Every finding on record at Holyoke Visiting Nurse Assoc & Hospice Life Care

Based on observation, record review, policy review and interview, the agency failed to implement an intervention based on the problems identified in the initial assessments, including services necessary for the palliation and management of the terminal illness and related conditions, for 1 Patient (#6), out of a total sample of 19 patients. Findings include: --- Review of the agency's policy entitled, Agency Philosophy, undated, included the following: *The agency and our staff shall operate and furnish services in compliance with all applicable federal, state, and local laws and regulations and disclosure and ownership information. *The services we provide comply with acceptable professional standards and principles. *The agency's philosophy is guided by the following principle: Designed to meet the unique needs of the clients, families, and caregivers. Patient #6 was admitted to the agency in July 2024 with a terminal diagnosis of cerebrovascular disease requiring hospice services. Review of the Nursing Admission Assessment, dated 7/13/24, indicated the following: *Patient is cachectic (physical wasting with loss of weight and muscle mass due to disease). *Patient is bed bound, total dependence for care, unable to perform activities of daily living. *Patient has no skin issues, has a foam border dressing on his/her bony coccyx to minimize skin breakdown. Review of the Plan of Care (POC), dated 7/19/24, included the following intervention: *Assess skin condition. *Teach skin care, pressure ulcer avoidance. Further review of the POC indicated no interventions for protective skin dressings, Review of nursing notes dated 71/5/24, 7/19/24, and 7/22/24, indicated the patient's skin was intact. The notes did not include documentation of the protective foam dressing nor the skin status underneath. On 7/24/24 at 10:30 A.M., the surveyor and Home Health Aide #1 made a home visit for Patient #6. During the visit, the patient's Health Care Proxy (HCP) said Patient #6 had a dressing on his/her buttocks that had been put on while he/she was in the hospital. The HCP said no one had changed the dressing since the patient had been home and being cared for by the hospice staff. The HCP was unsure if Patient #6 had an open area underneath the dressing. HHA #1 removed the dressing to inspect the skin after the HCP consented to it. HHA #1 said the skin was intact under the dressing and that the dressing was probably a protective dressing. HHA #1 said she had not been informed by nursing that a protective dressing was in place and was unaware of any skin care interventions. During an interview on 7/25/24 at 1:30 P.M., the Executive Director said nursing should have added an intervention for a protective foam dressing and should have been inspecting the skin under the dressing during their home visits.

Based on record review and interview, the agency failed to ensure that care and services were provided in accordance with the plan of care (POC), for 3 patients (#12, #15 and #16), out of a total sample of 19 patients. Findings include: --- Review of the agency's policy entitled, Agency Philosophy, undated, included the following: *The agency and our staff shall operate and furnish services in compliance with all applicable federal, state, and local laws and regulations and disclosure and ownership information. *The agency's philosophy is guided by the following principle: Designed to meet the unique needs of the clients, families, and caregivers. Services are tailored to assist individuals and family to achieve optimal level of function. Patient #12 was admitted to the agency in August 2023 with a terminal diagnosis of Atherosclerotic Heart Disease requiring hospice services. Review of the Hospice POC with benefit dates 4/13/24 through 6/11/24, indicated the following order: Home Health Aide (HHA) visit 5 times a week for 8 weeks. Review of the clinical record indicated the following weeks when 5 HHA visits were not provided as ordered: *The week of 6/2/24 through 6/8/24 indicated only 3 HHA visits were provided. Further review of the clinical record indicated no documented reason why the visits were not provided as ordered. Patient #15 was admitted to the agency in May 2024 with a terminal diagnosis of Atherosclerotic Heart Disease requiring hospice services. Review of the Hospice POC with benefit dates 5/6/24 through 8/3/24, indicated the following order: Home Health Aide (HHA) visit 3 times a week for 13 weeks. Review of the clinical record indicated the following weeks when 3 HHA visits were not provided as ordered: *The week of 5/6/24 through 5/11/24 indicated only 2 HHA visits were provided. *The week of 5/12/24 through 5/18/24 indicated only 2 HHA visits were provided. Further review of the clinical record indicated no documented reason the visits were not provided, Patient #16 was admitted to the agency in April 2024 with a terminal diagnosis of Hypertensive Heart Disease with heart failure requiring hospice services. Review of the Hospice POC with benefit dates 4/2/24 through 6/30/24, indicated the following order: Home Health Aide (HHA) visit once a week for 1 week, and 2 visits a week for 12 weeks. Review of the clinical record indicated the following weeks when 2 HHA visits were not provided as ordered: *The week of 4/2/24 through 4/6//24 (week one) indicated no HHA visit was provided. *The week of 4/14/24 through 4/20/24 indicated no HHA visits were provided. Further review of the clinical record indicated no documented reason the visits were not provided, During an interview on 7/26/24 at 2:00 P.M., the Director of Quality Improvement said staff are required to document the reason why a visit could not be provided, and then notify the physician that the service was not provided as ordered. The Director reviewed the records of Patients #12, #15 or #16, and HHA visits were not provided as ordered as noted above. She said staff had not documented the reasons for the missed visits but did notify the physician. She said no other attempts were made to reschedule the services when missed.

Based on record review and staff interview, The agency failed to ensure that a Nurse Aide Registry background check for 4 of 4 volunteers (Volunteer #1,#2, #3 and #4) 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 the facility policy entitled, Volunteer Policy and Procedure, revised July 2024, included the following: Assessment of Volunteer Suitability: *Background checks may include: -Reference checks, -Criminal Offender Record Information (CORI)/ Aid Registry check. Review of Volunteer #1 personnel record on 7/26/24 indicated that Volunteer #1 joined the volunteer program on 1/27/23. Further review of the file failed to indicate a Nurse Aide Registry check was conducted. Review of Volunteer #2 personnel record on 7/26/24 indicated that Volunteer #2 joined the volunteer program on 7/17/23. Further review of the file failed to indicate a Nurse Aide Registry check was conducted. Review of Volunteer #3's personnel record on 7/26/24 indicated that Volunteer #3 joined the volunteer program on 4/7/23. Further review of the file failed to indicate a Nurse Aide Registry check was conducted. Review of Volunteer #4s personnel record on 7/26/24 indicated that Volunteer #4 joined the volunteer program on 5/22/23. Further review of the file failed to indicate a Nurse Aide Registry check was conducted. During an interview on 7/26/24 at 12:30 P.M., the Volunteer Coordinator said that she checked with the Human Resource (HR) Department and was told that HR does not conduct Nurse Aide Registry checks for volunteers, as required.

Based on record reviews and staff interview, the Hospice Agency failed to ensure that a Registered Nurse (RN) supervised the services provided by the Hospice Aides, no less frequently than every 14 days, in order to assess the quality of care and services provided, for 2 patients (#9 and #10) out of 4 records reviewed who had Hospice Aides, in a total sample of 13 patients. Findings include: 1. Patient #9, with a diagnosis of End Stage Renal Disease (ESRD-a medical condition in which a person's kidneys cease functioning on a permanent basis), was recertified for Hospice services on 7/25/21. Review of the Plan of Care, for the Certification period of 7/25/21 through 10/22/21, indicated a Physician Order for a Hospice Aide to provide services two times a week. Review of the RN Routine Note, dated 7/27/21, indicated the RN had assessed the quality of care and services provided by the Hospice Aide. There was no other documentation found to indicate any other RN assessments of the quality of care and services provided by the Hospice Aide had been completed. During an interview on 10/26/21 at 1:20 P.M., the Interim Executive Director said the Hospice Agency had no evidence that the RN had assessed the quality of care and services provided by the Hospice Aide every 14 days as required, since the 7/27/21 RN Hospice Note. 2. Patient #10, with a diagnosis of Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors), was recertified for Hospice services on 9/12/21. Review of the Plan of Care, for the Certification period of 9/12/21 through 11/10/21, indicated a Physician Order for a Hospice Aide to provide services five times a week. Review of the RN Routine Note, dated 9/15/21, indicated the RN had assessed the quality of care and services provided by the Hospice Aide. There was no other documentation found to indicate any other RN assessments of the quality of care and services provided by the Hospice Aide had been completed. During an interview on 10/26/21 at 1:20 P.M., the Interim Executive Director said the Hospice Agency had no evidence that the RN had assessed the quality of care and services provided by the Hospice Aide every 14 days as required, since the 9/15/21 RN Hospice Note.

Based on record reviews and staff interview, the Hospice Agency failed to ensure that the written copy of the Rights and Responsibilities Acknowledgement form had been signed by the Patient or Responsible Party upon admission for 2 Patients (#9 and #10), in a total sample of 13 patients. Findings include: 1. Patient #9 was admitted to Hospice services on 4/26/21. Review of the clinical record indicated the Resident Rights and Responsibilities Acknowledgement form was signed by Patient #9 on 6/2/21. 2. Patient #10 was admitted to Hospice services on 3/16/21. Review of the clinical record indicated the Resident Rights and Responsibilities Acknowledgement form was signed by the Responsible Party on 5/25/21. During an interview on 10/26/21 at 1:20 P.M., the Interim Executive Director said the Resident Rights and Responsibilities Acknowledgement forms for Patient #9 and #10 were not signed upon admission to Hospice services, as required.

Based on review of 5 employee personnel files and interview with the Human Resources Coordinator, the Hospice Agency failed to conduct a Criminal Offender Record Information (CORI) check and a Certified Nurse Aide (CNA) Registry check, for one out of five employee records reviewed. Home Health Aide (HHA) #1 was hired on 7/5/16. Review of the the employee's personnel record indicated that a CORI and a CNA Registry check was never conducted upon hire. During an interview on 10/26/21 at 11:00 A.M., the Human Resources Coordinator said the CORI and CNA Registry checks were never completed upon hire for HHA #1, as required.