Every finding on record at Beyond Hospice

It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 26 (4%) clinical records reviewed, it was revealed that the agency did not ensure that all interventions for problems identified in the initial and updated comprehensive assessments were included in the plan of care. CLINICAL RECORD 9: The hospice election of benefit (EOVB) was 04/15/2026 with a primary diagnosis of Anal Cancer. The plan of care (POC) was dated 04/15/2026 - 07/13/2026. The history and physical stated that the patient had considered a colostomy to manage the fecal incontinence but was not a surgical candidate due to the cardiovascular status. The patient reported daily leakage from the rectum and needed to wear pads, stating she had not been using stool softeners related the leakage and fear of making it worse as documented on the nursing visit dated 04/15/2026. She also noted that she had a port in the right chest that was flushed 04/10/2026 but would require monthly flushing. There were no documented problems or interventions for the problems of incontinence and port management on the POC dated 04/15/2026 - 07/13/2026. During interview with the administrator and clinical director on 04/30/2026, who reviewed the record, it was stated that all the interventions were not documented.

It is required that each patient’s individualized written plan of care: Includes all services necessary for the palliation and management of the terminal illness, including the following: Measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 5 of 23 (22%) clinical records reviewed, the agency did not ensure that all outcomes included in the plan of care were measurable. CLINICAL RECORD 5: The hospice election of benefit (EOB) was 03/23/2026 for a primary diagnosis of Parkinson's. The goal dated 03/23/2026 for DME Management and supplies documented "Safe use of medical equipment" this was not measurable. The patient had a hospital bed, mattress, wheelchair, and a Hoyer Lift were all equipment that the patient had. The goal was not specific to "safe" for this equipment. A Problem Falls/Safety goal dated 03/23/2026, read in part, "minimize unavoidable dementia-induced fall risks for nursing facility residents "minimize was not measurable." CLINICAL RECORD 7: The hospice election of benefit (EOB) was 02/16/2026 for a primary diagnosis of rectal cancer. The problem dated 02/16/2026 documented "Patient quality of life will be at an optimal level. "optimal" was not measurable. CLINICAL RECORD 11: The hospice election of benefit (EOB) was 01/14/2026 for a primary diagnosis of Lung Cancer. A pain goal was documented 01/14/2026 read in part, "patients' quality of life will be at an optimal level." "optimal" was not measurable. Also, a problem for pain documented the goal "patient will report that pain is reduced to the level personally desired: -_____ on a scale of 1-10, the desired amount was blank as of review 04/29/2026. Nursing note clinical documentation described tolerable pain verbalized by patient was a 3 and that was a patient preferred score. CLINICAL RECORD 14: The hospice election of benefit (EOB) was 03/08/2026 for a primary diagnosis of Alzheimer's. A problem of pain documented first on 03/08/2026 with updated interventions every 2 weeks, the goal was documented as "Patient will report that pain is reduced to the level personally desired: _____ on a scale of 1-10. (the desire was blank). Also, Patient quality of life will be at an optimal level, "no definition of optimal" as of review 04/29/2026. CLINICAL RECORD 19: The hospice election of benefit (EOB) was 03/28/2026 with a primary diagnosis of chronic kidney disease and congestive heart failure. A problem for pain was documented first on 03/28/2026 with goal documented for pain as "Patient will report that pain is reduced to the level personally desired: ____ on a scale of 1-10". (the desired amount was blank) "Patients quality of life will be at an optimal level" Optimal was not defined as of 04/30/2026. During interview on 04/30/2026 with the administrator (Personnel Record 12) and clinical director (Personnel Record 13) who stated that they will be doing follow up as the goals were not measurable.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 23 (4%) clinical records reviewed, in which a hospice aide services were provided, it was revealed that the agency did not ensure that the registered nurse prepared a hospice aide plan of care that contained clear and specific instructions for the patient's required care. CLINICAL RECORD 12: The hospice aide plan of care was documented on 01/04/2026 with an assigned task of bad bath 2 times a week. The aide documented on 01/07/2026, 01/09/2026, 01/14/2026, 02/11/2026, -2/16/2026 , 02/18/2026, 03/09/2026, 02/25/2026, 04/08/2026, and 04/15/2026, no bath as the patient only wanted a bed bath or shower on Fridays. The aide plan of care was not updated for this as of 04/29/2026. The aide visits were 2 times a week. The aide did document notifying the nurse of the patient request for bathing only once a week. During interview of the administrator and clinical director on 04/29/2026 who reviewed the record stated that the aide plan should have been updated.

It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group; Included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 23 (4%) clinical records reviewed, in which a hospice aide provided care, the agency did not ensure that the hospice aide provided services as ordered by the Interdisciplinary Group (IDG). CLINICAL RECORD 15: The hospice aide care plan assigned task on 01/22/2026 and updated 02/27/2026 included the task of shower weekly. The ordered aide frequency was one (1) time a week. On the aide visit notes dated 02/04/2026, the aide documented that a bed bath was provided instead of a shower and again on 03/25/2026 a bed bath instead of a shower, there was no documented evidence that the nurse was notified. During interview on 04/29/2026 with the administrator and clinical director who reviewed the record and stated that the hospice aide did not document to the ordered plan of care.

It is required that the hospice inpatient facility provides meals to each patient that are obtained, stored, prepared, distributed, and served under sanitary conditions. This standard was not met as evidenced by interview and observation. A tour of the agency's inpatient unit (IPU) revealed that the agency did not ensure that the food that was made available for patient use was not expired. IPU TOUR: During a tour of the agency's IPU on 04/29/2026, the following items were found in a beverage preparation area for beverages that were made available to patients and families: Lipton Iced Tea Lemon instant mix, 47.2 oz container partially full, with an expiration date of 11/27/2025; Folgers Classic Decaf instant coffee crystals packets, box of 6 unopened, with an expiration date of 10/31/2021; Ferrara instant expresso coffee, 2 oz jar partially full, with an expiration date of 12/18/2022; Folgers coffee singles coffee bags, box of 19 unopened, with an expiration date of 01/04/2014; Archer Farms coconut macaroon coffee, 12 oz bag partially full, with an expiration date of 09/02/2020; and Lipton iced tea bags, box of 24 bags partially full, with an expiration date of 06/14/2018. During an interview on 04/29/2026, the agency's IPU Household Coordinator, who was present for the IPU tour, confirmed that the listed items were expired and had been available for patient use. A tour of the agency's inpatient unit (IPU) revealed that the agency did not ensure that food that was made available for patient use was not expired.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, home visit observation, document review and interview. In 2 of 17 (12%) clinical records reviewed, the organization did not ensure the patient’s medication profile was up to date and a medication review was completed with all medications ordered for the patient. Agency policy 2-005, “Identification of Medication for Administration (revision date 2022),” stated in part, "The hospice nurse’s responsibility will include knowledge of the medication to be administered, medication indications, normal dosage range, dilution, route and rate of delivery, precautions, side effects, expected therapeutic effect, proper antidote, and incompatibilities, as applicable.” Clinical Record 2/Home Visit 1: The patient elected hospice benefit on 05/23/23. During the home visit observation on 06/21/23, the patient was observed infusing FOLFIRINOX [a palliative chemotherapy regimen] per a port-a-catheter in the right chest. Review of the patient's medication profile revealed it did not include FOLFIRINOX. The nurse [personnel record 7] stated this was the third treatment since electing hospice and agreed the medication was not listed on the medication profile nor reviewed for potential interactions. Clinical Record 3/Home Visit 2: The patient elected hospice benefit on 05/27/23. The nursing visit note dated 06/14/23 documented the patient had increased lower extremity swelling with 3 to 4 plus edema and the physician ordered Lasix [diuretic] 40mg orally for 3 days as a new medication. During the home visit observation on 06/21/23, the nurse confirmed the patient had taken the Lasix with reduction in lower extremity swelling. Review of the clinical record on 06/22/23 revealed Lasix had not been added to the patient’s medication profile and a medication review had not been completed that included Lasix. During an interview on 06/22/23, the Clinical Manager stated the medications had not been added to the patients’ medication profiles and a medication review that included these medications had not been completed for these patients.

It is required that each patient’s individualized written plan of care: Reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 3 or 17 (18%) clinical records reviewed, the organization did not ensure each patient's plan of care (POC) included goals and interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 5: The patient elected the hospice benefit on 06/01/23. The chaplain documented an initial assessment dated 06/02/23. Review of the clinical record on 06/22/23 revealed the chaplain had a planned frequency of two times per month, but the plan of care did not include goals and interventions related to the spiritual assessment. Clinical Record 9: The patient elected the hospice benefit on 05/19/23. The chaplain documented an initial assessment dated 05/23/23. Review of the clinical record revealed the chaplain had a planned frequency of two times per month, but the plan of care did not include goals and interventions related to the spiritual assessment as of the patient’s death on 06/13/23. Clinical Record 17: The patient elected the hospice benefit on 05/20/23. The initial psychosocial and spiritual assessments were dated 05/23/23 and included planned frequencies of two times per month for each discipline. Review of the clinical record revealed the plan of care did not document goals or interventions related to the initial psychosocial and spiritual assessments as of the patient’s death on 05/30/23. During an interview on 06/22/23, the Clinical Manager stated the chaplain had been contacted as it was unclear how the interventions and goals were not documented. The chaplain typically documented all interventions and goals, but the software had only been in use a couple of weeks.

It is required that each patient’s individualized written plan of care, includes all services necessary for the palliation and management of the terminal illness, including a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review, document review and interview. In 9 of 12 (75%) clinical records reviewed with an updated plan of care, the agency did not ensure the patient's individualized plan of care (POC) clearly documented the frequency of visits for each discipline. Agency policy 9-017, "The Plan of Care (revision date November 2022)," stated in part, "The plan of care will identify the patient/family needs and services to meet those needs including the management of pain and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient/family/caregivers needs. The plan of care will include a detailed statement of scope and frequency of care support." Clinical Record 1: The patient elected the hospice benefit 05/15/23. The updated POCs dated 05/25/2023, 06/08/23, and 06/22/23 documented frequency for skilled nurse 2, social worker 2, chaplain 2, and hospice aide 2 with no defined weekly or monthly visit frequency. Clinical record review revealed the skilled nurse and hospice aide provided visits weekly and the chaplain and social worker provided visits monthly. The updated POCs did not document each discipline’s frequency of visits clearly. Clinical Record 2: The patient elected the hospice benefit 05/23/23. The updated POCs dated 05/25/2023, 06/08/23, and 06/22/23 documented frequency for skilled nurse 2, social worker 2, chaplain 2, and hospice aide 2 with no defined weekly or monthly visit frequency. Clinical record review revealed the skilled nurse and hospice aide provided visits weekly and the chaplain and social worker provided visits monthly. The updated POCs did not document each discipline’s frequency of visits clearly. Clinical Record 3: The patient elected the hospice benefit 05/27/23. The updated POCs dated 06/08/23 and 06/22/23 documented frequency for skilled nurse 2, social worker 2, chaplain 2, and hospice aide 2 with no defined weekly or monthly visit frequency. Clinical record review revealed the skilled nurse and hospice aide provided visits weekly and the chaplain and social worker provided visits monthly. The updated POCs did not document each discipline’s frequency of visits clearly. Clinical Record 5: The patient elected the hospice benefit 06/01/23. The updated POCs dated 06/08/23 and 06/22/23 documented frequency for skilled nurse 2, social worker 2, chaplain 2, and hospice aide 2 with no defined weekly or monthly visit frequency. Clinical record review revealed the skilled nurse and hospice aide provided visits weekly and the chaplain and social worker provided visits monthly. The updated POCs did not document each discipline’s frequency of visits clearly. Clinical Record 7: The patient elected the hospice benefit 05/19/23. The updated POCs dated 05/25/23 and 06/08/23 documented frequency for skilled nurse 7, social worker 2, chaplain 2, and hospice aide 2 with no defined weekly or monthly visit frequency. Clinical record review revealed the skilled nurse provided visits 7 times per week, the hospice aide provided visits 2 times per week, and the chaplain and social worker provided visits 2 times per month. The updated POCs did not document each discipline’s frequency of visits clearly. Clinical Record 9: The patient elected the hospice benefit 05/19/23. The updated POC dated 05/25/23 documented frequency for skilled nurse 1, social worker 2, chaplain 2, and hospice aide 1 with no defined weekly or monthly visit frequency. Clinical record review revealed the skilled nurse and hospice aide provided visits weekly and the chaplain and social worker provided visits monthly. The updated POCs did not document each discipline’s frequency of visits clearly. Clinical Record 12: The patient elected the hospice benefit 06/02/23. The updated POC dated 06/08/23 documented frequency for skilled nurse 2, social worker 2, chaplain 2, and hospice aide 1 with no defined weekly or monthly visit frequency. Clinical record review revealed the skilled nurse and hospice aide provided visits weekly and the chaplain and social worker provided visits monthly. The updated POCs did not document each discipline’s frequency of visits clearly. Clinical Record 13: The patient elected the hospice benefit 04/20/23. The updated POC dated 05/11/23 documented frequency for skilled nurse 1, social worker 1, chaplain 1, and hospice aide 1 with no defined weekly or monthly visit frequency. The updated POC dated 05/25/23 documented frequency for skilled nurse 7, social worker 2, chaplain 2, and hospice aide 1 with no defined weekly or monthly visit frequency. Clinical record review revealed the skilled nurse and hospice aide provided visits weekly and the chaplain and social worker provided visits monthly. The updated POCs did not document each discipline’s frequency of visits clearly. Clinical Record 17: The patient elected the hospice benefit 05/20/23. The updated POC on 05/25/23 documented frequency for skilled nurse 7, social worker 2, chaplain 2, aide 1 with no defined weekly monthly frequency. Clinical record review revealed the skilled nurse and hospice aide provided visits weekly and the chaplain and social worker provided visits monthly. The updated POC did not document each discipline’s frequency of visits clearly. During an interview on 06/22/2023, the Clinical Manager stated that the software company had been contacted and a return email from the software provider stated that the problem was resolved to include the frequency with weeks or months or days as required. This process will be verified with the next interdisciplinary meeting in two weeks.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, home visit observation, document review and interview. In 1 of 17 (6%) clinical records reviewed, the agency did not ensure that all medications were documented on the patient’s plan of care. Agency policy 9-017, "The Plan of Care (revision date November 2022)," stated in part, "The plan of care will include medications and treatment for the care of the patient." Clinical Record 2/Home Visit 1: The patient elected hospice benefit on 05/23/23. During the home visit observation on 06/21/23, the patient was observed infusing FOLFIRINOX [a palliative chemotherapy regimen]. The nurse [personnel record 7] stated this was the third treatment since electing hospice. Clinical record review revealed the medication was not included on the initial plan of care dated 05/23/23, and the updated plans of care dated 05/25/23 and 06/08/23. During an interview on 06/22/23, the Clinical Manager stated that the plan of care had now been updated to include the medication.

It is required that hospice aides are assigned to a specific patient by a registered nurse (RN) who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 3 of 17 (18%) clinical records reviewed, the organization did not ensure the RN documented clear and specific written instructions to the aide on the aide plan of care. Clinical Record 1: The hospice aide plan of care dated 05/15/23 ordered the task of shower weekly and may give bed bath if patient desires. Clinical record review revealed the patient’s primary diagnosis is Alzheimer's disease and the patient was unable to make the decision of shower verses bath. The aide plan of care did not include clear instructions for the aide related to the patient’s bath needs. Clinical Record 16: The hospice aide plan of care dated 05/12/23 ordered a bed bath weekly and inspect skin every visit. Clinical record review revealed the patient had a Mepilex dressing to the coccyx related to a pressure area. The aide plan of care did not include instructions to the aide on how to care for the dressing during the patient’s bed bath and what to do if the dressing becomes dislodged or saturated. Clinical Record 17: The hospice aide plan of care dated 05/20/23 ordered a weekly shower for the patient and may give a bed bath if patient desires. The initial comprehensive assessment dated 05/20/23 documented the patient had episodes of confusion with some hallucinations. The patient was unable to make the decision of shower verses bath. The aide plan of care did not include clear instructions for the aide related to the patient’s bath needs. During an interview on 06/22/23, the Executive Director and Clinical Manager stated aide plans of care have been an area they are working on and will continue to audit for all direction for care.