Every finding on record at Beacon Hospice, LLC

Based on observation and staff interview, the agency failed to ensure that infection control guidelines were followed for one patient (#27) of five patient home visits conducted in a total of 27 records.Findings include: --- Review of the agency’s policy, titled Infection Prevention Program Overview, last reviewed 5/12/25, indicated the following:*Purpose: To prevent and reduce the transmission of infection and communicable diseases. To educate staff and patients regarding infection control practices and principles.*The HHA (Home Health Aide) must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases.Patient #27 was admitted to the agency in June 2024 with a diagnosis of senile degeneration of the brain.Review of the Hospice Aide care plan for certification period 10/10/25 through 12/8/25, indicated Patient #27 was dependent on staff for daily care, including hygiene (bed bath and perineal care).On 10/22/25 at 9:30 A.M., a home visit was conducted with HHA #1 to perform personal care for Patient #27. The surveyor observed HHA #1 perform hand hygiene, put on gloves, and then remove the patient’s clothing and wash Patient #27’s upper body. HHA #1 then removed her gloves and without performing hand hygiene left the room to get more supplies. Upon returning to the room HHA #1 put on new gloves. She failed to perform hand hygiene. HHA #1 then removed the patients soiled brief to complete perineal care. HHA #1 removed her gloves, and without performing hand hygiene, put on a new pair of gloves. After completing perineal care, she removed her gloves, and without performing hand hygiene, she put on a new pair of gloves and started washing the patient’s lower body. After completing lower body care, HHA #1 removed her gloves and put on a new pair of gloves. She failed to perform hand hygiene.During an interview on 10/22/25 at 10:30 A.M., HHA #1 said that she should have performed hand hygiene after removing her gloves, and before putting on new gloves.During an interview on 10/22/25 at 1:00 P.M., the Director of Hospice services said hand hygiene should be performed after removing gloves during personal care.

Based on interview and document review, the agency failed to ensure supervision of the Home Health Aide (HHA) was provided no less frequently than every 14 days for 1 patient (#23), out of a total of 27 patients. --- Findings include:Review of the agency policy titled, Supervision of Disciplines-Hospice Aide and Homemaker, date as reviewed 8/5/25, included the following:-Services furnished are under the supervision and direction of a registered nurse (RN).-The Hospice Aide is supervised by the RN.-A supervisory visit will be made to the patient’s residence at least every 14 days or less, by the RN to assess relationships and determine whether goals are being met when skilled services are being provided.Patient #23 was admitted to the agency in May 2023, with a diagnosis of Alzheimer’s Disease.Review of the Physician ordered Plan of Care for certification period 8/13/25 through 10/25/25 included an order for a Home Health Aide (HHA) 3 times per week.Review of the clinical record on 10/22/25 indicated HHA services were provided 3 times per week for the weeks of 8/24/25, 8/31/25, 9/7/25, 9/14/25, 9/21/25, 9/28/25, 10/5/25 and 10/12/25. Further review indicated RN Supervisory visits were conducted only on 8/19/25 and 10/15/25.During an interview on 10/22/25 at 3:00 P.M., the Vice President of Clinical Services said supervisory visits should be completed at least every 14 days but were unable to provide documentation to indicate supervisory visits were conducted every 14 days 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 Volunteer Cost Savings Report between September 2024 and September 2025 indicated the following: 9/2024 - Cost Savings 0.06%10/2024 - Cost Savings 0.99%11/2024 - Cost Savings 1.59%12/2024 - Cost Savings 1.29%1/2025 - Cost Savings 1.56%2/2025 - Cost Savings 1.88%3/2025 - Cost Savings 2.14%4/2025 - Cost Savings 1.70%5/2025 - Cost Savings 1.61%6/2025 - Cost Savings 1.34%7/2025 - Cost Savings 1.31%8/2025 - Cost Savings 1.16%9/2025 - Cost Savings 1.01%Total Cost Savings last 12 months: 1.52% During an interview on 10/24/25 at 10:45 A.M., the Director of Operation/Administrator said the agency (parent and all 4 branches), has not been able to meet the requirement of 5% for volunteers.