Beacon Hospice Care

Quality assessment & performance improvement (42 CFR 418.58)

“Observed in Data Session. The organization failed to ensure the QAPI program involve all hospice services to include those services provided under contract or arrangement. When reviewing the QAPI program there was no documentation of including volunteer, bereavement, and contracted services in the QAPI plan. This observation was reviewed with the QAPI Coordinator and the Alternate Administrator.”

Rule L0559. Condition-level.

Core services (42 CFR 418.64)

“Observed in Tracer Activities. The organization failed to routinely provide substantially all core services directly by hospice employees to include medical social services. On discussion with the Operations Manager, DPCS, and the Medical Social Worker (MSW) it was revealed that the core services of the MSW were provided under contract as a 1099 contractor and not provided directly by the organization as required. This observation was reviewed with the Operations Manager, and DPCS.”

Rule L0587. Condition-level.

Governing body and administrator (42 CFR 418.100(b))

“Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by the leadership did not ensure that the Conditions of Participation for 418.58, and 418.64 were met per policy as determined through observations, documentation, and staff interviews.”

Rule L0651. Condition-level.

Rights of the patient (42 CFR 418.52(c)(4))

“Observed in Record Review. In 4 of 10 patient records reviewed, the organization failed to ensure the patient’s right to choose and attending physician. On review of RRHV#2, RRNHV#4, RRNHV#7, and RRNHV#10 the section to choose an attending physician was left blank on the patient’s election of benefits was left blank. This observation was reviewed with the DPCS.”

Rule L0515. Standard-level.

Content of comprehensive assessment (42 CFR 418.54(c)(5))

Rule L0529. Standard-level.

Patient outcome measures (42 CFR 418.54(e)(2))

“Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to maintain complete and accurate records. On review of RRNHV#9 the hospice aide services were declined after November 2024, yet the RN continued to document aide supervisory visits up until current most recent visit. This observation was reviewed with the DPCS.”

Rule L0535. Standard-level.

Content of plan of care (42 CFR 418.56(c)(1))

Rule L0546. Standard-level.

In-service training (42 CFR 418.76(d))

“Observed in HR File Review. In 1 of 1 HR files reviewed, for the hospice aide, the organization failed to ensure the hospice aide participate in at least 12 hours of in-service training during each 12 month period. On review of the organization process to provide 12 hours of annual aide in-services training, there was not 12 hours of training documented for HR#4 aide. This observation was reviewed with the Intake Coordinator/HR director.”

Rule L0620. Standard-level.

Hospice aide assignments and duties (42 CFR 418.76(g)(2)(ii))

“Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure the hospice aide provided services that are ordered by the physician or allowed practitioner as assigned in the plan of care. On review of RRHV#1 the Aide’s plan of care assigned a bed bath yet the aide documented each visit that shower was given or assisted with shower. This observation was reviewed with the DPCS.”

Rule L0626. Standard-level.

Supervision of hospice aides (42 CFR 418.76(h)(1)(i))

“Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure that a registered nurse supervise the hospice aide during an on-site visit to the patient’s home no less frequently that every 14 days. On review of RRHV#1 there was a 28 day gap in aide supervisory visits from March to April. This observation was reviewed with the DPCS.”

Rule L0629. Standard-level.

Recertification of the terminal illness (42 CFR 418.102(c))

“Observed in Record Review. In 5 of 8 patient records reviewed, with recertifications, the organization failed to ensure complete and accurate records. For example: on review for RRHV#3 the Certificate of Terminal Illness narrative by the hospice Medical Director remained nearly identical from certification to recertification and failed to address how the patient continued to meet the criteria for terminal status with current subjective and objective findings. Similar finding can be seen in RRNHV#5, RRNHV#6, RRNHV#7, and RRNHV#10. This observation was reviewed with the DPCS.”

Rule L0668. Standard-level.

Content (42 CFR 418.104(a)(3))

Rule L0674. Standard-level.

Authentication (42 CFR 418.104(b))

Rule L0679. Standard-level.

Criminal background checks (42 CFR 418.114(d)(1))

“Observed in HR File Review. In 1 of 8 HR files reviewed, the organization failed to obtain a criminal background check on hospice employees that have direct patient contact or access to patient records. On review of HR#8 for the hospice volunteer there was no documentation that a criminal background check was obtained. This observation was reviewed with the Intake Coordinator/HR Director.”

Rule L0795. Standard-level.