Every finding on record at Beacon Home Health Brentwood

An Emergency Preparedness survey was conducted along with a recertification survey beginning 8/25/25. This facility was found to be in compliance with the regulations reviewed related to Emergency Preparedness for Home Health agencies.

A recertification and re-licensure survey was conducted beginning 8/25/25. The survey was completed on 8/27/25 with facility staff being informed of survey findings during an exit conference.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on policy review, observation and interview, the facility failed to ensure staff performed hand hygiene to prevent the spread of infectious bacteria for 1 of 7 (Nurse #1) staff observed during home visits. The findings included: Review of the facility's "Hand Hygiene" policy (7/10/25) revealed, "...Perform hand hygiene as follows...After contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings...After removing gloves..." 2. Observations during a home visit for Patient #3 on 8/26/25 at 10:30 AM revealed Nurse #1 performed wound care. Observations revealed Nurse #1 attempted to remove an old dressing from the right heel of Patient #3. Nurse #1 then removed gloves, obtained a pair of scissors and donned a new pair of gloves without performing hand hygiene. Observations revealed Nurse #1 completed removing the dressing from the heel of Patient #3. Nurse #1 removed gloves and donned a new pair of gloves without performing hand hygiene. Observations revealed Nurse #1 measured Patient #3's right heel wound, removed gloves and picked up laptop without performing hand hygiene. In an interview on 8/27/25 at 10:00 AM, the Area Vice President of Operations verified staff should perform hand hygiene after removing gloves.

An Emergency Preparedness Survey was conducted along with a recertification survey beginning on 6/27/22. The facility was found to be in compliance with all regulations reviewed related to Emergency Preparedness.

A recertification survey was conducted 6/27/2022 through 6/30/2022. The facility was also assessed for compliance with the federal vaccine requirements for HHA's at 484.70 (d) Covid 19 Vaccination of facility staff.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on policy review, medical record review, observation, and interview, the facility failed to ensure the individualized plan of care included all of the medications and treatments for 1 of 5 (Patient #4) sampled patients with home visits. The findings included: 1. Review of the facility's policy, "Drug Regimen Review" revision date 1/2020 revealed, "...The clinician completing the OASIS Assessment must complete a comprehensive drug regimen review of all medications the patients is currently taking at the time of admission, recertification, resumption of care...Any discrepancies should be clarified with the patient's Physician and documented in the clinical record..." 2. Medical record review for Patient #4 revealed a Start of Care date of 12/9/2021 with a Certification Period of 6/7/2022 through 8/5/2022 with diagnosis which included Chronic Obstructive Pulmonary Disease and Pain. The medications listed in the Plan of Care are albuterol sulfate inhaler (rescue breather) 2 puffs 2 times daily (bid), furosemide (fluid pill) 20 milligram (mg) bid, and pregablin (pain) 300mg bid. Review of a Client Coordination Note Report dated 6/21/2022 revealed the nurse reviewed the medications with the patient and multiple discrepancies were found and the physician was notified. 3. Observations in the home on 6/29/2022 at 8:30 AM, revealed Physical Therapist #1 reconciled Patient #4's medications. Patient #4 had additional medications which were not on the medication profile: Uro-Mp, Diltiazem 24 ER, Omeprazole, Sertaline, Alprazolam, Valacyclovir, Enalapril, methanamine, glydo gel, estradiol, butalb-acet-caff, azithromycin, Alendronate Na, and vitamin D3. 4. In an interview in the conference room on 6/29/2022 at 10:10 AM, the Director of Operations verified there were no other orders for Patient #4.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on policy review, observation and interview, the facility failed to ensure measures were utilized to prevent exposure of potential infectious bacteria for 1 of 5 (Patient #1) home visit observations. The findings included: 1. Review of the facility’s “Hand Hygiene” policy, revision date 6/24/21, revealed, “…Perform hand hygiene as follows…Before donning gloves…After removing gloves…” 2. Observations in the home of Patient #1 on 6/28/2022 beginning at 10:40 AM, revealed Licensed Practical Nurse (LPN) #1 removed the patient’s old dressing from wound #1, then removed her gloves and donned new gloves, without performing hand hygiene. LPN #1 completed wound care for wound #1 then began wound care for wound #2. LPN #1 cleaned the wound, removed her gloves and donned a new pair of gloves without performing hand hygiene. 3. In a telephone interview on 6/30/2022 at 1:23 PM, the Director of Operations verified she expected nursing staff to perform hand hygiene between glove changes during wound care.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on medical record review and interview, the facility failed to provide an Occupational Therapy (OT) Evaluation for 1 of 3 ( Patient #5) sampled patients. The findings included: 1. Medical record review revealed Patient #5 had a Start of Care date of 6/1/2022 with diagnosis which included Hypertensive Heart Failure and End Stage Renal Disease. The physician ordered an OT evaluation effective 6/12/2022. The facility was unable to provide the OT evaluation for Patient #5 as of 6/28/2022. 2. In an interview in the conference room on 6/28/2022 at 4:47 PM, the Area Vice President of Operations verified the OT evaluation had not been completed for Patient #5.

An unannounced survey was conducted 4/19/2022 through 4/29/2022, to investigate the allegations for Intake #TN00062781. The facility was cited under the Provision of services by skilled professionals. The facility was also assessed for compliance with the federal vaccine requirements for home health agencies at 484.70 (d) Covid 19 Vaccination of Home Health Agency Staff. No deficiencies were cited.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on medical record review and interview, the facility failed to provide skilled nursing services as ordered by the physician for 1 of 3 (Patient #1) sampled patients. The findings included: 1. Medical record review revealed Patient #1 had a Start of Care date of 12/30/2021 with diagnoses which included Malignant Neoplasm of bladder with Metastasis to right lung. The physician order dated 2/13/2022 at 11:13 AM revealed, “DELETE SN [SKILLED NURSE] VISITS WEEK OF 2/6/22 DUE TO PT [PATIENT] HAVING MEDIPORT [an implanted venous access port] REMOVED AND PICC [peripherally inserted central catheter] placed 2/8/22…PICC DRESSING NEEDS TO BE CHANGED FOR FIRST TIME NO LATER THAN 2/15/22…” The Clinical Coordination Note Report by Registered Nurse (RN) #1 dated 3/2/2022 revealed missed visit the week of 2/19/2022 due to not answering the phone. The Physician was notified by phone. The facility was unable to provide evidence Patient #1’s PICC line dressing was changed for the first time no later then 2/15/2022 as ordered by the physician. 2. In a telephone interview on 4/22/2022 at 1:43 PM, RN#1 verified the missed visit for the week of 2/19/2022. When asked if the physician was notified of the missed dressing change, RN#1 revealed she did not know if she informed the physician about the dressing change.

The agency was entered on 2/8/2022 to investigate the complaint intake #61941. An entrance conference was conducted, and the Director of Operations was informed of the complaint. The investigation was completed on 2/8/2022, and the allegation for Admission, Transfer, and Discharge Rights was substantiated. The agency will be cited for failure to consult the physician responsible for the home health plan to discharge a patient based on the patient's acuity. An exit conference was conducted on 2/8/2022 with the Director of Operations and the Shared Services Vice President of Operations, and time was allotted for questions.

HHA can no longer meet the patient's needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient's welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities; This ELEMENT is not met as evidenced by: Based on review of agency policy, medical record review, and interview, the agency failed to consult the physician responsible for the home health plan of care to discharge a patient based on acuity for 1 of 3 (Patient #1) sampled patients. The findings included: 1. Review of the agency policy, "Discharge of Patients," revealed, "...PURPOSE: To ensure a standardized process for discharging patients form the home health agency...The HHA [Home Health Agency] may only transfer or discharge the patient from the HHA for...Acuity...The transfer or discharge is necessary for the patient's welfare because the HHA and the physician who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity..." 2. Medical record review for Patient #1 revealed a start of care date of 5/2/2021 with a certification period of 12/28/2021 to 2/5/2021. Patient #1 was admitted with diagnoses which included Paraplegia, Stage 4 Sacral Pressure Ulcer, Colostomy, Urinary Device, Primary Generalized Osteoarthritis, Atherosclerotic Heart Disease, Hypertension, History of Seizures, Chronic Pain Syndrome, Long Term Use of Opiate Analgesic, Anxiety Disorder, Nicotine Dependence, and Bed Confinement Status. The plan of care for the certification period of 12/28/2021 to 2/25/2022 revealed Patient #1 was to receive skilled nursing services 1 time a week for 1 week and two times a week for 7 weeks with an effective date of 1/2/2022. Patient #1 was to receive physical therapy services one time a week for 1 week, two times a week for 4 weeks, and one time a week for 2 weeks with an effective date of 1/9/2022. Patient #1 was to receive home health aide services one time a week for 7 weeks with an effective date of 1/9/2022. The plan of care was signed by Physician #1 on 1/13/2022. Patient #1 was admitted to Hospital #1 on 1/27/2022 with diagnoses which included Chest Pain and Urinary Tract Infection. The Discharge-Transfer Summary Report revealed, “…date…1/27/2022…Discharge Reason…DISCHARGED/TRANSFERRED TO A SHORT-TERM GENERAL HOSPITAL FOR INPATIENT CARE…Note Date…1/30/2022…DATE OF DISCIPLINE DISCHARGE: 1/27/2022…REASON FOR DISCHARGE: TRANSFER TO HOSPITAL…EVALUATION OF GOALS: NOT MET…” 3. In an interview on 2/8/2022 at 9:14 AM, the Director of Operations stated she decided the agency could no longer provide care for Patient #1 due to the increasing demands on the staff, multiple hospitalizations, and the lack of a responsible caregiver in the home. The Director of Operations stated the agency had to send out two nurses on each visit because the caregiver was unable to appropriately assist with her care. The Director of Operations stated Patient #1’s condition had deteriorated to the point where she felt Patient #1 needed a higher level of care which the agency could not provide. The Director of Operations stated she contacted the Accounting Executive (liaison for Hospital #1) to inform Hospital #1 that the agency would not perform a resumption of care following Patient #1’s hospitalization. In a telephone interview on 2/8/2022 at 11:00 AM, the Accounting Executive stated he was informed that the agency felt like Patient #1 was not safe in the home, and the agency was not able to provide the appropriate level of care. In a telephone interview, Physician #1 (Patient #1’s primary care physician who had signed the home health agency plan of care on 1/13/2022) stated she has provided care for Patient #1 since 2015. Physician #1 stated she had not seen Patient #1 in a while and was unaware of any deterioration in Patient #1’s condition. Physician #1 stated she had not been informed about Patient #1 being discharged from Home Health Agency #1, and she has not had any discussions with anyone from Home Health Agency #1 about Patient #1’s condition or any problems Patient #1 was having. In an interview on 2/8/2022 at 1:00 PM, the Director of Operations confirmed she did not consult with Physician #1 in the decision to discharge Patient #1 from Home Health Agency #1.