Every finding on record at New Beacon Healthcare Group, LLC

Upon patient record review 1 of 23 records (Patient #5) did not have evidence in the patient record that the comprehensive assessment identifies the 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 #5: There was not evidence of a spiritual assessment. (Completed while on site).

Upon patient record review, 9 of 23 records (Patient #1,#5,#6,#7,#8,#9,#10,#11,#14) 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 record contained an order for oxygen 2L/min prn. There was not evidence of a route. Corrected on site. In addition, Resinol 2% topical ointment daily to affected area. There was not evidence of a specific location. Patient #5: The record contained an order for oxygen 2-4L/min prn. There was not evidence of a route. Corrected on site. Patient #6: The record contained Miralax 17 Gm oral powder daily. There was not evidence of a diluent. Corrected on site. Patient #7: The record indicated for humidified oxygen 4-7L/min continuously. There was not evidence of a route. Corrected on site. Patient #8: The record indicated for oxygen 2L/min. There was not evidence of a route. Corrected on site. Patient #9: The record contained an order for oxygen 2-4L/min prn. There was not evidence of a route. Corrected on site. Patient #10: The record indicated 8 hour pain relief 650 mg tab extended release, 1 q6h prn fever and Hydrocodone 5-Acetaminophen 325, 1 q4h prn. There was not evidence of a parameter for the fever or a maximum allowable dose per 24 hours. Corrected on site. In addition, Miralax 17 Gm powder packet daily with no evidence of a diluent. Corrected on site. Patient #11: The medication profile indicated duplicate orders for Acetaminophen; Acetaminophen 650mg rectal supp, 1 q4h prn fever > 100, and Acetaminophen 650mg rectal supp, 1 q4h prn fever > 100.5. Corrected on site. Patient #14: The medication profile indicated duplicate orders for Mucinex; Mucinex 600mg tabs, extended release, 1 q12h x 7 days dated 4/27/23 (Remains on the medication profile), and Mucinex 600 mg tabs extended release BID dated 8/15/23. Corrected on site.

Upon patient record review, 2 of 23 records (Patient #4,#6) 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 #4:The patient was admitted on 2/23/23. The record indicated that the bereavement assessment was completed on 3/6/23. Patient #6: There was not evidence of a bereavement assessment.

Upon patient record review, 1 of 23 records (Patient #12) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #12: The record indicated a nursing assessment and RN visit on 8/21/23. The next documented RN assessment was 9/11/23, which is greater than the 15 day requirement.

Upon patient record review, 8 of 23 (Patient #1, 2, 6, 7, 10, 11, 14, 18) 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 #1: The patient developed a wound on her right ankle. There was not evidence that the plan of care was updated to include goals and interventions related to the wound. Corrected on site. Patient #2: The record indicated that the patient did not have end of life plans including funeral arrangements. There was not evidence that the plan of care reflected patient/family goals and interventions based on the problems identified related to end of life planning. Corrected on site. Patient #6: The record indicated goals and interventions for a care plan of facility coordination. The record indicated that the patient was at home and had not been in a facility while on hospice. Corrected on site. Patient #7: The record indicated that the patient did not have end of life plans including funeral arrangements. There was not evidence that the plan of care reflect patient/family goals and interventions based on the problems identified related to end of life planning. Corrected on site. Patent #10: The patient had a Foley catheter upon admission. There was not evidence that the plan of care reflected patient/family goals and interventions related to the Foley catheter, including care, flushing if indicated and changing of the catheter. Corrected on site. Patient #11: The record indicated that the patient tested positive for COVID, date 8/28/23. There was not evidence the plan of care was updated to reflect this change. Patient #14: The record indicated dated 8/16/23, that the patient tested positive for COVID. There was not evidence the plan of care was updated to reflect this change. Patient #18: The record indicated that a Foley catheter was placed on 8/17/23. There was not evidence that the plan of care was updated to include

Upon patient record review, 2 of 23 records (Patient #5,#17) 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 the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs Patient #5: The visit frequency for the social worker was 3 prn and changed to 2 prn for the benefit period beginning on 7/13/23. Corrected on site. Patient #17: The visit frequency for the social worker was 1 prn. Corrected on site.

Upon patient record review, 9 of 23 records (Patient #1,#5,#6,#7,#8,#9,#10,#14,#18) 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 record contained an order for oxygen 2L/min prn. There was not evidence of a route. Corrected on site. In addition, Resinol 2% topical ointment daily to affected area. There was not evidence of a specific location. Patient #5: The record contained an order for oxygen 2-4L/min prn. There was not evidence of a route. Corrected on site. Patient #6: The record contained an order for Miralax 17 Gm oral powder daily. There was not evidence of a diluent. Corrected on site. I Patient #7: The record contained an order for humidified oxygen 4-7L/min continuously. There was not evidence of a route. Corrected on site. Patient #8: The record indicated for oxygen 2L/min. There was not evidence of a route. Corrected on site. Patient #9: The record contained an order for oxygen 2-4L/min prn. There was not evidence of a route. Corrected on site. Patient #10: The record indicated 8 hour pain relief 650 mg tab extended release, 1 q6h prn fever and Hydrocodone5-Acetaminophen 325, 1 q4h prn. There was not evidence of a parameter for the fever or a maximum allowable dose per 24 hours. Corrected on site. Patient #14: Miralax 17 Gm powder packet daily with no evidence of a diluent. Corrected on site. Patient #18: The record indicated an order dated 8/17/23 to insert a Foley catheter. There was not evidence of the size of the catheter, balloon size, the conditions to flush the catheter or a time frame to change the catheter if indicated. Corrected on site.

Upon client record review, 1 of 23 records (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: IDG's dated 8/4/23, 8/18/23, and 9/1/23 indicated that the patient did not have an Advance Directive. The question in the narrative section of the IDG plan of care, by the social worker asking if the patient was a full code did not contain an answer. The patient was admitted on 7/22/23, and the record contained an OOHDNR signed by the patient representative on 7/22/23 and by the physician on 8/22/23. There was not evidence that the plan of care was revised. Corrected on site.

Upon client record review, 4 of 23 records (Patient #2,#3,#7,#12) 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 social work visit frequency was for an evaluation, then 1 every 2m2, 1m1. The record indicated that the social worker conducted an evaluation on 6/16/23 followed by routine visits on 7/31/23 and 8/31/23. Corrected on site. Patient #3: The skilled nurse visit frequency was 2x/week. The record indicated only 1 visit for the week of 9/3/23-9/9/23. Corrected on site. Patient #7: The visit frequency for the social worker was for an evaluation, then 2 every 2m2, 2m2. The record indicated that an evaluation was conducted on 6/30/23 and routine visits on 7/13/23, 7/21/23, 8/11/23, 8/18/23, and 9/7/23. Corrected on site. In addition, the spiritual care counselor visit frequency was for an evaluation, then1 every 2m2. The record indicated that the evaluation was conducted on 6/30/23 with subsequent routine visits on 7/21/23 and 8/22/23. Corrected on site. Patient #12: The visit frequency for the social worker was for an evaluation, then 1 every 2m2, 1m1. The record indicated that the evaluation was conducted on 7/3/23 followed by routine visits on 8/7/23 and 9/12/23. Corrected on site.

Upon patient record review 1 of 23 records (Patient #10) 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 #10: The social worker assessment dated 8/1/23 indicated that the patient enjoys companionship. A volunteer referral is to be completed to assist meeting psychological needs. There was not evidence of follow up regarding the volunteer referral

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 14, Aide: While on an observed home visit, the staff member was observed using a bar of soap and a towel that was hanging on a towel rack in the patient's bathroom, prior to providing care.

Upon patient record review, 2 of 23 records (Patient #21,#22) did not have evidence the hospice offers bereavement counseling that includes: • 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, and following the bereavement plan of care. Patient #21: The bereavement plan of care indicated to make a phone call or visit to the bereaved within 2-4 weeks post death of the patient. There was not evidence of a visit or a phone call. Patient #22: The bereavement plan of care indicated to make a phone call or visit to the bereaved within 2-4 weeks post death of the patient. There was not evidence of a visit or a phone call. In addition, the plan of care indicated to send a 3 month letter which was due by 6/30/23. There was not evidence that this letter was sent.

Upon patient record review, 3 of 23 records (Patient #3,#8,#12) 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 precautions and alerts for a hospice aide that must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 Patient #3: The record indicated that the patient was on Depakote, Citalopram, and Keppra (All for seizures). There was not evidence that seizure precautions were included in the aide plan of care. Corrected on site. Patient #8: The record indicated that the patient was on Depakote and Lamictal (for seizures). There was not evidence that seizure precautions were included in the aide plan of care. Corrected on site. Patient #12: The record indicated that the patient was on Warfarin 3mg daily. There was not evidence that bleeding precautions were on the aide plan of care. Corrected on site. In addition, The patient was on oxygen (documented in the client record and observed on home visit, with shortness of breath). There was not evidence of an alert for oxygen or oxygen precautions. Corrected on site. Also, the nurse assessment indicated that the patient was at a high risk for falls. There was not evidence of fall precautions in the aide plan of care. Corrected on site.

Upon patient record review 3 of 23 records (Patient #3,#9,#14) 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 #3: The aide visit frequency was 2x/week. The record indicated a missed visit note entered by the aide on 8/31/23 that was blank. There was not evidence of the date that the visit was missed or the reason for the missed visit. Patient #9: The aide visit frequency effective 7/30/23 was 6w1, 5w10, 4w1. The record indicated only 4 visits per week for the month of August. Corrected on site. Patient #14: The aide plan of care indicated to shower every visit and to shampoo weekly. The record indicated that a shampoo was given at every visit (Aide frequency was 3x/week). Upon interview with the aide prior to the observed visit, the aide indicated that she provides a tub bath with lots of bubbles then upon completion, showers the soap off. Also there is not a shampoo provided as the patient goes to a beauty salon every Friday to get her hair done. Upon interview with the patient and caregiver, this was confirmed.

Upon patient record review 3 of 23 records (Patient #6,#11,#12) did not have evidence of 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 #6: The aide visit frequency was 2x/week. For the certification period of 6/7/23-9/4/23, the aide conducted visits only on 6/8/23, 7/11/23, and 8/16/23 (The patient/family refused all other visits). There was not evidence that the RN assessed the adequacy of the aide services in relationship to the needs of the patient and family. Patient #11: The record indicated an aide supervisory visit on 8/7/23. The next documented aide supervisory was dated 8/22/23 which is greater than the 14 day requirement. Patient #12: The aide visit frequency was 2x/week, effective 7/31/23. The only documented aide supervisory visit was dated 8/2/23.

Upon client record review, 1 of 23 records (Patient #8) 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 #8: The visit frequency for the spiritual care counselor was for an evaluation and then 1 every 2m2, 1m1. The record indicated that the evaluation was conducted on 6/13/23, with subsequent routine visits on 7/14/23, and 8/3/23. Corrected on site.

Upon client record review, 2 of 23 records (Patient #1,#8) 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 #1: The record indicated that the patient had a stasis ulcer on her left ankle. An order dated 8/15/23 indicated to discontinue previous wound care orders. Apply skin prep daily as needed. Clean skin tear to left lateral shin with wound cleanser, apply skin prep peri wound, cover with xeroform and wrap with gauze every 4 days and prn. There was not evidence of which provider was to perform the wound care. Corrected on site. patient #8: The record indicated a wound care order to shave around the laceration, apply steri strips, cleanse with water, apply a band-aide. Remove steri strips after 5 days. There was not evidence of a location of the wound or which provider was to complete the wound care. Corrected on site.