Every finding on record at Athena Hospice Services of Western Massachusetts LLC

Based on record review and interview, the agency failed to ensure the comprehensive assessment was completed by the hospice interdisciplinary group (IDG) no later than 5 calendar days after the election of hospice care for 3 Patients (#4, #11 and #5), out of a total sample of 19 patients.Findings include: --- 3. Patient #5 was admitted to the agency in July 2025 with a diagnosis of chronic obstructive pulmonary disease (COPD- group of lung diseases that block airflow and make it difficult to breathe).Review of the clinical record indicated the following:-Initial Skilled Nurse Visit note, dated 7/8/25-MSW Admission Visit Summary, dated 7/10/25-Initial Chaplain assessment, dated 7/14/25.During an interview on 8/14/25 at 9:30 A.M., the Clinical Manager, after reviewing the clinical record for Patient #5, said the Comprehensive Assessment was not completed within five calendar days after the Patient was admitted to the agency, as required.     Review of the agency policy entitled, Assessment-Comprehensive Assessment of the Patient, dated 12/2/2008, indicated the following:*The hospice IDG conducts and documents a patient-specific comprehensive assessment that identifies the patient's needs for hospice care, including medical, nursing, psychosocial, emotional and spiritual care.*The comprehensive assessment of the patient is completed by designated members of the IDG in consultation with the patient's attending physician no later than five (5) calendar days after the patient elects the hospice benefit.1. Patient #4 was admitted to the agency in April 2025 with a diagnosis of liver cancer.Review of the clinical record indicated the following:-Skilled Nurse Visit note, dated 4/18/25.-Medical Social Worker (MSW) Admission Visit Summary, dated 4/20/25. -Initial Chaplain Assessment, dated 4/28/25.During an interview on 8/14/25 at 9:30 A.M., the Clinical Manager, after reviewing the clinical records for Patient #4, said the Comprehensive Assessments were not completed within the five calendar days after the patients were admitted to the agency, as required. 2. Patient #11 was admitted t the agency in June 2025 with a diagnosis of Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL-when the thickening of blood vessel walls blocks the flow of blood to the brain).Review of the clinical record indicated a MSW Admission Visit Summary, dated 6/17/25.During an interview on 8/14/25 at 9:30 A.M., the Clinical Manager, after reviewing the clinical records for Patient #11, said the Comprehensive Assessments were not completed within the five calendar days after the patients were admitted to the agency, as required.

Based on record review and interview, the agency staff failed to conduct an initial Bereavement Assessment of the needs of the patient's family that may potentially impact their ability to cope with the patient's death for two patients (#8 and #17), out of a total sample of 19 patients.Findings include: --- Review of the agency policy entitled, Bereavement-Care Services, dated 12/2/2008, indicated the following:*A bereavement care plan is developed for identified family members and other involved individuals after the patient's death.*During the initial bereavement assessment, the interdisciplinary group (IDG) identifies family members, caregivers, or significant others who may be significantly impacted by the patient's death. The initial bereavement assessment is updated during IDG meetings throughout the course of the patient's care.1. Patient #8 was admitted to the agency in October 2024 with a diagnosis of Huntington's Disease (an inherited condition in which nerve cells in the brain break down over time).Review of the clinical record did not contain documentation indicating that an initial Bereavement Assessment was completed on admission.During an interview on 8/14/25 at 9:30 A.M, the Clinical Manager (CM) after reviewing the clinical record, said the initial bereavement assessment was not completed, as required.2. Patient #17 was admitted to the agency in February 2025 with a diagnosis of systolic Congestive Heart Failure (CHF-heart is weakened and cannot forcefully contract enough to pump an adequate amount of blood through the body).Review of the clinical record indicated a Medical Social Worker (MSW) Admission Visit Summary, dated 2/28/25, that a bereavement assessment is not necessary as the patient has a legal guardian that is unrelated to the patient.During an interview on 8/14/25 at 1:12 P.M., the CM after reviewing the clinical record, said the initial bereavement assessment should have been completed regardless if the legal guardian was related or not related to the patient.

Based on record review and interview, the agency failed to ensure that care and services were provided in accordance with the plan of care (POC) for 4 patients (#3, #6, #2 and #14), out of a total sample of 19 patients.Findings include: --- Review of the agency policy entitled, Plan of Care, dated 12/2/2008, indicated the following:* Hospice care and services provided to patients and their families are in accordance with an individualized, written plan of care (POC) established by the hospice interdisciplinary group (IDG) in collaboration with the patient's attending physician (if any), and, if appropriate, the patient or representative and the primary caregiver.*The patient's plan of care specifies the care and services necessary to meet the needs of the patient/caregiver as identified in the initial, comprehensive and updated assessments of the patient.1. For Patient #3, the facility failed to ensure Home Care Aide Visit (HCAV) was provided, as ordered.Patient #3 was admitted to the agency in December 2024 with a diagnosis of senile degeneration of the brain.Review of the Hospice POC with benefit dates 5/18/25 through 7/16/25 indicated the following:-HCAV twice weekly for 8 weeks.Review of the clinical record indicated a HCAV was not provided for the week of 6/22/25 through 6/28/25, as ordered.During an interview on 8/14/25 at 9:30 A.M., the Clinical Manager (CM), after reviewing the clinical records for Patient #3, said  HCAVs were not provided the week of 6/22/25 through 6/28/25, as ordered.2. For Patient #6, the facility failed to ensure Home Care Aide Visit (HCAV) was provided, as ordered.Patient #6 was admitted to the agency in May 2025 with a diagnosis of Chronic Kidney Disease (CKD) Stage 3 (indicates moderate kidney damage and reduced function).Review of the Hospice POC with benefit dates 5/1/25 through 7/29/25 indicated the following:-HCAV-once a week for one week, twice a week for 13 weeks.Review of the clinical record indicated a HCAV was not provided for the week of 6/22/25 through 6/28/25, as ordered.During an interview on 8/14/25 at 9:30 A.M., the Clinical Manager (CM), after reviewing the clinical records for Patient #6, said HCAVs were not provided the week of 6/22/25 through 6/28/25, as ordered. 3. For Patient #2, the facility failed to ensure Volunteer Visits were provided as ordered.Patient #2 was admitted to the agency in October 2023 with a diagnosis of cerebral atherosclerosis.Review of the Hospice POC interim orders with benefit dates 2/11/25 through 4/11/25 indicated the following:-Volunteer: once a month x three months, PRN (as needed) x 7, verbal order provided by the physician on 2/11/25.Review of Patient Quick Notes indicated a Volunteer Visit was not provided for the month of March 2025, as ordered.Review of the Hospice POC interim orders with benefit dates 6/11/25 through 8/9/25 indicated the following:-Volunteer: once a month x three months, PRN x 4, verbal order provided by the physician on 6/11/25.Review of the medical record indicated a Volunteer Visit was not provided for the month of July 2025, as ordered.During an interview on 8/13/25 at 3:30 P.M., Patient #2’s Health Care Proxy (HCP – legal document where you name someone to make medical decisions for you if you’re unable to do so yourself) said the Volunteer was coming once a month but then told him/her that her job got in the way and would come visit when she could. The HCP said he/she could not remember when the last visit was.During an interview on 8/13/25 at 3:40 P.M., the Office Manager said the missed March Volunteer visit was not reported by the Volunteer to agency staff, therefore, no attempts were made to reschedule. She said there was no documentation in the medical record of the missed July visit but there should have been and said all visits should have been conducted per the patient’s plan of care.4. For Patient #14, the facility failed to ensure a physician’s order was obtained prior to Volunteer home visits being provided.Patient #14 was admitted to the agency in March 2025 with a diagnosis of Alzheimer’s Disease.Review of the Hospice Revision to the Plan of Care with benefit dates 6/1/25 through 8/29/25 indicated the following:-Volunteer: twice a month x one month (8/14/25 to 8/29/25), PRN x 4Review of the medical record indicated Volunteer home visits were provided on 6/18/25, 7/3/25, and 7/27/25.During an interview on 8/14/25 at 12:05 P.M., the Clinical Manager said there was an order for Volunteer Visits throughout the certification period, but it was never signed off by the physician, as required.  Review of the agency policy entitled, Plan of Care, dated 12/2/2008, indicated the following:* Hospice care and services provided to patients and their families are in accordance with an individualized, written plan of care (POC) established by the hospice interdisciplinary group (IDG) in collaboration with the patient's attending physician (if any), and, if appropriate, the patient or representative and the primary caregiver.*The patient's plan of care specifies the care and services necessary to meet the needs of the patient/caregiver as identified in the initial, comprehensive and updated assessments of the patient.1. For Patient #3, the facility failed to ensure Home Care Aide Visit (HCAV) was provided, as ordered.Patient #3 was admitted to the agency in December 2024 with a diagnosis of senile degeneration of the brain.Review of the Hospice POC with benefit dates 5/18/25 through 7/16/25 indicated the following:-HCAV twice weekly for 8 weeks.Review of the clinical record indicated a HCAV was not provided for the week of 6/22/25 through 6/28/25, as ordered.During an interview on 8/14/25 at 9:30 A.M., the Clinical Manager (CM), after reviewing the clinical records for Patient #3, said  HCAVs were not provided the week of 6/22/25 through 6/28/25, as ordered.2. For Patient #6, the facility failed to ensure Home Care Aide Visit (HCAV) was provided, as ordered.Patient #6 was admitted to the agency in May 2025 with a diagnosis of Chronic Kidney Disease (CKD) Stage 3 (indicates moderate kidney damage and reduced function).Review of the Hospice POC with benefit dates 5/1/25 through 7/29/25 indicated the following:-HCAV-once a week for one week, twice a week for 13 weeks.Review of the clinical record indicated a HCAV was not provided for the week of 6/22/25 through 6/28/25, as ordered.During an interview on 8/14/25 at 9:30 A.M., the Clinical Manager (CM), after reviewing the clinical records for Patient #6, said HCAVs were not provided the week of 6/22/25 through 6/28/25, as ordered.3. For Patient #2, the facility failed to ensure Volunteer Visits were provided as ordered.Patient #2 was admitted to the agency in October 2023 with a diagnosis of cerebral atherosclerosis.Review of the Hospice POC interim orders with benefit dates 2/11/25 through 4/11/25 indicated the following:-Volunteer: once a month x three months, PRN (as needed) x 7, verbal order provided by the physician on 2/11/25.Review of Patient Quick Notes indicated a Volunteer Visit was not provided for the month of March 2025, as ordered.Review of the Hospice POC interim orders with benefit dates 6/11/25 through 8/9/25 indicated the following:-Volunteer: once a month x three months, PRN x 4, verbal order provided by the physician on 6/11/25.Review of the medical record indicated a Volunteer Visit was not provided for the month of July 2025, as ordered.During an interview on 8/13/25 at 3:30 P.M., Patient #2’s Health Care Proxy (HCP – legal document where you name someone to make medical decisions for you if you’re unable to do so yourself) said the Volunteer was coming once a month but then told him/her that her job got in the way and would come visit when she could. The HCP said he/she could not remember when the last visit was.During an interview on 8/13/25 at 3:40 P.M., the Office Manager said the missed March Volunteer visit was not reported by the Volunteer to agency staff, therefore, no attempts were made to reschedule. She said there was no documentation in the medical record of the missed July visit but there should have been and said all visits should have been conducted per the patient’s plan of care.4. For Patient #14, the facility failed to ensure a physician’s order was obtained prior to Volunteer home visits being provided.Patient #14 was admitted to the agency in March 2025 with a diagnosis of Alzheimer’s Disease.Review of the Hospice Revision to the Plan of Care with benefit dates 6/1/25 through 8/29/25 indicated the following:-Volunteer: twice a month x one month (8/14/25 to 8/29/25), PRN x 4Review of the medical record indicated Volunteer home visits were provided on 6/18/25, 7/3/25, and 7/27/25.During an interview on 8/14/25 at 12:05 P.M., the Clinical Manager said there was an order for Volunteer Visits throughout the certification period, but it was never signed off by the physician, as required.

Based on record review and interview, the agency failed to ensure that care and services were provided based on a determination of post bereavement needs for one patient (#16), out of a total sample of 19 patients.Findings include:Review of the agency policy titled, Bereavement-Risk Assessment, revised 11/17/2008, indicated the following:*Each person designated to receive bereavement services is categorized according to level of risk for complicated grief reactions and receives appropriate interventions according to identified need.*The intervention associated with the three levels of risk are as follows:a. Low risk – initial sympathy call from Interdisciplinary Group (IDG) member, invitations to bereavement support groups and memorial services, and mailings at 1, 3, 6, 9, 11, and 13 months following the patient’s death.Patient #16 was admitted to the agency in October 2024 and had a diagnosis of senile degeneration of the brain.Review of the clinical record indicated the following:-Bereavement Risk Factor – Low Risk-Patient #16 expired in January 2025-Clergy for Bereavement Phone Call Visit Summary, dated 3/11/25Further review of the clinical record did not contain documentation indicating that an initial sympathy call was made to the bereaved to assess their potential need for bereavement care and services to be provided after Patient #16’s death until 3/11/25.During an interview on 8/14/25 at 2:13 P.M., the Clinical Manager, after reviewing the clinical record, said he could not locate documentation that at least two initial sympathy phone call attempts were made.

Based on record review and interview, the agency failed to ensure licensed practical nurse (LPN) supervision by a registered nurse (RN) occurred every 14 days to ensure services were provided as per the plan of care (POC) for 2 patients (#3 and #6), out of a total sample of 19 patients.Findings include: --- Review of the agency policy entitled, Nursing Services, dated 12/2/2008, included the following:*Nursing services are directed and staffed to assure that the nursing needs of all patients are met as identified in the patient's comprehensive and updated assessments. services*When nursing services are delegated to a LPN:a. The LPN is supervised by an RN who is available at least by phone during the hours the LPN is providing services or is on call; and b. The RN makes at least bi-monthly home visits (once every 2 weeks) and documents that the LPN is routinely providing nursing services in accordance with the patient's POC.1.Patient #3 was admitted to the agency in December 2024 with a diagnosis of senile degeneration of the brain.Review of the Hospice POC with benefit dates 7/17/25 through 9/14/2025 indicated the following:-Skilled Nurse Visit (SNV) one time for one week (7/17/25 to 7/19/25) and two times a week for 9 weeks (7/20/25 to 9/14/25).Review of the clinical record indicated documentation that RN supervision occurred on 7/17/25 and the next RN supervision on 8/8/25, over the 14 day timeframe.2. Patient #6 was admitted to the agency in May 2025 with a diagnosis of Chronic Kidney Disease (CKD) Stage 3 (indicates moderate kidney damage and reduced function).Review of the Hospice POC with benefit dates 5/1/25 through 7/29/25 indicated the following:-SNV twice a week for 14 weeks and 5 as needed (PRN) visits.Review of the clinical record indicated documentation that RN supervision occurred on 7/17/25 and the next RN supervision on 8/8/25, over the 14 day timeframe. During an interview on 8/14/25 at 9:30 A.M., the Clinical Manager, after reviewing the clinical records, said there was no RN supervision provided for Patients #3 and #6 every 14 days, as required.

Based on record review and interview, the agency failed to ensure Registered Nurse (RN) supervision of Hospice Aide occurred every 14 days to ensure the plan of care (POC) was followed for 4 patients (#3, #6, #12 and #14), out of a total sample of 19 patients.Findings include: --- 3. Patient #12 was admitted to the facility in April 2025 and had a diagnosis of Parkinson’s disease (disorder of the central nervous system that affects movement).Review of the Hospice POC with benefit dates 4/3/25 through 7/1/25 indicated the following:-HCA: twice a week x 14 weeks.Review of the clinical record indicated documentation that HCA #1 conducted a home visit on 6/16/25 and 6/18/25.Further review of the clinical record indicated that RN supervision for HCA #1 occurred on 7/8/25, greater than 14 days later.Review of the Hospice POC with benefit dates 7/2/25 through 9/29/25 indicated the following:-HCA: twice a week x 12 weeks.Review of the clinical record indicated documentation that HCA #1 conducted a home visit on 7/21/25.Further review of the clinical record indicated that RN supervision for HCA #1 occurred on 8/6/25, greater than 14 days later.During an interview on 8/14/25 at 9:34 A.M., the Clinical Manager, after reviewing the clinical record, said the RN supervisory visits for HCA #1 were not completed within 14 days as required. 4. Patient #14 was admitted to the agency in March 2025 with a diagnosis of Alzheimer’s disease.Review of the Hospice POC with benefit dates 6/1/25 through 8/29/25 indicated the following:-HCA: twice a week x 13 weeks.Review of the clinical record indicated documentation that HCA #1 conducted a home visit on 6/18/25.Further review of the clinical record failed to indicate RN supervision for HCA #1.During an interview on 8/14/25 at 12:05 P.M., the Clinical Manager, upon review of the clinical record, said a RN supervisory visit for HCA #1 did not occur as required.    Review of the agency policy entitled, Hospice Aide Supervision, dated 12/2/2008, indicated the following:*Hospice aides are supervised by a RN in a manner and frequency that assures the safety of patients and the quality of aide services provided.*A RN makes an on-site visit to the patient's home no less frequently than every 14 days to ensure that the services ordered by the interdisciplinary group (IDG) and provided by the aide are meeting the patient's need.  1. Patient #3 was admitted to the agency in December 2024 with a diagnosis of senile degeneration of the brain.Review of the Hospice POC with benefit dates 7/17/25 through 9/14/2025 indicated the following:-Home Care Aide (HCA) one time for one week (7/17/25 to 7/19/25) and two times a week for 9 weeks (7/20/25 to 9/14/25).Review of the clinical record indicated documentation that RN supervision occurred on 7/17/25 and the next RN supervision on 8/8/25, over the 14 day timeframe.During an interview on 8/14/25 at 9:30 A.M., the Clinical Manager, after reviewing the clinical records, said there was no RN supervision provided for Patient #3 every 14 days, as required.2. Patient #6 was admitted to the agency in May 2025 with a diagnosis of Chronic Kidney Disease (CKD) Stage 3 (indicates moderate kidney damage and reduced function).Review of the Hospice POC with benefit dates 5/1/25 through 7/29/25 indicated the following:-HCA one tome a week for one week, two times a week for 13 weeks.Review of the clinical record indicated documentation that RN supervision occurred on 7/17/25 and the next RN supervision on 8/8/25, over the 14 day timeframe. During an interview on 8/14/25 at 9:30 A.M., the Clinical Manager, after reviewing the clinical records, said there was no RN supervision provided for Patient #6 every 14 days, as required.

Based on record review and interview, the agency failed to ensure each patient’s record included clinical notes for two patients (#2 and #14).Findings include:Review of the facility’s policy titled, Volunteers-Documentation, undated, indicated the following:*Hospice volunteers use the Volunteer Progress Note for documentation of any and all contact with hospice patients and their caregivers (including visits and telephone calls).*Upon completion of a patient/caregiver visit (or phone contact), the volunteer completes the Volunteer Progress Note and brings or mails the completed documentation to the Volunteer Coordinator.*All volunteer documentation is submitted within one week after the end of the month after patient contact for incorporation into the patient’s clinical record.1. Patient #2 was admitted to the agency in October 2023 and had a diagnosis of cerebral atherosclerosis (condition in which the arteries in the brain become narrowed and hardened due to the buildup of plaque).Review of the medical record failed to indicate Volunteer visit notes for the months of April, May, and June 2025.During an interview on 8/14/25 at 4:15 P.M., the Office Manager and Clinical Manager said the process for volunteer documentation was not followed and the clinical record was not maintained as required.2. Patient #14 was admitted to the agency in October 2024 and had a diagnosis of senile degeneration of the brain.Review of the medical record indicated Volunteer home visits were provided on 6/18/25, 7/3/25, and 7/27/25.Further review of the medical record indicated the Volunteer visit notes were not incorporated into the clinical record.During an interview on 8/14/25 at 1:07 P.M., the Office Manager said the Volunteer visit notes were not maintained in the clinical record as required.

Based on record review and interview, the Agency staff failed to conduct an initial Bereavement Assessment of the needs of the patient's family that may potentially impact their ability to cope with the patient's death for one Patient (#4), out of 13 patient records reviewed. Findings include: Review of the Agency policy titled Bereavement-Risk Assessment, dated 12/2/08, included but not limited to: - During the comprehensive assessment of the patient, an initial bereavement assessment is conducted to determine the cultural, social, and spiritual factors that may impact the ability of family members or other involved individuals to cope with the patient's death. - Findings from the initial bereavement assessment are incorporated into the patient's plan of care and considered in the bereavement plan of care. Patient #4 was admitted to Hospice services in May 2022 with diagnoses of Parkinson's Disease and Alzheimer's Disease. Review of the clinical record did not contain documentation indicating that an initial Bereavement Assessment was completed on admission. During an interview on 8/3/22 at 12:00 P.M., the Quality Assurance and Performance Improvement (QAPI) Nurse said she could not provide evidence that the initial Bereavement Assessment was completed upon admission for Resident #4, as required.

Based on record reviews and interviews, the Agency staff failed to ensure Interdisciplinary Group (IDG) meetings were held for three Patients (#6, #9 and #10), out of 13 patient records reviewed. Findings include: Review of the Agency policy titled Interdisciplinary Group Meeting, dated 10/1/12, included but not limited to that the IDG review's each patient's plan of care every two weeks, or more frequently if needed, in order to continually monitor the care and services provided to the patient and his or her continued eligibility for hospice care. 1. Patient #6 was admitted to Hospice services in May 2022 with a diagnosis of cerebral atherosclerosis (the thickening and hardening of the walls of the arteries in the brain). Review of the clinical record indicated an IDG meeting occurred on 6/1/22 and 6/29/22. There was no documentation found to indicate an IDG meeting was held on 6/15/22 for Patient #6. During an interview on 8/3/22 at 12:15 P.M., the Quality Assurance and Performance Improvement (QAPI) Nurse said she could not provide evidence that the 6/15/22 IDG meeting was held for Patient #6, as required. 2. Patient #10 was admitted to Hospice services in June 2020 with diagnoses of lung and colon cancer. Review of the clinical record indicated an IDG meeting occurred on 6/1/22 and 6/29/22. There was no documentation found to indicate an IDG meeting was held on 6/15/22 for Patient #10. During an interview on 8/3/22 at 12:15 P.M., the QAPI Nurse said she could not provide evidence that the 6/15/22 IDG meeting was held for Patient #10, as required. 3. Patient #9 was admitted to the hospice in May 2022 with a diagnosis of Parkinson's Disease Review of the clinical record indicated an IDG meeting occurred on 6/1/22 and 6/29/22. There was no documentation found to indicate an IDG meeting was held on 6/15/22 for Patient #9. . During an interview on 8/3/22 at 12:15 P.M., the QAPI Nurse said she could not provide evidence that the 6/15/22 IDG meeting was held for Patient #9, as required.

Based on record review and interview, the Agency staff failed to develop and implement an individualized Bereavement care plan to address any grief/loss issues of the patient's family for three Patients (#2, #11 and #12), out of 13 patient records reviewed. Findings include: Review of the Agency policy titled Bereavement-Care Planning, dated 12/2/08, included but not limited to: - During the initial bereavement assessment, the Interdisciplinary Group (IDG) identifies family members, caregivers, or significant others who may be significantly impacted by the patient's death. The initial bereavement assessment is updated during IDG meetings throughout the course of the patient's care. -The Bereavement Coordinator is notified of all deaths and initiates the bereavement discussion and care planning at the first IDG meeting following the patient's death. At this time, the bereavement care plan is developed and information from the initial bereavement assessment is considered. - The bereavement plan of care reflects the assessed needs of the bereaved and notes the kind of bereavement services to be offered and the frequency of delivery. - The Bereavement Coordinator ensures the bereavement plan of care is followed for thirteen (13) months following the patient's death, appropriate to the level of need assessed. 1. Patient #11 expired in October 2021. Review of the clinical record did not contain evidence a bereavement care plan had been developed. During an interview on 8/3/22 at 12:35 P.M., the Quality Assurance and Performance Improvement (QAPI) Nurse said she could not find documentation that a Bereavement care plan had been developed after the death of Patient #11, as required. 2. Patient #2 was admitted to Hospice services in May 2022 with diagnoses of toxic liver disease (damage to the liver) with chronic active hepatitis (inflammation of the liver tissue) with ascites (abnormal build up of fluid in the abdomen). Review of the clinical record contained an Initial Psychosocial Assessment completed on (5/27/22). The Bereavement Risk Assessment included in this assessment indicated children were in the home and the Patient had a history of substance abuse. Further review of the clinical record did not indicate the bereavement risks identified were addressed or care planned. During an interview on 8/3/22 at 12:00 P.M., the QAPI Nurse said there was no bereavement care plan developed after bereavement risks were identified, as required. 3. Patient #12 was admitted to Hospice services in July 2020 and expired in January 2022. Review of the clinical record did not indicate a Bereavement care plan had been developed and implemented. During an interview on 8/3/22 at 12:45 P.M., the QAPI Nurse said there was no documentation found in the clinical record to indicate that a Bereavement care plan had been developed and implemented, as required.

Based on record reviews and interviews, the Agency staff failed to follow the plan of care relative to the frequency of home visits by the Social Worker (SW), Volunteer, Skilled Nurse (SN) and Hospice Care Aide (HCA) for six Patients (#2, #4, #5, #6, #9 and #12), out of a total sample of 13 patients. Findings include: Review of the Agency policy titled Plan of Care, dated 12/2/08, included but not limited to: - The patient's plan of care specifies the care and services necessary to meet the needs of the patient/caregiver as identified in the initial, comprehensive and updated assessments of the patient. - Each patient and his or her primary caregiver (s) receive education and training from the hospice as appropriate to their responsibilities for the care and services provided in the plan of care. 1. For Patient #2, the Hospice Agency failed to provide three HCA home visits, as care planned. Patient #2 was admitted to Hospice services in May 2022 with diagnoses of toxic liver disease (damage to the liver) with chronic active hepatitis (inflammation of the liver tissue) with ascites (abnormal build up of fluid in the abdomen). Review of Patient #2 plan of care indicated for a HCA visit once a week for 10 weeks (effective 6/19/22).. Review of the clinical record indicated no documentation that a HCA visit occurred the week of 6/5/22-6/11/22, 6/12/22-6/18/22 and 7/3/22-7/9/22. During an interview on 8/3/22 at 12:00 P.M., the Quality Assurance Performance Improvement (QAPI) Nurse said there was no documentation found to indicate a HCA home visit occurred for the weeks of 6/5/22-6/11/22, 6/12/22-6/18/22 and 7/3/22-7/9/22, as required. 2. For Patient #4, the Hospice Agency failed to provide one HCA home visit, as care planned. Patient #4 was admitted to Hospice services in May 2022 with diagnoses of Alzheimer's Disease and Parkinson's Disease. Review of Patient #4 plan of care indicated for a HCA home visit for twice a week for two weeks, once a week for one week and three times a week for six weeks (effective 5/15/2022). Review of the clinical record indicated no documentation that the third HCA visit for the week of 7/3/22-7/9/22 occurred. During an interview on 8/3/22 at 12:10 P.M., the QAPI Nurse said there was no documentation found to indicate the third HCA home visit for the week of (7/3/22-7/9/22) had occurred, as required. 3. For Patient #6, the Hospice Agency failed to provide documentation that a Volunteer home visit had occurred for the month of July. Patient #6 was admitted to Hospice services in May 2022 with a diagnosis of cerebral atherosclerosis (thickening and hardening of the walls of the arteries of the brain). Review of Patient #6 plan of care indicated for a Volunteer home visit one to two times a month for three months (effective 5/13/22). Review of the clinical record indicated no documentation that a Volunteer home visit had occurred in July. During an interview on 8/3/22 at 11:00 A.M., the Volunteer Coordinator said a Volunteer home visit did occur in July but she could not provide any documentation to indicate the visit had occurred, as required. 4. For Patient #12, the Hospice Agency failed to provide three HCA visits, as care planned. Patient #12 was admitted to Hospice services in July 20202 with a diagnosis of senile degeneration of the brain (the loss of intellectual ability that is associated with or the characteristics of old age). Review of Patient #12 plan of care indicated for a HCA visit twice a week (effective 11/23/21). Review of the clinical record indicated one HCA visit did not occur during the week of 12/19/21-12/25/21 and two HCA visits did not occur during the week of 12/26/21-1/1/22. During an interview on 8/3/22 at 12:40 P.M., the QAPI Nurse said there was no documentation found to indicate a HCA home visit occurred during the week of 12/19/21-12/25/21 and two visits had occurred during the week of 12/26/21-1/1/22, as required. 5. For Patient #5 the Agency failed to ensure a Skilled Nursing visit was completed for the week of 6/12/22-6/18/22. Patient #5 was admitted to the Hospice in April 2022, with a diagnosis of colon cancer. Review of the physician's orders, dated 4/13/22, indicated that the Patient received skilled nursing services from the Agency one time per week. Review of the clinical record indicated that there was no skilled nursing visit during the week of 6/12/22-6/18/22. During an interview with the QAPI Nurse on 8/3/22 at 12:00 P.M., she said that there was no evidence a skilled nursing visit occurred between 6/12/22 and 6/18/22, as ordered. 6. For Patient #9 the Agency failed to ensure a social work visit was completed, during the month of July 2022. Patient #9 was admitted to the Hospice in May 2022, with a diagnosis of Parkinson's Disease. Review of the physician's order, dated 5/20/22, indicated social work visits one time per month. Review of the clinical record indicated there was no social work visits occurred for the month of July 2022. During an interview with the QAPI Nurse on 8/3/22 at 12:00 P.M., she said that there was no evidence a social work visit occurred during the month of July 2022, as ordered.

Based on review of quality improvement records and interview, it was determined the hospice failed to develop, implement and maintain an ongoing Quality Assessment and Performance Improvement (QAPI) plan. This had the potential to affect the 86 patients who were currently receiving hospice services and all future hospice patients. Findings include: Review of the QAPI Documentation indicated that the QAPI Meetings were held quarterly, Performance Improvement Plans were developed, however there was no evidence that a QAPI Plan was developed. During an interview on 8/3/22 at 2:20 P.M. the QAPI Nurse and the Executive Director both said they could not find the QAPI Plan and there was no evidence the QAPI Plan was developed.

Based on review and interview, the Agency failed to ensure that the Abuse Policy contained reporting timelines consistent with the State Regulations. Review of the Massachusetts State Regulation 105.CMR.155.004 indicated: (A) Any mandatory reporting individual, as defined in 105 CMR 155.003, shall immediately make an oral report of suspected patient or resident abuse, neglect, mistreatment or misappropriation of patient or resident property to his or her supervisor or employer whenever he or she has reasonable cause to believe that any patient or resident has been abused, neglected or mistreated or had property misappropriated. Upon receiving such report, said supervisor or employer shall immediately notify the Department by oral communication, electronically transmitted report or facsimile in accordance with such guidelines as may be established by the Department...... Review of the Facility Abuse Policy, revised November 2021, indicated but not limited to: "1. Any clinician who discovers, within the course of rendering care, any suspected abuse or neglect will immediately report such occurrences to his/her immediate supervisor. This includes: A. Any knowledge of abuse or neglect B. Any knowledge of patient self-abuse or neglect C. Reasonable cause to suspect abuse or neglect D. Reasonable cause to suspect self-abuse or self-neglect E. Any knowledge that a patient has sustained an injury that is not reasonably explained by the patient's history of injuries 2. The clinician will submit a verbal report of the suspected abuse/neglect to the proper authorities in accordance with state law and complete a suspected abuse and/or neglect investigation report within 24 hours of the incident, with the addition of the following information: A. Name of alleged perpetrator B. Relationship to patient, if any C. Information regarding suspected abuse or neglect: 1. Date of occurrence 2. Witness to occurrence, if any 3. Nature of occurrence (as indicate above) 4. Description of the abuse/neglect 3. If a patient is in immediate jeopardy, the proper authorities will be contacted by the clinician immediately as required by state or local law. 4. The suspected abuse/neglect investigation report with specific information relating to the occurrence is forwarded to the Clinical Supervisor, who will: A. Notify the physician and referral source (as appropriate) or direct the clinician to do so B. Review the documentation for completeness and objectivity C. Forward the information to the Executive Director/Administrator 5. The Executive Director/Administrator will: A. Review all reports (incident report and follow-up investigation) B. Conduct any further review if necessary C. Document additional information D. Submit reports to the proper authorities 6. Reports, reviews, and investigations of suspected abuse/neglect will be held in the strictest confidence....." There was no specific information relative to reporting the abuse to the Department of Public Health, as required by law. During an interview with the Quality Assurance and Performance Improvement (QAPI) Nurse on 8/3/22 at 2:20 P.M. she said that the abuse policy was not specific and should have included information on reporting the alleged abuse to the Department of Public Health.