Every finding on record at Beth Israel Deaconess Hospital - Plymouth, Inc.

Based on record review and interview, the Agency failed to ensure that a Nurse Aide Registry background check for 3 of 3 volunteers (Volunteer #1, #2, and #3) was conducted prior to hire, as required. --- Findings include:Review of the 105 CMR 155.000: Patient and Resident Abuse Prevention, Reporting, Investigation, Penalties and RegistrySection: 105CMR 155.010 (E)(3) included the following:-All home health agencies, homemaker agencies, and hospice programs shall contact the Registry prior to hiring an individual who will provide direct care to patients or have access to patients or their property to ascertain if there is any sanction, finding or adjudicated finding of patient or resident abuse, neglect, mistreatment, or misappropriation of patient or resident property against the prospective employee.Review of Manual for MassHealth Providers, 130 CMR 437.000: Hospice Services: Hospice Providers Regulation indicated the following:Massachusetts Regulations 130 CMR 437.421: Administration and Staffing Requirements *Volunteer Services: The hospice provider must use volunteers in administrative or direct patient-care roles. The hospice provider must appropriately train volunteers and document its ongoing efforts to recruit and retain volunteer staff. The hospice provider must complete the same personnel screenings for volunteer staff that are required for paid employees of the hospice provider.Review of Volunteer #1’s personnel record on 7/18/25 indicated that a background check was completed, and that Volunteer #1 joined the volunteer program on 9/2023. Further review of the file failed to indicate a Nurse Aide registry check was conducted.Review of Volunteer #2’s personnel record on 7/18/25 indicated that a background check was completed, and that Volunteer # 2 joined the volunteer program on 2/2024. Further review of the file failed to indicate a Nurse Aide registry check was conducted.Review of Volunteer #3’s personnel record on 7/18/25 indicated that a background check was completed, and that Volunteer # 3 joined the volunteer program on 3/2017. Further review of the file failed to indicate a Nurse Aide registry check was conducted.During an interview on 7/18/25 at 9:50 A.M., the Administrator said that the agency checks for Criminal Offender Record information (CORI) but not nurse aide registry check for volunteers.