Every finding on record at Brookhaven Hospice, LLC

Upon patient record review, 1 of 20 (Patient #16) 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 #16: There was no evidence of initial bereavement assessment by RN, SC, MSW.

Upon patient record review, 1 of 20 (Patient #4) 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 #4: All MSW visits (6/17, 7/14, 8/6, 9/22, 10/17, 11/18/25) made by telephone only with no option presented to patient (per home visit interview). Telephone visits were not specified in the plan of care.

Upon patient record review, 5 of 20 (Patient #1, 2, 3, 4, 10) 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 #1: 10/2/25 MSW frequency 1-2/month and 6 prn. No detailed scope and frequency with too many PRN visits. Patient #2: 9/26/25 MSW 2/month and 6 prn. Vol 1/month and 3 prn. No detailed scope and frequency. with too many PRN visits. Patient #3: MSW 1/mo. and 6 prn. No detailed scope and frequency with too many PRN visits. Patient #4: 6/15/25 SN 1-2/wk. and 6/16/25 SN 8 prn. MSW 1/month and 5 prn. No detailed scope and frequency with too many PRN visits. Patient #10: 7/25/25 SN 2x/wk and 5 prn. No detailed scope and frequency with too many PRN visits.

Upon patient record review, 2 of 20 (Patient #4, 8) 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 #4: Home patient admitted 6/13/25 with indwelling Foley catheter in place. Plan of care does not include specific orders regarding plan for changing or not changing catheter routinely and/or for complications. The plan of care includes red skin: skin prep, barrier. Family provides care; prn hospice nurse. Treatment orders do not include location and/or specific barrier to be used. Patient #8: Patient admitted 10/31/25 with Foley catheter in place. Plan of care does not include specific order or intervention regarding plan for changing or not changing catheter routinely and/or for complications.

Upon patient record review, 1 of 20 (Patient #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#8: Home patient admitted 10/31/25. 11/26/25 SN note references new pressure ulcers left heel and toe. No update to problems, goals, and interventions.

Upon client record review, 1 of 20 (Patient #14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #14: Home patient admitted 10/2/25. SC frequency 1x/month. First SC visit made 11/11/25 with no visit for October and no explanation for the delay.

Upon patient record review 1 of 20 (Patient #3) 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 #3: SNF resident admitted 10/23/25. 10/27/25 MSW visit notes that patient reported being lonely and bored… noted patient was very engaged in conversation. 10/27/25 SN note referenced that patient was being visited from volunteer department. It was unclear if volunteer was hospice or facility. Interview with staff unable to verify if agency volunteer referral received. There is no reference to discussion, offer or referral for volunteer service for companionship.

Upon observation and home visit, 1 of 4 (Patient #11) there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #11: RN placed nursing bag on nurses station counter top and on patient over the bed table without wiping surface before or after and without barrier (required per 5.5b Bag Policy).

Upon patient record review, 4 of 20 (Patient #16, 17, 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 Patients #16, 17, 18, 19: Agency was unable to provide evidence of ongoing bereavement services up to 1 year following the death of the patient. Evidence of mailing is stored in spread sheet that was not available.

Upon patient record review, 1 of 20 (Patient #8) 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 #8: Patient admitted with colostomy - with no reference/identification of colostomy to alert aide noted in aide care plan.

Upon patient record review 1 of 20 (Patient #7) 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 #7: 10/28/25 note to omit aide. Facility aware and will provide care. There was no documented evidence of reason, of effort to substitute or reschedule the omitted visit.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Upon review and interview, there is no evidence that agency is able to demonstrate cost savings of 5%.

Upon patient client record review, 2 of 20 (Patient #6,10) 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 #6: SNF resident admitted 11/5/25. Initial RN assessment includes documentation of hospice aide supervision although no aide service provided at that time. In addition, the patient was admitted with multiple wounds. 11/5 Initial visit, 11/6/25, 11/11/25 SN notes say dressings changed yes. Per orders. See care plan. RN documentation did not provide detail of wound care performed or how they tolerated wound care. Patient #10: SNF resident admitted 7/25/25, the patient currently has Stage 2 left hip pressure wound, first identified 11/25/25. SN noted Wound care. Yes. Per orders. See care plan. RN documentation did not provide detail of wound care performed or how they tolerated wound care.

Upon client record review, 6 of 20 (Patient #5, 6, 7, 9, 10, 11) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #5: SNF resident admitted 10/28/25. Initial RN visit nurse noted BLLE and left forearm wound care: performed this visit yes. Per orders. See care plan. Problems, goals, interventions/Plan of Care do not include specific wound care orders. Patient #6: SNF resident admitted 11/5/25 with MSW frequency of 1x/month. First visit 12/1/25, with no visit for November and no explanation for delay. Admitted with multiple wounds. 11/5 Initial visit, 11/6/25, 11/11/25 SN notes say dressings changed yes. Per orders. See care plan. Problems, goals, interventions/Plan of Care includes Coordinate wound care with facility staff. Facility to perform wound care daily. During patient visit, noted no current wound care with all wounds healed. Hospice problems, goals, interventions/plan of care do not reflect updated 11/21/25 assessment of healed wounds. Patient #7: SNF resident with order 10/31/25 Vol 1/month through 11/30/25 when order discontinued. Clinical note by Volunteer Coordinator to start volunteer for companionship 1x/month. There was no documented evidence that the visit was made and/or refused. Patient #9: SNF resident admitted 10/8/25. Noted NP visits 11/12, 11/18, 11/26/25 related to knee wound with treatment recommendations by NP. Problems, goals, interventions/plan of care not updated to reflect NP treatment recommendations. Patient #10: SNF resident admitted 7/25/25 with SC frequency 1x/month. No documented visits provided Aug, Sept, Oct or Nov. Currently has Stage 2 left hip pressure wound, first identified 11/25/25. SN noted Wound care. Yes. Per orders. See care plan. The plan of care did not include specific wound care orders. During facility visit, noted facility record to have specific treatment orders. RN updated hospice Plan of Care following visit. Patient #11: SNF resident with MSW frequency 1x/month for 8/25 and 10/24/25 benefit periods. There were no documented orders for PRN visits. Patient was seen 8/25, 9/24, 10/22, 10/29, 11/6, 11/18/25.

Upon client record review, 2 of 20 (Patient #5,10) 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 #5: SNF resident admitted 10/28/25. Initial RN visit nurse noted BLLE and left forearm wound care: performed this visit yes. Per orders. See care plan. Problems, goals, interventions/Plan of Care do not include specific wound care orders of who would perform the dressing changes. Patient #10: SNF resident admitted 7/25/25 , the patient currently has Stage 2 left hip pressure wound, first identified 11/25/25. SN noted Wound care. Yes. Per orders. See care plan. Problems, goals, interventions/Plan of Care do not include specific wound care orders of who would perform the dressing changes. During facility visit, noted facility record to have specific treatment orders. RN updated hospice Plan of Care following visit.

Upon patient record review 4 of 13 (Patient #1,#3,#11,#12) 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 #1,#3,#12: There was not evidence of a spiritual assessment. Patient #11: There was not evidence of a psycho-social assessment or a spiritual assessment.

Upon patient record review, 6 of 13 (Patient #1,#4,#7,#8,#9,#11) 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: The medication profile indicated Polyethylene Glycol Packet 3350 by mouth 17 Gms prn constipation. There was not evidence of a diluent. Corrected on site. Patient #4: The medication profile indicated Tylenol 650mg prn q6h. There was not evidence of an indication. Corrected on site. Patient #7: The medication profile indicated Acetaminophen rectal supp 650mg q6h prn for elevated temp. There was not evidence of a parameter for the temperature. In addition, Levaquin (dated 12/2/22) 250mg, give 500mg daily po x 5 days remained on the medication profile. Corrected on site Patient #8,#9: The medication profile indicated Acetaminophen 325mg tabs, 650mg po q4h prn for pain or fever. There was not evidence of a parameter for the fever. Corrected on site. Patient #11: The medication profile indicated Acetaminophen 650mg po q6h prn for pain or fever. There was not evidence of a parameter for the fever.

Upon patient record review, 7 of 13 (Patient #1,#2,#3,#4,#9,#11,#12) 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,#2,#3,#4,#9,#11,#12: There was not evidence of a bereavement assessment.

Upon patient record review, 3 of 13 (Patient #4,#7,#10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient that reflects 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 #4: The patient was admitted with a diagnosis of Parkinson's Disease. There was not evidence of patient/family goals and interventions based on the patient's neurological disease. Corrected on site. Patient #7: The patient was admitted with a diagnosis of heart failure. There was not evidence of patient/family goals and interventions based on the patient's cardiac disease. Corrected on site. Patient #10: The patient was admitted with a diagnosis of acute on chronic diastolic heart failure. There was not evidence of patient/family goals and interventions based on the patient's cardiac disease. Corrected on site.

Upon patient record review, 6 of 13 (Patient #1,#4,#7,#8,#9,#11) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: The record indicated an order for Polyethylene Glycol Packet 3350 by mouth 17 Gms prn constipation. There was not evidence of a diluent. Corrected on site. Patient #4: The record indicated an order for Tylenol 650mg prn q6h. There was not evidence of an indication. Corrected on site. Patient #7: The record indicated an order for Acetaminophen rectal supp 650mg q6h prn for elevated temp. There was not evidence of a parameter for the temperature. Corrected on site. Patient #8,#9: The record indicated an order for Acetaminophen 325mg tabs, 650mg po q4h prn for pain or fever. There was not evidence of a parameter for the fever. Corrected on site. Patient #11: The record indicated an order for Acetaminophen 650mg po q6h prn for pain or fever. There was not evidence of a parameter for the fever.

Upon client record review, 1 of 13 (Patient #3) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #3: The record indicated that IDG reviewed and revised and documented the plan of care on 11/8/22. The next documented review was on 12/7/22, which is greater than the 15 day requirement.

Upon client record review, 2 of 13 (Patient #2,#4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: The visit frequency for the nurse was 1-2x/week. For the week of 11/13/22-11/19/22, the record indicated that 4 routine visits were conducted on 11/14/22, 11/15/22, 11/16/22, and 11/18/22. Patient #4: The record did not contain evidence of a routine visit frequency for the skilled nurse from 11/8/22 to current. The skilled nurse conducted weekly routine visits. Corrected on site.

Upon patient record review, 5 of 13 (Patient #1,#2,#3,#7,#10) 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 including alerts and precautions for a hospice aide 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 specifically 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: The tasks of shower and shampoo were indicated "as desired." Patient #2: The tasks of bed bath and assist with dressing/undressing were indicated as 'as patient tolerated.' Patient #3: The aide plan of care indicated for the task of applying lotion after bathing. Bathing was not indicated as a task on the aide plan of care. Patient #7: The tasks of provide pivot assist with transfer and assist with dressing/undressing was listed as 'as needed'. Patient #10: The record indicated that the patient was on Eliquis 2.5 mg po BID. There was not evidence that bleeding precautions were on the aide plan of care. Corrected on site.

Upon patient record review 5 of 13 (Patient #1,#2,#4,#7,#10) 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 Patient #1: The aide visit frequency was 2x/week. For the week of 11/20/22-11/26/22, the record indicated only 1 visit. The second visit was not provided and the documentation indicated, 'omitted due to Brookhaven Holiday.' In addition, many tasks, including apply lotion, assist with urinal, change bed linens, complete bath, peri care, ROM were indicated to be provided with each visit. On multiple visits by the aide, the documentation for these tasks revealed 'not required at todays visit.' Patient #2: The tasks of apply lotion, bed bath, and assist with dressing/undressing were indicated to be provided with each visit. On multiple visits by the aide, the documentation for these tasks revealed 'not required at todays visit.' In addition, the aide visit frequency was 3x/week. For the week of 11/20/22-11/26/22, the record indicated only 2 visits. The third visit was not provided and the documentation indicated, 'omitted due to Brookhaven Holiday.' Patient #4: The visit frequency for the aide was 2x/week. There was not evidence of any visits by the aide. Patient #7: The tasks of complete bed bath, peri care and DNR were to be provided at each visit. On multiple visits by the aide, the documentation for these tasks revealed 'not required at todays visit.' In addition, the missed visit documentation for 11/24/22 indicated that it was omitted due to Brookhaven Holiday. Patient #10: The aide visit frequency was 3x/week. The record indicated that the aide provided visits only 2x/week. In addition, the missed visit documentation for 11/24/22 indicated that it was omitted due to Brookhaven Holiday.

Upon personnel record review, 1 of 14 (Personnel # 2) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Corrected on site.

Upon contract review, 1 of 4 contracts (Bayada) did not have evidence of the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Authorized by the hospice • Delivered in accordance with the patient's plan of care • The care/services to be furnished • The necessity to conform to all applicable agency policies and procedures, including personnel qualifications, orientation, competencies, and required background checks • The responsibility for participating in developing plans of care • The manner in which care/services will be controlled, coordinated, and evaluated by the hospice • Any additional requirements as out lined in the Social Security Act section 1861(w) • There are copies of professional liability insurance certificates on file for any contract personnel providing direct patient care

Upon personnel record review, 2 of 14 (Personnel #4,#5) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #4: There was not evidence of a competency. Corrected on site. Personnel #5: There was not evidence of an initial competency. Corrected on site.

Upon patient client record review, 4 of 13 (Patient #2,#8,#9,#10) 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. Patient #2: For the dates of 11/8/22, 11/9/22, 12/6/22, 12/7/22, and 12/8/22, the record indicated 2 visits each of these days by the aide. The aide visit frequency was 3x/week. Leadership confirmed that there was only 1 visit each of these days and a new orientee was shadowing and should not have documented the visit. Patient #8: For the dates of 11/14/22, 11/15/22, 11/16/22, 11/21/22, and 11/22/22, the record indicated 2 visits each of these days by the aide. The aide visit frequency was 3x/week. Leadership confirmed that there was only 1 visit and a new orientee was shadowing and should not have documented the visit. Patient #9: For the date of 11/11/22, the record indicated 2 visits by the aide. The aide visit frequency was 3x/week. Leadership confirmed that there was only 1 visit and a new orientee was shadowing and should not have documented the visit. Patient #10 The patient was admitted with a diagnosis of acute on chronic diastolic heart failure. There was not evidence of a cardiac assessment during the skilled nurse visits for the dates of 12/1/22, 12/2/22 or 12/9/22.

Upon client record review, 1 of 13 (Patient #11) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #11: The skilled nurse visit frequency was 1-2x/week and the spiritual care visit frequency was 1x/month. The record indicated that most of the visits were conducted via telehealth. There was not evidence that telehealth was a part of the plan of care.

Upon personnel record review, 1 of 14 (Personnel #10) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions. There was not evidence of a personnel record for the SLP.

Upon personnel record review, 1 of 14 (Personnel #9) did not have evidence all Physical Therapy Services are provided by a qualified licensed Physical Therapist (PT) in accordance with the state's Physical Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. There was not evidence of a personnel record for the PT

Upon personnel record review, 3 of 14 (Personnel #8,#9,#10) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Upon personnel record review, 2 of 14 (Personnel #9,#10) did not have evidence of background checks being obtained which include: • Office of Inspector General Exclusion List check for employees/contract employees with direct patient care access or access to patient records • National sex offender registry check for employees/contract employees with direct patient care access

Upon personnel record review, 2 of 14 (Personnel #9,#10) did not have evidence that all personnel have been fully vaccinated for COVID-19.