Every finding on record at Brookhaven Hospice of New Hampshire, LLC

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. No evidence that the emergency plan was tested annually. No evidence that it was completed for 2024.

Upon patient record review 3 of 19 (Patient #2,4,5) 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 on 5/22/25. The spiritual care assessment was completed on 5/29/25. Patient 4: The patient was admitted on 7/3/25. The spiritual care assessment was completed on 7/11/25. Patient 5: The patient was admitted on 4/23/25. The spiritual care assessment was completed on 4/30/25.

Upon patient record review, 4 of 19 (Patient #1,3,8,11) 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 current medication profile has MiraLAX PRN daily by mouth, Senna PRN 2 times daily by mouth, and Bisacodyl PRN daily by mouth for constipation. No evidence that instructions were given on which medication to give first in the event of constipation. Also the medical record contained an order for oxygen with no delivery method. Both COS - New physician order written to update the active medication profile to include instructions and a delivery method during survey. Patient 3: The current medication profile has Bisacodyl supp 10mg 1 as directed - directions stated 1 sup PRN. No evidence that a frequency was included on the active medication profile. COS- Active medication profile updated to include frequency during survey. Patient 8: The current medication profile has MiraLAX once daily prn. No evidence that a dilutant was included on the active medication profile. COS- Active medication profile updated during survey. Patient 11: The RN documentation indicated that the patient used oxygen at 2.5L NC and 3LNC. The current medication profile has oxygen flow rate ordered at 2L via NC. No evidence that oxygen at 2.5L or 3LNC was included on the current medication profile or that a titration order was obtained. COS- active medication profile updated during survey.

Upon patient record review, 2 of 19 (Patient #4,8) 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: The medical record indicated that the patient has an active problem with seizures, takes seizure medications daily, and has an active problem with dysphagia. No evidence of problems, goals, and interventions related to seizures or dysphagia included in the current plan of care. Order written to update the current plan of care during survey Patient 8: The medical record indicated that the patient has an active problem with contractures and altered mobility. No evidence of problems, goals, and interventions related to altered mobility included in the current plan of care. COS - Order written to update the current plan of care during survey.

Upon patient record review, 4 of 19 (Patient #1,3,8,11) 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 contains orders for MiraLAX PRN daily, Senna PRN 2 times daily, and Bisacodyl PRN daily for constipation. No evidence that instructions were given on which medication to give first in the event of constipation. The medical record contained an order for oxygen with no delivery method. Both COS - New physician order written to include a delivery method during survey and instructions for giving PRN constipation medication. Patient 3: The active plan of care has orders for Bisacodyl supp 10mg 1 as directed - directions stated 1 sup PRN. No evidence that a frequency was included in the order. COS- New order written to include frequency during survey. Patient 8: The plan of care has orders for MiraLAX once daily prn. No evidence that a dilutant was included on the current order. COS- New order written to include a dilutant during survey. Patient 11: The RN documentation indicated that the patient used oxygen at 2.5L NC and 3LNC. The plan of care has the oxygen flow rate ordered at 2L via NC. No evidence that the an order was received for 2.5L or 3LNC or that a titration order was obtained. COS- New order oxygen order written during survey.

Upon patient record review, 2 of 19 (Patient #1,8) 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 equipment and supply needs. Patient 1: The medical record indicated that the patient uses a Hoyer lift for all transfers. The aide current plan of care has instructions to use a Hoyer lift with all transfers from the bed to the chair at every visit. No evidence that the Hoyer was included on the current DME supply list. COS -Plan of care DME list updated during survey. Patient 8: The medical record indicated that the patient had active wounds. No evidence that wound care supplies were included on the current supply list. COS- Plan of care supply list updated during survey.

Upon client record review, 5 of 19 (Patient #1,2,12,13,14) 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 #1: No evidence of RN contribution for IDG from the time of admit up until the most recent IDG that occurred on 09/04/2025. Patient #2: No evidence of SC contribution for IDG from the time of admit up until the most recent IDG that occurred on 09/04/2025. No evidence of RN contribution for the IDG that occurred on August. Patient #12: No evidence of RN contribution for IDG that occurred on 07/9/25. Patient #13: No evidence of RN contribution for IDG on 08/05/2025. IDG SN contribution for IDG's that occurred on 05/15/25, 05/29/25, 06/12/25, 6/26/25 was not updated, the RNs admission narrative copied and pasted to each note. Patient #14: No evidence of RN contribution for IDG from 04/30/25 until 07/24/25.

Upon client record review, 1 of 19 (Patient #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5: The current plan of care includes orders for the foley catheter to be changed monthly. No evidence that the foley catheter was changed for the month of June 2025.

Upon patient record review, 2 of 19 (Patient #2,8) 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 2: The medical record indicated the the patient requires 2 person assist with a Hoyer lift for all transfers. No evidence that the aide plan of care included instructions for related altered mobility. COS - new order written to add to those instructions to the aide plan of care during survey. Patient 8: The medical record indicated the the patient requires 2 person assist for baths. No evidence that the aide plan of care included instructions for 2 person assist. COS - new order written to add to those instructions to the aide plan of care during survey.

Upon patient record review 3 of 19 (Patient #1,4,12) 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 1: Aide plan of care has visit frequency set as three weekly starting on 06/18/2025. No evidence that 3 visits occurred from 06/18/2025 until the time of survey. Patient receiving 2 visits a week during that time, which was the previously ordered visit frequency. No missed visit notes and orders to change frequency noted at the time of survey. Patient 4: Aide plan of care has visit frequency set as three weekly starting on 07/06/2025. No evidence that the aide completed visits from 07/06/25-07/21/25. Evidence that the visits were missed at the request of the patient/caregiver or that orders were received to change frequency noted at the time of survey. Patient 12: Aide plan of care has orders for foot care and nail care to be completed once a week. No evidence that either task were completed for the weeks of 07/07, 07/14, 07/28, or 08/13/2025. No evidence that the tasks were not performed due to patient request. The aide documented that the task "were not required at the visit".

Upon patient record review 1 of 19 (Patient #3) 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. Patient 3: No evidence that a registered nurse made an aide supervisory visit every 14 days between 05/08/25-06/05/25 (27 days).

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. No evidence that the agency did utilized volunteers at least 5% of the total patient care hours in 2024. The total usage of volunteers for 2024 was 2.48%

Upon patient client record review, 2 of 19 (Patient #2,6) 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 2: The RN documentation included supervisory for the LVN on 12/26/2024 and 01/02/2025. No evidence that a LVN completed a visit during the patients time on services. Patient 6: The medical director stated in all 3 CTIs that the patient was a DNR. The medical record and advances directives stated the the patient was a full code.

Upon client record review, 2 of 19 (Patient #2,6) 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 2: The plan of care has RN visit frequency ordered as 3 times starting on 08/20/2025. No evidence that the patient received 3 visits since that time. No evidence that visits were missed at the request of the patient/caregiver or that an order was received to change the visit frequency for those weeks. The medical record indicated that the patient continued to receive visits at the previously ordered visit frequency which was twice a week. Patient 6: The plan of care has SC visits ordered as 2-3 visits a month. No evidence that a SC visit occurred for the month of June 2025. No evidence that visit was missed at the request of the patient/caregiver or that an order was received to change the visit frequency for the week.

Upon patient record review, 5 of 13 (Patient #1,#2,#4,#8,#10) 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 included Miralax powder 17 gm, 1 scoop, by mouth daily. There was not evidence of a diluent. Corrected on site. Patient 2: The medication profile included Hydrocodone/APAP 5/325 1 tab 4 x per day (straight order), and Tylenol 650 PRN Q 4 hours. There was not evidence of a maximal allowable dose per 24 hours and there was not a reason for administering PRN Tylenol. Corrected on site. Patient 4: The medication profile included Miralax powder 17 gm, 1 scoop, by mouth daily. There was not evidence of a diluent. Corrected on site. Patient 8: The medication profile included Miralax powder 17 gm, 1 scoop, by mouth daily. There was not evidence of a diluent. In addition, The medication profile indicated for Keflex for 7 days. This was not end dated in the medication profile. Both were corrected on site. Patient 10: The record indicated that the patient was on Nystatin powder for redness under the abdominal folds. Nystatin was not included on the medication profile. Corrected on site.

Upon patient record review, 1 of 13 (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 7/20/22. There was not evidence of a bereavement assessment.

Upon patient record review, 4 of 13 (Patient #1,#2,#10,#13) 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 1: The record indicated that the patient had a Foley catheter. There was no evidence that this was on the plan of care. Corrected on site. Patient 2: The record indicated that the patient had a Foley catheter. There was no evidence that this was on the plan of care. Corrected on site. Patient 10: The medication record indicated that the patient was on Eliquis. Bleeding precautions were not included on the plan of care. Corrected on site. Patient 13: The record indicated that the patient was changed to GIP level of care on 7/18/22. There was not evidence of an update to the plan of care.

Upon patient record review, 5 of 13 (Patient #1,#2,#4,#8,#10) 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 included an order for Miralax powder 17 gm, 1 scoop, by mouth daily. There was not evidence of a diluent. Corrected on site. Patient 2: The record included orders for Hydrocodone/APAP 5/325 1 tab 4 x per day (straight order), and Tylenol 650 PRN Q 4 hours. There was not evidence of a maximal allowable dose per 24 hours and there was not a reason for administering PRN Tylenol. Corrected on site. Patient 4: The record included an order for Miralax powder 17 gm, 1 scoop, by mouth daily. There was not evidence of a diluent. Corrected on site. Patient 8: The record included an order for Miralax powder 17gm, by mouth daily. There was not evidence of a diluent. Corrected on site. Patient 10: The record indicated that the patient was on Nystatin powder for redness under the abdominal folds. There was not evidence of an order. Corrected on site.

Upon patient record review, 2 of 13 (Patient #1,#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 equipment and supply needs. Patient 1: The record indicated the patient was on oxygen and also had a Hoyer lift used for transfers. There was not evidence that a Hoyer lift, oxygen, or oxygen supplies was a part of the plan of care. Corrected on site. Patient 4: The record indicated that the patient had a Hoyer lift. The Hoyer Lift was not on the plan of care. Corrected on site.

Upon patient record review, 1 of 9 applicable (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 record indicated that telehealth visits were conducted by the nurse on 9/2/22 and 9/16/22. There was no evidence the plan of care included approval for telehealth. Corrected on site.

Upon observation visit(s), 1 of 3 (Patient #3) there was not evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #3, RN: was observed placing equipment which was in a plastic bag on a dining room table that was unclean. The staff member removed the equipment from the plastic bag, used it, cleaned it and then placed the equipment back in the plastic bag. The plastic bags were then placed in her nursing bag (without cleaning the plastic bags) next to already cleaned stethoscope.

Upon patient record review, 3 of 12 applicable (Patient #1,#4,#10) did not have evidence in the patient record that hospice aide assignments and duties are: • Written patient care instructions for a hospice aide, including alerts and precautions that must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.7 • There is evidence in the patient record that the plan of care specifically indicates 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 record indicated that the patient was on Eliquis 2.5mg 1 tab BID. Bleeding precautions were not included on the aide plan of care. Corrected on site. In addition, the task of complete bed bath and the use of 2 person Hoyer lift for transfers did not contain evidence of a frequency to perform these tasks. Corrected on site. Patient 4: The aide Plan of Care included shampoo and shave 'per patient request'. Corrected on site. In addition, upon observed visit, the aide indicated the Hoyer lift was used to get the patient out of bed. Hoyer lift was not included on the Aide plan of care. Corrected on site. Patient 10: The medication profile indicated the patient was on Eliquis. Bleeding precautions were not included on the aide plan of care. Corrected on site.

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

Upon patient record review, 1 of 13 (Patient #3) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient 3: The record indicated that the patient/representative wished to receive The patient Notification of Hospice Non-Covered Items, Services and Drugs. The patient was admitted on 8/1/22. There was not evidence of the date that this document was furnished. Documentation revealed that it was signed on 9/1/22.

Upon patient record review, 2 of 4 applicable (Patient #2,#4) 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 2: The Nurse practitioner note dated 10/25/22 indicated that the patient had a stage 1 wound on his coccyx and the wound care included cleansing with skin cleanser, applying zinc and covering with a foam dressing. There was not evidence of an order. Corrected on site. Patient 4: Upon observed visit, the patient was observed to have dressings on bilateral heels. The aide indicated that the patient had wounds on his heels. There was not evidence of wound orders in the plan of care. Corrected on site.