Every finding on record at Beneficial Hospice and Palliative Care

Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities in a language and manner that the patient understands. During observation upon home visits, all 3 patients and caregivers spoke Vietnamese. There was no evidence the agency provided written Patient Rights and Responsibilities in Vietnamese.

Upon patient record review, 14 of 14 (Patients #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11,#12,#13,#14) did not have evidence of the appropriate documentation for release of confidential information.

Upon patient record review, 1 of 14 (Patient #6) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 6: The medication profile contained a lidocaine topical patch with no area defined for administration. Corrected on site.

Upon patient record review, 3 of 14 (Patients #3,#6,#7) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 3: The medical record contained nursing documentation upon admission identifying patient issues with dysphagia. There was no evidence of problems, goals, and interventions related to dysphagia included in the plan of care. Corrected on site. Patient 6: The medical record contained nursing documentation upon admission identifying the patient is a high risk for falls. There was no evidence of problems, goals, and interventions related to fall safety included in the plan of care. Patient 7: The medical record contained nursing documentation upon admission identifying patient issues with dysphagia. There was no evidence of problems, goals, and interventions related to dysphagia included in the plan of care. Corrected on site.

Upon patient record review, 1 of 14 (Patient #6) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 6: The medical record contained an order for lidocaine topical patches with no area defined for administration. Corrected on site.

Upon patient record review, 3 of 14 (Patients #1,#2,#4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patients 1,2: The medical record contained nursing documentation upon admission identifying patient use of a walker. There was no evidence of an order for the walker included in the plan of care. Patient 4: The medical record contained nursing documentation upon admission identifying patient use of a cane. There was no evidence of an order for the cane included in the plan of care.

Upon personnel record review, 1 of 13 (Personnel #6) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel 6: There was no evidence the required skills above were performed by an aide and observed by an RN during orientation.

Upon patient record review 2 of 14 (Patients #1,#6) 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 1: The medical record contained an ordered aide frequency of visits twice weekly. There was no evidence of a second visit the week of 6/1/25. Patient 6: The medical record contained an ordered aide frequency of visits twice weekly. There was no evidence of visits completed the week of 5/25/25. The record also contained aide documentation 6/4/25 with task of recording last bowel movement not completed by the aide. Late data entry of BM corrected on site.

Upon inpatient contract review, 1 of 4 (Vermont Care Center contract) did not have evidence that the hospice retains responsibility for ensuring that the training of personnel who will be providing the patient's care in the inpatient facility has been provided and that a description of the training and the names of those giving the training are documented.

Upon SNF/NF contract review, 1 of 4 (Vermont Care Center contract) did not have evidence of the manner in which the SNF/NF and the hospice are to communicate with each other and how each will document such communications to ensure that the needs of patients are addressed and met 24 hours a day.

Upon SNF/NF contract review, 1 of 4 (Vermont Care Center contract) did not have evidence that specifies the provision of hospice services in the facility, including: A provision that the SNF/NF or ICF/IID immediately notifies the hospice if: • A significant change in a patient's physical, mental, social or emotional status occurs • Clinical complications appear that suggest a need to alter the plan of care • When a need to transfer a patient from the SNF/NF or ICF/MR arises, and the hospice makes arrangements for, and remains responsible for, any necessary continuous care or inpatient care necessary related to the terminal illness and related conditions • A patient dies

Upon SNF/NF contract review, 1 of 4 (Vermont Care Center contract) did not have evidence of a provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.

Upon SNF/NF contract review, 1 of 4 (Vermont Care Center contract) did not have evidence that it is the hospice's responsibility to provide services at the same level and to the same extent as those services would be provided if the SNF/NF resident were in his or her own home.

Upon SNF/NF contract review, 1 of 4 (Vermont Care Center contract) did not have a provision that the hospice may use the SNF/NF nursing personnel where permitted by state law and as specified by the SNF/NF to assist in the administration of prescribed therapies included in the plan of care only to the extent that the hospice would routinely use the services of a hospice patient's family in implementing the plan of care.

Upon SNF/NF contract review, 1 of 4 (Vermont Care Center contract) did not have a delineation of the responsibilities of the hospice and the SNF/NF to provide bereavement services to SNF/NF personnel.

Upon observation, there was no evidence the organizational chart matches the hospice's information submitted to CMS and/or State licensing agencies for management personnel. The hospice did not have evidence they submitted the changes of administrator, DPCS, and MD to the state. They did have change of ownership, but the previous hospice leaders were still listed with the state.

Upon patient record review, 3 of 5 (Patient #1, 2, 3) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #1 There is no evidence in the patient record of a revised plan of care for the management of edema as documented on 3/25/22 or management of pain rated as 3/10 on 3/28/22, the pts threshold is rated as 0/10 according to the admission assessment. The POC was previously resolved prior to meeting the stated goals. Patient #2 There is no evidence in the patient record of a revised plan of care for the management of nutrition/appetite. The previously stated goals state that "the patient will consume 50% of her meals" and has been resolved/closed without updating the goals or interventions although the visit notes on 3/19/22 report that the patient consumes just 5-7 bites of food per meal and this remains an active issue and concern for her caregivers. Patient 3# There is no evidence in the patient record that the plan of care has been updated/revised to address cardiovascular issues including elevated blood pressure as documented on nursing visit dated 3/31/22, medication given during visit (amlodipine 5mg as prescribed.) The previous plan of care was resolved/closed although the symptoms and interventions have remained.