Every finding on record at Brighton Hospice Massachusetts, LLC

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. This standard was not met as evidenced by document review, interview, and observation. Agency policy #7-009, "Hand Hygiene" (revised May 2024), stated in part, "Wash hands for at least fifteen (15) seconds covering all surfaces of the hand and fingers …" In 1 of 3 (33%) home visits observed, the agency did not ensure that the Hospice Aide performed hand hygiene correctly, as indicated per the agency's policy. Home Visit 1: During the home visit with the Hospice Aide (HA) [Personnel Record 4], the HA washed their hands at the sink three (3) times with soap and water; each hand wash lasted eight to ten seconds, not fifteen (15) seconds per the policy. During an interview following the home visit, the HA did not explain or disagree with the time spent hand-washing at the sink, even when told that it lasted only eight to ten seconds.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients with a live discharge from hospice services, the agency did not ensure that the discharge summary was sent to the patient’s physician. Clinical Record 11: The patient elected the hospice benefit on 03/13/2024 and was discharged due to an extended prognosis on 09/07/2024. The discharge summary was dated 09/11/2024. A clinical record review revealed that an attempt was made to fax the discharge summary to the patient’s physician, but the document failed to transmit. There was no evidence documenting that the discharge summary was successfully sent to the physician. Clinical Record 12: The patient elected the hospice benefit on 10/09/2024 and revoked hospice services on 01/17/2025. The discharge summary was dated 01/20/2025. It indicated that an attempt was made to fax the discharge summary to the patient’s physician, but the document failed to transmit. A clinical record review revealed that an attempt was made to fax the discharge summary to the patient’s physician, but the document failed to transmit. There was no evidence documenting that the discharge summary was successfully sent to the physician. During a joint clinical record review and interview on 01/29/2025, the Vice President of Compliance confirmed that there was no documentation that the discharge summaries were successfully provided to the patient’s physician.

It is required that each patient’s individualized written plan of care: Includes all services necessary for the palliation and management of the terminal illness, including: Drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. 3 of 10 (30%) clinical records reviewed revealed that the POC did not include required elements. Clinical record #66204 was reviewed and identified that the patient elected the hospice benefit on 2/16/2022. Wound care orders written on 2/17/2022 do not specify how frequently the care should be preformed. The order read "cleanse with normal saline, apply calcium alginate and cover with contort foam dressing." No frequency provided for how often the wound care should have been performed. Clinical record # 57970 was reviewed and identified that the patient elected the hospice benefit on 1/21/2022. Wound care orders written on 1/21/2022 stated "coccyx: cleanse with normal saline, dress with medihoney cover with foam dressing. Left sacral (left upper buttock) cleanse with normal saline,dress with medihoney, cover with foam dressing Right shin: cleanse with normal saline dress with medihoney, cover with foam dressing." No frequency provided for how often the wound care should have been provided. Wound care orders written on 2/15/2022 stated "Coccyx: cleanse with normal saline, apply medihoney cover with foam dressing. Right ear Cleanse with normal saline, apply barrier cream cover with foam dressing for comfort." No frequency provided for how often the wound care should have been performed. Clinical record # 27466 was reviewed and identified that the patient elected the hospice benefit on 1/25/2022. Wound care orders written on 2/21/2022 stated "cleanse right elbow and left forearm with normal saline pat dry, and cover with comfort foam dressing." No frequency provided for how often the wound care should have been performed. The Director of Clinical Services was interviewed on 3/2/2022 and had no additional information to provide.

It is required that drugs and biologicals related to the palliation and management of the terminal illness and related conditions are identified in the plan of care; This standard was not met as evidenced by clinical record review and interview. 1 of 10 (10%) clinical records reviewed revealed that drugs/biologicals were not provided per POC. Clinical Record #66204 was reviewed and identified the patient elected the hospice benefit on 2/16/2022. IDG notes from 2/23/2022 stated that the physician "decreased Zoloft to 25mg, discontinued PRN and scheduled Ativan and added Trazadone 25mg q 6hrs PRN". The was no order written and the medication changes were not present on the medication profile. The Director of Clinical Services was interviewed on 3/2/2022 and had no additional information to add.