Every finding on record at Beacon Hospice Care, Inc.

Observed in Record Review. In 4 of 10 patient records reviewed, the organization failed to ensure the patient's right to choose and attending physician. On review of RRHV#2, RRNHV#4, RRNHV#7, and RRNHV#10 the section to choose an attending physician was left blank on the patient's election of benefits was left blank. This observation was reviewed with the DPCS.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure documentation of a patient-specific comprehensive assessment and reassessment of the patient's need for hospice care and services. On review of RRHV#3 the patient had documentation of wounds. On admission the comprehensive assessment failed to document the size of the wound to the heel. On recertification there was documentation of 2 new wounds yet the size of the wounds was not documented as required policy and standards of practice. These observations were reviewed with the DPCS.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to maintain complete and accurate records. On review of RRNHV#9 the hospice aide services were declined after November 2024, yet the RN continued to document aide supervisory visits up until current most recent visit. This observation was reviewed with the DPCS.

Observed in Record Review. In 2 of 10 patient records reviewed, The organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of RRHV#3 the documentation specified an issues with swallowing that required aspiration precautions with education provided on most all nursing visits yet the issue was not reflected in the patient's plan of care. In RRNHV#8 there was an incomplete order that read Abdominal Folds: Cleanse with soap and water. Pat dry. Apply dime size amount to redness 2 times per day. The order did not specify what to apply. In RRNHV#10 there were wound care orders that did not specify a frequency to perform the care. The order for the right and left buttocks wounds read cleanse with wound cleanser, pat dry, and applied medi-honey then covered with calcium alginate and 4x4 island dressing. These observations were reviewed with the DPCS.

Observed in Data Session. The organization failed to ensure the QAPI program involve all hospice services to include those services provided under contract or arrangement. When reviewing the QAPI program there was no documentation of including volunteer, bereavement, and contracted services in the QAPI plan. This observation was reviewed with the QAPI Coordinator and the Alternate Administrator.

Observed in Tracer Activities. The organization failed to routinely provide substantially all core services directly by hospice employees to include medical social services. On discussion with the Operations Manager, DPCS, and the Medical Social Worker (MSW) it was revealed that the core services of the MSW were provided under contract as a 1099 contractor and not provided directly by the organization as required. This observation was reviewed with the Operations Manager, and DPCS.

Observed in HR File Review. In 1 of 1 HR files reviewed, for the hospice aide, the organization failed to ensure the hospice aide participate in at least 12 hours of in-service training during each 12 month period. On review of the organization process to provide 12 hours of annual aide in-services training, there was not 12 hours of training documented for HR#4 aide. This observation was reviewed with the Intake Coordinator/HR director.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure the hospice aide provided services that are ordered by the physician or allowed practitioner as assigned in the plan of care. On review of RRHV#1 the Aide's plan of care assigned a bed bath yet the aide documented each visit that shower was given or assisted with shower. This observation was reviewed with the DPCS.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure that a registered nurse supervise the hospice aide during an on-site visit to the patient's home no less frequently that every 14 days. On review of RRHV#1 there was a 28 day gap in aide supervisory visits from March to April. This observation was reviewed with the DPCS.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by the leadership did not ensure that the Conditions of Participation for 418.58, and 418.64 were met per policy as determined through observations, documentation, and staff interviews.

Observed in Record Review. In 5 of 8 patient records reviewed, with recertifications, the organization failed to ensure complete and accurate records. For example: on review for RRHV#3 the Certificate of Terminal Illness narrative by the hospice Medical Director remained nearly identical from certification to recertification and failed to address how the patient continued to meet the criteria for terminal status with current subjective and objective findings. Similar finding can be seen in RRNHV#5, RRNHV#6, RRNHV#7, and RRNHV#10. This observation was reviewed with the DPCS.

Observed in Record Review. In 1 of 10 patient records reviewed, The organization failed to ensure the patient record contain all information to reflect the patient's care, treatment, and services. On review of RRHV#3 the patient had wounds that required wound treatment however there was no documentation of the wound care dressing procedure. The documentation noted wound care provided per MD order - patient tolerated well and complete wound care treatment to right heel. There was documentation of the procedure followed to explain what care was provided. This observation was reviewed with the DPCS.

Observed in Record Review. In 8 of 10 patient records reviewed, the organization failed to ensure all entries to the record were appropriately authenticated and dated in accordance with hospice policy and accepted standards of practice. On review of patient records there multiple entries for clinical notes there were not signed and dated. In RRHV#1 and RRHV#3 all skilled nursing notes were in various stages of QA/approval and were not signed and dated as part of the record. Further examples of notes not signed and dated in the electronic system could be seen in RRNHV#5, RRNHV#6, RRNHV#7, RRNHV#8, RRNHV#9, RRNHV#10 These observations were reviewed with the DPCS.

Observed in HR File Review. In 1 of 8 HR files reviewed, the organization failed to obtain a criminal background check on hospice employees that have direct patient contact or access to patient records. On review of HR#8 for the hospice volunteer there was no documentation that a criminal background check was obtained. This observation was reviewed with the Intake Coordinator/HR Director.

Observed in Record Review. In 4 of 11 patient records reviewed, the organization failed to ensure complete and accurate patient records. For example: Upon review of the Certificate of Terminal Illness in RR#6 it was noted that the physicians narrative was nearly identical for benefit period 3, 4, and 5, and did not account for the changes noted in the RN documentation. Similar findings of nearly identical physician's CTI narrative on RR#7 for benefit period 20, 21, and 22 were noted. Similar findings were also noted in RR#5 and HV#2. These observations were reviewed with the Operations Manager, QAPI Nurse, and DPCS.

Observed in Record Review. In 6 of 11 patient records reviewed, the organization failed to ensure that the goals established were individualized, specific, measurable, and time bound. For example: upon review of HV#2 the goal for cardiovascular was patient will maintain optimal peripheral circulation; for mobility the goal stated minimize complication due to impaired mobility, and for pain the goal read patient will remain in comfortable level during care. The goal for psychosocial noted that MSW will compile added resources and support as needed. Similar findings of goals that were not specific, measurable, and time bound can be seen in RR#4, RR#5, RR#7, RR#9, and RR#10. These observations were reviewed with the DPCS, QAPI Nurse, and Operations Manager.

Observed in Record Review. In 7 of 11 patient records reviewed, the organization failed to provide a detailed statement of the scope and frequency of services necessary to meet the patient and family needs. For example: upon review of HV#1 the frequency for the MSW was noted as 1 as needed and recert. There was no indication noted for the PRN visit. In HV#3 the frequency read 1 initial and PRN. There was no quantity of PRN visits ordered and no indication for the visits. Further, the RN visits for HV#1, RR#4, and HV#3 stated RN as needed and Q14 days for supervision. Although RN's were visiting per plan of care, there was no quantity of the PRN visits and no indication or reason for the PRN visits to be made. Similar observations can be seen in HV#2, RR#5, RR#7, and RR#8. These observations were reviewed with the Administrator, and DPCS.

Observed in Infection Control Tracer. During discussion with the RN QAPI Nurse it was noted that the organization failed to carry out their infection control plan for monitoring employee infections. Upon review of the infection control plan there were tools for documenting and logging employee infections however the RN QAPI Nurse acknowledged that the organization was not utilizing these tools nor documenting employee infections per policy beyond Covid.

Observed in Record Review. In 10 of 11 patient records reviewed, where hospice aide services were provided, the organization failed to ensure that the written patient care instructions for the hospice aide were complete. For example: upon review of HV#3 in was noted that some of the tasks, such as bathing, hair and mouth care, assigned to the hospice aide did not include a frequency. Further the patient was ordered oxygen yet there was no instructions on the aide assignment on how to handle the oxygen during the patient's care. The lack of including a frequency for assigned tasks such as bathing, hair and mouth care can be seen as a trend throughout all aide assignments. These observations were reviewed with the Administrator and the DPCS.

Observed in Patient Home. in the one home observation that medication reconciliation was performed, the organization failed to ensure that the medication profile was accurate. For example: upon medication reconciliation during the home observation of HV#2, it was noted that the assisted living medication profile did not include melatonin and Miralax which were both listed on the hospice medication profile. This observation was reviewed with the clinician and the DPCS. Observed in Record Review. In 2 of 11 patient records reviewed, the patient's record did not contain complete information pertaining to the patient's care, treatment, and services provided. For example: upon review of HV#3 the medication profiled included diclofenac gel, however there was no dosage for the medication noted on the record, nor where to apply the medication. Example 2: upon review of HV#1 the narrative for the initial nursing comprehensive assessment notes that the patient was an elderly female and refers to she in the verbiage when the patient was a male. These observations were reviewed with the Administrator and the DPCS.

Observed in Record Review. In 1 of 1 patient records reviewed, that reside in a skilled nursing facility, the organization failed to ensure that the hospice plan of care reflected the participation of the hospice, and the SNF. For example: upon review of the record for RR#8, who resides in a SNF, there was no evidence noted in the clinical record of collaboration and/or coordination with the SNF reflected in the plan of care. This observation was reviewed with the DPCS, the QAPI Nurse, and the Operations Manager.