.This failure placed Pt #1 at risk of receiving irrelevant and inadequate care. Findings Included:Review of the clinical record for Patient #1 revealed a start of care date of 01/14/2026. Review of the clinical record for the time period 04/14/2026-06/12/2026 revealed an individualized plan of care for Patient #1 was not included.An interview was conducted on 07/13/2026 at 12:37 P.M. with the Administrator. Documentation of the plan of care for Patient #1 for the time period 04/14/2026-6/12/2026 was requested for review. The Administrator reviewed the record and confirmed there was no POC in the EMR. The Administrator contacted RN- B and asked if he completed the POC. The Administrator ended the call and advised RN- B was going to look at his notes and call back. Surveyor asked if the agency routinely reviewed clinical records to ensure all documentation was complete and accurate. The Administrator stated, “No, not now. It will be the DON’s responsibility in the future.” Surveyor asked why it was important for each patient to have an individualized plan of care. The Administrator stated, “To ensure safe and individualized care is provided to each patient.” Review of the agency’s Policy and Procedure Manual included a policy titled “Plan of Care Process,PC.30, Last Reviewed:09/01/24,” which read in part, “I. All hospice care and services furnished to patients and their families will follow an individualized written POC established by the Hospice Interdisciplinary Group/Team (IDG/IDT) in collaboration with the Attending Physician (if any), the patient or representative, and the primary caregiver, if any of them so desire, and in accordance with the patient’s needs. II. The Hospice will develop an individualized written POC for each patient. The POC must reflectpatient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The POC will include all services necessary for the palliation and management of the terminal illness and related conditions. III. The Hospice will review and revise patient care in accordance with changes in the patient’s condition; spiritual status, psychosocial status, residential environment; patient’s response to care; and changes that have occurred regarding diagnosis, treatment, medications, precautions, and limitations.””

“Based on record review and interviews, the agency failed to provide a skilled nursing facility or nursing facility with the patient’s advance directives specific to the patient for 1 of 4 patients (Patient #3) for which records were reviewed. The agency failed to obtain the patient’s Out of Hospital Do Not Resuscitate form and provide it to the facility to post in the patient’s room. Failure to provide a copy of the patient’s advance directives caused the facility to contact emergency medical services during the patient’s physical decline. Patient #1 died during cardiopulmonary resuscitation. This failure may have caused extreme physical distress to Patient #3 and caused extreme emotional distress to the patient’s family members. Findings Included:Review of the clinical record for Patient #3 revealed a start of care date of 04/09/2025 with a diagnosis of Cancer. Review of patient consent forms dated 04/09/2025, revealed page 3 of 5, “I have signed an Advance Directive.” Review of the SN admission summary comments dated 04/09/2025 read, “She has an OOHDNR.” Review of a LNSW visit note dated 04/15/2025 read, “Pt has an OOHDNR and funeral arrangements have been made.”Further review of the clinical record for Patient #3 revealed a SN visit note dated 04/30/2025 which read, “Received call from RNCM at 17:46 on 04/30/2025 in regards to the expiring of Patient #3. Arrived at 18:10. Upon arrival BPD and EMS present, due to facility no being able to provide DNR, life saving measures were performed. Patients/Patient’s FM present, as well as (Police Officer). BPD did not have a case number to provide. Ambu bag removed that was left by EMS per (FM) request. Funeral home was notified.” A telephone interview was conducted on 07/14/2026 at 10:09 a.m. with FM- B. Surveyor reviewed the allegations in the intake and asked if there was any additional information she would like to provide. FM- B stated, “We had a DNR but it was never given to the facility. It was supposed to be posted in her room but it wasn’t. When I got there, my 99 ½ year old mother was laying on the floor, intubated with electrodes stuck all over her. I was so upset. She was so lively and just wanted to pass away peacefully.” An interview was conducted on 07/14/2026 at 2:51 p.m. with the ASN regarding the allegations in intake #1012384. The clinical record was reviewed and the ASN confirmed it was documented that Patient #3 had an OOH DNR. The ASN searched the record and was not able to find a copy of the document. The ASN stated “We didn’t get a copy of the DNR. That is why the patient was given CPR.” An interview was conducted on 07/14/2026 at 3:20 p.m. with the Administrator regarding the allegations in Intake #1012384. The Administrator acknowledged the agency failed to obtain a copy of the patient’s OOH DNR and did not provide it to ALF- D. Surveyor asked why the document was not provided to the ALF. The Administrator stated, “I don’t know. We were under different management then. The nurse RN- A) that would have been responsible tor that is no longer with the agency.” The nurse’s (RN- A) contact information was requested. Surveyor asked what harm may have been caused due to the failure. The Administrator stated, “The patient underwent unnecessary life saving measures and the family did not have the peaceful and comfortable passing for their loved one that they expected.” A telephone interview was attempted on 07/15/2026 at 10:53 a.m. with RN- A regarding the allegations in Intake #1012384. There was no answer and voicemail was not set up.Review of the agency’s Policy and Procedure Manual revealed a policy titled, “Expected Patient Death, PC.55, reviewed:09/01/24”, which read, “The organization will follow the patient’s advance directives completed according to the advance directives requirement of the jurisdiction of the state in which the patient resides. A written No Not Resuscitate (DNR) order or Out of Hospital DNR, signed by the patient’s physician (or other authorized independent practitioner), must be on file in the patient’s clinical record and made part of the admission folder in the patient’s home.””

“Based on record review and interview the agency failed to provide bereavement services to 22 of 22 family members or caregivers (Family 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 and 22) on the agencys bereavement list. Failure to provide bereavement services to family or caregivers after the death of a loved one may have caused the bereaved additional emotional stress and feelings of not being supported by the hospice agency. Surveyor reviewed the agencys bereavement list for the time period 06/09/2023 - 02/26/2024. There were 22 individuals on the list: Family 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 and 22. Surveyor conducted an interview on 03/08/2024 at 11:00 a.m. with the Alternate Administrator. Surveyor requested to review documentation of bereavement activities for the families of the individuals on the bereavement list. The Alternate Administrator stated the agency did not provide bereavement services to anyone. The Surveyor asked who was responsible for completing bereavement activities. The Alternate Administrator stated, “;[SW- A] was the bereavement coordinator but she is gone.” The Alternate Administrator stated the CH was the current bereavement coordinator. Review of the agencys online policies and procedures revealed a policy titled, “;Bereavement, PC.130, Reviewed:110(0)121” which read, “;The hospice will have an organized program for the provision of bereavement services furnished under the supervision of a qualified professional with experience or education in grief and/or loss counseling. The purpose of the bereavement program is to facilitate a normal grieving process by providing counseling, coping strategies, and caring interventions to families and caregivers. The program will provide referrals to appropriate community resources to those who may be experiencing pathologic grief. The hospice will make bereavement services available to the family and other individuals in the bereavement plan of care (POC) before, and for up to one year following the death of the patient.””

“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, document review, and interview. In 1 of 14 (7%) clinical records reviewed revealed that the agency did not ensure the comprehensive assessment included an initial bereavement assessment. Document 3: Policy PC.130. Bereavement (dated 11/01/2021), “stated in part, “Procedure I. The Hospice will perform an initial bereavement assessment of the needs of the patient’s family and other care individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death as part of the Initial Comprehensive Assessment.” Clinical Record 11: The patient elected hospice benefit on 01/16/2024 and died 01/28/2024. The record lacked a completed initial bereavement assessment as part of the comprehensive assessment. The Administrator/Owner/Medical Director/Volunteer Coordinator, Director of Nursing/Registered Nurse, and Alternate Director of Nursing/Registered Nurse stated in an interview on 02/07/2024 that the agency did not ensure the comprehensive assessment included an initial bereavement assessment.”

“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. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. In 2 of 14 (14%) Clinical Records reviewed, revealed that the agency did not ensure the comprehensive assessment included an initial bereavement assessment. Document 3: Policy PC.130. Bereavement (dated 11/01/2021), “stated in part, “Procedure I. The Hospice will perform an initial bereavement assessment of the needs of the patient’s family and other care individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death as part of the Initial Comprehensive Assessment.” Clinical Record 7: Patient elected hospice benefit on 02/02/2024. There was no documented evidence of an initial bereavement assessment as part of the comprehensive assessment. Clinical Record 11: Patient elected hospice benefit on 01/16/2024 and died 01/28/2024. There was no documented evidence of an initial bereavement assessment as part of the comprehensive assessment. The Administrator/Owner/Medical Director/Volunteer Coordinator, Director of Nursing/Registered Nurse, and Alternate Director of Nursing/Registered Nurse stated in an interview on 02/07/2024 that the agency did not ensure the comprehensive assessment included an initial bereavement assessment.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plans as frequently as the patient’s condition requires; but no less frequently than every 15 calendar days. A revised plan of care includes information from the patient’s updated comprehensive assessment and record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. In 5 of 14 (36%) clinical records reviewed revealed that the agency did not ensure the patients individualized care plan was reviewed every 15 days. Document 2: Policy PC.40 “Interdisciplinary Group Roles and Responsibilities (Dated 01/012/2024).” stated in part, “IV. IDG/IDT meetings will be held during the course of patient care to monitor and evaluate the patient’s interdisciplinary POC progress, at least every 15 days, or more frequently if warranted by the patient’s condition.” Clinical Record 1: The Interdisciplinary Group (IDG) documented review and revision of the patients individualized care plans in IDG on 06/08/2023, and 07/06/2023 (28 days). Clinical Record 5: The Interdisciplinary Group (IDG) documented review and revision of the patients individualized care plans in IDG on 06/08/2023, and 07/06/2023 (28 days). Clinical Record 6: The Interdisciplinary Group (IDG) documented review and revision of the patients individualized care plans in IDG on 06/08/2023, and 07/06/2023 (28 days). Clinical Record 12: The Interdisciplinary Group (IDG) documented review and revision of the patients individualized care plans in IDG on 06/8/23, and 7/06/23. 28 days apart and 13 days past required 15 days minimum. Clinical Record 13: The Interdisciplinary Group (IDG) documented review and revision of the patients individualized care plans in IDG on 06/08/2023, and 07/06/2023 (28 days) The Administrator/Owner/Medical Director/Volunteer Coordinator, Director of Nursing/Registered Nurse, and Alternate Director of Nursing/Registered Nurse stated in an interview on 02/06/2024 that the agency did not ensure the patients individualized care plan was reviewed every 15 days.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene, use of gloves, mask, eye protection, or face shield depending on anticipated exposure, safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids, safe handling of soiled items in the patient’s care environment, and other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, interview, and observation. In 2 of 2 (100%) Home visits observed, revealed that the agency did not ensure adherence to infection control requirements including the use of standard precautions, such as hand hygiene, safe handling of equipment in the patient’s care environment, and safe handling of soiled items in the patient’s care environment. Document 1: Policy IC.60 (dated 01/18/2024) stated in part. “III. Bag Technique. E. The bag is placed on a clean, safe surface in the home, close to the patient and near a source of water, if possible. If this is not possible, a barrier (i.e., newspaper, paper towel, small trash bag, etc.) is to be placed under the bag. Bags should never be placed on the floor.... J. When the visit is completed, reusable equipment is cleaned using alcohol, disinfectant wipe and/or antimicrobial soap and water as appropriate, hands are washed, and equipment and supplies are returned to the bag.” Home Visit 1: During home visit observation on 02/06/2024 it was observed that the registered nurse (RN) (Personnel Record 1) brought a visit bag into the patient (Clinical Record 1) home and was observed placing bag on patients’ bed without protective barrier. The RN proceeded taking equipment (stethoscope, pulse oximeter, blood pressure cuff and thermometer) from that bag and placed the equipment on patient’s bed without protective barrier. The RN placed the equipment (stethoscope, pulse oximeter, blood pressure cuff and thermometer) back into the bag without cleaning it. Home Visit 3: During home visit observation on 2/06/2024 it was observed that the RN (Personnel Record 1) brought a visit bag into the Skilled Nursing Facility (SNF) and was observed placing the bag on patients’ bedside table without a protective barrier. The RN proceeded taking equipment (stethoscope, pulse oximeter, blood pressure cuff and thermometer) from the bag, and placed the equipment on patient’s bed without protective barrier. Furthermore, the RN placed the equipment (stethoscope, pulse oximeter, blood pressure cuff and thermometer) back into the bag without cleaning it. The Administrator/Owner/Medical Director/Volunteer Coordinator, Director of Nursing/Registered Nurse, and Alternate Director of Nursing/Registered Nurse stated in an interview on 02/06/2024 that the RN did not follow the required bag technique to prevent transmission of infection.”

“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. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. 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, document review, and interview. In 1 of 2 (50%) clinical records reviewed, revealed that the agency did not ensure the development of a bereavement plan of care that included the type of bereavement services to be offered and the frequency of service delivery. Document 3: Policy PC. 130 “Bereavement (Dated 11/01/2021).” stated in part, “Procedure VII. After the death of the patient: The Bereavement Coordinator will complete a follow-up assessment and develop a POC for bereavement services based on the re-assessment and the family and/or caregiver’s willingness to receive services. This POC will be discussed at the next IDG/IDT meeting.” Clinical Record 12: The post death Interdisciplinary Group Meeting on 12/06/2023 identified the need for bereavement services. The clinical record did not include documented evidence of a bereavement assessment or bereavement plan of care with the type of services or frequency of services. The Administrator/Owner/Medical Director/Volunteer Coordinator, Director of Nursing/Registered Nurse, and Alternate Director of Nursing/Registered Nurse stated in an interview on 02/07/2024 that bereavement program needs to develop a plan of care to the define and include the bereavement services being provided. services being provided.”

“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 an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 12 (33%) clinical records reviewed of patient’s receiving hospice aide services revealed that the hospice agency did not ensure that the hospice aide care plan provided specific instructions to the aide. Clinical Record 1: The aide plan of care created by the Registered Nurse (RN) was dated 05/10/2023 and updated 11/23/2023, and 01/05/2024, for aide services 2 times a week. The assigned hospice aide the tasks stated, “Personal Care: Complete Bed Bath every visit... Partial Bath/Shower every visit... Complete Shower every visit.” The plan did not provide clear instructions to the hospice aide regarding the type of bath, allowing the aide to make decisions outside of the aide’s scope of practice. Clinical Record 3: The aide plan of care created by the RN dated 06/15/2023 and updated 09/13/2023 for aide services 3 times a week. The assigned hospice aide the tasks stated, “Personal Care: Complete Bed Bath every visit... Partial Bath/Shower every visit... Complete Shower every visit.” The plan did not provide clear instructions to the hospice aide regarding the type of bath, allowing the aide to make decisions outside of the aide’s scope of practice. Clinical Record 4: The aide plan of care created by the RN dated 06/19/2023 and updated 09/17/2023 for aide services 3 times a week. The hospice aide the tasks stated, “Personal Care: Complete Bed Bath every visit... Partial Bath/Shower every visit... Complete Shower every visit.” The plan did not provide clear instructions to the hospice aide regarding the type of bath, allowing the aide to make decisions outside of the aide’s scope of practice. Clinical Record 8: The aide plan of care created by the RN dated 04/14/2023 and updated 11/10/2023 for aide services 3 times a week. The hospice aide plan of care tasks stated, “Personal Care: Complete Bed Bath every visit... Partial Bath/Shower every visit... Complete Shower every visit.” The plan did not provide clear instructions to the hospice aide regarding the type of bath, allowing the aide to make decisions outside of the aide’s scope of practice. The Administrator/Owner/Medical Director/Volunteer Coordinator, Director of Nursing/Registered Nurse, and Alternate Director of Nursing/Registered Nurse stated in an interview on 02/07/2024 that the hospice aide care plan needed clear instructions for the aide to follow.”

“It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. In a joint review of the Volunteer Program manual with the Administrator/Owner/Medical Director/Volunteer Coordinator and Volunteer on 02/07/2024 it was revealed that the agency had no documentation of volunteer recruitment efforts. The Administrator/Owner/Medical Director/Volunteer Coordinator and Volunteer stated that the agency did not ensure ongoing volunteer recruitment activity, and this is why recruitment efforts have not been documented. In a joint review of the Volunteer Program manual with the Administrator/Owner/Medical Director/Volunteer Coordinator and Volunteer on 2/7/24 it was revealed that the agency had no documentation of volunteer recruitment efforts. The Administrator/Owner/Medical Director/Volunteer Coordinator and Volunteer stated that the agency did not ensure ongoing volunteer recruitment activity, and this is why recruitment efforts have not been documented.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, interview, and personnel record review. In 4 of 9 (44%) records reviewed revealed the agency did not ensure all individuals that provided care to agency patients had completed the initial skills competencies as per the agency Staff Competency Policy Document 4: Policy HR.10. Staff Competency (Dated 10/01/2021), “stated in part, “Policy I. The Hospice will provide for competency assessments by qualified individuals on hire and annually to assess direct care staff’s basic skill levels for all staff providing care, including paraprofessionals and professionals...Procedure V. The competency evaluation and/or checklist will be completed and retained in the staff’s personnel file.” Personnel Record 1: The Registered Nurse (RN) was hired on 01/17/2023. As of 02/08/2024, the record lacked evidence of an initial skills competency for the registered nurse position. Personnel Record 4: The Master of Social Work (MSW) was hired on 01/03/2024. As of 02/08/2024, the record lacked evidence of an initial skills competency for the social worker position. Personnel Record 5: The Chaplain/Bereavement Coordinator (BC) was hired on 11/29/2023. As of 02/08/2024, The record lacked evidence of an initial skills competency for the Chaplain and BC roles. Personnel Record 6: The Volunteer was hired on 07/22/2023. As of 02/08/2024, the record lacked evidence of an initial skills competency for the volunteer position. The Administrator/Owner/Medical Director/Volunteer Coordinator, Director of Nursing/Registered Nurse, and Alternate Director of Nursing/Registered Nurse stated in an interview on 02/08/2024 that the agency did not ensure documentation of initial skills competencies as per the agency policy.”