Serenity Hospice Solutions

“It is required that testing: The hospice providing care in the patient’s home conducts exercises to test the emergency preparedness plan annually, including participation in a full-scale exercise that is community-based every two (2) years. When a community-based exercise is not accessible, testing includes participation in an individual, facility-based functional exercise every two (2) years. If the organization experiences a natural or man-made emergency that requires activation of the emergency plan, the organization is exempt from engaging in its next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the emergency event. Conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted. This exercise may include, but is not limited to a second full-scale exercise that is community-based or a facility-based functional exercise; or a mock disaster drill; or a tabletop exercise or workshop that is led by a facilitator that includes a group discussion using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan. This standard was not met as evidenced by document review and interview. The agency did not ensure documentation of exercises to test the emergency preparedness plan annually. Review of the agency’s emergency preparedness plan and program revealed no documented evidence of an exercise to test the plan for 2023. During a joint review of the agency’s documented testing of the Emergency Plan and interview on 07/17/2025, the Administrator (Personnel Record 2) stated the Emergency Plan was activated for a hurricane on 07/08/2024, but no exercise or event was documented for 2023. During a joint review of the agency’s documented testing of the Emergency Plan and interview with the Administrator (Personnel Record 2) on 07/17/2025 revealed the Emergency Plan was activated for a hurricane on 07/08/2024, but no exercise or event was documented for 2023.”

“It is required that during the initial assessment visit and in advance of providing care the hospice provides the patient—or his or her representative—with verbal (meaning spoken) and written notice of the patient’s rights and responsibilities. This information is provided in a language and manner that the patient understands. The hospice obtains the patient’s or representative’s signature confirming that he or she received a copy of the Bill of Rights and Responsibilities statement. This standard was not met as evidenced by document review, clinical record review, and interview. In 14 of 14 (100%) clinical records reviewed, the agency did not ensure the patient was provided with patient’s rights information required by state statute regarding the “Rights of the Elderly.” The state statute/regulation required in part, that an agency providing services to a patient over sixty years of age provide each patient with “Rights of the Elderly” before providing services. The statute required, “A person providing services shall provide each elderly individual with a written list of the individual’s rights and responsibilities, including each provision of Section 102.003 (Sec. 102.003. Rights of the Elderly), before providing services or as soon after providing services as possible, and shall post the list in a conspicuous location...” CLINICAL RECORD 1: The patient elected the hospice benefit on 05/16/2025. The Hospice Consent for Treatment Form was signed by the patient on 05/16/2025. The hospice consent form included the Patient Bill of Rights but did not include documentation to verify that the patient was provided with information related to the Rights of the Elderly as required by state statute. CLINICAL RECORD 2: The patient elected the hospice benefit on 10/21/2024. The Hospice Consent for Treatment Form was signed by the patient on 10/21/2024. The hospice consent form included the Patient Bill of Rights but did not include documentation to verify that the patient was provided with information related to the Rights of the Elderly as required by state statute. CLINICAL RECORD 3: The patient elected the hospice benefit on 05/25/2024. The Hospice Consent for Treatment Form was signed by the patient on 05/25/2024. The hospice consent form included the Patient Bill of Rights but did not include documentation to verify that the patient was provided with information related to the Rights of the Elderly as required by state statute. CLINICAL RECORD 4: The patient elected the hospice benefit on 06/25/2025. The Hospice Consent for Treatment Form was signed by the patient on 06/25/2025. The hospice consent form included the Patient Bill of Rights but did not include documentation to verify that the patient was provided with information related to the Rights of the Elderly as required by state statute. CLINICAL RECORD 5: The patient elected the hospice benefit on 10/25/2024. The Hospice Consent for Treatment Form was signed by the patient on 10/25/2024. The hospice consent form included the Patient Bill of Rights but did not include documentation to verify that the patient was provided with information related to the Rights of the Elderly as required by state statute. CLINICAL RECORD 6: The patient elected the hospice benefit on 02/11/2025. The Hospice Consent for Treatment Form was signed by the patient on 02/11/2025. The hospice consent form included the Patient Bill of Rights but did not include documentation to verify that the patient was provided with information related to the Rights of the Elderly as required by state statute. CLINICAL RECORD 7: The patient elected the hospice benefit on 02/02/2024. The Hospice Consent for Treatment Form was signed by the patient on 02/02/2024. The hospice consent form included the Patient Bill of Rights but did not include documentation to verify that the patient was provided with information related to the Rights of the Elderly as required by state statute. CLINICAL RECORD 8: The patient elected the hospice benefit on 05/10/2025. The Hospice Consent for Treatment Form was signed by the patient on 05/10/2025. The hospice consent form included the Patient Bill of Rights but did not include documentation to verify that the patient was provided with information related to the Rights of the Elderly as required by state statute. CLINICAL RECORD 9: The patient elected the hospice benefit on 12/09/2024. The Hospice Consent for Treatment Form was signed by the patient on 12/09/2024. The hospice consent form included the Patient Bill of Rights but did not include documentation to verify that the patient was provided with information related to the Rights of the Elderly as required by state statute. CLINICAL RECORD 10: The patient elected the hospice benefit on 03/18/2025. The Hospice Consent for Treatment Form was signed by the patient on 03/18/2025. The hospice consent form included the Patient Bill of Rights but did not include documentation to verify that the patient was provided with information related to the Rights of the Elderly as required by state statute. CLINICAL RECORD 11: The patient elected the hospice benefit on 04/15/2024. The Hospice Consent for Treatment Form was signed by the patient on 04/15/2024. The hospice consent form included the Patient Bill of Rights but did not include documentation to verify that the patient was provided with information related to the Rights of the Elderly as required by state statute. CLINICAL RECORD 12: The patient elected the hospice benefit on 10/19/2023. The Hospice Consent for Treatment Form was signed by the patient on 10/19/2023. The hospice consent form included the Patient Bill of Rights but did not include documentation to verify that the patient was provided with information related to the Rights of the Elderly as required by state statute. CLINICAL RECORD 13: The patient elected the hospice benefit on 03/14/2025. The Hospice Consent for Treatment Form was signed by the patient on 03/14/2025. The hospice consent form included the Patient Bill of Rights but did not include documentation to verify that the patient was provided with information related to the Rights of the Elderly as required by state statute. CLINICAL RECORD 14: The patient elected the hospice benefit on 09/09/2024. The Hospice Consent for Treatment Form was signed by the patient on 09/09/2024. The hospice consent form included the Patient Bill of Rights but did not include documentation to verify that the patient was provided with information related to the Rights of the Elderly as required by state statute. During a joint review of the sample admission packet with the Patient Bill of Rights, the state statutes, clinical records, and an interview on 07/15/2025, the Administrator (Personnel Record 2) confirmed that the patients were not provided with the Rights of the Elderly as required by the state.”

“It is required that each patient’s individualized written plan of care reflects patient, and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by document review and clinical record review. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure the individualized plan of care included planned interventions based on problems identified in updated assessments. Agency policy PC.C31 Comprehensive Assessment of the Patient, no date, required in part, “Discipline specific assessment tools obtain accurate and timely information that guide decisions for the development of the patient’s plan of care...” Agency policy PC.I60 Interdisciplinary Group Meeting, no date, required in part, “The focus of the Interdisciplinary Group Meeting is reviewing the patient’s plan of care and revising it as needed, based on updated comprehensive assessments...” CLINICAL RECORD 8: The patient elected the hospice benefit on 05/10/2025 with a primary diagnosis of chronic respiratory failure with hypoxia. The Registered Nurse (RN) documented on the nursing visit note dated 06/07/2025 that the patient was short of breath at rest, needed to sit and rest after ambulation, and required continuous oxygen at 5 liters per minute via nasal cannula. The Licensed Vocational Nurse documented on the nursing visit note dated 06/10/2025 that the patient wore CPAP (continuous positive airway pressure machine) at night and exhibited dyspnea (shortness of breath) during conversation. The plan of care dated 05/10/2025 to 08/07/2025 did not include planned interventions related to the patient’s shortness of breath identified during the nursing assessments. During the nursing visit on 06/10/2025 the Licensed Vocational Nurse also documented that the patient had inflammation and redness to the left lower extremity and had received a new order for Doxycycline. On 07/04/2025, the Registered Nurse documented the left lower extremity was red and warm to the touch and the facility’s nurse practitioner had ordered Doxycycline 100mg orally twice daily for ten days. The plan of care did not include interventions related to the patient’s left lower extremity cellulitis identified during the nursing assessments. CLINICAL RECORD 10: The patient elected the hospice benefit on 03/18/2025 with diagnosis of hemiplegia of right dominant side after cerebral vascular accident. The RN documented on the nursing visit note dated 07/09/2025 that the patient had behavior changes, such as attempting to get out of bed at night, picking at her brief and becoming more confused. A physician’s order was documented on 07/07/2025 for Cefdinir (antibiotic) 300mg orally twice daily for four days for suspected urinary tract infection. The behaviors appeared to calm after the first dose of the antibiotic. The plan of care did not include interventions related to the patient’s urinary tract infection and altered behaviors identified during the nursing assessment.”

“It is required that each patient’s individualized written plan of care include measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and document review. In 3 of 14 (21%) clinical records reviewed, the agency did not ensure the individualized plan of care included measurable goals. Agency policy PC.I60 Interdisciplinary Group Meeting, no date, required in part, “The focus of the Interdisciplinary Group Meeting is reviewing the patient’s plan of care and revising it as needed, based on updated comprehensive assessments...” Agency policy PC.C31 Comprehensive Assessment of the Patient, no date, required in part, “Discipline specific assessment tools obtain accurate and timely information that guide decisions for the development of the patient’s plan of care...” CLINICAL RECORD 1: The patient elected the hospice benefit on 05/16/2025. The Registered Nurse (RN) documented on the initial nursing assessment dated 05/16/2025, that the patient experienced frequent bilateral knee and wound pain that was evidenced by moaning and grimacing and interfered with the patient’s sleep, appetite, and mood. The RN documented that the patient’s acceptable pain value was documented as 1 out of 10. A physician order dated 05/16/2025 included orders for Acetaminophen 325mg - 2 tablets orally every 6 hours as needed for fever or pain, Tramadol 50mg - 1 tablet orally every 8 hours as needed for pain, and Meloxicam 7.5mg orally once daily. The plans of care dated 04/02/2025 to 06/30/2025 and 07/01/2025 to 08/29/2025 included documentation that pain was identified as a problem for the patient. The associate goal for pain on the plans of care was to control the patient’s pain at an acceptable level. The goal was not measurable when it did not include what an acceptable pain level would be for the patient. CLINICAL RECORD 10: The patient elected the hospice benefit on 03/18/2025 and was most recently recertified for the episode of care dated 05/17/2025 to 07/15/2025. The RN documented on the nursing visit note dated 07/09/2025 the patient had developed a wound on the buttocks that measured 3.1 cm x 0.5 cm. The plan of care dated 05/17/2025 to 07/15/2025 included documentation that risk of pressure ulcers was an active problem for the patient and included the associated goal that the patient would not have skin breakdown. The goal on the plan of care was not updated when staff identified an active wound for the patient. CLINICAL RECORD 8: The patient elected the hospice benefit on 05/10/2025 with a primary diagnosis of chronic respiratory failure with hypoxia. The RN documented on the nursing visit note dated 06/07/2025 that the patient was short of breath at rest, needed to sit and rest after ambulation, and required continuous oxygen at 5 liters per minute via nasal cannula. The Licensed Vocational Nurse documented on the nursing visit note dated 06/10/2025 that the patient wore CPAP (continuous positive airway pressure machine) at night and exhibited dyspnea (shortness of breath) during conversation. The plan of care dated 05/10/2025 to 08/07/2025 did not include patient-specific measurable goal(s) related to the patient’s shortness of breath. The Licensed Vocational Nurse also documented on the nursing visit note dated 06/10/2025, that the patient had inflammation and redness to the left lower extremity and that a new order for Doxycycline (antibiotic) was obtained. The RN documented on the nursing visit note dated 07/04/2025, that the patient’s left lower extremity was red and warm to the touch and documented that the facility’s nurse practitioner had ordered Doxycycline 100mg orally twice daily for ten days. The plan of care did not include patient-specific measurable goal(s) related to the patient’s identified 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. 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 document review, clinical record review, and interview. In 2 of 2 (100%) clinical records reviewed with bereavement services applicable, the agency did not ensure the development of a bereavement plan of care that noted the kind of bereavement services to be offered and the frequency of service delivery. Agency policy PC.B30 Bereavement Services, no date, required in part, “Bereavement services provided are based on the assessed needs of the deceased’s survivors and are in accordance with a bereavement plan of care formulated after the patient’s death...” Agency policy PC.B35 Bereavement - Tracking and Evaluation, no date, required in part, “The hospice monitors the patient’s family, caregiver and/or significant others receiving bereavement care for twelve months following the death of the patient...The Bereavement Coordinator documents the dates when each of the follow-up services, as specified in the bereaved person’s plan of care, has been completed...To ensure that the bereavement program meets the individual bereavement needs of the persons served, the schedule of services may vary somewhat from the initial bereavement plan of care. Any deviations are documented...” CLINICAL RECORD 13: The patient elected the hospice benefit on 03/14/2025 and passed away on 06/25/2025. Following the patient’s death, the Chaplain/Bereavement Coordinator conducted a bereavement evaluation on 06/26/2025, during which the patient’s sister was contacted, and condolences and prayers were offered. The bereavement evaluation did not include documentation of identified coping challenges, stressors, or cultural barriers for the bereaved. A sympathy card was mailed to the patient’s sister on 06/27/2025. The Chaplain also noted that she spoke with a family member on 06/28/2025, confirming the patient was cremated with no funeral services held. There is no documented evidence in the clinical record of a post-death Interdisciplinary Group Meeting or a formal bereavement plan of care that outlined interventions and a schedule of services. CLINICAL RECORD 14: The patient elected the hospice benefit on 09/09/2024 and passed away on 04/22/2025. After the patient’s death, the Chaplain/Bereavement Coordinator documented a bereavement evaluation on 04/22/2025 with the patient’s daughter. The bereavement evaluation did not include documentation of identified coping challenges, stressors, or cultural barriers for the bereaved. On 04/23/2025, the Chaplain noted that condolences were offered to the family, and a sympathy card was sent. There is no documented evidence in the clinical record of a post-death Interdisciplinary Group Meeting or a formal bereavement plan of care that outlined interventions and a schedule of services. During an interview on 07/10/2025, the Alternate Administrator/Co-Bereavement Coordinator discussed the clinical record findings and agreed that the agency needs to put together a better process in order to document post-death and bereavement activities. During a joint clinical record review and interview on 07/15/2025, the Administrator (Personnel Record 2) confirmed lack of a bereavement plan of care documented for each patient that included frequency of scope of services to be provided to the bereaved.”

“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 a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse provide patient specific care instructions to the hospice aide. CLINICAL RECORD 1: The patient elected the hospice benefit on 05/16/2025. The Registered Nurse documented on the admission assessment dated 05/16/2025 that the patient had a stage four pressure wound to the left lateral thigh measuring 3cm x 3cm. A treatment order was documented by the physician on 05/27/2025 that included soaking gauze with Vashe or Dakins and applying to the wound for five minutes, then cleansing with sterile water and patting dry with gauze. Apply skin prep to the peri-wound skin and apply Tetracyte (ointment) to the wound bed. Place Santyl to the wound bed and cover with Hydrofera blue moistened with saline with a bordered gauze dressing to cover. Dressing to be changed three times weekly and as needed. The plans of care for the benefit periods dated 04/02/2025 to 06/30/2025 and 07/01/2025 to 08/29/2025 included an order for the hospice aide to provide visits to the patient twice a week. The Hospice Aide Assignment/Plan of Care dated 05/16/2025, assigned the aide the task of showers twice a week. The aide assignment did not include instructions to the aide related to the patient’s wound and dressing and did not instruct the aide what to do with the wound dressing while showering the patient or if the dressing would become loose, wet, or soiled. CLINICAL RECORD 10: The patient elected the hospice benefit on 03/18/2025. The plan of care for the benefit period dated 05/17/2025 to 07/15/2025 included an order for the hospice aide to provide visits to the patient three times a week. The hospice aide documented aide visits from 03/19/2025 to 07/07/2025. There was no documented evidence in the clinical record that a Hospice Aide Assignment/Plan of Care had been developed by the Registered Nurse to provide instructions to the aide related to the patient’s care. During a joint record review and interview on 07/16/2025, the Administrator (Personnel Record 2) confirmed that an aide care plan was absent from the clinical record and that instructions to the aide regarding the patient’s wound and dressing were missing.”

“It is required that a registered nurse makes an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. This standard was not met as evidenced by personnel record review and interview. In 1 of 1 (100%) hospice aide personnel files reviewed, the agency did not ensure the Registered Nurse documented an annual on-site visit to observe and assess the aide performing care. PERSONNEL RECORD 7: Hospice Aide date of hire 04/27/2023. Personnel record review revealed no documented evidence that the RN completed an annual on-site visit with the Hospice Aide for 2024. During a joint personnel record review and an interview on 07/17/2025, the Administrator (Personnel Record 2) confirmed that there was no documentation of an on-site visit by the RN for the Hospice Aide for 2024.”

“It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. The agency did not ensure documentation of volunteer recruitment and retention efforts. Review of the agency’s volunteer program revealed no documented evidence of volunteer recruitment and retention efforts. During a joint review of the volunteer program and interview on 07/17/2025, the Administrator/Volunteer Coordinator (Personnel Record 2) confirmed the absence of any volunteer recruitment or retention documentation for 2024 or 2025. An interview with the Administrator/Volunteer Coordinator (Personnel Record 2) and joint document review on 07/17/2025 revealed and confirmed the absence of any volunteer recruitment or retention documentation for 2024 or 2025.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services in an amount that equaled at least five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. Review of the agency’s volunteer program revealed no documented evidence of hospice volunteer hours for 2024. During a review of the volunteer program and interview on 07/17/2025, the Administrator/Volunteer Coordinator (Personnel Record 2) explained that the only active volunteer was onboarded on 10/09/2024 and began seeing patients in December of 2024. The agency did not have documentation of a report that indicated the percentage of patient care hours for 2024. An interview with the Administrator/Volunteer Coordinator (Personnel Record 2) on July 17, 2025, revealed that the only active volunteer was onboarded on October 9, 2024, and did not begin seeing patients until December 2024. There were no volunteer hour cost-saving or volunteer reports indicating the percentage of patient care hours for 2024. The Volunteer Percentage for 2024 was below the required 5%.”

“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, personnel record review, and interview. In 5 of 7 (71%) personnel records reviewed with competency assessments required, the agency did not ensure staff competency evaluations were completed as required by agency policy. Agency policy HR.C10 Competency Assessment, no date, required in part, “As a component of the orientation process, new staff and volunteers complete a competency evaluation prior to providing care or assuming administrative responsibilities. Competency evaluations are specific to the skills needed for each job category, and specific competencies are delineated in job descriptions and performance evaluations. The competency of staff and volunteers...is assessed through self-evaluations and checklists, supervised visits, interviews, simulated practice, and/or written tests. Competency assessment occurs during the orientation period, annually (as a component of performance evaluations), and as needed...” PERSONNEL RECORD 4: Social Worker date of hire 12/29/2020. Review of the personnel record revealed no documented evidence that the Social Worker’s competency was assessed for 2023 and 2024. PERSONNEL RECORD 5: Chaplain/Bereavement Coordinator date of hire 03/10/2023. Review of the personnel record revealed no documented evidence that the Chaplain’s competency was assessed for 2024. PERSONNEL RECORD 6: Licensed Vocational Nurse date of hire 09/21/2022. Review of the personnel record revealed no documented evidence that the Licensed Vocational Nurse’s competency was assessed for 2024. PERSONNEL RECORD 7: Hospice Aide date of hire 04/27/2023. Review of the personnel record review revealed no documented evidence that the Hospice Aide’s competency was assessed for 2024. PERSONNEL RECORD 8: Volunteer date of hire 10/09/2024. Review of the personnel record revealed no documented evidence that the Volunteer’s competency was assessed upon hire. During joint personnel records review and interview on 07/17/2025, the Administrator (Personnel Record 2) confirmed the absence of skills competencies in the personnel records.”

“It is required that each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by document review and clinical record review. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the clinical record included physician orders. Agency policy PC.P30 Physician Orders, no date, required in part, “Some of the reasons orders are obtained from physicians include...new medication...dressing changes/wound care...Documentation of receipt of verbal orders and of written orders sent to the physician for signature is maintained in the patient’s clinical record...” CLINICAL RECORD 8: The patient elected the hospice benefit on 05/10/2025. The Licensed Vocational Nurse (LPN) documented on the nursing visit note dated 06/10/2025, that the patient had inflammation and redness to the left lower extremity and had received a new order for Doxycycline (antibiotic). The clinical record did not include a physician’s order for Doxycycline. The Registered Nurse documented on the nursing visit note dated 07/04/2025, that the patient’s left lower extremity was red and warm to the touch and documented that the facility’s nurse practitioner had ordered Doxycycline 100mg orally twice daily for ten days. The clinical record did not include a physician’s order for the Doxycycline. During the same visit the RN also documented a wound to the patient’s left lower leg that resulted from a fluid filled blister that had opened. The RN documented that the wound was cleaned with normal saline and a Xeroform dressing was placed over the wound and then secured with a dry dressing. The clinical record did not include a physician order for the wound care provided.”