Every finding on record at Beacon Hospice of West Detroit LP

Observed in Record Review. In 1 of 10 patient records reviewed, it was noted that the organization did not ensure its policy titled Ongoing Comprehensive Assessment was implemented. For example, during a review of the initial comprehensive assessment for RRNHV#3, the clinician documented the patient was experiencing severe pain, an order for Morphine as needed was obtained and the medication administration documented. There was no documented evidence that an assessment of the patient's response to treatment of the identified pain symptoms was completed. This observation was reviewed with agency leadership.

Observed in Record Review. In 1 of 10 patient records reviewed, it was noted that the organization did not ensure the plan of care goals included outcome measures for specific care activities. For example, a review of the medical record for RRHV#2, revealed that the patient’s terminal illness diagnosis was Cerebral Atherosclerosis. The plan of care did not include a goal statement to evaluate the response, to care, treatment, and services related to Cerebral Atherosclerosis. This observation was reviewed with agency leadership.

Observed in Record Review. In 1 of 10 patient records reviewed, it was noted that the organization did not ensure the plan of care included interventions for specific care activities. For example, a review of the medical record for RRHV#2, revealed that the patient’s terminal illness diagnosis was Alzheimer’s disease. The plan of care did not include interventions related to Cerebral Atherosclerosis. This observation was reviewed with agency leadership.

Observed in Record Review. In 1 of 3 patient records reviewed, for patients receiving Hospice Aide services, it was noted that the organization did not ensure Hospice Aide visits were completed in accordance with the plan of care. For example, during a review of the medical record for RRNHV#1, the plan of care included an order for Hospice Aide visits 1 time per week. There was no documented evidence that Hospice Aide visits were completed during week 4 and week 5 of services. This observation was reviewed with agency leadership.

Observed in Record Review. In 1 of 3 patient records reviewed for bereavement services, it was noted that organization did not ensure its policy related to bereavement services was implemented. For example, a review of the medical record for RRDC#2, revealed that a bereavement plan of care that specifies the type of bereavement services to be offered and the frequency of service delivery was not completed. This observation was reviewed with agency leadership.

Observed in Competency Session. During a review of 1 of 1 Human Resource files for Hospice Aides, it was noted that an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she was performing care was not documented for the year 2023. This observation was reviewed with agency leadership.

Observed in Record Review. In 1 of 10 patient records reviewed, it was noted that the organization did not ensure its policy related to record authentication was implemented. For example, during a review of the medical record for RRHV#1, it was noted that the physician certification of illness statement signature line(s) for the Attending Physician and the Medical Director did not include a date. This observation was reviewed with the Administrator.