Brookhaven Hospice

“Upon patient record review, 1 of 20 (Patient #16) 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 #16: There was no evidence of initial bereavement assessment by RN, SC, MSW.”

“Upon patient record review, 1 of 20 (Patient #4) 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 #4: All MSW visits (6/17, 7/14, 8/6, 9/22, 10/17, 11/18/25) made by telephone only with no option presented to patient (per home visit interview). Telephone visits were not specified in the plan of care.”

“Upon patient record review, 5 of 20 (Patient #1, 2, 3, 4, 10) did not have evidence the plan of care must 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 • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #1: 10/2/25 MSW frequency 1-2/month and 6 prn. No detailed scope and frequency with too many PRN visits. Patient #2: 9/26/25 MSW 2/month and 6 prn. Vol 1/month and 3 prn. No detailed scope and frequency. with too many PRN visits. Patient #3: MSW 1/mo. and 6 prn. No detailed scope and frequency with too many PRN visits. Patient #4: 6/15/25 SN 1-2/wk. and 6/16/25 SN 8 prn. MSW 1/month and 5 prn. No detailed scope and frequency with too many PRN visits. Patient #10: 7/25/25 SN 2x/wk and 5 prn. No detailed scope and frequency with too many PRN visits.”

“Upon patient record review, 2 of 20 (Patient #4, 8) 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 #4: Home patient admitted 6/13/25 with indwelling Foley catheter in place. Plan of care does not include specific orders regarding plan for changing or not changing catheter routinely and/or for complications. The plan of care includes red skin: skin prep, barrier. Family provides care; prn hospice nurse. Treatment orders do not include location and/or specific barrier to be used. Patient #8: Patient admitted 10/31/25 with Foley catheter in place. Plan of care does not include specific order or intervention regarding plan for changing or not changing catheter routinely and/or for complications.”

“Upon patient record review 1 of 20 (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: SNF resident admitted 10/23/25. 10/27/25 MSW visit notes that patient reported being lonely and bored… noted patient was very engaged in conversation. 10/27/25 SN note referenced that patient was being visited from volunteer department. It was unclear if volunteer was hospice or facility. Interview with staff unable to verify if agency volunteer referral received. There is no reference to discussion, offer or referral for volunteer service for companionship.”

“Upon patient record review, 4 of 20 (Patient #16, 17, 18, 19) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • 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 Patients #16, 17, 18, 19: Agency was unable to provide evidence of ongoing bereavement services up to 1 year following the death of the patient. Evidence of mailing is stored in spread sheet that was not available.”

“Upon patient record review, 1 of 20 (Patient #8) 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 for a hospice aide 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 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #8: Patient admitted with colostomy - with no reference/identification of colostomy to alert aide noted in aide care plan.”

“Upon patient client record review, 2 of 20 (Patient #6,10) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #6: SNF resident admitted 11/5/25. Initial RN assessment includes documentation of hospice aide supervision although no aide service provided at that time. In addition, the patient was admitted with multiple wounds. 11/5 Initial visit, 11/6/25, 11/11/25 SN notes say dressings changed yes. Per orders. See care plan. RN documentation did not provide detail of wound care performed or how they tolerated wound care. Patient #10: SNF resident admitted 7/25/25, the patient currently has Stage 2 left hip pressure wound, first identified 11/25/25. SN noted Wound care. Yes. Per orders. See care plan. RN documentation did not provide detail of wound care performed or how they tolerated wound care.”

“Upon client record review, 6 of 20 (Patient #5, 6, 7, 9, 10, 11) 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 #5: SNF resident admitted 10/28/25. Initial RN visit nurse noted BLLE and left forearm wound care: performed this visit yes. Per orders. See care plan. Problems, goals, interventions/Plan of Care do not include specific wound care orders. Patient #6: SNF resident admitted 11/5/25 with MSW frequency of 1x/month. First visit 12/1/25, with no visit for November and no explanation for delay. Admitted with multiple wounds. 11/5 Initial visit, 11/6/25, 11/11/25 SN notes say dressings changed yes. Per orders. See care plan. Problems, goals, interventions/Plan of Care includes Coordinate wound care with facility staff. Facility to perform wound care daily. During patient visit, noted no current wound care with all wounds healed. Hospice problems, goals, interventions/plan of care do not reflect updated 11/21/25 assessment of healed wounds. Patient #7: SNF resident with order 10/31/25 Vol 1/month through 11/30/25 when order discontinued. Clinical note by Volunteer Coordinator to start volunteer for companionship 1x/month. There was no documented evidence that the visit was made and/or refused. Patient #9: SNF resident admitted 10/8/25. Noted NP visits 11/12, 11/18, 11/26/25 related to knee wound with treatment recommendations by NP. Problems, goals, interventions/plan of care not updated to reflect NP treatment recommendations. Patient #10: SNF resident admitted 7/25/25 with SC frequency 1x/month. No documented visits provided Aug, Sept, Oct or Nov. Currently has Stage 2 left hip pressure wound, first identified 11/25/25. SN noted Wound care. Yes. Per orders. See care plan. The plan of care did not include specific wound care orders. During facility visit, noted facility record to have specific treatment orders. RN updated hospice Plan of Care following visit. Patient #11: SNF resident with MSW frequency 1x/month for 8/25 and 10/24/25 benefit periods. There were no documented orders for PRN visits. Patient was seen 8/25, 9/24, 10/22, 10/29, 11/6, 11/18/25.”

“Upon client record review, 2 of 20 (Patient #5,10) 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 #5: SNF resident admitted 10/28/25. Initial RN visit nurse noted BLLE and left forearm wound care: performed this visit yes. Per orders. See care plan. Problems, goals, interventions/Plan of Care do not include specific wound care orders of who would perform the dressing changes. Patient #10: SNF resident admitted 7/25/25 , the patient currently has Stage 2 left hip pressure wound, first identified 11/25/25. SN noted Wound care. Yes. Per orders. See care plan. Problems, goals, interventions/Plan of Care do not include specific wound care orders of who would perform the dressing changes. During facility visit, noted facility record to have specific treatment orders. RN updated hospice Plan of Care following visit.”