Beacon Hospice, An Amedisys Company

“Upon patient record review, 1 of 19 (Patient #11) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments: Patient #11: The Physician SOC CTI referenced: 1) Stage II pressure ulcer R hip; 2) Stage II pressure ulcer thoracic spine; and 3) Deep Tissue injury to L hip. Wound care was documented as being provided for all three of these sites. However, the SOC POC included only the following order: RN perform/teach patient/caregiver pressure ulcer care to _____. Irrigate/cleanse with _____. Apply _____. Cover with _____. Secure with _____. Change every _____ days, and p.r.n. for _____. There were no other interim wound care orders located. This is not a complete wound care order.”

“Upon patient record review, 1 of 19 (Patient #9) did not contain evidence that the Hospice Plan of Care identified 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 #9: A verbal order was obtained on 06/10/24 for, “SN to perform wound care to Sacrum Stage II. Cleanse with wound cleanser, apply calcium alginate, may apply skin barrier to peri-wound. Cover with foam dressing. Change every day, and prn soiling”. This is an incomplete order, as it does not include ‘who’ is responsible for this dressing change on days that the Hospice nurse is not completing it.”

“Based on clinical record reviews, review of agency policies and interview with agency personnel for one of two patients (Patients #1) in the survey sample, the hospice agency failed to conduct a patient specific assessment with a change in condition to ensure the patient’s safety, psychosocial, emotional, and physical needs were met. The finding includes: Patient #1 elected the Hospice benefit on 12/17/2023 with diagnoses that included muscle weakness, difficulty walking, severe protein-calorie malnutrition, dysphagia, seizures, cardiac disease, and dementia. The physicians orders dated 12/17/2023 included nursing services once a week for symptom management and assessments, home health aide services once a week for assistance with activities of living, and a social worker evaluation for caregiver support. Review of Patient #1s hospice start of care summary dated 12/17/2023, identified Patient #1 was hospitalized after having a seizure, admitted to a skilled nursing facility for rehabilitation services and discharged to a private home to reside with a caregiver. The hospice agencys Medical Director approved end of life services related to Patient #1s severe protein-calorie malnutrition after a twenty-six-pound weight loss since 11/2023. The start of care summary further identified the home environment presented with no safety issues and the caregiver was assisting the Patient with ambulation, transfers from the chair to the bed, dressing, bathing, incontinence care, housekeeping, meal preparation, shopping, and laundry. The admitting Registered Nurse (RN) identified no signs of neglect or abuse and the caregiver had no limitations but would need respite care or sitter services to meet the Patients increasing care needs. Review of Social Worker #1s clinical note dated 01/09/2024, identified an as needed visit was made related to Patient #1s increased care needs, an unclean living environment, and the caregiver leaving the Patient home alone after being advised not to by the primary case manager RN #1. Social Worker #1 offered the Patients caregiver additional support in the home, but the caregiver declined. Review of RN #1s clinical notes dated 01/18/2024, 01/26/2024, and 01/30/2024 identified providing Patient #1s caregiver with education about safety concerns in the home, and the importance of not leaving the Patient alone for any period due to increased confusion and weakness. Review of Social Worker #1s clinical note date 01/30/2024, identified Social Worker #1 spoke with the Patients caregiver about the Patients increased care needs, safety concerns, and the need for an additional caregiver in the home. The Patients caregiver declined assistance and indicated having people who could assist if needed. Review of Social Worker #1s clinical note dated 02/15/2024, identified a joint visit was conducted with RN #1. Patient #1 was anxious, agitated and the caregiver appeared stressed but continued to decline the need for supportive services. Review of the Administrators case coordination note dated 02/21/2024, identified contacting Patient #1s caregiver on 02/21/2024 to discuss concerns for the unclean home environment, the caregivers ability to safely manage the Patients medications and leaving the Patient home alone. Review of RN #2s clinical note dated 02/28/2024, identified Patient #1s caregiver contacted the hospice agencys answering service to report the Patient was confused and vomiting. Upon arrival to the Patients home, RN #2 identified the Patient was lying on the floor covered in feces and vomit. Patient #1s caregiver indicated the Patient may have eaten old food from the wastebasket which resulted in him/her vomiting. RN #2 advised the caregiver that Patient #1 needed to be transferred to the hospital bed and cleaned. The caregiver indicated the Patient sleeps on the couch, and he/she sleeps in the hospital bed provided by the hospice. RN #2 assisted the Patient to the hospital bed and attempted to clean the Patient, but the caregiver lacked necessary supplies such as washcloths, a wash basin, clean clothing, or linen. RN #2 cleaned the Patient with paper towels. RN #2 left the home and contacted SCS #1 to report the unsafe and concerning conditions in the Patients home. Interview and review of Patient #1s clinical record with RN #1 on 03/11/2024 10:40 AM, identified the Patients home environment as cluttered, with unclean surfaces, a strong odor present and waste overflowing from the wastebasket. RN #1 indicated the Patient appeared disheveled and the caregiver was unable to safely manage the Patients medications. RN #1 identified the caregiver reported having weapons in the home and would become agitated toward the hospice staff and the Patient. RN #1 and Social Worker #1 reported the concerns to the Administrator and the Supervisor of Clinical Services (SCS) #1 at the beginning of February 2024. Social Worker #1 left a message for Protective Services for the Elderly on 02/21/2024 and filed a report with Protective Services for the Elderly on 02/27/2024. The Administrator and SCS #1 advised hospice clinicians to not return to Patient #1s home but did not discharge the Patient. Interview and review of Patient #1s clinical record with the Administrator on 03/11/2024 at 12:00 PM, identified RN #1 and Social Worker #1 reported the Patients living conditions as unsanitary and the caregiver was unable to safely care for the Patient. The Administrator indicated the Patient was not discharged for cause from the hospice agency, but clinicians were advised not to return to Patient #1s home after Protective Service for the Elderly was contacted on 02/21/2024. The Administrator identified Patient #1 was visited by hospice clinicians on 02/15/2024 and did not receive another visit until 02/28/2024. The Administrator identified hospice services were not provided for twelve days (02/16/2024 to 02/27/2024), as the agency was waiting for directives from the Regional Managers of Clinical Services. The Administrator indicated after RN #2 reported concerns for Patient #1’s safety on 02/28/2024, SCS #1 contacted the police and the Patient was removed from the home. Interview with the Regional Vice President of Clinical Services on 03/11/2024 1:00 PM, identified the hospice agency failed to conduct a comprehensive patient assessment with a change in the Patient’s condition (vomiting, fall and suspected abuse or neglect) to ensure the Patient’s safety, psychosocial, emotional and physical needs were met. Review of the agencys Assessments policy, identified the hospice conducts patient specific assessments at the time of admission, signification change and on an ongoing basis as the condition of the patient requires. The comprehensive assessment identifies the physical, psychosocial, emotional, behavioral and spiritual needs of the patient are addressed in order to promote the hospice patient’s wellbeing, comfort and dignity throughout the dying process.”

“Based on clinical record reviews, review of agency policies and interview with agency personnel for one of two patients (Patients #1) in the survey sample, the hospice agency failed to ensure the patient’s right to be free from abuse or neglect and failed to follow the agency policies. The finding includes: Patient #1 elected the Hospice benefit on 12/17/2023 with diagnoses that included muscle weakness, difficulty walking, severe protein-calorie malnutrition, dysphagia, seizures, cardiac disease, and dementia. The physicians orders dated 12/17/2023 included nursing services once a week for symptom management and assessments, home health aide services once a week for assistance with activities of living, and a social worker evaluation for caregiver support. Review of Patient #1s hospice start of care summary dated 12/17/2023, identified Patient #1 was hospitalized after having a seizure, admitted to a skilled nursing facility for rehabilitation services and discharged to a private home to reside with a caregiver. The hospice agencys Medical Director approved end of life services related to Patient #1s severe protein-calorie malnutrition after a twenty-six-pound weight loss since 11/2023. The start of care summary further identified the home environment presented with no safety issues and the caregiver was assisting the Patient with ambulation, transfers from the chair to the bed, dressing, bathing, incontinence care, housekeeping, meal preparation, shopping, and laundry. The admitting Registered Nurse (RN) identified no signs of neglect or abuse and the caregiver had no limitations but would need respite care or sitter services to meet the Patients increasing care needs. Review of Social Worker #1s clinical note dated 01/09/2024, identified an as needed visit was made related to Patient #1s increased care needs, an unclean living environment, and the caregiver leaving the Patient home alone after being advised not to by the primary case manager RN #1. Social Worker #1 offered the Patients caregiver additional support in the home, but the caregiver declined. Review of RN #1s clinical notes dated 01/18/2024, 01/26/2024, and 01/30/2024 identified providing Patient #1s caregiver with education about safety concerns in the home, and the importance of not leaving the Patient alone for any period due to increased confusion and weakness. Review of Social Worker #1s clinical note date 01/30/2024, identified Social Worker #1 spoke with the Patients caregiver about the Patients increased care needs, safety concerns, and the need for an additional caregiver in the home. The Patients caregiver declined assistance and indicated having people who could assist if needed. Review of Social Worker #1s clinical note dated 02/15/2024, identified a joint visit was conducted with RN #1. Patient #1 was anxious, agitated and the caregiver appeared stressed, but continued to decline the need for supportive services. Review of the Administrators case coordination note dated 02/21/2024, identified contacting Patient #1s caregiver on 02/21/2024 to discuss concerns for the unclean home environment, the caregivers ability to safely manage the Patients medications and leaving the Patient home alone. Review of RN #2s clinical note dated 02/28/2024, identified Patient #1s caregiver contacted the hospice agencys answering service to report the Patient was confused and vomiting. Upon arrival to the Patients home, RN #2 identified the Patient was lying on the floor covered in feces and vomit. Patient #1s caregiver indicated the Patient may have eaten old food from the wastebasket which resulted in him/her vomiting. RN #2 advised the caregiver that Patient #1 needed to be transferred to the hospital bed and cleaned. The caregiver indicated the Patient sleeps on the couch, and he/she sleeps in the hospital bed provided by the hospice. RN #2 assisted the Patient to the hospital bed and attempted to clean the Patient, but the caregiver lacked necessary supplies such as washcloths, a wash basin, clean clothing, or linen. RN #2 cleaned the Patient with paper towels. RN #2 left the home and contacted SCS #1 to report the unsafe and concerning conditions in the Patients home. Interview and review of Patient #1s clinical record with RN #1 on 03/11/2024 10:40 AM, identified the Patients home environment as cluttered, with unclean surfaces, a strong odor present and waste overflowing from the wastebasket. RN #1 indicated the Patient appeared disheveled and the caregiver was unable to safely manage the Patients medications. RN #1 identified the caregiver reported having weapons in the home and would become agitated toward the hospice staff and the Patient. RN #1 and Social Worker #1 reported the concerns to the Administrator and the Supervisor of Clinical Services (SCS) #1 at the beginning of February 2024. Social Worker #1 left a message for Protective Services for the Elderly on 02/21/2024 and filed a report with Protective Services for the Elderly on 02/27/2024. The Administrator and SCS #1 advised hospice clinicians to not return to Patient #1s home but did not discharge the Patient. Interview and review of Patient #1s clinical record with the Administrator on 03/11/2024 at 12:00 PM, identified RN #1 and Social Worker #1 reported the Patients living conditions as unsanitary and the caregiver was unable to safely care for the Patient. The Administrator indicated the Patient was not discharged for cause from the hospice agency, but clinicians were advised not to return to Patient #1s home after Protective Service for the Elderly was contacted on 02/21/2024. The Administrator identified Patient #1 was visited by hospice clinicians on 02/15/2024 and did not receive another visit until 02/28/2024. The Administrator identified hospice services were not provided for twelve days (02/16/2024 to 02/27/2024), as the agency was waiting for directives from the Regional Managers of Clinical Services. The Administrator indicated after RN #2 reported concerns for Patient #1’s safety on 02/28/2024, SCS #1 contacted the police and the Patient was removed from the home. Interview with the Regional Vice President of Clinical Services on 03/11/2024 1:00 PM, identified the hospice agency failed to follow the Assessment and Reporting of Abuse, Neglect and Exploitation policy, Safety Management policy and the Discharge for Cause policy. The Regional Vice President of Clinical Service indicated the hospice agency failed to immediately report suspected abuse and/or neglect to the appropriate state agency, failed to coordinate care by having the Patient immediately removed from the unsafe situation, then discharge the Patient from the hospice agency due to compromised patient and staff safety. Additionally, the Vice President of Clinical Services identified the hospice agency staff failed to ensure the Patient’s safety by not providing oversight of the Patient for twelve days. Review of the agencys Assessment and Reporting of Abuse, Neglect and Exploitation policy, identified agency staff would assess, identify, and intervene on the behalf of victims of abuse and neglect and exploitation in an appropriate and professional manner. All cases of alleged, observed, or suspected abuse, neglect or exploitation would be investigated by the agency and appropriate interventions would be initiated, including mandated reported requirements in accordance with the state regulations. When abuse or neglect is suspected, the hospice staff would report the incident to the Administrator immediately and complete an incident report. If the patient is felt to be in immediate danger, the staff member would first ensure the patients personal safety and notify the Administrator. The Administrator would immediately start an investigation and notify the appropriate state agencies. Review of the agencys Discharge for Cause policy, identified the agency reserved the right to discharge patients for cause if all attempts to remediate the situation failed. There may be circumstances in which a hospice would be unable to continue to provide hospice care to a patient. These situations would include issues where the patient safety or hospice staff safety was compromised. The agency must make referrals to all relevant state agencies. The hospice would assist in coordinating continued care for the patient. Review of the agencys Safety Management policy, identified upon admission and at every visit, all patients would be assessed for falls and the home environment would also be evaluated for safety issues. Suspected or confirmed patient abuse or neglect would be reported to specified state agencies and living conditions which place patients in eminent danger.”

“Based on review of the clinical record, review of agency policies and staff interview, for two of eleven patients (Patients #1 and 2) in the survey sample, the agency licensed personnel failed to ensure accuracy and authenticity of the documentation. The finding includes: a. Patient #1 elected the Hospice benefit on 10/23/23 and resided in a Skilled Nursing Facility/SNF. Patient #1s diagnoses included senile degeneration of the brain, dementia and dysphagia. The physicians orders dated 10/23/23 included nursing services five to six times a week for symptom management and assessments, social worker and chaplain services. Interview and review of agency documentation with the Administrator on 1/04/24 at 9:30 AM identified that Patient #1 died on 10/30/23, although review of the clinical record identified that on 10/31/23 from 5:57 PM - 6:27 PM, RN#1 documented a visit with Patient #1 in the SNF. RN #1was notified of the discrepancy and was instructed that s/he was suspended pending the outcome of the investigation. On 11/6/23, RN #1 resigned his/her position without the benefit of an interview by the Administrator. Interview with the Supervisor of Clinical Services/SCS #1 on 1/04/24 at 10:16 AM identified that on 11/01/23, s/he was conducting a daily visit for Patient #1, proceeded to check in at the front desk and was notified that Patient #1 passed away on 10/30/23. The SCS indicated that s/he confirmed with the Director of Nursing at the SNF that the patient was pronounced on 10/30/23 at 11:34 PM and indicated that RN #1 documented a visit with Patient #1 on 10/31/23. Furthermore, the SCS indicated that this information was brought to the attention of the Administrator on 11/01/23. As a result of this falsification of documentation from RN #1, an investigation of RN #1s patient visits from 10/17/23 through 10/31/23 was conducted by the agencys Compliance Department. Subsequently, an investigation was initiated of RN #1s patient visits from 10/17/23 through 10/31/23 and revealed on 10/27/23 from 3:37 PM - 4:08 PM, RN #1 documented a visit with Patient #1 in the SNF, although review of the Global Positioning System/GPS coordinates of RN #1s electronic device failed to identify that a visit was conducted that day at the SNF and failed to ensure an authentic record. b. Patient #2 elected the Hospice benefit on 6/16/23 and resided in a SNF. Patient #2s diagnoses included Alzheimers disease, adult failure to thrive and anxiety. The physicians orders for the certification period of 9/14/23 to 12/12/23 included nursing services once weekly for assessments and symptom management, hospice aide services twice weekly to assist with personal care, social worker and chaplain services. Interview and review of agency documentation with the Administrator on 1/04/24 at 1:30 PM identified that on 10/17/23 from 4:03 PM - 4:36 PM, RN#1 documented a visit with Patient #2 in the SNF, although review of the GPS coordinates of RN #1s electronic device failed to identify that a visit was conducted that day at the SNF and failed to ensure an authentic record. Interview with the Vice President of Compliance on 1/04/24 at 1:13 PM indicated that a report was run of the GPS coordinates of all the visits conducted by RN #1 and identified for Patient #1, on 10/27/23 and 10/31/23 and Patient #2, on 10/17/23, RN #1s GPS coordinates failed to identify the location of the visits on 10/17/23, 10/27/23 and 10/31/23 occurred in the SNFs. Review of agency policies for Clinical Records Maintenance and Confidentiality directed all entries must be complete, and appropriately authenticated in accordance with acceptable standards of practice.”

“Based on clinical record review, review of agency policies and interview with agency personnel for two of eleven patients (Patients #1 and 2) in the survey sample, the hospice agency failed to follow agency policies and the Regulations of Connecticut State Agencies. The finding includes. Patient #1 elected the Hospice benefit on 10/23/23 and resided in a Skilled Nursing Facility/SNF. Patient #1s diagnoses included senile degeneration of the brain, dementia and dysphagia. The physicians orders dated 10/23/23 included nursing services five to six times a week for symptom management and assessments, social worker and chaplain services. Interview and review of agency documentation with the Administrator on 1/04/24 at 9:30 AM identified that Patient #1 died on 10/30/23, although review of the clinical record identified that on 10/31/23 from 5:57 PM - 6:27 PM, RN #1 documented a visit with Patient #1 in the SNF. Subsequently, an investigation was initiated of RN #1s patient visits from 10/17/23 through 10/31/23 and revealed on 10/27/23 from 3:37 PM - 4:08 PM, RN #1 documented a visit with Patient #1 in the SNF, although review of the GPS coordinates of RN #1s electronic device failed to identify that a visit was conducted that day at the SNF and failed to follow agency policies for visit authentication and code of conduct. b. Patient #2 elected the Hospice benefit on 6/16/23 and resided in a SNF. Patient #2s diagnoses included Alzheimers disease, adult failure to thrive and anxiety. The physicians orders for the certification period of 9/14/23 to 12/12/23 included nursing services once weekly for assessments and symptom management, hospice aide services twice weekly to assist with personal care, social worker and chaplain services. Interview and review of agency documentation with the Administrator on 1/04/24 at 1:30 PM identified that on 10/17/23 from 4:03 PM – 4:36 PM, RN#1 documented a visit with Patient #2 in the SNF, although review of the GPS coordinates of RN #1s electronic device failed to identify that a visit was conducted that day at the SNF and failed to follow agency policies for visit authentication and code of conduct. Review of agency policies for Code of Conduct directed longstanding policies and guidelines to ensure its business is conducted with integrity and in compliance with applicable laws, rules and regulations. No medical record should ever be falsified, altered or otherwise written in such a way that it does not accurately reflect the services actually provided and agency policies for Clinical Records Maintenance and Confidentiality directed all entries must be complete, and appropriately authenticated in accordance with acceptable standards of practice.”