Every finding on record at New Beacon Healthcare Group, LLC

Upon observation, there was no evidence that the patient has the right: • To exercise his or her rights as a patient of the hospice • Have one's property and person treated with respect • To not be subjected to discrimination or reprisal for exercising his or her rights On one of four home visits (Patient #7 with RN) the RN did not have an agency generated photo ID.

Upon patient record review 1 of 19 (Patient #1) 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 #1-The patient was admitted on 08/24/23. A spiritual assessment was not completed until 08/30/23.

Upon patient record review 1 of 19 (Patient #14) 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 #14-The patient was admitted on 08/23/23 and refused Chaplain and Social Worker Services. A Spiritual assessment was not performed by the RN. A spiritual assessment is not on record. (corrected on site)

Upon patient record review, 4 of 19 (Patient #1, #3, #6, #7) 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 #1-The medication profile includes Hydrocodone 7.5mg-Acetaminophen 325mg/15ml two times daily prn pain and Morphine 20mg/ml .5ml-1ml po hourly prn pain/SOB. The profile does not provide a differentiation of parameters/circumstances for choosing medication administration. (corrected on site) Patient #3- On 09/27/23 the nurse documents the family administers MiraLax to the patient and a fleet suppository was given. The medication profile does not include MiraLax or Fleet suppository. (corrected on site) Patient #6-On 08/09/23 the record indicates a nursing order was received to increase the patients Morphine to 60 mg twice daily. The medication profile was not updated with the increase in dosage. (corrected on site) Patient #7-The medication profile includes MiraLax 17gm dose oral powder 1 scoop daily. A diluent is not included. Namenda is listed as 10 mg 1 tab twice weekly on the medication profile. The correct dosage per orders on 10/05/23 is Namenda 15 mg 1 tab twice daily. (corrected on site)

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 08/24/23 and a bereavement risk assessment was not completed until 08/30/23

Upon patient record review, 1 of 19 (Patient #3) did not have evidence that the Registered Nurse ensured continuous assessment of the patient and family's needs. Patient #3- On 09/27/23 the nurse documented the patient had not had a bowel movement in 13 days. A fleet suppository was given and family instructed in use of Miralax. The record does not document a follow up visit/contact until 10/03/23 at which time the nurse documented the patient had not had a BM in 2 weeks. A digital exam was performed and the patient had a small bowel movement but a large amount of stool remained in the rectum. The record did not document a timely/effective resolution to manage the patients constipation.

Upon patient record review, 2 of 19 (Patient #3, #10) 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-On 09/27/23 the nurse documents the patient is constipated and has not had a bowel movement in 13 days. Subsequent visits 10/03, 10/05 and 10/09 indicate the patient continues to have problems with constipation. The plan of care does not include goals for constipation. (corrected on site) Patient #10-The nurse documented the family called to report falls on 08/12/23 and 09/15/23. The social worker documented witnessing a fall on 09/11/23. The plan of care does not include goals and interventions for fall prevention.

Upon patient record review, 4 of 19 (Patient #1, #3, #7, #12) 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 specific/accurate orders for all medications and treatments. Patient #1-The 08/24/23 plan of care includes orders that the hospice nurse or facility nurse may obtain pulse oximetry. The patient does not reside in a facility. The plan of care includes Hydrocodone 7.5mg-Acetaminophen 325mg/15ml two times daily prn pain and Morphine 20mg/ml .5ml-1ml po hourly prn pain/SOB. The orders do not provide a differentiation of parameters/circumstances for choosing medication administration. The patient was admitted with a PEG tube and the plan of care does not address management of the PEG tube or site dressing changes. (corrected on site) Patient #3- On 09/27/23 the nurse documents the family administers MiraLax to the patient and a fleet suppository was given. The plan of care does not include MiraLax or Fleet suppository. (corrected on site) Patient #7-The 09/19/23 plan of care includes MiraLax 17gm dose oral powder 1 scoop daily. A diluent is not included. Orders are on record 10/05/23 for Remeron (Mirtazapine) 10 mg every evening. The correct order was for Mirtazapine 15 mg at bedtime based on review of medication profile and late entry correction on site. Patient #12-The patient was admitted with a tracheal stoma and the plan of care does not address the stoma. (corrected on site)

Upon patient record review, 3 of 19 (Patient #3, #4, #8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3- On 09/27/23 the nurse documents performing a manual disimpaction. Orders are not on record to perform a disimpaction. (corrected on site) Patient #4-On 09/07/23 orders were written for the social worker to visit twice weekly. Between 09/07/23 and 09/30/23 only one visit was made on 09/19/23. (corrected on site) Patient #8-On 09/26/23 the Social worker was ordered to visit 1q2m2 (once every two months). The social worker visited monthly on 09/27/23 and 10/05/23(corrected on site)

Upon patient record review, 1 of 19 (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- On 09/11/23 the Social Worker documented the patient requested a volunteer. There is no further documentation on record regarding the request. (corrected on site)

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient #7 -The record documents a witnessed fall by the Social Worker on 09/11/23. The record also documents the family called reporting an unwitnessed fall on 09/15/23. The agency did not have fall occurrence records for these dates. (corrected on site)

Upon patient record review, 3 of 19 (Patient #4, #8,#10) did not have evidence in the patient record that hospice aide assignments and duties are: • Complete written patient care instructions including all identified safety measures. Patient #4-The Aide care plan does not include bleeding precautions which are applicable to the patient's plan of care. (corrected on site) Patient #8-The Aide care plan does not include aspiration precautions which are applicable to the Aide plan of care. (corrected on site) Patient #10-The Aide care plan does not include wound precautions, Oxygen precautions, and aspiration precautions which are applicable to the patient's care.(corrected on site)

Upon patient record review 1 of 19 (Patient #3) did not evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group and included in the plan of care Patient #3-Effective 09/10/23 the Aide was ordered to visit the patient 3 times weekly. One of the three weekly visits was scheduled for 09/11/23. On 09/11/23 the Aide documents a missed visit with the reason: The patient was okay without a visit today. (corrected on site) The Aide is assigned to document the patients last bowel movement each visit. Between 09/08/23 and 10/09/23 the Aide documented the date of the last bowel movement as the same day of the visit. On 09/27/23 the nurse documented the patient had not had a bowel movement in 13 days and the date of the last bowel movement was 09/14/23.

Upon patient record review, 3 of 19 (Patient #1, #3, #9) did not have evidence that all entries are legible, clear, and accurate. Patient #1- On 08/28/23 the nurse documented the patient had 2 plus A Demon to lower extremities. (late entry clarification/correction on site) Patient #3- On 09/21/23 the nurse documents the patient states that "bright" knee is increasingly painful. On 10/09/23 the nurse documented a suppository was given. The documentation is not specific for the name of the suppository. (corrected on site) Patient #9-On admission 09/13/23 the nurse documented the patient was 80 years old. The patient was 83 years old on admission. (corrected on site)

Upon patient record review, 1 of 19 (Patient #19) did not evidence the discharge summary included all required information. Patient #19-The patient revoked the Hospice election on 08/12/23. The discharge summary only documents the patient wished to receive aggressive treatment. The discharge summary does not include a summary of the patient's stay, including treatments, symptoms and pain management.