Every finding on record at Affinity Care of Maine LLC

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that planned interventions based on problems identified in the initial and updated comprehensive assessments were included in the patient's individualized written plan of care. CLINICAL RECORD 4: The patient elected the hospice benefit on 06/25/2025 with a terminal diagnosis of Alzheimer's Disease. The Registered Nurse documented on the initial assessment dated 06/25/2025 that the patient experienced neurological deficits as evidenced by a FAST (Functional Assessment Staging Tool, used in hospice to assess the decline in individuals with dementia) score of 7A (severe dementia, speaks five to six words during the day). The plan of care dated 06/25/2025 to 10/21/2025 did not include interventions to address the neurological needs of the patient. During joint clinical record review and an interview on 12/11/2025, the Administrator stated there was no interventions in the plan of care to address the hospice terminal diagnosis from 06/25/2025 to 10/22/2025. She stated that there would be a nurse's meeting in the near future to provide education on plan of care development.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene, use of gloves, mask, eye protection, or face shield depending on anticipated exposure, safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids, safe handling of soiled items in the patient’s care environment, and other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, observation, and interview. In 1 of 4 (25%) home visit observations, the agency did not ensure staff performed hand hygiene as required by agency policy and process. Agency document "Infection Control Bag Technique and Surface Barriers Form," required in part, "Clean up: Remove gloves. Dispose in a trash receptacle to maintain infection control practices and a clean environment." HOME VISIT 2: During the home visit observation on 12/09/2025 with the Registered Nurse Case Manager (RNCM) [PERSONNEL RECORD 2], the RNCM was observed to place used gloves on the patient's furniture which had no barrier. During an interview and review of the home visit with the Administrator on 12/10/2025, the Administrator stated that the Registered Nurse did not follow the training provided to staff to remove used gloves and dispose in a trash receptacle and stated the glove removal process was reviewed in detail with the staff member on 12/10/2025.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient's clinical record included physician orders. CLINICAL RECORD 11: The patient elected the hospice benefit on 02/21/2025 with a diagnosis of malignant neoplasm of the breast with metastasis to the bone. The Registered Nurse documented on the initial comprehensive assessment dated 02/21/2025 that the patient had stitches on the left leg following a recent hip fracture repair. The history and physical report from the hospital stated the patient had a fall which resulted in a hip fracture and an open reduction and internal fixation surgery on 01/30/2025. The hospice plans of care were reviewed for the dates from 02/21/2025 through 12/11/2025 and included an intervention for wound care as per the physician orders. The clinical record review contained no documented evidence of a physician order for care of the patient’s surgical wound. During an interview and a joint record review on 12/11/2025, the Administrator stated that the clinical record did not include orders to care for the hip repair and stated that there should have been orders to care for the surgical wound to prevent infection. She stated the nurse who admitted this patient was a new nurse and struggled with documentation.