Every finding on record at Beta Hospice Care Inc

Upon observation, there was no evidence that the patient has the right: • To exercise his or her rights as a patient of the hospice • Have one's property and person treated with respect • To not be subjected to discrimination or reprisal for exercising his or her rights Patient #1,2,3, LVN did not have picture ID on her person during visits.

Upon patient record review, 4 of 14 (Patient #1,2,3,5) 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 #1,2,3,5, No MSW or SC care plan initiated.

Upon patient record review, 1 of 14 (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 equipment and supply needs. Patient #1, No DME on plan of care documented. Patient has walker.

Upon client record review, 7 of 14 (Patient #1,2,3,5,6,9,12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, SC eval completed on 5/13/23 stating patient declined any further visits. Next visit completed 8/9/23 without any orders for visit. MSW eval on 5/12/23 without any further orders for additional visits. Next visit completed 8/11/23 without orders. Patient #2, SC order 1/22/23 for visits 1x/month. Visits made 1/22/23, 2/23/23, 3/29/23, 5/25/23, 7/23/23. Missing visits for April, June and Aug. Patient #3, SC order for eval only, visits made 2/20/23, 4/18/23, 6/20/23, 8/16/23. MSW order for eval only, visits made 2/18/23, 4/20/23, 6/19/23, 8/17/23. Patient #5, SC eval states patient declined further visits. No order for additional visits. SC seen patient 4/30/23, 6/27/23, 8/26/23. SN frequency 2xweek, patient was not seen the second visit of the first week. SN visits 4/28/23, 5/2/23, 5/4/23, 5/9/23, 5/11/23, 5/16/23, 5/19/23. Patient #6, MSW eval only, patient seen on 5/8/23, 8/7/23, 9/1/23, 9/2/23 without additional orders for visits. SC eval only, patient seen on 5/9/23, 8/5/23 without additional order for visit. Patient #9, LVN frequency 1x/week, visits 8/21/23, 8/29/23, no visit completed first week. MSW frequency eval and every cert period, patient seen 8/21/23, 8/29/23. No order for additional visit. Patient #12, LVN frequency 2x/week, pt visited 1 x week on 8/5/23, 8/12/23, 8/19/23, 8/23/23, 8/27/23.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1,2,3, LVN broke infection control by going in and out of bag with gloves on hands. Patient #1 and 2 LVN did not place barrier between her bag and floor prior to setting her bag down. Patient #3, LVN hung bag on side rail of patients bed.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1, care plan instructed vital signs to be completed by aide without parameters noted to notify RN.