Every finding on record at Beacon of Hope Hospice Inc

Upon patient record review, 2 of 14 (Patients #6 and 7) did not contain evidence that a Registered Nurse had been designated to ensure continuous assessment of the patient and family's needs: Patient #6: On the 03/27/24 home visit the nurse documented, "Wound/pressure ulcer left buttock. Nurse cleansed with Normal Saline, applied Zinc Oxide, and documented that this daily wound treatment should be provided by the ALF personnel". There was no mention of the Hospice nurse having followed-up, related to this wound, on the next sequential home visit on 03/30/24. That SN visit had documented, "Integument not assessed at this visit." Patient #7: An RN entered the following entry into the 04/18/24 IDG Meeting note, "At the 04/08/24 home visit the patient had a small scab to right great toe resultant of nail clipping." This patient has a diagnosis of Diabetes. On the next SN visit made on 04/16/24, the nurse did not address this area of skin concern. The documentation under the Integumentary section was limited to, "No problems noted or verbalized."

Upon patient record review, 2 of 14 (Patients #1 and 2) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs: Patient #1: During Surveyor-attended home visit on 04/23/24, it was noted that the patient had the following DME in the home: 1) Hospital bed; and 2) Bed-side table. These DME were not included on the POC. Patient #2: During Surveyor-attended home visit on 04/23/24, it was noted that the patient had the following DME in the home: 1) Hospital bed; 2) Bed-side table; and 3) Nebulizer. These DME were not included on the POC.

Upon patient record review, 1 of 14 (Patient #3) did not contain evidence that the revised Plan of Care included information from the patient's updated comprehensive assessment: Patient #3: This patient reports having had a colostomy since 11/2023. The most recent IDG POC includes, "Family members to complete colostomy care", without any details of this Physician-ordered colostomy care process/frequency, no problems, goals, and interventions for the colostomy.

Upon patient record review, 4 of 14 (Patients #1, 3, 6, and 8) did not contain evidence that the IDG had ensured that care and services were provided in accordance with the Plan of Care: Patient #1: The Spiritual Counselor was making home visits at a frequency of 2x per month. There was no IDG-ordered frequency on the 03/31/24 updated POC. Patient #3: The Hospice POC included a Chaplain visit frequency of 2x per month. There was only (1) Chaplain visit made the month of 02/2024. The Hospice POC effective 01/10/24 included an order for a Hospice nurse to, "prefill medication boxes every Wednesday." This was not provided/documented on the 04/03 or 04/10/24 nursing visits. Patient #6: On the 03/27/24 home visit the nurse documented, "Wound/pressure ulcer left buttock. Nurse cleansed with Normal Saline, applied Zinc Oxide". The nurse documented that this daily wound treatment should be provided per ALF personnel in the absence of the Hospice nurse. On the 04/05/24 and 04/10/24 visits the nurse documented that she had completed a wound dressing change. However, there were no details of such dressing change. Just "see POC." There were no wound orders on the POC to provide such wound care. Patient #8: A verbal order was obtained for the Chaplain to make an evaluation visit between 02/23 to 02/27/24. A Chaplain note was made on 02/28/24 that, "the patient is to be evaluated". There was no further documented evidence of this occurring.

Upon patient record review, 1 of 14 (Patient #6) did not contain evidence that the IDG documented the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement: Patient #6: The Hospice received a phone call from the SNF on 04/04/24 pm. that the patient had fallen. SNF staff had administered the patient Morphine, and had re-located patient into her bed. However, they stated that they had some concern as to whether the patient may have fractured a hip. The Hospice RN made a home visit, noting that the patient was asleep upon her arrival, but awakened easily. Patient denied hip pain but did complain of lower back pain. The Hospice nurse conducted a physical assessment of the patient's lower back and hips, which included discussion of further pain management. However, there was no documented evidence that the Hospice had notified the Medical Director of such patient event.

Upon patient record review, 1 of 14 (Patient #14) did not contain evidence that the Hospice had offered Bereavement counseling that included: • Making Bereavement services available to the family and other individuals in the Bereavement Plan of Care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the Bereavement Plan of Care • Ensuring that Bereavement services reflect the needs of the bereaved • Development of a Bereavement Plan of Care that notes the kind of bereavement services to be offered and the frequency of service delivery: Patient #14: Death on 11/08/2023. The Bereavement POC included, "Contact the bereaved within 14 days, to arrange for a phone call or visit within the first two months." The first documented contact made to the bereaved was not conducted until 01/05/2024.

Upon patient record review, 1 of 14 (Patient #3) did not contain evidence that the Hospice Aide had provided care/services only as: • Ordered by the Interdisciplinary Group • Included in the Plan of Care Patient #3: The Aide POC assigned the tasks of: 1) Denture care; and 2) Oral care every visit. These assigned tasks were not provided/documented on the 04/12, 04/16, and 04/19/24 Aide home visits.

Upon personnel record review, 1 of 12 (Personnel #8) did not contain evidence that a Registered Nurse had made an annual on-site visit, to the location where a patient was receiving care, in order to observe and assess each Aide while he/she is performing care. The supervising nurse must assess an Aide's ability to demonstrate initial and continued satisfactory performance in meeting specific outcome criteria that include all CMS-required content, as follows: Personnel #8: An RN made an annual on-site visit on 01/17/23 to a home where this Aide was providing care/service. The tool used by the RN did not include the evaluation of the Aide's: Compliance with infection control policies and practices.

Upon patient record review, 1 of 14 (Patient #12) did not contain evidence that the Hospice had forwarded a Transfer Summary, and a copy of the patient record if requested, to the receiving Hospice upon transferring this patient to the receiving Hospice provider: Patient #12: Transferred to a different Hospice provider on 01/11/24. There was not documented evidence of Beacon of Hope Hospice having forwarded a Transfer Summary to the receiving Hospice. It had only been sent to the SNF where the patient had been residing.

Upon patient record review, 1 of 14 (Patient #11) did not contain evidence that the Discharge Summary included all CMS-required content: Patient #11: Revoked on 03/26/2024. The DC Summary did not contain the following CMS-required content: • A summary of the patient's stay, including treatments, symptoms and pain management • The patient's current Plan of Care • The patient's latest Physician orders

Upon patient record review, 1 of 14 (Patient #1) did not contain evidence that the Hospice had provided the SNF with the following required documents/information: Patient #1: During surveyor-attended home visit on 04/23/24, it was noted that there was not documented evidence that the following required documents had been provided to the SNF: Physician Certification and Re-certification of the terminal illness.