Every finding on record at Beacon Hospice, L.L.C.

Upon patient record review, 1 of 23 (Patient #12) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #12: Upon record review, on the election statement where the choice for attending physician should be written, "Beacon Hospice" was written.

Upon patient record review, 1 of 23 (Patient #2) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #2: Upon observation during the home visit, the hospice had lorazepam intensol 2mg/ml every 4 hours as needed and trazodone 50 mg three times daily as needed on the medication record. The facility did not have the medications on their medication list.

Upon patient record review, 1 of 23 (Patient #14) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #14: Upon record review the Chaplain created a plan of care without identifying a visit frequency.

Upon patient record review, 1 of 23 (Patient #2) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2: Upon observation during the home visit, the hospice had an order lorazepam intensol 2mg/ml every 4 hrs. as needed and trazodone 50 mg three times daily as needed on the medication record. The facility did not have those medications on their plan of care orders.

Upon patient record review, 3 of 23 (Patient #1,8,15) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #1: Upon record review on 5/16/25 an order for Keflex 500 mg 4 times daily X 3days for UTI. The plan of care was not updated with problem, intervention and goals for infection. Patient #8: Upon record review the patient was admitted on 4/24/25. The patient accepted a phone call rather than visit from the MSW on 4/26/25. The patient identified he wanted to be cremated but did not have a location/funeral home chosen. On 5/9/25 the patient refused further MSW services. The nurse did not update the nursing plan of care to reflect psychosocial needs to complete final arrangements. Patient #15: Upon record review on 5/20/25 and order for O2 2l/min via NC PRN for shortness of breath. The plan of care was not updated with problem, interventions and goals for oxygen or shortness of breath

Upon patient record review, 4 of 23 (Patient #15,16,17,18) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #15, 16, 17: Upon record review the MSW visit frequency was 1M3. In May 2025 there were no MSW visits. Patient #18: Upon record review the nurse visit frequency was 1Xwk. The week of 6/15/2025 there were no nursing visits.

Upon home visit, 1 of 6 (Patient #10), there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Upon observation of the home visit, the nurse placed her nursing bag on the floor. Also, the nurse put equipment on the patient overbed table without creating a "clean" area as per "Bag Policy". There was not a barrier placed nor was the surface cleaned.

Upon patient record review 6 of 23 (Patient #1,2,3,5,10,11) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1: Upon patient record review, the aide plan of care included shampoo every visit. On 5/6/25, 5/8/25 and 5/22/25, the aide documented shampoo "not completed". Patient #2: Upon patient record review, the aide plan of care included shampoo and shave every visit. On 6/17/25 and 6/19/25, the aide documented shampoo and shave "not completed". Patient #3: Upon patient record review, the aide plan of care included shampoo and shave every visit. On 6/19/25 and 6/20/25, the aide documented shampoo and shave "not completed". Patient #5: Upon patient record review, the aide plan of care included shampoo every visit. On 5/20/25 and 5/21/25, the aide documented shampoo "not completed". Patient #10: Upon patient record review, the aide plan of care included shampoo every visit. On 5/12/25 and 5/14/25, the aide documented shampoo "not completed". Patient #11: Upon patient record review, the aide plan of care included shampoo and assist with shower every visit. On 6/20/25 the aide documented assist with shower "not completed" and 6/23/25, the aide documented shampoo "not completed".

Upon patient record review 1 of 23 (Patient #18) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #18: Upon record review on 6/9/25 an RN made an on-site visit to the patients home to supervise the aide. No supervisory visit was completed on or before 6/23/25.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Upon observation the Volunteer percentage for the past year was 0.7%. The agency has an ongoing Agency PIP and national PIP to increase volunteer hours.

Based on record review and staff interview it has been determined that the agency failed to follow the plan of care for 1 of 2 patients relative to following orders for volunteer visits, Patient ID #8. --- Findings are as follows: Record review for Patient ID #8, who has a start of care date of 12/5/2021, revealed an order dated 9/19/2022 with an effective date of 10/1/2022 for a volunteer 4 times per month for 2 months and 2 as needed visits for unexpected changes in companionship needs. Record review on 10/17/2022 revealed scheduled volunteer visits for the following dates: 10/3/2022, 10/10/2022 and 10/17/2022. The record failed to reveal that any of the above visits were completed. During a surveyor interview on 10/17/2022 at 11:56 AM with the Director of Operations in the North Kingstown office, she was unable to produce evidence that the above visits were completed as ordered.

Based on record review, surveyor observation and staff interview it has been determined that the hospice failed to update the plan of care based on assessment findings, relative to pressure ulcers for 1 of 3 patients reviewed, Patient ID # 18. --- Findings are as follows: 1) Record review of the notes for Patient ID #18 reveled s/he was admitted to the agency on 9/12/2022 with a primary diagnosis of senile degeneration of the brain. Additional diagnoses of muscular sclerosis and vitamin D deficiency. Further review of the record revealed the patient sustained a fall in July, requiring surgical intervention and returned to the assisted living facility. The patient was receiving home care services for nursing and physical therapy until admitted to hospice on 9/12/2022. Record review of the initial nursing visit on 9/12/2022, indicating that the patient was seated in a wheelchair, alert and non-verbal, skin pale, poor skin turgor, unable to stand, appears weak and fatigued. The patient was unable to stand for the nurse to assess the buttock wound. The patient refused to return to bed for the nurse to complete the skin assessment. The nurse contacted the home care agency that was providing services to the patient, who informed the nurse that the patient had a stage 3 on the coccyx that they were treating twice a week. The plan of care revealed that the nurse would revisit the following day, 9/13/2022 to complete the initial assessment. Review of the record failed to reveal a nursing visit until 9/14/2022. Surveyor interview with the Director of Nurses, on 10/28/2022 at approximately 11:50 AM, she was unable to explain why the patient was not seen by the nurse on 9/13/2022 to complete the initial skin assessment. 2) Additional review of the record reveals, the patient was seen by the nurse on the following dates, 9/14/2022, 9/16/2022, 9/19/2022, 9/21/2022, 9/23/2022, 9/25/2022, 9/26/2022 & 9/28/2022. During the 9/14/2022 nurse visit, documentation reveals a foul odor in the room, while performing wound care to buttocks, and a large amount of purulent drainage and a large necrotic area. Nursing visits were increased to 3 times a week. Review of the wound record states on 9/14/2022, section "wound details" "indicate details of physician notification and interventions provided", revealed "PCP [Primary Care Physician] notified by FSN [facility skilled nurse], orders of ABTX [antibiotic] obtained". Further review of the record failed to reveal evidence of an order for an antibiotic. The Hospice agency was unable to provide evidence that the antibiotic ordered by the PCP per the FSN was ever obtained or administered. 3) Record review of the 9/16/2022 nurse visit, reveals the wound continues with a large amount of purulent drainage and a strong odor, large necrotic area remains, wound bed not visible. Record review of a 9/19/2022 nurse visit, documentation reveals the left buttock wound bed with soft black eschar, with large amount sero-sanguineous drainage, no odor. New order for dressing, cleanse with normal saline, skin prep to peri wound, followed by Thera honey to wound bed, pack with Calcium alginate and cover with self-adhesive foam dressing 3 times a week as needed. Upon arrival of the nurse the patient was found resting in a recliner, s/he was transferred with a maximum assist of 2 to a wheelchair and returned to his/her room. S/he was then transferred to his/her bed with a maximum assist of 2, the nurse then cleaned the patient before wound care as s/he had been soiled with a large bowel movement. Record review of a 9/21/2022 nurse visit, documentation reveals the patient was seated in a wheelchair in the dining room, staff not available to assist nurse with return to bed. Hospice case manager called and on route to assist. Facility staff arrived to assist hospice nurse to return patient to bed. Strong odor noted from coccyx and large amount of drainage noted. Additionally, 4 new DTI's( Deep tissue injury) to feet were noted. 2x2x0cm necrotic area on lateral middle edge of right foot 2x1.5x0 cm necrotic area on right lateral malleolus 3x2x0 cm right medial heel unstageable DTI 3x1.5x0 necrotic left medial malleolus Record review of a 9/23/2022 nurse visit, documentation reveals that the patient was in bed experiencing pain during the coccyx dressing change, wound continues with large amount of purulent drainage. On 9/25/2022 the facility nurse was not available, so patient's son was contacted to go to the facility and give the patient the Tramadol( a medication for pain) prior to the nurse's arrival for the dressing change. Record review failed to include an order for the patient to be pre medicated for pain prior to the nurses arrival for the dressing change. During an interview with the Director of Nurses on 10/18/2022 at approximately 11:55 AM, she stated that she would have expected a physician's order if the patient needed to be medicated prior to dressing changes. 4) Record review of a 9/25/2022 nurse visit, documentation revealed the buttocks wound continues with purulent drainage, the patient continues to require extensive assistance for transfers and bed mobility and was noted to be incontinent of urine with no dressing covering the buttocks wound upon arrival of the hospice nurse. Record review of a 9/26/2022 nurse visit, documentation revealed a new pressure area (#6) to right anterior edge of right foot. New orders for left medial malleolus wound and new area pressure # 6. Hospice nurse notified patient's son. Record review of a 9/28/2022 nurse visit, documentation revealed 2 additional pressure areas were identified, (#7) stage 1 to 5th right toe 1.5x1.3, and (#8) and unstageable to left heel measuring 1.3 x 1.2 x 0.1 new orders for skin prep obtained. It further reveals upon the nurses arrival the patient was lying in bed, the right buttock dressing and brief were both noted to be saturated with urine, feet were not offloaded, and the left medial malleolus dressing was dislodged, and it had drained onto the right foot dressing. Record review revealed that on 9/28/2022 the patient was transferred to a SNF (skilled nursing facility). Further review of the record reveals that the patient was noted to be incontinent on several occasions and the buttocks dressing saturated with urine and or not on the patient, upon arrival of the hospice staff, the plan of care failed to be updated based on these findings. During a surveyor interview with the East Providence Director of Operations on 10/18/2022 at approximately 11:50 AM, she was unable to produce evidence that the patient's plan of care was updated relative to the patient being incontinent of urine and the patient without the a dressing on multiple occasions when the hospice staff visited.

Based on record review and staff interview, it has been determined that the agency failed to review patient medications and update the comprehensive assessment for 2 of 9 patients reviewed during home visits, Patient ID #s7 and 11. Additionally the agency failed to complete weekly measuring and assessment of pressure wounds for 2 out of 4 patients reviewed for pressure, Patient ID #s11 and 25. --- Findings are as follows: A) Record review of the agencys policy titled ";Medication Management" revealed in part, ";...Medication Reconciliation will be done at admission, recertification, a change in patients condition requiring medication changes, when a medication is discontinued, when a medication is a new order, or a change in existing medication order..." 1) Record review of the current medication list for Patient ID #7 printed on 10/12/2022, revealed the following physicians orders: Torsemide (used to reduce extra fluid in the body) 10 milligrams (mg) 1 tablet every other day Sennosides 8.6 mg- Docusate Sodium 50 mg (used to prevent constipation) 2 tablets daily During a surveyor home visit for Patient ID #7 with the Health Aide, Staff B on 10/13/2022 at 8:30 AM the patients current medications were reviewed with the patients son. He revealed the following medications were administered in place of the above medications: Torsemide 20mg 1 tablet every other day. The bottle was dated 8/30/2022, and the Patients son revealed that the resident had been taking this dosage for a long time. Docusate sodium 100 mg (used to prevent constipation) 1 capsule daily was being used instead of Sennoside 8.6mg – Docusate Sodium 50mg. The patients son stated this has been used for over a month in place of the Sennosides 8.6mg- Docusate sodium 50mg. During a surveyor interview on 10/13/2022 at 3:03 PM with the Director of Operations for the North Kingstown office she was unable to provide evidence that the medication reconciliation was completed. She further revealed that she would expect the doctor to be contacted with any change in medications and the current medication list to be updated. 2) Record review of the current medication list for Patient ID #11 printed on 10/12/2022, revealed the following physicians orders: Fluticasone Propionate (steroid medicine that is used to treat nasal congestion, sneezing, runny nose, and itchy or watery eyes related to allergies) 50 micrograms (mcg) / actuation nasal spray 1 spray each nostril daily. Simvastatin (helps to lower cholesterol and fats) 40 mg 2 times per week Vitamin E mixed 400-unit capsule daily During a surveyor home visit for Patient ID #11 with Registered Nurse, Staff C on 10/13/2022 at 1:00 PM the patients current medications were reviewed with the patients caretaker and the nurse. The patients caretaker revealed the following: Fluticasone Propionate 50 mcg nasal spray has not been used for a couple of months. Simvastatin 40 mg was given daily not 2 times per week. There were 2 bottles which also stated once daily. The bottles were dated 6/3/2022 and 9/1/2022. Vitamin E 400 units has not been used for about a month. During a surveyor interview on 10/13/2022 at approximately 2:00 PM with Staff C, she acknowledged that the medication discrepancies had not been addressed on the current medication sheet. During a surveyor interview on 10/13/2022 at 3:03 PM with the Director of Operations in the North Kingstown office she revealed the above medication discrepancies should have been addressed and could not provide evidence that the medications were reconciled. B) Record review of the agency's policy titled, ";The Provision of Wound and Skin Care" revealed in part, ";...Measuring: In accordance with best practice and standard of care, wounds will be measured a minimum of one time a week, preferably on the first visit of the week, by the same nurse, utilizing the same tool and measurement terminology..." 1) Record review of the Hospice Certification and plan of care for Patient ID #11 revealed in part, ";Hospice Nurse to observe and assess integumentary [skin] status to identify changes and intervene to minimize complications..." Record review of the Wound Record Report revealed the Patient had a stage 2 pressure ulcer (partial-thickness skin loss into but no deeper than the dermis) to the coccyx. Review of the measurements and assessments of the pressure ulcer revealed the following: Week of 9/29/2022- measurements- 3 centimeter (cm) by 1cm by 0.1 cm Week of 10/2- 10/8/2022- No measurements or documented assessment Week of 10/13/2022- measurements- 3.3 cm by 2.5 cm by 0 cm During a surveyor interview on 10/18/2022 at 2:52 PM with the Director of Operations at the North Kingstown office, she was unable to provide evidence that the wound was assessed during the week of 10/2/2022- 10/8/2022. 2) Record review of the Hospice Recertification orders for Patient ID #25 revealed in part, ";...Hospice Nurse to observe and assess integumentary status to identify changes and intervene to minimize complications..." Record review of the Wound Record Report revealed the patient had an unstageable deep tissue injury (This means that the stage is not clear. In these cases, the base of the sore is covered by a thick layer of other tissue and pus that may be yellow, gray, green, brown, or black) on her/his right heel. Review of the measurements and assessments of the unstageable deep tissue injury revealed the following: Week of 9/12/2022- measurements- 1.3 cm by 1.7 cm by 0.1 cm Week of 9/18 – 9/24/2022- No measurements or documented assessment Week of 9/26/2022- measurements- 1.5 cm by 1.5 cm by 0 cm Record review of the Wound Record Report revealed the patient had an unstageable deep tissue injury on her/his left heel. Review of the measurements and assessments of the unstageable deep tissue injury revealed the following: Week of 9/12/2022- measurements- 1 cm by 1 cm by 0.1 cm Week of 9/18- 9/24/2022- No measurements or documented assessment Week of 9/26/2022- measurements- 1.5 cm by 1.5 cm by 0 cm During a surveyor interview on 10/18/2022 at 4:42 PM with the Director of Operations in North Kingstown she was unable to provide evidence that the bilateral heel wounds were measured and assessed during the week of 9/18– 9/24/2022.

Based on record review and staff interview it has been determined that the hospice failed to include a hospice-wide data-driven quality assessment and performance improvement program, that reflects the complexity of its organization and services; and involves all hospice services (including those services furnished under contract or arrangement). --- Findings are as follows: Review of the hospice Quality Assurance program, revealed that the committee meets quarterly, however fails to include a volunteer or pharmacists representative. During a surveyor interview on 10/18/2022 at 11:15 AM with the Quality Assurance Coordinator, she was unable to produce evidence that the hospice included a volunteer or a pharmacist on the committee as required.

Based on surveyor observation, record review and staff interview it has been determined that the hospice failed to provide nursing care and services to ensure that the nursing needs of the patient are met as identified in the patient's initial assessment, comprehensive assessment, and updated assessments, for 1 of 3 Patients, Patient ID #1, relative to weekly skin assessments. --- Findings are as follows: Record review of the agency's policy titled " Management/Prevention of Pressure Injuries" dated 1/20/2022, states in part; "Skin Assessment Complete skin assessment is part of the risk assessment. Inspect regularly for signs of redness in individuals identified as being at risk for pressure injury". During a surveyor observation on 10/12/2022 at approximately 1:40 PM with the Registered Nurse, Staff A of Patient ID #1 who resides in an Assisted Living Facility, revealed Patient ID # 1 was seen seated in a wheelchair in the common area. Staff A, asked the patient if s/he would return to her/his room for the nursing visit and the patient agreed. The nurse assessed the patient who remained seated in the wheelchair fully dressed including socks and shoes. She interviewed the patient and obtained vital signs. She then pulled the residents socks down to the ankles and looked at his/her legs for swelling. During a surveyor interview with the Director of Nurses on 10/18/2022 at approximately 9:50 AM, when she was asked what "Inspects regularly" means in the policy. She stated that the expectation is at least weekly a skin assessment is to be completed. During a surveyor interviewed with Staff A on 10/20/2022 at 10:30 AM, she acknowledged that she did not complete the weekly skin assessment on Patient ID #1 as required during the 10/12/2022 weekly visit.

Based on record review and staff interview, it has been determined that the agency failed to provide durable medical equipment related to the palliation and management of the terminal illness and related conditions as identified in the hospice plan of care for 1 of 4 patients with pressure wounds, Patient ID #25. --- Findings are as follows: Review of an agency policy titled, ";Management /Prevention of Pressure Injuries" states in part, ";...IDENTIFY RISK FACTORS AND IMPLEMENTING PREVENTION MEASURES...Minimize Pressure...Regular positioning is not possible for some individuals because of their medical condition, and an alternative prevention strategy such as providing a high-specification mattress or bed may need to be considered..." Record review of Patient ID #25 revealed a start of care date of 12/29/2021. Record review of the patients ";Wound Report Record" revealed and unstageable coccyx wound (This means that the stage is not clear. In these cases, the base of the sore is covered by a thick layer of other tissue and pus that may be yellow, gray, green, brown, or black) with a start date of 6/6/2022. Review of the record revealed a narrative note dated 6/6/2022 which reveals in part, ";...unstageable wound to coccyx measuring 1.2 by 0.5 by 0.1, 50% granulating tissue [ new vascular tissue in granular form on an ulcer or the healing surface of a wound] in wound bed, 50 % slough [dead skin tissue that may have a yellow or white appearance] in wound bed, wound is unstageable at this time...Facility staff nurse feel an air mattress would put patient at a significantly high fall risk at this time, gel overlay ordered and agreed upon..." Further record review of the patients ";Wound Report Record" revealed the following wounds: Wound #2- Right heel unstageable Deep Tissue Injury (DTI-persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues) with a start date of 6/24/2022. Wound #3- Left heel unstageable DTI with a start date of 6/24/2022. Wound #4- Coccyx stage 2 pressure ulcer (partial-thickness skin loss into but no deeper than the dermis) with a start date of 8/24/2022 Wound #5- An unstageable right lower buttock wound with a start date of 8/24/2022 Wound #6- Right lower buttock stage 2 pressure ulcer with a start date of 8/24/2022 Wound #8- An unstageable iliac crest (the curved superior border of the ilium, the largest of the three bones that merge to form the hip bone) wound with a start date of 9/9/2022 Further record review failed to reveal any further discussion about an air mattress until one was provided for the resident on 9/12/2022, at which point all the above wounds were already present. During a surveyor interview on 10/18/2022 at approximately 11:04 AM with the Director of Operations in the East Providence office she revealed that the patient was moved from the Assisted Living Residence to a Nursing and Rehabilitation center from 7/21/2022 through 8/19/2022. She further revealed that she would have expected a discussion with the Assisted Living about an air mattress after the wounds developed on 8/24/2022.