Every finding on record at Compassionate Care Hospice of Massachusetts, LLC

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by a review of clinical records and interview. In 1 of 12 (8%) records reviewed, it was revealed that the hospice failed to ensure that all members of the interdisciplinary group completed the initial comprehensive assessment within 5 calendar days after the election of hospice care. Clinical Record 1: The patient was admitted on 8/13/21 with a diagnosis of Parkinson's Disease. The initial evaluation visit for the social worker was scheduled 8/18/22. That visit was missed and never rescheduled; therefore, no initial psychosocial evaluation was completed. The Acting Administrator agreed that the initial psychosocial evaluation was not done.

It is required that the Interdisciplinary Group determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in their home. The plan of care identifies the IDG’s finding regarding safe self-administration and/or family administration of drugs and biologicals. If the patient and/or family cannot administer drugs or biologicals, it is noted in the plan of care, as well as how it is addressed by the IDG. This standard was not met as evidenced by a review of clinical records and interview. In 1 of 1 (100%) record reviewed, in which the patient lived at home and had to self-administer medications, the agency failed to ensure that the nurse assessed that the patient/family was able to safely administer the medications in the home. Clinical Record 1: The patient was admitted to hospice services on 8/13/2021 with a diagnosis of Parkinson's Disease. In a joint record review with the Acting Administrator, it was revealed that the record lacked evidence that the nurse had evaluated and documented the patient/family's ability to safely administer medications. The Acting Administrator agreed that the documentation was missing in this record.

It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or patient’s legal representative(s). This standard was not met as evidenced by a review of clinical records and interview. In 1 of 1 (100%) record reviewed where controlled medications had been ordered and placed in the home, the organization failed to provide a copy of the policy and procedure for the management and disposal of controlled medications to the patient. Clinical Record 1: The patient was admitted to hospice services on 8/13/2021 with a diagnosis of Parkinson's Disease. The patient had morphine ordered per plan of care dated 8/13/21. The patient's clinical record revealed no evidence that a written policy and procedure for the management and disposal of controlled medications had been provided to the patient/family. The Acting Administrator stated that they do not give a copy of the policy to the patients.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 9 of 12 (75%) records reviewed, of patients receiving hospice services in a skilled nursing facility (SNF), revealed the agency did not ensure that the plans of care included the identification of which provider was responsible for performing the interventions on the plan of care (POC). Clinical Record 2: The patient was admitted to hospice services on 6/15/22 with a diagnosis of Breast Cancer. On joint review of the record with the Acting Administrator, it was discovered that the plan of care did not state whether hospice or the facility were responsible for the interventions in the plan of care. Clinical Record 3: The patient was admitted to hospice services on 10/11/22 with a diagnosis of Multiple Sclerosis. On joint review of the record with the Acting Administrator, it was discovered that the plan of care did not state whether hospice or the facility were responsible for the interventions in the plan of care. Clinical Record 4: The patient was admitted to hospice services on 10/23/22 with a diagnosis of Brain Cancer. On joint review of the record with the Acting Administrator, it was discovered that the plan of care did not state whether hospice or the facility were responsible for the interventions in the plan of care. Clinical Record 5: The patient was admitted to hospice services on 11/26/22 with a diagnosis of Brain Cancer. On joint review of the record with the Acting Administrator, it was discovered that the plan of care did not state whether hospice or the facility were responsible for the interventions in the plan of care. Clinical Record 7: The patient was admitted to hospice services on 10/28/22 with a diagnosis of Lymphoma. On joint review of the record with the Acting Administrator, it was discovered that the plan of care did not state whether hospice or the facility were responsible for the interventions in the plan of care. Clinical Record 9: The patient was admitted to hospice services on 8/2/22. On joint review of the record with the Acting Administrator, it was discovered that the plan of care did not state whether hospice or the facility were responsible for the interventions in the plan of care. Clinical Record 10: The patient was admitted to hospice services on 8/2/22. On joint review of the record with the Acting Administrator, it was discovered that the plan of care did not state whether hospice or the facility were responsible for the interventions in the plan of care. Clinical Record 12: The patient was admitted to hospice services on 5/25/22 with a diagnosis of Heart Failure. On joint review of the record with the Acting Administrator, it was discovered that the plan of care did not state whether hospice or the facility were responsible for the interventions in the plan of care. Clinical Record 13: The patient was admitted to hospice services on 5/8/2019 with a diagnosis of Alzheimer's. On joint review of the record with the Acting Administrator, it was discovered that the plan of care did not state whether hospice or the facility were responsible for the interventions in the plan of care. The Acting Administrator stated that the organization does delineate responsibility for performing the functions in the plan of care on a coordination form that they use, however she confirmed that form is missing from these charts.