Every finding on record at Hospice of Nashoba Nursing Service

Based on record review and interview, the Agency failed to initiate an individualized Bereavement Plan of Care to address any grief/loss issues for the patient families for two out of two bereavement records reviewed for Patients (#10 and #11). Findings include: Review of the Agency policy titled Bereavement Care and Assessment, dated 6/19/13, included but not limited to: 1. Patient/caregiver (s) are assessed upon admission and on an ongoing basis for anticipatory grief issues and bereavement risk. 2. The Interdisciplinary Group (IDG) members participate in the assessment bereavement risk factors and identify any need for bereavement periods. 3. A formalized and organized Bereavement program is offered over a twelve-month timeframe after the death of the Hospice patient. 4. Bereavement group support services are open to the community at large. 5. Reassess Bereavement Risk factors after the death of the patient and the Coordinator of Bereavement Support/designee develops a formalized plan of care which includes, but is not limited to the following: a. Makes initial call/contact to the bereaved with the offer of a home visit by the Coordinator of Bereavement Services to further assess bereavement risk and develop the plan of care for specific follow up needed........ Document all assessment care/services in the electronic medical record (EMR). 1. Patient #10 was admitted to Hospice services in January 2022 with a diagnosis of malignant neoplasm of the bile duct (small tubes that carry bile from the liver and gallbladder to the small intestine). Patient #10 expired in April 2022. Review of the medical record did not contain any documentation that a Bereavement Plan of Care was initiated and that any bereavement services were offered to the bereaved. During a telephone interview on 9/13/22 at 11:00 A.M., the Bereavement Coordinator said she mailed a Grief packet (contains a letter and information on grief) to the bereaved. She said she did not document this in the medical record. She further said a Bereavement Risk Assessment and Bereavement Plan of Care for the bereaved were not completed as required. 2. Patient #11 was admitted to Hospice services in December 2021 with a diagnosis of End Stage Heart Failure (the heart cannot pump enough blood to meet the body's needs). Patient #11 expired in February 2022. Review of the medical record did not contain any documentation that a Bereavement Plan of Care was initiated and that any bereavement services were offered to the bereaved. During a telephone interview on 9/13/22 at 11:00 A.M., the Bereavement Coordinator said she mailed a Grief packet (contains a letter and information on grief) to the bereaved. She said she did not document this in the medical record. She further said a Bereavement Risk Assessment and Bereavement Plan of Care for the bereaved were not completed as required.

Based on review of three out of six personnel files and interview, the Hospice Agency failed to conduct a Criminal Offender Record Information (CORI) check, for one employee by the end of the employee's first working day. Findings include: Review of the Agency policy titled Selection and Hiring of Employees, revised 5/31/2004, included but not limited to: Nashoba Nursing Services & Hospice conducts selection and hiring activities in a manner that complies with applicable federal and state laws and ensures selection of those applicants who are most qualified..... -Reference forms and CORI release forms are signed at the conclusion of interview. -Final applicant selection will be based on interview findings, suitability for position filled......successful CORI report.... Employee #4 was hired on 7/12/21. Review of the employee's personnel file indicated the CORI check was done on 7/20/21. During an interview on 9/8/22 at 1:15 P.M., the Chief Financial Officer (CFO) said the CORI check for Employee #4 was not completed upon hire as required.

Based on policy review, personnel record review and interview, the Agency failed to ensure: 1) The Abuse Policy contained reporting timelines consistent with the State regulations, and 2) The Nurse Aide Registry checks and licensure verifications were completed during the hiring process for five out of six personnel records reviewed. Findings include: 1. The Agency failed to ensure the Abuse Policy contained reporting timelines for allegations of abuse consistent with the State regulations. Review of the Massachusetts State Regulation 105.CMR.155.004 indicated: (A) Any mandatory reporting individual, as defined in 105 CMR 155.003, shall immediately make an oral report of suspected patient or resident abuse, neglect, mistreatment or misappropriation of patient or resident property to his or her supervisor or employer whenever he or she has reasonable cause to believe that any patient or resident has been abused, neglected or mistreated or had property misappropriated. Upon receiving such report, said supervisor or employer shall immediately notify the Department by oral communication, electronically transmitted report or facsimile in accordance with such guidelines as may be established by the Department...... Review of the Agency policy titled, Reporting of Fraud, Abuse, Neglect or Exploitation: Protection of Patients, revised 3/22/22, included but limited to: - All alleged violations involving mistreatment, neglect, or verbal, mental, sexual and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone furnishing services on behalf of the hospice, are reported immediately by hospice employees and contracted staff to the Hospice Administrator and Skilled Nursing Facility (SNF)/Nursing Facility (NF) or Intermediate Care Facility (ICF) administrator with 24 hours of the hospice becoming aware of the violation. During an interview with the Clinical Manager on 9/8/22 at 1:45 P.M., she said the Abuse Policy did not reflect to immediately report allegations of abuse to the Department of Public Health as required. 2. Review of the Massachusetts State Regulation 105.CMR.155.010 (E) indicated: (4) Except as provided in 105 CMR 155.014(A)(2), no facility, home health agency, homemaker agency or hospice program shall hire or employ an individual whose name appears in the Registry with a finding or adjudicated finding of patient or resident abuse, neglect, mistreatment or misappropriation of patient or resident property, or, if a sanction was imposed upon that individual, such individual may not be hired or employed until the terms of such sanction have been fulfilled. Furthermore, no facility, home health agency, homemaker agency or hospice program shall hire or employ an individual if such individual has been found guilty of, or pleaded guilty or nolo contendere to (a plea of no contest or no defense), or admitted to sufficient facts to support a guilty finding of patient or resident abuse, neglect, mistreatment or misappropriation of patient or resident property in a court of law. Review of the Agency policy titled Selection and Hiring of Employees, revised 5/31/04, included but not limited to: Final applicant selection will be based on interview findings, suitability for position being filled, successful completion of test requirements (if indicated), references received (minimum of one work reference and one character reference), successful Criminal Offender Record Information (CORI) report and verification of applicable license. The Agency failed to: complete a. Nurse Aide Registry checks for Employees (#2, #3 and #4) and b. licensure verifications for Employees (#2, #4, #5 and #6) during the hiring process. a. Employee #2 was hired on 6/8/22. Review of Employee #2 personnel file indicated the Nurse Aide Registry check was completed on 6/9/22 and the Licensed Independent Clinical Social Worker (LICSW) verification was completed on 6/9/22. b. Employee #3 was hired on 12/22/20. Review of Employee #3 personnel file indicated the Nurse Aide Registry check was completed on 1/15/21. c. Employee #4 was hired on 7/12/21. Review of Employee #4 personnel file indicated the Nurse Aide Registry check was completed on 7/20/21 and the Registered Nurse (RN) license verification was completed on 7/20/21. d. Employee #5 was hired on 3/14/22. Review of Employee #5 personnel file contained an undated Occupational Therapist (OT) license detail verification form. e. Employee #6 was hired on 6/27/22. Review of Employee #6 personnel file contained an undated OT license detail verification form. During an interview on 9/8/22 at 1:15 P.M., the Chief Financial Officer (CFO) said the Nurse Aide Registry check and the license verification were completed after the date of hire for Employee #2. She said the Nurse Aide Registry check was completed after the date of hire for Employee #3. She said the Nurse Aide Registry check and license verification were completed after the date of hire for Employee #4. She said the license verification forms for Employee #5 and #6 did not have the date documented indicating the date the verifications were completed and she could not verbalize the exact date the verifications occurred.