Every finding on record at Accentcare of Massachusetts, Inc.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following, the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (11%) home visits observed, the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient's current medications. HOME VISIT 1/CLINICAL RECORD 11: The patient elected hospice care on 03/25/2024 with a diagnosis of senile degeneration of the brain. The patient resided in a skilled nursing facility (SNF). The hospice medication profile printed on 10/07/2025 documented "morphine concentrate 100 mg/5 ml (20 mg/ml) oral solution, give 0.25 ml every 3 hours orally as needed for breakthrough pain/sob [shortness of breath]," started 07/26/2024. During the home visit with the Chaplain (SC) [Personnel Record 7] on 10/08/2025, the SNF medication profile did not document morphine concentrate. The SNF nurse confirmed that morphine concentrate was not documented on the SNF medication record and was not in the facility for use. HOME VISIT 2/CLINICAL RECORD 12: The patient elected hospice care on 03/29/2024. The patient resided in a SNF. The hospice medication profile printed on 10/07/2025 documented "clotrimazole-betamethasone 1 %-0.05 % topical cream, apply a thin layer to the rash on the back 2 times a day as needed," started 04/10/2025. During the home visit with the Hospice Aide (HA) [Personnel Record 8] on 10/08/2025, the SNF medication profile documented "atorvastatin 20 mg tablet, take one (1) tablet orally at bedtime, started 01/31/2020; glucagon hcl 1 mg/ml solution for injection, give one (1) mg by injection 2 times daily as needed for severe hypoglycemia and unresponsive, started 12/26/2023; hydrocortisone 0.5 % topical cream, apply a small amount 3 times a day as needed for itching, started 04/27/2023; and One Daily Multivitamins with minerals 4.5 mg iron tablet, take one (1) tablet orally daily, started 02/14/2022. The SNF medication profile did not document the use of clotrimazole-betamethasone. The SNF nurse stated that the patient had previously used clotrimazole-betamethasone. The hospice medication profile documented the following discontinuation dates: atorvastatin on 05/28/2025, glucagon hcl on 10/02/2024, hydrocortisone cream on 02/01/2025, and One Daily Multivitamin on 05/28/2025. The SNF nurse verified that the patient was receiving atorvastatin and One Daily Multivitamin routinely, and the glucagon and hydrocortisone were available as needed. The medication profile was not updated when changes were made. During a joint clinical record review and interview on 10/08/2025, the Executive Director/Registered Nurse confirmed that there was no documented evidence that the medications were reconciled at the time of each comprehensive assessment and updated to the drug profile. The Executive Director/Registered Nurse explained that the Hospice Medical Director/Physician is contacted for medication changes. Then, a recommendation is presented to the facility's physician for confirmation or denial of the request for the change.

It is required that a hospice aide provide services: included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 13 (15%) clinical records reviewed of patients receiving Hospice Aide (HA) services, the agency did not ensure that the HA provided services included in the plan of care. CLINICAL RECORD 14: The patient elected hospice care on 12/19/2024 with a diagnosis of unspecified protein-calorie malnutrition. The HA care plan dated 08/18/2025 assigned the HA the relevant tasks: "assist to toilet, partial sponge bath, deodorant, dressing, hair care, nail care - clean nails, nail care - file nails, perineal care, post mortem care - once at time of death, skin care, fall precautions, maintain isolation precautions - universal precautions, use assistive devices for transfers, offer fluids, date of last BM [bowel movement], - notify RNCM (Registered Nurse Case Manager) is no BM in 3 days or greater, other (please describe) - companionship." The HA visit notes dated 08/21/2025, 08/26/2025, 08/28/2025, 09/02/2025, 09/04/2025, and 09/08/2025 documented, "Shaved, barrier cream to hip, ambulated." Shaving and ambulating were not assigned as tasks in the care plan. CLINICAL RECORD 18: The patient elected hospice care on 12/28/2024 with a diagnosis of unspecified sequelae of cerebral infarctions. The patient resided in a skilled nursing facility (SNF). The HA care plans dated 12/28/2024 and 03/07/2025 assigned the HA the relevant tasks: "bed bath, oral care, perineal care, shaving (no frequency)." The HA visit note dated 12/31/2024 documented, "Washed pt (patient) bottom half. Fed (patient) (patient) ate 100 percent. Notified facility aide and facility nurse." The Aide Hospice Visit note dated 01/02/2025 documented, "Washed, lotioned, dressed pt and repositioned..." The HA visit note dated 01/06/2025 documented, "tasks already completed" for bed bath, perineal care, and shaving. The narrative stated, "Washed lotioned, and transferred pt to chair with help from facility aide." Feeding, applying lotion, and repositioning the patient were not assigned as tasks in the care plan. During a joint clinical record review and interview on 10/10/2025, the Director of Clinical Operations confirmed that the HA provided services not included in the HA care plan.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 3 of 13 (23%) clinical records reviewed with Hospice Aide services, the agency did not ensure that the HA notified the Registered Nurse (RN) of the changes in the patient’s needs. CLINICAL RECORD 14: The patient elected hospice care on 12/19/2024 with a diagnosis of unspecified protein-calorie malnutrition. The HA care plan dated 08/18/2025 assigned the HA the relevant tasks: "assist to toilet, partial sponge bath, deodorant, dressing, hair care, nail care - clean nails, nail care - file nails, perineal care, skin care, fall precautions, maintain isolation precautions - universal precautions, use assistive devices for transfers, offer fluids, date of last BM [bowel movement], - notify RNCM (Registered Nurse Case Manager) is no BM in 3 days or greater, other (please describe) - companionship." The HA visit notes dated 08/21/2025, 08/26/2025, 08/28/2025, 09/02/2025, 09/04/2025, and 09/08/2025 documented, "Shaved, barrier cream to hip, ambulated." Shaving and ambulating were not assigned as tasks in the care plan. A clinical record review revealed no evidence that the Registered Nurse (RN) was notified of changes to the plan of care. CLINICAL RECORD 18: The patient elected hospice care on 12/28/2024 with a diagnosis of unspecified sequelae of cerebral infarctions. The patient resided in a skilled nursing facility (SNF). The HA care plans dated 12/28/2024 and 03/07/2025 assigned the HA the relevant tasks: "bed bath, oral care, perineal care, shaving (no frequency)." The HA visit note dated 12/31/2024 documented, "Washed pt (patient) bottom half. Fed (patient) (patient) ate 100 percent. Notified facility aide and facility nurse." The Aide Hospice Visit note dated 01/02/2025 documented, "Washed, lotioned, dressed pt and repositioned..." The HA visit note dated 01/06/2025 documented, "tasks already completed" for bed bath, perineal care, and shaving. The narrative stated, "Washed lotioned, and transferred pt to chair with help from facility aide." Feeding, applying lotion, and repositioning the patient were not assigned as tasks in the care plan. A clinical record review revealed no evidence that the RN was notified of changes to the plan of care. CLINICAL RECORD 19: The patient elected hospice care on 05/05/2023 with a diagnosis of hypertensive heart disease with heart failure. The patient resided in a SNF. The HA care plan dated 05/23/2025 assigned the HA the relevant tasks: "assist to toilet, bathing - bed bath, deodorant, dressing, hair care, hail care - clean nails, perineal care, skin care, transfer client from bed/chair, transfer client from chair/bed, fall precautions, maintain isolation precautions - universal precautions, use assistive devices for transfers - walker, empty trash, date of last BM- notify RNCM if no BM in 3 days or greater, and other (please describe) - provide companionship, bleeding precautions. Hospice aide services began on 05/11/2023. The HA visit note dated 05/28/2025 documented "not required this visit" for: assist to toilet, clean nails, and transfers client from bed/chair; "task already completed" for: bed bath, deodorant, hair care, skin care, perineal care, dressing, transfer client from bed/chair; and the narrative stated, "Facility provided care. Companionship provided." The HA visit note dated 06/02/2025 documented "not required this visit" for: assist to toilet, and transfer client from chair/bed; "task already completed" for: bed bath, deodorant, hair care, skin care, perineal care, dressing, and transfer client from bed/chair; and the narrative documented, "facility provided care. This HA provided nail care and companionship. Set pt up with lunch." The HA visit note dated 06/25/2025 documented "not required this visit for": assistive devices for transfers, assist to toilet were documented, clean nails, dressing, transfer client from bed/chair, and transfer client from chair/bed, and "task already completed for: "bed bath, deodorant, and hair care. A clinical record review revealed no evidence that the RN was notified of changes to the plan of care. During a joint clinical record review and interview on 10/10/2025, the Director of Clinical Operations confirmed that the HA had not notified the RN of changes to the plan of care.

It is required that hospice aides are supervised by a registered nurse who makes 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] ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s needs. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the HA was supervised by a Registered Nurse (RN) during an on-site visit to the patient’s home, at least every 14 days. CLINICAL RECORD 8: The patient elected hospice care on 04/21/2025. Hospice Aide services began on 04/22/2025 and were ordered five (5) times a week. The RN completed HA supervisory visits on 07/08/2025 and 07/25/2025, with 17 days outstanding. The RN completed HA supervisory visits on 09/12/2025 and 09/30/2025, with 18 days outstanding. A clinical record review revealed no evidence that the supervisory visits occurred at least every 14 days. During a joint clinical record review and interview on 10/10/2025, the Director of Clinical Operations confirmed that the RN did not conduct on-site supervisory visits at least every 14 days.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—include at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of live discharges, the agency did not ensure the discharge summary included at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. CLINICAL RECORD 15: The patient elected hospice care on 09/05/2024 and revoked it on 02/28/2025. A clinical record review revealed no completed discharge summary documenting the patient’s hospice stay, including treatments, symptoms, and pain management. CLINICAL RECORD 16: The patient elected hospice care on 05/01/2025 and was transferred on 05/21/2025. A clinical record review revealed no completed discharge summary documenting the patient’s hospice stay, including treatments, symptoms, and pain management. During a joint record review and interview on 10/10/2025, the Director of Clinical Operations confirmed that the record lacked evidence of a completed discharge summary that included a summary of the patient’s hospice stay, including treatments, symptoms.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 13 (8%) clinical records reviewed identified that the initial comprehensive assessment was not completed within five calendar days. Clinical Record 11: The patient elected the hospice benefit on 3/1/2021. The initial social services evaluation was completed on 3/11/2022 (10 calendar days after the election of the hospice benefit). There was no documented evidence to explain why this visit was late. The Executive Director was interviewed on 12/14/2022 and agreed that the assessment was late. She stated that the agency currently has a PIP (performance improvement plan) in place to address this issue.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs; Supplements. The medication review process includes the identification of the following: The effectiveness of drug therapy; Drug side effects; Actual or potential drug interactions; Duplicate drug therapy. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records, interviews and observation on home visits. 3 of 13 (23%) clinical records reviewed identified that the drug profiles were not updated to include all medications. Clinical Record 3: The patient elected the hospice benefit on 1/6/2022. During an observation visit with the Registered Nurse Case Manager (RNCM, Personnel Record 6) on 12/15/2022, it was identified that the medications in the home do not match the medications on the drug profile. The drug profile included 3 medications that the primary caregiver stated that the patient was no longer taking: Fluoxetine 40mg capsule 1 po q day; Humalog Kwikpen (U-100) insulin 100 unit/ml subcutaneous administer 18u 3 times daily; Lantus U-100 insulin 100 unit/ml subcutaneous solution 30u at bedtime. There was one medication which was identified as discontinued on the drug profile that the primary caregiver stated that the patient continued to take: Atorvastatin 80mg tablet 1 tablet daily. This medication was last filled on 11/4/2022. The primary caregiver also stated that she was giving the patient nectar thickened liquids utilizing Thick-It. Thick-it was not included on the drug profile. The RNCM was interviewed at the end of the visit. She stated that the primary caregiver independently changes medications on a regular basis. The Executive Director was interviewed on 12/14/2022 and agreed that the drug profile was not updated at each comprehensive assessment. Clinical Record 5: The patient elected the hospice benefit on 11/4/2022. The Certification of Terminal Illness (CTI), completed on 11/4/2022, documented that the patient required oxygen at 4Lpm (liters per minute) continuously. Oxygen was not included on the drug profile. The Executive Director was interviewed on 12/14/2022 and agreed that oxygen was not present on the drug profile. Clinical Record 12: The patient elected the hospice benefit on 6/13/2022. The admission assessment, as well as subsequent RN visits, identified that the patient required oxygen continuously at 2Lpm. Oxygen was not included on the drug profile. The Executive Director was interviewed on 12/14/2022 and agreed that oxygen was not present on the drug profile.

It is required that the comprehensive assessment includes an initial bereavement assessment of 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 considered in the bereavement plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 13 (15%) clinical records reviewed identified that the initial bereavement assessments were not completed as an element of the initial comprehensive assessments. Clinical Record 8: The patient elected the hospice benefit on 9/22/2020. There was no evidence of a completed initial bereavement assessment in the electronic medical record. Clinical Record 11: The patient elected the hospice benefit on 3/1/2021. The initial bereavement assessment was completed on 3/16/2022 (15 calendar days after election of the hospice benefit). There was no documentation present in the record to explain why the bereavement assessment was not completed in the first five days after election of the benefit. The Executive Director was interviewed on 12/15/2022 and agreed that the initial bereavement assessments were not completed timely in each of these cases. She stated that the site currently has a PIP (Performance Improvement Plan) in place to address completion of the comprehensive assessment, including the initial bereavement assessment within the first five days.

It is required that hospice care and services provided to patients and families follow the individualized plan of care established by: 1. The hospice IDG in collaboration with the attending physician (if any); 2. The patient or patient representative; 3. The primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 10 (10%) applicable clinical records of patients who accepted social work services revealed that the medical social services were not provided in accordance with the plan of care with respect to visit frequency. Clinical Record 6: The patient elected the hospice benefit on 2/8/20222. The plan of care ordered a visit frequency of one time each month for Social Services. There were no visits documented for the month of November 2022. The Executive Director was interviewed on 12/14/2022 and agreed that Social Services did not accurately document completed visits in the electronic medical record. She was able to identify communication notes indicating that the medical social worker had contact/conversations with the patient.

It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 3 of 11 (27%) applicable clinical records of patients receiving hospice aide services revealed that aide services were not provided as ordered by the interdisciplinary group. Clinical Record 4: The patient elected the hospice benefit on 1/22/2021. The visit frequency for the Hospice Aide was ordered on the plan of care as 5 times a week. There were no documented visits for 11/25/2022, 11/29/2022, 12/2/2022 or 12/5/2022. There were no notes documenting why these visits were missed. Clinical Record 7: The patient elected the hospice benefit on 8/17/2022. The visit frequency for the Hospice Aide was ordered on the plan of care as 7 times a week. There were no documented visits for 11/26/2022, 11/27/2022, 12/1/2022, 12/2/2022, 12/3/2022, 12/4/2022, 12/5/2022, 12/6/2022, 12/7/2022, 12/8/2022, 12/9/2022 or 12/10/2022. There were no notes documenting why these visits were missed. Clinical Record 8: The patient elected the hospice benefit on 9/22/2022. The visit frequency for the Hospice Aide was ordered on the plan of care as 5 times a week. There were no documented visits for 11/15/2022, 11/15/2022, 11/16/2022, 11/17/2022, 11/18/2022, 11/21/2022, 11/23/2022, 11/24/2022, 11/28/2022, 11/29/2022, 12/2/2022, 12/5/2022 or 12/9/2022. There were no notes documenting why these visits were missed. The Executive Director was interviewed on 12/14/2022 and stated that these patients frequently refuse aide visits but agreed that there was no documentation in the clinical records which stated that the patients or families had refused the visits.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: A summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 2 (100%) applicable clinical records reviewed, of patients who were discharged from the hospice agency, did not evidence that the discharge summaries were sent to the receiving facilities. Clinical Record 12: The patient elected the hospice benefit on 5/3/2022 and was discharged to the hospital on 6/13/2022. There was no documentation that the discharge summary was forwarded to the hospital. Clinical Record 13: The patient elected the hospice benefit on 10/12/2022 and was discharged to the hospital on 11/7/2022. There was no documentation that the discharge summary was forwarded to the hospital. The Executive Director was interviewed on 12/15/2022 and stated that a new process had been established on 12/1/2022 to ensure that discharge summaries were consistently sent to the appropriate facility and/or physician.