Every finding on record at Beacon Hospice LLC

Based on review of the Emergency Preparedness Plan (E.P.P.) documents, it was determined the facility failed to ensure disaster drills (or exercises) were conducted on an annual basis to test the effectiveness of the E.P.P. --- Review of the E.P.P. disaster drills on 04/08/25 with Staff A (Administrator) revealed the facility submitted the following training documents for consideration of the annual testing requirements:01/19/2022 Pandemic Surge tabletop exercise (TTX) and review with six management (participants) signatures.04/19/2023 Earthquake tabletop exercise (TTX)conducted by the State Emergency Management Office, with only one (participant) signature from the Emergency Preparedness Coordinator. There failed to be any After Action Review (AAR) in any form. 01/05/2024 Earthquake tabletop exercise. This TTX was the exact same presentation and single signature with the exception of the date being changed on the cover.02/17/25 Ice/snow/blizzard/power outage real event with two signatures, but no actual information or documented effects, changes to the E.P.P., or an after-action review. Interview on 04/08/25 with Staff A confirmed the available documentation.