Every finding on record at Beacon Hospice, LLC

Based on record review and interview, the agency failed to ensure the comprehensive assessment was completed by the hospice interdisciplinary team no later than 5 calendar days for 2 patients (#12 and #15), out of a total sample of 19 patients.Findings include: --- Review of the agency policy entitled, Assessments, revised 10/2/25, included the following:*The hospice IDT, in consultation with the patient's physician (if any) completes the comprehensive assessment within 5 calendar days of the election of the hospice benefit.1. Patient #12 was admitted to the agency in August 2025 with a diagnosis of unspecified malignant neoplasm (a type of cancer where the location or type cannot be determined).Review of the clinical record indicated the following:*Board Certified Social Worker (BCSW) note completed on 8/18/25.Further review of the clinical record indicated the Comprehensive Assessment was completed on 8/18/25.2. Patient #15 was admitted to the agency in September 2025 with a diagnosis of malignant neoplasm of the lung (cancer).Review of the clinical record indicated a Chaplain Assessment had not been completed for Patient #15.During an interview on 11/5/25 at 2:30 P.M., after reviewing the clinical records for Patients #12 and #15, the Clinical Director said the Comprehensive Assessment was not completed with the required 5 day timeframe from admission for Patient #12. She further said there was no Chaplain assessment completed for Patient #15, therefore the Comprehensive Assessment was not completed with the required timeframe.

Based on record review and interview, the agency failed to ensure a Chaplain Assessment was completed and incorporated into the initial Comprehensive Assessment for 1 patient (#15), out of a total sample of 19 patients.Findings include: --- Review of the agency policy entitled, Assessments, revised 10/2/25, included the following:-The comprehensive assessment identifies the physical, psychosocial, emotional, behavioral, and spiritual needs of the related to the terminal illness that must be addressed in order to promote the patient's wellbeing, comfort, and dignity, throughout the dying process.-A history of any religious affiliation and support, spiritual beliefs, traditions and rituals.-The nature and scope of spiritual concerns or needs includes, but is not limited to:  *Loneliness  *Despair  *Fear  *Guilt  *Anger  *Forgiveness  *Reconciliation    *Inner strengths or weaknesses, as appropriate.Patient #15 was admitted to the agency with a diagnosis of malignant neoplasm of the lung (cancer).Review of the initial Comprehensive Assessment did not contain any documentation that a Chaplain Assessment had been completed.During an interview on 11/5/25 at 2:30 P.M., after reviewing the clinical record, the Hospice Director said the initial Comprehensive Assessment was incomplete as it did not contain a Chaplain Assessment, as required.

Based on document review and staff interview, the agency failed to provide volunteers in a day-to-day administrative and/or direct patient care service position in an amount that, at a minimum, equals five (5) percent (%) of the total patient care hours of all paid hospice employees and contract staff.  Findings include: --- Review of the Hospice Volunteer Requirement Report for cost savings between September 2024 through September 2025 indicated the following:9/2024-Cost Savings 3.39%10/2024-Cost Savings 5.06%11/2024-Cost Savings 3.83%12/2024-Cost Savings 3.63%1/2025-Cost Savings 6.81%2/2025-Cost Savings 6.22%3/2025-Cost Savings 3.93%4/2025-Cost Savings 5.07%5/2025-Cost Savings 2.54%6/2025-Cost Savings 3.34%7/2025-Cost Savings 2.08%8/2025-Cost Savings 1.79%9/2025-Cost Savings 1.85%Total Cost Savings last 12 months: 3.9%During an interview on 11/4/25 at 2:30 P.M., the Volunteer Coordinator said it is difficult to meet the 5% all the time because of the fluctuations in patient census and what the volunteers are able to do in the volunteer role.  During an interview on 11/5/25 at 3:00 P.M., the Director of Hospice said she has been working with the Volunteer Coordinator to get the percentage up. She said they need to do a better job by getting the agency out in the community and be more present.

Based on document review and staff interview, the agency failed to ensure clinical documentation was complete and appropriately authenticated and dated in accordance with currently accepted standards of practice for 8 patients (#2, #12, #15, #16, #9, #3, #1 and #19), out of a total sample of 19 patients.Findings include: --- 8. Patient #2 was admitted to the agency in January 2025 with a diagnosis of degeneration of the brain.Review of the physician ordered POC for certification period 9/13/25 through 11/11/25 indicated the following:-SN visit: once a week times 9 weeks, and 8 PRN for unexpected medical needs.-MSW visit: once a month times one, 3 times a month times one, one time a month times one, and 3 PRN phone calls.Review of the clinical record indicated the following:-9/17/25 BCSW visit note was signed on 9/22/25.-10/2/25 BCSW visit note was signed on 10/6/25.-10/7/25 SN visit note was signed on 10/12/25.10/23/25 RN visit note was signed on 10/27/25.During an interview on 11/4/25 at 4:30 P.M., the Hospice Director said documentation on visits should be completed by the end of the shift. On 11/5/25 at 3:00 P.M., the Hospice Director said she was unable to find any documentation to indicate why the visit notes were not completed timely. 5. Patient #12 was admitted to the agency in August 2025 with a diagnosis of unspecified malignant neoplasm (a type of cancer where the location or type cannot be determined).Review of the physician ordered POC for certification period 8/10/25 through 11/7/25 indicated the following:-MSW visit: once a month times one.Review of the clinical record indicated the following:*8/14/25 Board Certified Social Worker (BCSW) visit note was signed 8/18/25. 6. Patient #15 was admitted to the agency in September 2025 with a diagnosis of malignant neoplasm of the lung.Review of the physician ordered POC for certification period 9/5/25 through 12/3/25 indicated the following:-SN visit: once a week for one week, twice a week for one week, once a week for 12 weeks, and 8 PRN visits.-MSW visit: once a month times one.Review of the clinical record indicated the following:*9/5/25 SN visit note was signed on 9/7/25.*9/26/25 SN visit note was signed on 9/29/25.*9/26/25 MSW visit note was signed on 9/30/25.7. Patient #16 was admitted to the agency in September 2025 with a diagnosis of senile degeneration of the brain.Review of the physician ordered POC for certification period 9/29/25 through 12/27/25 indicated the following:-SN visit: three times a week for one week, twice a week for 12 weeks, and 8 PRN visits.-MSW visit: one a month times one.Review of the clinical record indicated the following:*10/14/25 SN visit was signed on 10/16/25.*10/28/25 SN visit note was signed on 10/30/25.*10/2/25 BCSW visit note was signed on 10/7/25.  Review of the agency policy entitled, Clinical Records Maintenance and Confidentiality, revised date 7/25/25, included the following:-All documentation is timely, detailed and accurate and reflects the care, treatment, and services provided by employees or contracted personnel.-All entries into the clinical record must be legible, complete and appropriately authenticated and dated in accordance with accepted standards of practice.-Visit documentation must be submitted by the end of their scheduled shift.1.Patient # 9 was admitted to the agency in October 2025 with a diagnosis of colon cancer.Review of the physician ordered Plan of Care (POC) for certification period 10/26/25 through 1/23/25 indicated the following:-Skilled Nursing (SN) visit: four times a week for one week, three times a week for 12 weeks and 8 as needed (PRN) visits.Review of the clinical record indicated the following:-10/26/25 SN visit note was signed on 10/28/25.2. Patient #3 was admitted to the agency in October 2025 with a diagnosis of cirrhosis of the liver.Review of the physician ordered POC for certification period 10/30/25 through 1/27/25 indicated the following:-SN visit: twice a week for 13 weeks and 8 PRN visits.Review of the clinical record indicated the following:-10/31/25 SN visit note was signed on 11/3/25.3. Patient #1 was admitted to the agency in August 2025 with a diagnosis of cerebral atherosclerosis (fatty deposit build up in the arteries which supply blood to the brain).Review of the physician ordered POC for certification period 8/14/25 through 10/10/25 indicated the following:-SN visit: twice a week for 9 weeks and 8 PRN visits.-Medical Social Worker (MSW) visit: once a month times one.-Chaplain visit: once a month times one.Review of the clinical record indicated the following:-8/18/25 MSW visit note was signed on 8/20/25.-8/18/25 Chaplain visit note was signed on 8/20/25.-9/25/25 SN visit note was signed on 10/1/25.4. Patient #19 was admitted to the agency in September 2025 with a diagnosis of unspecified dementia.Review of the physician ordered POC for certification period 9/5/25 through 12/3/25 indicated the following:-SN visit: twice a week for 13 weeks, once a week for one week and 8 PRN visits.Review of the clinical record indicated the following:-9/5/25 SN visit note was signed on 9/8/15.