Every finding on record at Beacon Hospice of Michigan LP

Observed in Record Review. In 1 of 2 patient records reviewed, it was noted by the nurse surveyor that the patient/patient’s representative was not issued a Notice of Medicare Non-coverage (NOMNC) at least two days prior to of discharge as required. For RRDC#2, the signed NONMC was not a part of the medical record nor could it be located during record review. Documentation in the Electronic Medical Record stated that discharge paperwork had been signed. Finding was verified and discussed with the Administrator/Director of Nursing.

Observed in Record Review. In 3 of 14 patient records reviewed, it was noted by the nurse surveyor that for RRHV#2, the RN did not visit the hospice patient no less than 15 days to conduct an assessment. The RN visits were 21 days between assessments. For RRNHV#1, the patient had a missed RN visit which resulted in 16 days between RN assessments. For RRNHV#2, RN visits were 18 days apart. An LPN had been seeing all three patients. Findings were verified by the Administrator/Director of Nurses. Observed in Record Review. In 14 of 14 patient records reviewed, for active patients, it was noted by the nurse surveyor that for all records reviewed, the interdisciplinary group meeting notes did not consistently document decline, revisions to plans of care and goals of care. The notes consisted of cutting and pasting from staff visit notes with no documented progress toward goals Findings were discussed with the Administrator/Director of Nursing.

Observed in Record Review. In 1 of 14 patient records reviewed, for active patients, it was noted by the nurse surveyor that orders were not clear or complete. For RRNHV#1 the medication orders were unclear. The patient had Hydrocodone 5mg/Acetaminophen 325mg 1/1 tablet by mouth every four hours as needed for pain ordered. Additionally, the patient had Methocarbamol 500mg 1/1 tablet every six hours by mouth as needed for pain. There were no specific instructions on which medication to take first. Finding was discussed with the Administrator/Hospice Director.

Observed in HR File Review. In 1 of 8 HR files reviewed, it was noted by the nurse surveyor that for RRHR#3, the Nurse Practitioner did not have a competency completed since her hire over two years ago. Organization policy is to complete competencies yearly. This was verified by the Administrator/Director of Nursing.

Observed in Record Review. In 5 of 14 patient records reviewed, for active patients, it was noted by the nurse surveyor that hospice aide supervisory visits were not documented no less frequently than every fourteen days. For RRHV#1, hospice aide supervisory visits were completed one day late last month (fifteen days apart) and two days late (sixteen days apart) this month. For RRHV#2, hospice aide supervisory visits were completed seven days late (twenty one days apart). For RRHV#3, hospice aide supervisory visits were completed five days late last month (nineteen days apart). For RRNHV#1, hospice aide supervisory visits were three days late last month (seventeen days apart). For RRNHV#2, hospice aide supervisory visits were three days late (seventeen days between supervisory visits). Findings were verified with the Administrator/Director of Nursing.

Observed in Tracer Activities. It was noted by the nurse surveyor that volunteers did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff for 2024 and all but two months of 2025. For 2024, the percentage of Volunteer of hours was 0.54%. For 2025, the percentage of volunteer hours was under 3.00% until July and August which were strong months. For the month of September of 2025, it was 0.00%. Findings were verified by the part-time shared Volunteer Coordinator and the Administrator/DON.

Observed in Record Review. It was noted by the nurse surveyor that Leadership failed to draft and approve a functional policy that provided clear direction to medical staff regarding their expectations for the documentation of CTI (Certification of Terminal Illness) and to nursing staff related to the registered nurse reassessing patients no less than every fifteen days, as evidenced by record review and that the following Condition of Participations were not met: §418.102, and §418.54.

Observed in Record Review. In 14 of 14 patient records reviewed, for active patients, it was noted by the nurse surveyor that the physician’s certificate of terminal illness (CTI) did not contain the required narrative. The CTI consisted of cutting the narratives out of the nurse’s notes along with some patient physical findings that did not demonstrate that the patient was hospice appropriate. Findings were validated by the Nurse Administrator/Director of Nursing and discussed with the Medical Director.

Observed in Record Review. In 2 of 2 patient records reviewed, for active records on patients who had been recertified, it was noted by the nurse surveyor that for RRHV#1 (9 recertifications) and RRHV#2 (9 recertifications), the physician’s certificate of terminal illness (CTI) for recertification did not contain the required narrative. The CTI consisted of cutting the narratives out of the nurse’s notes along with some patient physical findings that did not demonstrate that the patient was hospice appropriate. Findings were validated by the Nurse Administrator/Director of Nursing and discussed

Observed in Record Review. In 2 of 6 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 RRNHV#4 the medication profile included an order for sliding scale insulin yet the order was incomplete as it did not specify a frequency the sliding scale was to be used. There were no orders for blood glucose monitoring to be used along with the sliding scale insulin, nor was the patient's diabetes reflected on the plan of care. In RRNHV#6 there were duplicate active orders for Morphine. One order was for Morphine 100mg/5ml (20mg/ml) Give 0.5 ml by mouth every 4 hours as needed for pain/SOB, and another read Morphine 20mg/ml take 5 mg every 3 hours as needed 0.25 ml PO/SL Q3 hrs prn pain. There was an Ativan order that was incomplete that read Ativan 1mg tab, take 1 tablet Q4 as needed for. The order had no indication, and did not specify a frequency beyond Q4 such as minutes, hours, or days. Further, there was documentation that the patient had a wound with treatment, yet there was no wound care order noted on record or included in the plan of care. These observations were reviewed with the Administrator and Regional Director.

Observed in Record Review. In 1 of 1 patient records reviewed, the were discharged for extended prognosis, the organization presented the Notice of Medicare Non-Coverage but failed to complete the task within the required time frame as the form on record was signed the day of discharge and not 2 days prior to discharge as required. This observation was reviewed with the Regional Director.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure the comprehensive assessment was completed no later than five calendar days after the election of hospice care. On review of RRHV#3 there was no documentation of the MSW initial psychosocial assessment noted on the record until Mid February several weeks after the patient's hospice election date. This observation was reviewed with the Administrator who noted the assessment was done on paper yet the assessment presented on paper had a date of Mid February.

Observed in Record Review. In 7 of 10 patient records reviewed, the organization failed to ensure the plan of care goals were specific, measurable, realistic, and time-bound. Throughout the patient records reviewed with care plan goals were noted to not be specific, measurable, realistic, and time-bound. For example: in RRHV#1 and example was . Patient maintains highest level of mobility possible. An example in RRHV#3 was continuity of care will be maintained as appropriate to patient/primary caregiver needs. In RRNHV#4 examples were Anxiety/agitation controlled through course of care and patient will be able to demonstrate improved safety awareness as evidenced by:(___). In RRNHV#5 a goal was Decreased s/s exacerbations with medication regimen through certification period. Start Date- 12/19/2023 Target Date - 06/21/2024. Throughout RRNHV#7 there were goals that were non-specific with target dates that were not realistic such as Patient/caregiver verbalize understanding and adhere to measures to maintain adequate nutrition/hydration. Start Date- 12/11/2023 Target Date - 06/22/2024 4. Patient will maintain optimum bowel functioning consistent with food intake and stage of disease process Start Date- 12/11/2023 Target Date - 06/22/2024 and Patient/caregiver verbalize/demonstrate proper wound care/dressing procedures Start Date- 12/11/2023 Target Date - 06/22/2024. Similar goals were noted in RRNHV#8 such as Patient/caregiver will demonstrate understanding of appropriate use of medications for pain and symptom management Start Date: 9/28/2023; Target Date: 6/7/2024. The goal target date to demonstrate use of pain medication was noted to span 9 months. In RRNHV#9 an example was patient nutritional needs will be met as patient condition comfort allows These observations were reviewed with the Administrator and Regional Director.

Observed in Record Review. In 7 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#1 the plan of care included interventions for risk for impaired nutrition and documentation of declining appetite with weight/MAC loss yet there was no goal established for nutrition. There was documentation of a yeast rash in skin folds with medications added for treatment yet there was no integumentary care plan to guide the care. On review of RRHV#2 there were interventions for fall safety and wound care but no goals. There was documentation of a peg tube with feedings but no care plan to reflect the issues. In RRHV#3 the care plan included interventions for pain, impaired mobility, swallowing, skin integrity and respiratory yet no goals established. There were orders for an ultrasound to the neck yet the care was not reflected on the care plan. In RRNHV#4 there were changes in the pain medication regimen but the changes were not reflected in the care plan. There was documentation of a skin tear but no care plan to guide the treatment. In RRNHV#5 there was documentation on a stage 1 wound to the buttocks, but the issue was not reflected in the care plan. In RRNHV#7 the patient had a colostomy yet the gastrointestinal care plan did not reflect its presence. In RRNHV#8 the documentation noted the patient to have nephrostomy tubes and a colostomy yet there were no care plans to guide their care. These observations were reviewed with the Administrator.

Observed in Record Review. In 5 of 10 patient records reviewed, the organization failed to assess potential medication-related problems, including duplicate drug therapy. In review of RRHV#2 there were 2 active orders for oxygen, one for 3 lts continuous and another for 5 lts continuous. On review of RRHV#3 the medication profile noted duplicate orders for Lorazepam as one order was started on admission in January for Lorazepam 0.5 mg oral tablet. Take one tablet PO every 4 hours PRN for anxiety. An additional order started day of survey of Ativan 0.5 mg Q4 as needed for anxiety/agitation. In RRNHV#7 there were duplicate orders for pain medications: an order for MS Contin 30 mg tab extended release - give 1 tab by mouth every 12 hours. There was another MS Contin order that noted the same dosage but instead of every 12 hours it specified a frequency of 2 times a day. There were 4 active Morphine orders, 2 active Hydrocodone orders, and 2 active orders for Lorazepam. In RRNHV#8 there were also duplicate medication orders. There were 3 active Lorazepam orders; one order was for 0.5 mg 1 and 1/2 tab 3 times a day at 10, 2, and 6. Another was for Lorazepam 0.5 mg at 10 pm. The 3rd Lorazepam order was for 1 mg 1 tab every 6 hours. Further, there were 2 active orders for Ativan. There were 2 Morphine orders one stated Morphine concentrate 100mg/5ml (20mg/ml) by mouth/under tongue every hour when needed for pain/SOB, another active Morphine order noted to give the same dosage every 3 hours as needed. Multiple active orders for Morphine, and Ativan/Lorazepam were also noted in RRNHV#10. These observations were reviewed with the Administrator. Observed in Record Review. In 5 of 10 patient records reviewed, the organization failed to ensure the plan of care include all medications and treatment necessary to meet the patient's needs. For example: on review of RRHV#2 there was documentation of a heel wound yet no orders noted on the record for wound care. In RRNHV#4 there was documentation of skin tears yet no physicians orders to treat the skin tears. In RRNHV#5 there was documentation of a stage 1 wound to the buttocks yet no treatment orders. In RRNHV#6 there was an order for tube feeding that was noted to be incomplete reading tube feeding with Nephro supplement 10ml/hr start 4 pm - 8 am there were no further specifics such as flushes, check residual, or tube site care. Most meds were also ordered to be given PO but the patient was ordered pleasure feeds only. In RRNHV#8 the wound care order was incomplete as it stated cleanse with saline, pat dry, apply A&D ointment, ABD pad and tape There was no frequency the care was to be performed or who was to perform the care. These observations were reviewed with the Administrator.

Observed in Record Review. In 6 of 10 patient records reviewed, the organization failed to ensure care and services were provided in accordance with the plan of care. For example: on review of RRHV#3 the MSW was ordered a frequency of 1 time a month however documentation and conversation with the social worker noted the visit were being made 2 times a month. In RRHV#4 the social worker was also ordered 1 time a month yet documented visits 2 times a month in April and May. Further, review of RRNHV#4 the RN documented providing wound yet there were no wound care orders included on the plan of care. In RRNHV#5, and RRNHV#9 the Chaplain was ordered 1 time a month yet documented 2 time a month visits. Further, the aide was ordered a frequency of 5 times a week yet in May there was a gap of 8 missed visits. On discussion with the Administrator it was explained that the aide was out and the facility did not want a replacement aide for the time the aide was out yet this was not reflected in the plan of care. In RRNHV#7 the MSW was ordered 1 time a month but documented 2 visits in April, and the Chaplain was ordered 1 time a month and documented 3 visits in April. There were also examples of the Aide and Chaplain not meeting the established plan of care frequency noted in RRNHV#10. These observations were reviewed with the administrator.

Observed in Record Review. In 1 of 1 HR files reviewed, the organization failed to ensure that the required elements for the aide competency evaluation was evaluated by observing an aide's performance of the task with a patient or a pseudo-patient for the required elements of Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other staff - Reading and recording temperature, pulse, and respirations - Appropriate and safe techniques in personal hygiene and grooming that include bed, sponge, tub, or shower bath; sink, tub, or bed shampoo; nail and skin care; oral hygiene; toileting and elimination - Safe transfer techniques and ambulation - Normal range of motion and positioning. On review of HR#4 for the Hospice Aide the initial competency was documented as being evaluated verbally and not per observation. This observation was reviewed with the Regional Director.

Observed in Record Review. In 4 of 9 patient records reviewed, with aide services elected, the organization failed to ensure the RN provide written patient care instructions for the hospice aide. On review of RRHV#2 the patient have a peg tube and a wound to the heel yet the aide plan of care did not include instructions on how to handle the tube of wound while providing care. On review of RRNHV#4 the aide plan of care specified a tub bath and a bed bath yet no specific instructions on when to give which bath. In RRNHV#7 the patient had a foley catheter and a colostomy yet no instructions for the aide to know how to handle while providing care. In RRNHV#8 the patient had nephrostomy tubes and a colostomy yet there was no reflection of their presence with instructions for handling during care on the Aide's care plan. These observations were reviewed with the Administrator.

Observed in HR File Review. In 1 of 1 HR files reviewed, the organization failed to document the Registered Nurse make an annual on-site visit to the location where the patient is receiving care in order to observe and assess the aide while the aide is providing care. On review of HR#4 for the Hospice aide there was documentation of annual competency for aide skills that were evaluated verbally, yet there was no documentation that the aide was observed while performing care. This observation was reviewed with the Regional Director.

Observed in Tracer Activities. Upon review of all tracer activities, it was noted that there was a pattern of staff failing to follow established organization policy and the governing body/leadership did not ensure that the Conditions of Participation for 418.100, and 418.56, were met per policy as determined through observations, documentation, and staff interviews.

Observed in Competency Session. In 2 of 5 contracts reviewed, the organization failed to ensure the contract agreement with an outside agency providing services contain all of the required elements. On review of the Nursing Facility and Therapy contact there was no stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This observation was reviewed with the Regional Director.

Observed in Emergency Management Session. The organization did not ensure Staff was provided emergency management training at required intervals. For example, the surveyor noted there was no documentation of emergency management training for the staff in the last two years. Standards require the organization to provide emergency preparedness training to staff, volunteers, and individuals providing on-site services under arrangement at least every two years. These findings were reviewed, discussed, and validated by the RDO.

Observed in Record Review. In 6 of 8 patient records reviewed, The organization did not ensure patient care plan goals were individualized, measurable and realistic. The surveyor noted the following documented on HV #1/HV #1, “Patient/caregiver will demonstrate necessary behaviors to maintain good safety awareness and minimize the risk of falls and/or injury Start Date- 10/11/2022 Target Date - 10/20/2022”, HV #2/RR #2, “Patient will have information necessary for decision making; Target Date: 10/31/2022”, HV #3/RR #3, Complete wound healing without complication, Patient/caregiver will demonstrate necessary behaviors to maintain good safety awareness and minimize the risk of falls and/or injury”, RR #5 “Decreasing fatigue as evidenced by patient reporting of increased energy and endurance and by participation in paced activities”, RR #8, “Patient will be free of preventable complications; Target Date: 5/26/2022”, and RR #6, there no care plan problem, interventions or goals included in the patient’s plan of care orders. These stated goals do not contain information that can be accurately measured to assist staff in determining whether the patient is progressing towards achieving their goals. These findings were reviewed, discussed, and validated with the Administrator and RDO.

Observed in Record Review. The organization did not ensure the interdisciplinary group discussed/revised the patient’s plan of care at required intervals. For example, the surveyor noted in RR #7 there was no documentation of an interdisciplinary group collaboration from the admission date of 03/28/2022, until 06/10/2022. Additionally, there was no meeting documented for the month of August 2022. Standards require the interdisciplinary group, in collaboration with the attending physician, review and revise the patient’s plan of care at least every fifteen calendar days. These findings were reviewed, discussed and validated with the RDO.

Observed in Regulatory Review. The organization failed to ensure there was 24-hour service availability during afterhours. For example, the surveyor noted on 10/25/2022, between 8:00a.m. and 9:00a.m., there was no answer to a call that was placed to the phone number the organization had listed for 24-hour services, nor was there the ability to leave a message. Standards require the hospice organization to make covered services available 24 hours a day, to meet the patients/family needs. The findings were discussed and acknowledged by the CNO, RDO and Administrator. The CNO reported measures were currently being taken to rectify the issue.

Observed in Record Review. In 6 of 8 patient records reviewed, The organization did not ensure the initial certification of terminal illness (CTI) was present in the patient’s record or signed by the hospice physician. For example, the surveyor noted on HV #1/RR #1, RR #4 and RR #6, the initial CTI was not signed, HV #2/RR #2 and HV #2/RR #3, the CTI was not present, and on RR #7, it was not signed until 08/31/2022, although the patient was admitted to hospice on 08/31/2022. Standards require a written initial certification statement of terminal illness be signed by the hospice physician and be present in the patient record. These findings were reviewed, discussed, and confirmed with the RDO.

Observed in Record Review. The organization failed to ensure a completed discharge summary was submitted for the patient. For example, the surveyor noted on RR #8, the discharge summary form was present in the patient’s record, however, the form was not completed, in that it did not contain a narrative or any information regarding the patient’s hospice stay and the events leading up to discharge. Regulations require a completed discharge summary be sent to the health care professionals who will be providing care to the patient. These findings were reviewed, discussed, and validated with the Administrator and RDO.

Observed in Patient Home. The organization did not take actions to ensure safe storage of the patient’s oxygen cylinders. For example, on HV #2/RR #2, the surveyor observed the patient’s oxygen cylinder laying down, behind a recliner chair, not secured in a holder/rack. The RN, Regional Director of Operations, present at the visit, contacted the equipment company, who was to deliver immediately an oxygen cylinder holder. Standards require the organization take actions to identify and minimize risks to patient safety. These findings were observed and discussed with the organization’s Administrator and RDO.