Every finding on record at Community Health & Nursing Services

Based on document reviews and interviews, the hospice failed to provide evidence of Emergency Preparedness training for three (3) of ten (10) personnel files that were reviewed (Employee #1, #2 and #6). --- Findings: The "Emergency Operations Plan for MaineHealth CHANS Home Health and Hospice" states, in part, "Training program. Home health and hospice will:a. Provide initial training in emergency preparedness policies and procedures to all new employees, and individuals providing services under arrangement, consistent with their expected roles.b. Provide emergency preparedness training at least every 2 years. This will be done sooner if emergency preparedness policies and procedures are significantly updated.c. Periodically review and rehearse its emergency preparedness plan with home health and hospice employees, with special emphasis placed on carrying out the procedures necessary to protect patients, staff, and others. This will be done via the testing program.d. Demonstrate staff knowledge of emergency procedurese. Maintain documentation of all emergency preparedness training." On 02/05/2025 from 9:30 AM – 11:26 AM, ten (10) personnel records were reviewed with the Human Resources Director. The following was identified: Employee #1 was hired on 12/05/2022; Employee #2 was hired on 11/21/2022; Employee #6 was hired on 07/17/2023; and As of 02/07/2025, no documented evidence of EP training was in their personnel file. On 02/05/2025, at the time of the review, the Human Resources Director confirmed the above findings.

Based on document reviews and interviews, the hospice failed to ensure that staff were provided with the required four (4) hour orientation training prior to delivering care to patients for one (1) of ten (10) staff reviewed (Employee #6). --- Findings: The "Performance Management" policy, last revised 01/01/2023, states in part, "It is the policy of MaineHealth that our leadership ensures the competence of all employees and continuously assesses to help maintain and improve our employees so that job-specific performance standards are met. ... This policy applies to all regular full-time, part-time, temporary employees and per diem employees." On 02/05/2025 from 9:30 AM – 11:26 AM, ten (10) personnel records were reviewed with the Human Resources Director. The following was identified: Employee #6 was hired on 07/17/2023; and As of 02/07/2025, there was no documented evidence of the required training in her personnel file. On 02/05/2025, the above finding was confirmed by the Human Resources Director at the time of the review.

Based on document reviews and interviews, the hospice failed to assess the skills and competence of all individuals furnishing care in five (5) of ten (10) personnel files reviewed (Employee #1, #5, and #6, #7, #8). --- Findings: The "Performance Management" policy, last revised 01/01/2023, states in part, "It is the policy of MaineHealth that our leadership ensures the competence of all employees and continuously assesses to help maintain and improve our employees so that job-specific performance standards are met. ... This policy applies to all regular full-time, part-time, temporary employees and per diem employees." On 02/05/2025 at approximately 9:15 AM, the Hospice Director stated that competencies must be done by all staff who are "patient facing". On 02/05/2025 from 9:30 AM – 11:26 AM, ten (10) personnel records were reviewed with the Human Resources Director. The following was indicated: Employee #1, a Hospice Aide, was hired on 12/05/2022; Employee #5, a Chaplain, was hired on 05/01/2023; Employee #6, a Volunteer Assistant, was hired on 07/17/2023; Employee #7, a Hospice Aide, was hired on 07/24/2023; Employee #8, a Social Worker, was hired on 10/06/2024; and As of 02/07/2025, there was no documented evidence of the required competencies. On 02/05/2025, during the review, the Hospice Director and the Human Resources Director confirmed the above findings.

Based on document reviews and interviews, the hospice failed to obtain a criminal background check to employees who provide direct patient care and have access to patient records for one (1) of ten (10) reviewed employees (Employee #10). --- Finding: According to the Maine Statute 22 MRSA §9054, hospice care providers are mandated to utilize the Maine Background Check Center for comprehensive background checks. A letter was sent, by the Maine Background Check Center, to all home health care providers specifying that agencies were required to use the Maine Background Check Center system for all new hires starting May 1, 2017 and that all direct care employees must be checked through the system within one (1) year (5/1/2018). The "Hiring Process" policy, last revised 01/29/2024, states in part, " A criminal history background check is conducted on external candidates and offers are contingent upon and the results of this background check. ... Additional criminal history background checks may be conducted during employment for certain positions as required by law, including by the Maine Background Check Center law and New Hampshire Code of Administrative Rules. Care team members will be informed of any such additional background checks. On 02/05/2025 from 9:30 AM – 11:26 AM, ten (10) personnel records were reviewed with the Human Resources Director. The following was indicated: - On 05/15/2023, Employee #10 was hired. As of 02/07/2025, there was no evidence that a criminal background check was completed in accordance with the requirements prior to providing care. On 02/05/2025 at 11:11 AM, the Human Resources Director confirmed the above findings.

Based on document reviews and interviews, the hospice failed to obtain a criminal background check as required by 22 MRSA §9054 for one (1) of ten (10) reviewed employees, hired after 5/1/2017 (Employee #10). --- Findings: According to the Maine Statute 22 MRSA §9054, hospice care providers are mandated to utilize the Maine Background Check Center for comprehensive background checks. A letter was sent, by the Maine Background Check Center, to all home health care providers specifying that agencies were required to use the Maine Background Check Center system for all new hires starting May 1, 2017 and that all direct care employees must be checked through the system within one (1) year (5/1/2018). The "Hiring Process" policy, last revised 01/29/2024, states in part, " A criminal history background check is conducted on external candidates and offers are contingent upon and the results of this background check. ... Additional criminal history background checks may be conducted during employment for certain positions as required by law, including by the Maine Background Check Center law and New Hampshire Code of Administrative Rules. Care team members will be informed of any such additional background checks. On 02/05/2025 from 9:30 AM – 11:26 AM, ten (10) personnel records were reviewed with the Human Resources Director. The following was indicated: - On 05/15/2023, Employee #10 was hired. As of 02/07/2025, there was no evidence that a criminal background check was completed in accordance with the Maine Statute 22 MRSA §9054. On 02/05/2025 at 11:11 AM, the Human Resources Director confirmed the above finding.