Every finding on record at Bethany Hospice, LLC

Upon patient record review, 2 of 5 (Patients #2,#4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 2: The medication profile contained duplicative instructions for administration of paroxetine. Patient 4: The medication profile contained duplicative acetaminophen instructions, and unclear morphine instructions with 0.5ml for mod pain and 1ml for pain or dyspnea.

Upon patient record review, 1 of 5 (Patients #3) 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 contains nursing documentation since admission identifying suspicions of C-diff diagnosis and ongoing testing and monitoring. There was no evidence of problems goals, and interventions related to the potential issue requiring contact precautions during investigation.

Upon patient record review, 1 of 5 (Patient #5) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 5: The medical record contained an order 2/5/26 for social work visit frequency of one PRN visit. There was no evidence of an anticipated need for social work visit frequencies.

Upon patient record review, 3 of 5 (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 medications and treatments. Patient 1: The medical record contained nursing documentation since admission identifying patient need for compression socks per physician orders. There was no evidence of an order for compression sock type and frequency of treatment needed in the plan of care. Corrected on site with order clarification received. Patient 2: The medical record contained duplicative orders for paroxetine. Patient 4: The medical record contained duplicative acetaminophen orders, and unclear morphine orders with 0.5ml for mod pain and 1ml for pain or dyspnea.

Upon patient record review 3 of 19 (Patient #5,8,12) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 5: No evidence that a spiritual assessment was completed within 5 days of admit. The patient was admitted on 10/08/25. The spiritual care assessment was completed on 10/20/2025, 12 days after admission. Patient 8: No evidence that a spiritual assessment was completed within 5 days of admit. The patient was admitted on 1/25/23. The record indicated that spiritual coordinator was declined at that time. The mini spiritual assessment was completed on 02/15/2023, 21 days after admission. Patient 12: No evidence that a spiritual assessment was completed within 5 days of admit. The patient was admitted on 03/01/2025. The record indicated that spiritual coordinator was declined at that time. The mini spiritual assessment was completed on 03/31/2025, 30 days after admission.

Upon patient record review, 3 of 19 (Patient #1,8,9) 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 1: During observation of home visit and medication reconciliation, the caregiver reported that the patient currently takes Benztropine 1mg 1-2 tabs daily, does not current take Dulcolax sup, and takes MiraLAX PRN daily instead of every day. Corrected on site. Active medication list updated during survey. Patient 8: Duplicate drug on active medication profile. 2 entries (7/4/23 &12/22/23) for Magnesium oxide 500mg 1 tab daily. Corrected on site. Active medication profile updated during survey. Patient 9: The medical record indicated that the patient has orders for oxygen 2-4 Liters PRN. No evidence that the active medication profile included a route for the oxygen. Corrected on site. Active medication profile updated during survey.

Upon patient record review, 1 of 19 (Patient #1) 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 1: The patient was admitted on 04/20/2021. There was no evidence of a bereavement risk assessment was completed within 5 days. Assessment completed on 06/18/2021.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 2 of 19 (Patient #6,7) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 6: The medical record indicated that the patient was admitted with a unstageable coccyx wound. No evidence that the patient's wound was measured weekly between 11/14/2025 and the time that the wound discontinued on 12/12/2025. Gentiva policy is for wounds to be measured weekly. Patient 7: The medical record indicated that the patient was admitted with stage 3 coccyx wound. No evidence that the patient's wound was measured weekly between 11/07/2025 and 11/21/2025, then again between 11/21/2025 and 12/05/2025. Gentiva policy is for wounds to be measured weekly.

Upon client record review, 6 of 19 (Patient #3,6,10,11,12,14) did not have evidence that the hospice follows the individualized plan of care developed in in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire. Patient 3: The medical record contained nursing documentation identifying patient fell on 12/16/25, 12/21/25, and 1/06/26. The occurrence reports indicated that the patient did not have injuries with either fall. There was no evidence of physician notification regarding either of the falls. The physician notified, time of notification, and physician response portion left blank on both occurrence reports. Patient 6: The medical record contained nursing documentation identifying patient had 2 fall one on 11/02/25 and another on 11/09/2025. The occurrence reports indicated that the patient did not have injuries with either fall. There was no evidence of physician notification regarding either of the falls. The physician notified, time of notification, and physician response portion left blank on both occurrence reports. Patient 10: The medical record contained nursing documentation identifying patient fall 10/09/25 and 11/18/2025. The occurrence reports indicated that the patient did not have injuries with either fall. There was no evidence of physician notification regarding either of the falls. The physician notified, time of notification, and physician response portion left blank on both occurrence reports. Patient 11: The medical record contained nursing documentation identifying patient fall 11/15/25. The occurrence report indicated that the patient did not have injuries. There was no evidence of physician notification regarding the fall. The physician notified, time of notification, and physician response portion left blank on the occurrence report. Patient 12: The medical record contained nursing documentation identifying patient fall 05/11/25. The occurrence report indicated that the patient had a small skin tear to left elbow that the family had covered with a bandage. There was no evidence of physician notification regarding the fall. The physician notified, time of notification, and physician response area left blank on the occurrence report. Patient 14: The medical record contained nursing documentation identifying patient fall 10/24/2025 and 12/21/25. The occurrence report for both falls indicated that the patient did not have injuries. There was no evidence of physician notification regarding either fall. The physician notified, time of notification, and physician response portion left blank on the occurrence report for both falls.

Upon patient record review, 3 of 19 (Patient #1,4,13) 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: The medical record indicated that the patient is at risk for aspiration and falls. The medical record also indicated that the patient is having increased shortness of breath, pitting edema, and has a history of heart failure. No evidence of problems, interventions, and goals related to swallow safety, fall safety, or cardiac on the current plan of care. Corrected on site. New orders written to update the plan of during survey. Patient 4: Pre-bereavement risk assessment was completed by the nurse at the time of admit (10/23/2025) and was scored as high. No evidence that a follow-up was completed or that anything was done to start supporting the caregiver. No evidence that the admitting nurse communicated the high pre-bereavement risk with the rest of the team. No evidence that the care plan was updated to reflect the caregivers needs. Patient 13: Pre-bereavement risk assessment was completed by the nurse at the time of admit (05/24/2025) and was scored as low. 5 days later the MSW completed another pre-bereavement risk assessment which was scored high. 5 days later the Chaplain completed a 3rd pre-bereavement risk assessment that also scored high. On 09/10/2025, a 4th pre-bereavement risk assessment was completed and scored moderate risk. No evidence that a follow-up was completed or that anything was done to start supporting the caregiver. No evidence that the care plan was updated to reflect the caregivers needs with either high or moderate risk assessment.

Upon patient record review, 2 of 19 (Patient #12,13) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 12: The initial visit frequency for both the social worker and the spiritual care counselor was 1 prn. Both disciplines corrected with follow-up orders. Pt refused routine visits from both disciplines. Patient 13: The initial visit frequency for both the social worker and the spiritual care counselor was 1 prn. Both disciplines corrected with follow-up routine orders. Orders previously written for the social worker and chaplain to see patient monthly.

Upon patient record review, 4 of 19 (Patient #1,5,8,9) 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 1: During observation of home visit and medication reconciliation, the caregiver reported that the patient currently takes Benztropine 1mg 1-2 tabs daily, does not currently take Dulcolax sup, and takes MiraLAX PRN daily instead of every day. No evidence that order was received for Benztropine, the Dulcolax sup to be stopped, or MiraLAX to be changed from daily to PRN daily. Corrected on site. New orders received from the medical director for medication changes. Patient 5: The RN documentation indicated that the patient used a BiPAP at night to sleep. No evidence that an order for the BiPAP or its settings was received at the time the chart was surveyed. Corrected on site. New orders received from the MD for the BiPAP. Patient 8: Duplicate drug on active medication profile. 2 entries (7/4/23 &12/22/23) for Magnesium oxide 500mg 1 tab daily. Corrected on site. Active medication profile updated during survey. Patient 9: The medical record indicated that the patient has orders for oxygen 2-4Liters PRN. No evidence that the active medication profile included a route. Corrected on site. Active medication profile updated during survey.

Upon patient record review, 1 of 19 (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. conditions, including equipment and supply needs. Patient 1: The medical record indicated that the patient developed a wound while on services that was discontinued. No evidence that the current supply list was updated to remove wound care supplies from the supply list. Corrected on site. Supply list updated during survey.

Upon patient record review, 3 of 19 (Patient #1,7,10) 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: The current plan of care has interventions for an external catheter. The administrator confirmed that the patient does not have an external catheter. Corrected on site. Plan of care updated during the survey. Patient 7: The current plan of care has interventions for spiritual care. The medical record indicated that the family declined any further visits from the chaplain on 12/09/25. No evidence that the plan of care updated to remove problems, goals, and interventions to spiritual care. Corrected on site. Plan of care updated during the survey. Patient 10: The current plan of care has interventions for spiritual care. The medical record indicated that the family declined any further visits from the chaplain on 11/30/2025. No evidence that the plan of care updated to remove problems, goals, and interventions to spiritual care. Corrected on site. Plan of care updated during the survey.

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: The medical record has orders for the volunteer to visit the patient once a month starting in December 2025. No evidence that a visit was made for the month of December. No evidence that this was done at the request of the patient/caregiver.

Upon patient record review 2 of 19 (Patient #4,13) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 4: Pre-bereavement risk assessment was completed by the nurse at the time of admit (10/23/2025) and was scored as high. No evidence that the nurse communicated the high pre-bereavement risk with the rest of the team. No evidence that the caregiver needs were addressed. Patient 13: Pre-bereavement risk assessment was completed by the nurse at the time of admit (05/24/2025) and was scored as low. 5 days later the MSW completed another pre-bereavement risk assessment which was scored high. 5 days later the Chaplain completed a 3rd pre-bereavement risk assessment that also scored high. On 09/10/2025, a 4th pre-bereavement risk assessment was completed and scored moderate risk. No evidence that the caregiver needs addressed or that full communication was provided with the IDG team.

Upon patient record review, 2 of 19 (Patient #18,19) did not have evidence the hospice offers bereavement counseling that includes: • 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 18: Assessment completed during the survey. Bereaved scored moderate on the initial bereavement assessment. No evidence that the bereavement care plan was updated to reflect caregiver needs. The medical record indicated that one attempt was made to follow-up with the bereaved on 02/24/2025. No evidence that any other attempts to reach the bereaved was made. Patient 19: Assessment completed during the survey. No evidence that the bereavement care plan was updated to reflect caregiver needs. The medical record indicated that one attempt was made to follow-up with the bereaved on 02/24/2025. No evidence that any other attempts to reach the bereaved was made.

Upon patient record review 1 of 19 (Patient #13) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. interdisciplinary group meet the patient's needs. Patient 13: No evidence that a registered nurse made a supervised visit every 14 days between 11/19/25-12/24/25 (30days). No evidence that a supervised has been completed since 12/24/2025, currently 16 days without a supervised visit.

Upon patient client record review, 1 of 19 (Patient #1) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 1: Nurse practitioner visits that occurred on 09/16/2025 and 11/11/2025 indicated that the patient has oxygen within the home but refused to use it for his dyspnea. Agency administrator confirmed that the patient does not use oxygen, does not have oxygen within the home and the verbiage was incorrect.

Upon client record review, 1 of 19 (Patient #7) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 7: The medical record indicated the patient was admitted with an indwelling Foley catheter. No evidence that an order was received that included catheter size, change frequency, and who would provide the care and management of the indwelling Foley catheter the hospice agency or the SNF.

Upon patient record review 2 of 13 (Patient #2, #12) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #2-The patient was admitted 11/21/22 and the spiritual assessment was not completed until 12/05/22. Patient #12- The patient was admitted on 11/22/22 and a spiritual assessment was not completed until 11/30/22.

Upon patient record review 2 of 13 (Patient #3, #13) 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. Patient #3- The patient was admitted on 12/01/22 and refused Chaplain and Social Worker. A spiritual assessment was not performed by the RN. A spiritual assessment is not on record. Patient #13- The patient was admitted 11/28/22 and declined Chaplain services. A Spiritual assessment was not performed by the Social Worker or RN.

Upon patient record review, 3 of 13 (Patient #1, #2, #3) 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: Patient #1- On 12/29/22 the nurse documents the patient received an Oxygen concentrator. The medication profile does not include Oxygen. (corrected on site) Patient #2- The medication profile lists 12/11/22 Morphine Concentrate 100mg/5ml .25 ml hourly for shortness of breath. The Morphine is listed to be administered hourly as a scheduled medication. The correct orders are for prn administration for shortness of breath. (corrected on site) Patient #3- The medication profile contains duplicative/unclear doses of Armour Thyroid. 10/26/21 Armour Thyroid 90 mg tab 1 po qd and 12/11/21 Armour Thyroid 15 mg 1 po qd. The medication profile also lists Fentanyl 100mcg/hr 1 patch q72h. Special instructions includes: Patches are 125mcg/hr which is not listed in the medication system. 125 mcg/hr is incorrect dosage as Fentanyl is not supplied as 125 mcg/hr. The medication profile includes duplicative doses of Morphine without differentiation for administration. The profile lists Morphine 15 mg immediate release tab 2 tabs q4h prn pain. The profile also lists Morphine Concentrate 100 mg/5ml .5-1ml hourly prn pain/SOB. (corrected on site)

Upon patient record review, 2 of 13 (Patient #1, #3) did not have evidence that a Registered Nurse ensured continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). Patient #1- On 12/11/22 Triage documents receiving a call from the patient's caregiver. The caregiver stated they went to the pharmacy and there was a hold on the patients Duragesic patches until the 14th. Triage documented the patients concerns would be forwarded to the RN on call for further handling. There is no documentation on record from the RN on call to address the medication concern. Patient #3- On 12/16/22 Triage documented the pharmacy called to clarify prescriptions. Morphine tablets had been sent in with two different quantities and the prescription for Fentanyl patches were sent in as 125mcg and Fentanyl is not supplied in that strength. Triage documented the medication profile and orders needed to be corrected and resent and the RN on call was notified to follow up with the medication concerns. On 12/16/22 the RN only documents the MD sent in the appropriate orders. The documentation does not state what the correct orders are and Fentanyl and/or Morphine was not corrected in the orders or the medication profile. There is also no documentation that the family was advised of any changes in medications. On 01/02/23 10:17 am triage also documented the patient called and stated he would be out of Morphine 15 mg at the next dose around 12 noon. Triage documented a call was dispatched to the RN on call to address the medication refill. There is no documentation from the RN on call to address the medication issue.

Upon patient record review, 5 of 13 (Patient #1, #2, #3, #6, #8 ) did not have evidence the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including complete/accurate orders for all medications and treatments. Patient #1- On 12/29/22 the nurse documents the patient received an Oxygen concentrator. The plan of care was not updated with Oxygen orders. (corrected on site) Patient #2- On 12/11/22 orders for Morphine Concentrate 100mg/5ml .25 ml were written to be administered hourly as a scheduled medication for shortness of breath. The correct orders to update the plan of care are for hourly administration prn for shortness of breath. The plan of care also includes Licensed professional to report vs outside of the following established parameters: Temp <0 (error). (corrected on site) Patient #3- The 12/01/22 plan of care contains duplicative/unclear doses of Armour Thyroid. 10/26/21 Armour Thyroid 90 mg tab 1 po qd and 12/11/21 Armour Thyroid 15 mg 1 po qd. The plan of care also lists Fentanyl 100mcg/hr 1 patch q72h. Special instructions includes: Patches are 125mcg/hr which is not listed in the medication system. 125 mcg/hr is an incorrect dosage as Fentanyl is not supplied as 125 mcg/hr. The plan of care also includes duplicative/unclear doses of Morphine. The plan of care includes Morphine 15 mg immediate release tab 2 tabs q4h prn pain. The plan of care also lists Morphine Concentrate 100 mg/5ml .5-1ml hourly prn pain/SOB. (corrected on site) Patient #6- On 12/06/22 orders were written to update the plan of care which read: Insert Foley catheter. The orders are not specific for the size/balloon size and management of the catheter. (corrected on site) Patient #8- The 10/21/22 plan of care includes orders for the nurse to teach the patient administration of insulin. The patient is not on insulin. (corrected on site)

Upon patient record review, 2 of 13 (Patient #3, #8) 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 #3-The IDG notes/revised plan of care 12/08/22 and 12/22/22 do not address the patients progress towards outcome/goals from the plan of care. The only nursing documentation is the patient has metastatic cancer and is not seeking treatment. There is no documentation regarding the patients response to treatments and effectiveness of pain management. Patient #8-The IDG/revised plans of care 10/27/22 to 12/26/22 do not include medical issues and changes in patient condition identified in nursing assessments and progress towards nursing goals. Each of the revisions do not contain problems identified and only document the patient needs more assistance with ADLs , no changes or concerns and the patient will continue to be monitored.

Upon patient record review, 1 of 13 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3- Orders are for the nurse to visit the patient weekly. The week of 12/25/22-12/31/22 a nursing visit is not on record. There is no documentation regarding a missed visit.

Upon personnel record review, 1 of 13 (Personnel # 2) did not have evidence the alternate administrator's personnel record includes: • A signed job description for this role and orientation to this role Personnel #2- The Alternate Administrator's file only contains a signed job description for an RN.

Upon patient record review, 1 of 13 (Patient #12) did not have evidence that the discharge summary includes all required information. Patient #12-The patient revoked the hospice election on 01/02/23. The discharge summary on record does not include a summary of the patient's stay, including treatments, symptoms and pain management.