Every finding on record at Beta Caring Hands Hospice, Inc.

Upon patient record review 2 of 5 (Patient #1,3) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. #1,3-There is no evidence that the patient received a spiritual assessment as part of the comprehensive assessment.

Upon patient record review, 1 of 5 (Patient #1) 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 #1-The medication profile dated 09/01/25 includes an order for Caldesene Powder 15-81% topically, one application daily prn. There is no location for application or indicator included in the order.

Upon patient record review, 1 of 5 (Patient #1) 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. #1-The plan of care dated 09/01/25 includes an order for Caldesene Powder 15-81% topically, one application daily prn. There is no location for application or indicator included in the order. Wound care order for stage 2 open wound on right lower extremity: cleanse with normal saline solution, pat dry, apply Silvadene and cover with non-adherent dressing , wrap with Kerlex. Change daily and when soaked. The order does not indicate who will complete the wound care on non-nursing visit days.

Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient's clinical record in confidential manner as agency was unable to produce prior patient records from 2023.

Upon observation, the agency was unable to produce medical records from 2023.

Upon observation, there was no evidence the patient record, whether hard copy or in electronic form, is made readily available on request by an appropriate authority. The agency was unable to present medical records until the director of nursing arrived approximately 2 hours after the start of survey.

Upon patient record review, 1 of 5 (Patient #2) 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 #2 The patient medication profile is for Vitamin D 1.25mg 1 time weekly. The patient has on hand Vitamin D2 50,000 IU taken once a month.

Upon patient record review, 1 of 5 (Patient #2) 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 #2 The patients medication listed in the plan of care is for Vitamin D 1.25mg 1 time weekly, upon medication review during the home visit, the patient has Vitamin D2 50,000 IU taken once a month.