Every finding on record at Broad Reach Hospice & Palliative Care LLC

Based on personnel file review and staff interview, the hospice agency failed to ensure that the annual performance evaluation/field supervision was completed for professional personnel who had direct patient care roles and had been employed 12 months or longer in 1 of 5 (Hospice Aide (HA) #3) personnel files reviewed. Findings include: HA #3 date of hire was 7/22/2019. During review of the personnel file on 8/29/24, indicated that there was no evidence that an annual evaluation/field supervision has been completed as required annually. During an interview on 8/29/24 at 11:50 A.M., the Administrator showed the surveyor an incomplete field supervision form for HA #3. She said that the field supervision was due on January 2024 and not done for HA #3.

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 #1s personnel record on 8/29/24 indicated that a background check was completed, and that Volunteer #1 joined the volunteer program on 3/16/21. Further review of the file failed to indicate a Nurse Aide registry check was conducted. Review of Volunteer #2s personnel record on 8/29/24 indicated that a background check was completed, and that Volunteer # 2 joined the volunteer program on 3/5/24. Further review of the file failed to indicate a Nurse Aide registry check was conducted. Review of Volunteer #3s personnel record on 8/29/24 indicated that a background check was completed, and that Volunteer #3 joined the volunteer program on 3/5/24. Further review of the file failed to indicate a Nurse Aide registry check was conducted. During an interview on 8/29/24 at 11:50 A.M., the Administrator said that they check for Criminal Offender Record Information (CORI) but not Nurse Aid registry check for volunteers.

Based on record review and staff interview, the agency failed to ensure that Hospice Aides had successfully completed a competency evaluation program for 3 out of 3 Hospice Aides (HA) (#1, #2, and #3) . Findings include: 1. HA #1 was hired in May 2019. Review of her personnel file indicated there was no written competency evaluation or skills checklist in the file. During an interview on 12/13/21 at 3:00 P.M., with the Clinical Director, she said HA #1 was active and working as a per diem HA since hire, but had not completed the written competency or a skills checklist currently. 2. HA #2 was hired in August 2020. Review of her personnel file indicated there was no written competency or a skills checklist completed. 3. HA #3 was hired in December 2015. Review of her personnel file indicated there was no initial written competency or a skills checklist completed. 4. During an interview on 12/13/21 at 3:00 P.M., the Clinical Director said there had been some turnover in the Human Resources staff, and these written competencies and skills checklists were not completed as required.