Every finding on record at Beacon of Hope Hospice of Illinois, Inc.

Upon patient record review, 2 of 19 (Patient #6, 8) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #6 - Medication profile did not contain Montelukast 10mg 1 tab daily for allergies but on ALF's medication profile. Patient #8 - Medication profile did not contain Seroquel 25mg 1/2 tablet in AM - but on SNF medication profile.

Upon patient record review, 1 of 19 (Patient #19) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #19 - SOC 11/09/23-no documentation of bereavement assessment until day 13.

Upon client record review, 1 of 19 (Patient #9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #9 - POC dated 05/11/24 - Order to change Foley catheter monthly on the 1st visit of the 2nd week" Foley catheter changed 05/31/24 - this was a scheduled visit.

Upon patient record review 6 of 19 (Patient #12,13,14,15,16,18) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #12 - Visit note 06/25/24 aide gave patient bed bath but shower is ordered on aide care plan. Patient #13 - Visit note 06/12/24 aide washed back and applied cream - applying cream is not on aide care plan. Patient #14 - Aide care plan - make bed and oral care every visit - on visit date 05/02/24 aide documented "not applicable". Patient #15 - Aide care plan - shampoo every visit, shower every visit and dress every visit - on visit date 05/17/24 aide documented "not applicable". Patient #16 - Aide care plan - shampoo every visit, make bed every visit and lotion every visit - on visit date 06/14/24 aide documented "not applicable". Patient 18 - Aide care plan - make bed every visit, shave every visit and change linen every visit - on visit date 06/03/24 aide documented "not applicable".

Upon patient record review 1 of 19 (Patient #13) did not have evidence in the patient record that the hospice aides report: • Changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities • Hospice aides must also complete appropriate records in compliance with the hospice's policies and procedures Patient #13 - Aide documented on visit 06/12/24 "increased back pain - like his skin is burning, back washed and cream applied" no documentation that the nurse was notified.

Upon client record review, 1 of 19 (Patient #1) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #1 - Patient discharge summary sent to the Hospice Medical Director and not the PCP.

Upon client record review, 1 of 19 (Patient #19) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #19 - POC dated 05/07/24 - no order for volunteer but patient was seen 1 x week x 5 beginning 05/07/24.