Beacon Home Health

“Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA’s policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This Standard is not met as evidenced by: Based on policy review, medical record review, and interviews, the agency failed to ensure contact information of other home health agencies were provided for 1 (Patient #1) of 3 patients reviewed for discharge. The findings included: Review of the agency’s policy titled “Discharge of Patients,” last reviewed 02/11/2026, revealed “...The HHA [home health agency] may only transfer or discharge the patient from the HHA if...The HHA determines...that the patient’s (or other persons in the patient’s home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired...Provide the patient and representative...with contact information for other agencies...who may be able to provide care...” Review of the medical record revealed Patient #1 was admitted to the agency on 08/15/2026. The patient’s diagnoses included Chronic Obstructive Pulmonary Disease (COPD), Hyperlipidemia, Obstructive Sleep Apnea, and Polyneuropathy. Review of the Discharge Order dated 10/06/2025, revealed “...NON VISIT DC [discharge] TO BE PERFORMED DT [due to] THREATENING MESSAGES AND UNSAFE ENVIRONMENT MD [medical doctor] IS AWARE...” The agency provided no documentation that contact information was given to Patient #1 for home health agencies potentially able to provide care. During a phone interview on 07/06/2026 at 3:30, Patient #1 said the agency did not provide contact information for any other home health agencies who could potentially provide care. She said, “They just dropped me.” During an interview on 07/10/2026 at 10:20 AM, the Branch Director said she did not have any documentation that she provided contact information for other home health agencies to Patient #1.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on policy review, observation, and interview, the agency failed to perform appropriate hand hygiene by 1 of 2 (Licensed Practical Nurse (LPN) #2) nurses observed performing wound care. The findings included: Review of the agency’s “Hand Hygiene,” policy dated 6/26/2024, revealed, “…The term hand-hygiene includes both handwashing with soap and water and use of alcohol-based products that do not require the use of water…Perform hand hygiene as follows…Before donning gloves…After removing gloves…” Review of the medical record revealed Patient #7 was admitted with a start of care date of 1/28/2025 with diagnoses of Stage 3 Sacral Pressure Ulcer, Non-Pressure Chronic Ulcer of Left Lower Leg, Burn of Left Lower Leg, Adjustment of Urinary Catheter, Anxiety, and Paraplegia. Review of the physician order dated 4/21/2025, revealed, “…CLEAN WITH WOUND CLEANSER AND PAT DRY…APPLY SKIN PROTECTANT TO ALL SURROUNDING SKIN FOR INCREASED PROTECTION FROM URINE…APPLY CALCIUM ALGINATE [substance that forms a protective gel and non-adherence to the wound] TO OPEN SORE AND COVER WITH BORDERED GAUZE [dressing with a non-adherent pad in the center surrounded by a flexible adhesive border to secure the dressing in place]…NURSING TO CHANGE 1XWEEK [one time each week] AND CAREGIVER TO CHANGE IF LOOSE OR SOILED…” Observations in Patient #7’s home on 4/29/2025 at 11:05 AM, revealed LPN #2 performed a dressing change to Patient #7’s sacrum. LPN #2 failed to perform hand hygiene 3 times between glove changes during the removal of the soiled dressing and the cleaning of the wound and failed to perform hand hygiene 2 times between glove changes during the application of the new dressing. During an interview on 4/29/2025 at 11:45 AM, LPN #2 confirmed she was supposed to perform hand hygiene between each glove change. During an interview on 4/30/2025 at 915 AM, Director of Operations #1 confirmed staff were to perform hand hygiene between glove changes.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on policy review, medical record review, and interview, the agency failed to update the medication profile for 3 of 7 (Patient #1, #2, and #7) patients reviewed. The findings included: 1. Review of the agency’s “Drug Regimen Review,” policy last revised 12/9/2024, revealed, “...Purpose: To identify appropriateness, inconsistencies, and/or significant drug interactions in the patient’s current medication regimen, as well as ensure the comprehensive list of medications are updated any time there is a medication change including dose changes, new medications, and any medications discontinued…” 2. Review of the medical record revealed Patient #1 was admitted with a start of care date of 3/20/2025 with diagnoses of Dehiscence of Abdominal Wound, Malignant Neoplasm of Right Ovary, Diabetes Mellitus, and Hypertension. Review of the Physician Orders revealed: Minocycline (treats infection) 100 mg (milligrams) orally twice daily. Observations in Patient #1’s home on 4/28/2025 at 2:17 PM, revealed the following medications: Eliquis (anticoagulant) 2.5 mg orally twice daily. Over the counter (OTC) Vitamin E (supplement) 180 mg (400 IU [international units]) orally every day. The Eliquis and OTC Vitamin E were not listed on Patient #1’s medication list from the agency. During an interview on 4/28/2025 at 3:05 PM, Patient #1 confirmed she was taking Eliquis and Vitamin E, but she was not taking Minocycline. 3. Review of the medical record revealed Patient #2 was admitted with a start of care date of 4/17/2025 with diagnoses of Orthopedic Aftercare and Presence of Right Artificial Hip Joint. Review of the Physician Orders revealed: Amlodipine (treats high blood pressure) 5 mg orally every day. Cefadroxil (treats infection) 500 mg orally every day. Observations in Patient #2’s home on 4/28/2025 at 3:15 PM, revealed the following medications: OTC Jet-Asleep Nighttime Hydroxyzine 50 mg orally three times daily Furosemide (treats fluid retention and swelling) 20 mg orally every day. OTC Allergy Relief 4 mg orally as needed. The OTC Jet-Asleep Nighttime, hydroxyzine, furosemide, and OTC Allergy Relief medications were not listed on Patient #2’s medication list from the agency. During an interview on 4/28/2025 at 4:10 PM, Patient #2 stated “If it is not in that basket, I don’t take it.” She confirmed she had not taken Amlodipine in a long time and was not currently taking the cefadroxil. 4. Review of the medical record revealed Patient #7 was admitted with a start of care date of 1/28/2025, with diagnoses of Stage 3 Sacral Pressure Ulcer, Non-Pressure Chronic Ulcer of Left Lower Leg, Burn of Left Lower Leg, Adjustment of Urinary Catheter, Anxiety, and Paraplegia. Review of the Physician Orders revealed: Potassium chloride 10 extended release 10 meq 2 tablets twice daily. Observations in Patient #7’s home on 4/29/2025 at 11:35 AM, revealed the following medications: OTC naproxen (treats symptoms of arthritis) 2 bottles of OTC aspirin (treats pain) 325 mg orally as needed. L-Lysine (enzyme) 75 mcg (microgram) orally every morning. 1 bottle of OTC ibuprofen. 1 bottle of OTC milk thistle 175 mg 1 bottle of Milk of Magnesia 1 bottle of potassium chloride liquid 20 meq (milliequivalent)/5 ml (milliliter) 15 ml (60 meq) orally twice daily OTC triamcinolone acetonide nasal spray There were no potassium chloride 10 meq extended release tablets observed with Patient #7’s medications. The naproxen, aspirin, L-lysine, ibuprofen, milk thistle, Milk of Magnesia, potassium chloride liquid, and OTC triamcinolone acetone nasal spray were not listed on Patient #7’s medication list from the agency. During an interview on 4/29/2025 at 11:05 AM, LPN #2 stated, “…the daughter gives the patient her medications, and they come from the pharmacy in a bubble pack…” During a telephone interview on 4/29/2025 at 2:01 PM, Pharmacist #1 confirmed Patient #7 received her medications from their pharmacy. Pharmacist #1 stated, “…We do pack this patient’s [Patient #7] medications. A receipt and medication information are stapled to the bag of bubble packs when they are paid for and picked up…” 5. During an interview on 4/30/2025 at 9:20 AM, Director of Operations #1 confirmed medications were to be reconciled with each home visit.”