Every finding on record at New Beacon Healthcare Group, LLC

Upon patient record review 5 of 27 (Patients #2,#3,#5,#10,#11) 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 medical record contained a comprehensive spiritual assessment completed 2/7/23 with start of care date 5/11/22. Patient 3: The medical record contained a comprehensive spiritual assessment completed 5/30/23 with start of care date 5/24/23. Patient 5: The medical record contained a comprehensive spiritual assessment completed 2/7/23 with start of care date 5/3/22. Patient 10: The medical record contained a comprehensive spiritual assessment completed 6/14/23 with start of care date 6/8/23. Patient 11: The medical record contained a comprehensive spiritual assessment completed 1/31/23 with start of care date 1/25/23.

Upon patient record review 1 of 27 (Patient #15) 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 15: There was no evidence of a comprehensive spiritual assessment. Corrected on site.

Upon patient record review, 6 of 27 (Patients #2,#8,#13,#17,#18,#19) 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. Patient 2: The medication profile contained oxygen with no delivery method and conflicting frequencies stating both as needed and continuous. Corrected on site. Patient 8: The medication profile contained past medications of cefdinir antibiotic course 4/20/23, ceftriaxone one time injection 8/1/23, and mucinex for 7 days 8/1/23 still listed as active medications. The profile also contained lorazepam with a frequency as needed. There was no evidence of instructions of how frequently the PRN dose could be administered. Corrected on site. Patient 13: The medical record contained nursing documentation 7/31/23 and 8/8/23 identifying patient use of milk of magnesia and gas ex. There was no evidence of the milk of magnesia and gas ex included on the medication profile. Patient 17: The medication profile contained immodium as needed with no evidence of instructions for frequency or maximum doses and oxygen with no delivery method. Corrected on site. Patient 18: The medical record contained nursing documentation upon recertification 8/16/23 identifying patient use of intermittent oxygen throughout the benefit period. There was no evidence of oxygen on the medication profile. Corrected on site. Patient 19: The medication profile contained biofreeze menthol and voltaren topical medications with no defined area for administration. Corrected on site.

Upon patient record review, 2 of 27 (Patients #5,#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 5: The medical record contained an initial bereavement assessment completed 5/11/22 with start of care date 5/3/22. Patient 16: The medical record contained an initial bereavement assessment completed 2/7/23 with start of care date 1/20/23.

Upon patient record review, 1 of 27 (Patient #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 7: The medical record contained documentation of active sacral and right buttock wounds. There was no evidence of hospice nurse assessment from 7/24/23 to current.

Upon patient record review, 3 of 27 (Patients #7,#15,#16) 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 7: The medical record contained documentation of active sacral and right buttock wounds. There was no evidence of problems, goals, and interventions related to skin impairment included in the plan of care. Corrected on site. Patient 15: The medical record contained nursing documentation upon admission identifying patient history of recent falls and high fall risk. There was no evidence of problems, goals, and interventions related to fall safety included in the plan of care. Corrected on site. Patient 16: The medical record contained nursing documentation upon recertification visit 7/4/23 identifying patient was monitored for episode of possible aspiration. There was no evidence of problems, goals, and interventions related to risk of aspiration or respiratory dysfunction included in the plan of care. Corrected on site.

Upon patient record review, 3 of 27 (Patients #8,#11,#16) 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 Patient 8, 11, 16: The medical record contained an unclear social work frequency stating 1 every 2 month 2 then 1 month 2. Agency leadership could not interpret intended frequency. Corrected on site.

Upon patient record review, 6 of 27 (Patients #2,#8,#13,#17,#18,#19) 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 2: The medical record contained an order for oxygen with no delivery method and conflicting frequencies stating both as needed and continuous. Corrected on site. Patient 8: The medical record contained an order for lorazepam with a frequency as needed. There was no evidence of instructions of how frequently the PRN dose could be administered. Corrected on site. Patient 13: The medical record contained nursing documentation 7/31/23 and 8/8/23 identifying patient use of milk of magnesia and gas ex. There was no evidence of orders for the milk of magnesia and gas ex. Corrected on site. Patient 17: The medical record contained orders for immodium as needed with no evidence of instructions for frequency or maximum doses, and oxygen with no delivery method. Corrected on site. Patient 18: The medical record contained nursing documentation upon recertification 8/16/23 identifying patient use of intermittent oxygen throughout the benefit period. There was no evidence of an order for oxygen. Corrected on site. Patient 19: The medical record contained orders for biofreeze menthol and voltaren topical medications with no defined area for administration. Corrected on site.

Upon patient record review, 7 of 27 (Patients #7,#8,#11,#12,#14,#15,#19) 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 7: The medical record contained nurse practitioner documentation 6/5/23 identifying patient use of a geri-chair. There was no evidence of the chair included as DME in the plan of care. Corrected on site. Patient 8: The medical record contained a CTI for benefit period starting 7/19/23 identifying patient use of a hoyer lift for transfers and the medication profile identified patient use of a nebulizer. There was no evidence of the lift and nebulizer included as DME in the plan of care. Corrected on site. Patient 11: The medical record contained a duoneb prescription and nursing documentation 6/29/23 identifying patient use of a nebulizer and mechanical lift. There was no evidence of the nebulizer and lift included as DME in the plan of care. Corrected on site. Patient 12: The medical record contained nursing documentation upon admission identifying patient use of a walker. There was no evidence of the walker included as DME in the plan of care. Corrected on site. Patient 14: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, oxygen concentrator, and shower chair. There was no evidence of the bed, oxygen, and shower chair included as DME in the plan of care. Corrected on site. Patient 15: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, over bed table, shower chair, and walker. There was no evidence of the bed, table, shower chair, and walker included as DME in the plan of care. Corrected on site. Patient 19: The medical record contained nursing documentation upon recertification 6/13/23 identifying patient use of oxygen and a duoneb prescription 8/9/23. There was no evidence of the oxygen and nebulizer included as DME in the plan of care. Corrected on site.

Upon client record review, 2 of 27 (Patients #5,#18) 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 medical record contained an ordered social work visit frequency of once monthly effective 7/1/23 for the benefit period ending 8/25/23. There was no evidence of social work visits completed in July and August, and no documentation of attempts to contact the patient for a visit until the end last week of July and the last week of the benefit period. Documentation of missed visits stated no call back received to schedule visit prior to end of July and benefit period. Patient 18: The medical record contained an ordered social work frequency of once weekly. There was no evidence of visits completed the weeks of 7/2/23, 7/9/23, 7/23/23 and 8/6/23.

Upon patient record review, 4 of 27 (Patients #8,#9,#12,#13) did not have evidence in the patient record that hospice aide assignments and duties indicate what tasks are to be done by the Aide. Patient 8: The medical record contained CTI documentation for benefit period starting 7/19/23 identifying patient required transfer of 2 person maximum assist or hoyer lift. There was no evidence of instructions for transfer needs for shower task included in the aide care plan. Corrected on site. Patient 9: The medical record contained nursing documentation upon recertification visit 7/17/23 identifying patient was bedbound and no longer able to ambulate. The aide care plan contained instructions for patient use of walker, cane, and commode. Corrected on site. Patient 12: The medical record contained nursing documentation upon admission identifying patient use of a walker. There was no evidence of instructions of patient dependence on walker included in the aide care plan. Corrected on site. Patient 13: The medical record contained nursing documentation upon admission identifying patient is bedbound. The aide care plan contained instructions for stand-by assist with ambulation. Corrected on site.

Upon personnel record review, 3 of 15 (Personnel #13,#14,#15) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel 13,14,15: There was no evidence the contracted therapists received orientation to the hospice philosophy.

Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient's clinical record in confidential manner. Personnel 5: During interview before the home visit, the clinician shared names and community positions of two former hospice patients.

Upon client record review, 2 of 27 (Patients #3,#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 3: The medical record contained an ordered spiritual care frequency of once monthly. There was evidence of two scheduled spiritual care visits completed in July. Patient 11: The medical record contained an ordered spiritual care frequency of two visits for July. There was no evidence of a second visit completed in July. Corrected on site with late documentation for reason frequency was not met.

Upon patient record review, 1 of 27 (Patient #3) did not have evidence that the hospice provided the following information to the SNF: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names of hospice personnel involved in hospice care of each patient • Hospice medication information specific to each patient Patient 3: Upon observation during home visit, there was no evidence of updated care plan and medication profile since May 2023, hospice election forms, Advance Directives, CTIs, and names of hospice personnel involved in hospice care included in the patient specific hospice binder. There was no evidence documented in the medical record that these were provided either.