Every finding on record at Hospice of the Fisher Home

Based on record review, policy review and interview, the agency failed to ensure the interdisciplinary group (IDG), in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care for 4 Patients (#1, #10, #12 and #18), out of a total sample of 19. Findings include: --- Review of the agency's policy entitled, Comprehensive Assessment of The Patient, undated, indicated the following: *The hospice IDG conducts and documents a patient specific comprehensive assessment that identifies the patient's need for hospice care, including medical, nursing, psychosocial, emotional and spiritual care. *The comprehensive assessment of the patient is completed by the designated members of the IDG, in consultation with the patient's attending physician, no later than 5 calendar days after the patient elects hospice benefits. 1. Patient #1 was admitted to the agency September 2024 with a terminal diagnosis of End Stage Heart Failure. Review of the clinical record indicated the election of benefits (EOB) was signed 9/27/24. Review of the Combined IDG Review of the Comprehensive Assessment/Plan of Care, dated 10/1/24, indicated only the Registered Nurse (RN) had signed the review as completed on 10/1/24. The remaining IDG group including the hospice physician, the social worker (SW) and the bereavement/spiritual counselor did not complete the comprehensive assessment within 5 calendar days of the EOB as required. 2. Patient #10 was readmitted to the agency in May 2024 with a terminal diagnosis of Toxic Encephalopathy (a brain disease that occurs when the brain's structure or function is altered by exposure to toxins or other factors. Review of the clinical record indicated the EOB was signed 5/16/24. Review of the Combined IDG Comprehensive Assessment/Plan of Care, dated 5/12/24, indicated the hospice physician had not completed his review until 5/29/24, not within the 5 calendar days as required. 3. Patient #12 was admitted to the agency in June 2024 with a terminal diagnosis of End Stage Heart Failure. Review of the clinical record indicated the EOB was signed on 6/7/24. Review of the Combined IDG Comprehensive Assessment/Plan of Care, dated 6/11/24, indicated the hospice physician had not completed his review until 6/18/24, not within the 5 calendar days as required. 4. Patient #18 was admitted to the agency in November 2023 with a terminal diagnosis of Dementia. Review of the clinical record indicated the EOB was signed 11/1/23. Review of the Combined IDG Comprehensive Assessment/Plan of Care, dated 11/7/23, indicated the completion and review of the assessment was not done within 5 calendar days as required, and the hospice physician had not completed his review until 11/17/24, also not within the 5 calendar days as required. During an interview on 11/6/24 at 8:30 A.M., the Director of Operations said all members of the IDG need to complete their reviews within 5 calendar days of the EOB as required, but it was not done timely for the 4 patients noted above.

Based on record review, policy review and staff interview, the agency failed to ensure initial bereavement risk assessments were completed upon admission for 2 Patients (#13, #17), out of a total sample of 19 patients. Findings include: --- Review of the agency policy, entitled, Bereavement Care Planning, undated, indicated the following: *During the comprehensive assessment of the patient, an initial bereavement assessment is conducted to determine the cultural, social and spiritual factors that may impact the ability of family members or other involved individuals to cope with the patient's death. *Findings from the initial bereavement assessment are incorporated into the patient's plan of care and considered in the bereavement plan of care. 1.Patient #13 was admitted to the agency in June 2024 with a diagnosis of Alzheimer's Disease. Review of the clinical record did not contain documentation that an initial bereavement risk assessment was completed upon admission. 2. Patient #17 was admitted to the agency in June 2024 with a diagnosis of neoplasm of the bladder (cancer). Review of the clinical record did not contain documentation that an initial bereavement risk assessment was completed upon admission. During an interview on 11/6/24 at 11:40 A.M., the Director of Operations (DO), after reviewing the clinical records for Patient #13 and Patient #17, said the initial bereavement risk assessments were not completed upon admission, as required.

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 10 patients (#2, #4, #6, #7, #13, #12, #14, #16, #18 and #19), out of a total sample of 19 patients. Findings include: --- Review of the agency policy, entitled, Plan of Care, undated, indicated the following: *The patient's plan of care specifies the care and services necessary to meet the needs of the patient/family as identified in the initial, comprehensive and updated assessments of the patient. Review of the agency policy, entitled, Charting Error, undated, indicated the following: *The Clinical Director will conduct a follow-up assessment within 24 hours of notification to the charting error, including documentation on the reason for the missed visit. 1. Patient #2 was admitted to the agency in March 2024 with a diagnosis of Alzheimer's Disease. Review of the Inpatient Combined Disciplinary POC for certification period 9/15/24 through 11/13/24, indicated the following: *Skilled Nurse Visit (SNV); once a week. Review of the clinical record indicated a SNV was not provided for the week of 9/30/24 through 10/5/24. During an interview on 10/30/24 at 4:17 P.M., the Director of Operations (DO) a SNV did not occur for the week of 9/30/24 through 10/5/24, as ordered. 2. Patient #4 was admitted to the agency in October 2024 with a diagnosis of breast cancer. Review of the Physician Orders Visit Frequency indicated the following: *Medical Social Worker Visit (MSWV); once every 4 weeks and 2, as needed, (PRN) visits.. Review of the clinical record indicated a MSWV occurred on 10/16/24, 10/18/24 and 10/28/24. Review of the documentation for each visit did not indicate the visits were PRN. During an interview on 11/1/24 at 11:20 A.M., the DO said the MSWVs did not follow the POC, as ordered. 3. Patient #6 was admitted to the agency in September 2024 with a diagnosis of cerebral infarction (stroke). Review of the Physician Orders, effective 9/5/24, indicated the following: *Hospice Aide Visits (HAVs);19 visits every week and 2 PRN visits *MSWV; one visit every 4 weeks and 2 PRN visits. a. Review of the clinical record indicated the the following HAVs were provided: -Week of 9/8/24 through 9/14/24, 21 visits.. -Week of 9/15/24 through 9/21/24, 21 visits. -Week of 9/22/24 through 9/28/24, 20 visits. -Week of 9/29/24 through 10/5/24, 20 visits. -Week of 10/6/24 through 10/12/24, 20 visits. -Week of 10/13/24 through 10/19/24, 21 visits. -Week of 10/20/24 through 10/26/24, 21 visits. b. Review of the clinical record indicated the following MSWVs were provided: -PRN MSWVs occurred on 9/23/24, 9/23/24 and 10/23/24. -MSWVs occurred on 9/6/24, 10/7/24 and 10/22/24. c. Review of the clinical record indicated the following Spiritual Counselor (SC) visits were provided on 9/9/24, 9/26/24 and 10/23/24. During an interview on 11/1/24 at 1:45 P.M., the Certified Nurse Aide (CNA) Supervisor said the listed HAVs were not provided, as ordered. During an interview on 11/1/24 at 2:00 P.M., the Executive Director (ED) said the MSWVs and the PRN visits were not provided, as ordered. She further said there was no physician order in place for the SC visits that were provided, as required. 4. Patient #7 was admitted to the agency in July 2024 with a diagnosis of lung cancer. Review of the Combined Disciplinary Plan of Care, for certification period 10/15/24 through 1/12/25, indicated the following: *SNV: once a week. Review of the clinical record indicated a SNV did not occur the week of 10/20/24 through 10/26/24. During an interview on 11/1/24 at 3:15 P.M., the DO said there was no documentation in the clinical record to indicate a SNV occurred the week of 10/20/24 through 10/26/24, as ordered. 5. Patient #13 was admitted to the agency in June 2024 with a diagnosis of Alzheimer's Disease. Review of the Physician order, dated 6/3/24, indicated the following: *SNV; once a week. Review of the clinical record indicated a SNV was not provided for the week of 7/14/24 through 7/20/24. During an interview on 11/6/24 at 10:40 A.M., the DO said a SNV was not provided for the week of 7/14/24 through 7/20/24, as ordered. 7. For Patient #12, Hospice Aide Visits (HAVs) were not provided as ordered in the plan of care. Patient #12 was admitted to the agency in June 2024 with a terminal diagnosis of End Stage Heart Failure. Review of the physician ordered Plan of Care for certification period 6/7/24 through 9/4/24, indicated the following: *HAVs: 3 times a week. *SNV: 1 time a week. Review of the clinical record indicated no HAVs were provided for the weeks of 7/7/24 through 7/13/24, 7/14/24 through 7/20/24, and 7/21/24 through 7/27/24, and a SNV was not provided for the week of 7/21/24 through 7/27/24. Additionally, there was no documentation of why the visits were not provided as ordered. During an interview on 11/5/24 at 3:00 P.M., the Director of Operations said the SNV and HAVs were not provided as ordered, and staff had not documented why they were missed. 8. For Patient #14, HAVs were not provided as ordered in the plan of care. Patient #14 was admitted to the agency in September 2024 with a terminal diagnosis of End Stage Heart Failure. Review of the physician ordered Plan of Care for certification period 9/24/24 through 12/22/24, indicated the following: *HAVs: 2 times a week. Review of the clinical record indicated only one HAV was provided for the weeks of 9/24/24 through 9/28/24, and 9/29/24 through 10/5/24. Additionally, there was no documentation of why the visits were not provided as ordered. During an interview on 11/5/24 at 1:30 P.M. the DO said the plan of care for HAVs was not provided as ordered, for the two weeks noted above, and staff did not document why the visits were missed. 9. For Patient #16, HAVs and Spiritual Counselor visits (SCVs) were not provided as ordered in the plan of care. Patient #16 was admitted to the agency in March 2024 with a terminal diagnosis of Senile Degeneration of the Brain (Dementia). Review of the physician ordered Plan of Care for certification period 925/24 through 11/23/24, indicated the following: *HAVs: 3 times a week. *SCV: 1 time every 4 weeks and 2 as needed (PRN) visits. Review of the clinical record indicated only 2 HAVs were provided for the week of 10/13/24 through 10/19/24, not 3 as ordered, and no SCVs were provided in October. Additionally, there was no documentation of why the visits were not provided as ordered. During an interview on 11/6/24 at 8:40 A.M., the DO said the third HAV was missed the week of 10/13/24, and the SCV was not provided at all during October. She said the plan of care was not followed and staff did not document why visits were missed. 10. For Patient #18, HAVs were not provided as ordered. Patient #18 was admitted to the agency in November 2023 with a terminal diagnosis of Dementia. Review of the physician ordered Plan of Care for 11/1/23 through 1/9/24, indicated the following: *Effective 11/5/23: HAVs 3 times a week. Review of the clinical record indicated only one HAV was provided (11/15/23) between 11/5/23 and 11/21/23. Additionally, there was no documentation of why the visits were not provided as ordered. During an interview on 11/6/24 at 2:40 P.M. the DO said the plan of care was not followed as ordered and staff had not documented why the visits were missed. 11. For Patient #19, HAVs were not provided as ordered in the plan of care. Patient #19 was admitted to the agency in April 2024 with a terminal diagnosis of Malignant Neoplasm (cancer) of the brain. Review of the physician ordered Plan of Care for 4/25/24 through 7/23/24, indicated the following: *Effective 5/22/24: HAV 1 time a week and 2 PRN visits. Review of the clinical record indicated no HAV was provided between 5/22/24 and 5/25/24, and no documentation indicating why it was not provided. During an interview on 11/6/24 at 2:15 P.M., the DO said the HAV was not provided as ordered and staff had not documented why it was missed.

Based on record review, policy review and interview, the agency failed to ensure there was ongoing communication for care and services relative to the bereavement process, in accordance with the hospice's policy, for 2 patients (#18 and #19), out of total sample of 19 patients. Findings include: --- Review of the agency's policy, entitled Bereavement Care Planning, undated, indicated the following: *During the comprehensive assessment of the patient, an initial bereavement assessment is conducted to determine the cultural, social and spiritual factors that may impact the ability of family members or other involved individuals to cope with the patient's death. *The Bereavement Coordinator is notified of all deaths and initiates the bereavement discussion and care planning at the first interdisciplinary group (IDG) meeting following the patient's death. *The Bereavement Coordinator ensures that the bereavement plan of care is followed for 13 months following the patient's death, appropriate to the level of need assessed. 1. Patient #18 was admitted to the agency in November 2023 with a terminal diagnosis of dementia. Review of the clinical record indicated an initial bereavement assessment was completed upon admission and reviewed with the IDG at a meeting on 11/7/24. Review of the clinical record indicated Patient #18 expired on 11/21/23. Review of Patient #18's bereavement follow-up outreach guideline indicated the 9 month follow-up mailing had not been completed and was overdue by 82 days. 2. Patient #19 was admitted to the agency in April 2024 a terminal diagnosis of Malignant Neoplasm (cancer) of the Brain. Review of the clinical record indicated an initial bereavement assessment was completed upon admission and reviewed with the IDG at a meeting on 4/30/24. Review of the clinical record indicated Patient #19 expired on 6/6/24. Review of Patient #19's bereavement follow-up outreach guideline indicated the 3 month follow-up mailing, and phone call had not been completed, and was overdue by 63 days. During an interview on 11/6/24 at 2:15 P.M., the Director of Operation said the Bereavement Coordinator had not completed the ongoing communication with the families of Patients #18 and #19, as required per the agency's policy.

Based on record review, policy review and interview, the agency failed to ensure there was communication shared with the physician when services were not provided, as ordered, for 10 Patients (#12, #14, #16, #18, #19, #2, #4, #6, #7, and #13), out a total sample of 19 patients. Findings include: --- 6. Patient #2 was admitted to the agency in March 2024 with a diagnosis of Alzheimer's Disease. Review of the Inpatient Combined Disciplinary POC for certification period 9/15/24 through 11/13/24, indicated the following: *Skilled Nurse Visit (SNV); once a week. Review of the clinical record indicated a SNV was not provided for the week of 9/30/24 through 10/5/24. 7. Patient #4 was admitted to the agency in October 2024 with a diagnosis of breast cancer. Review of the Physician Orders Visit Frequency indicated the following: *Medical Social Worker Visit (MSWV); once every 4 weeks. Review of the clinical record indicated a MSWV occurred on 10/16/24, 10/18/24 and 10/28/24, beyond the ordered visit frequency. 8. Patient #6 was admitted to the agency in September 2024 with a diagnosis of cerebral infarction (stroke). Review of the Physician Orders, effective 9/5/24, indicated the following: *Hospice Aide Visit (HAV) Frequency;19 visits every week and 2 PRN visits *MSWV; one visit every 4 weeks and 2 PRN visits. a. Review of the clinical record indicated the the following HAVs were provided beyond the ordered frequency: -Week of 9/8/24 through 9/14/24, 21 visits.. -Week of 9/15/24 through 9/21/24, 21 visits. -Week of 9/22/24 through 9/28/24, 20 visits. -Week of 9/29/24 through 10/5/24, 20 visits. -Week of 10/6/24 through 10/12/24, 20 visits. -Week of 10/13/24 through 10/19/24, 21 visits. -Week of 10/20/24 through 10/26/24, 21 visits. b. Review of the clinical record indicated the following MSWVs were provided beyond the ordered frequency: -PRN MSWVs occurred on 9/23/24, 9/23/24 and 10/23/24. -MSWVs occurred on 9/6/24, 10/7/24 and 10/22/24. c. Review of the clinical record indicated the following Spiritual Counselor (SC) visits were provided on 9/9/24, 9/26/24 and 10/23/24. There was no physician order in place for SC visits. 9. Patient #7 was admitted to the agency in July 2024 with a diagnosis of lung cancer. Review of the Combined Disciplinary Plan of Care, for certification period 10/15/24 through 1/12/25, indicated the following: *SNV; once a week. Review of the clinical record indicated a SNV did not occur the week of 10/20/24 through 10/26/24, as ordered. 10. Patient #13 was admitted to the agency in June 2024 with a diagnosis of Alzheimer's Disease. Review of the Physician order, dated 6/3/24, indicated the following: *SNV; once a week. Review of the clinical record indicated a SNV was not provided for the week of 7/14/24 through 7/20/24, as ordered. During an interview on 11/6/24 at 3:00 P.M., after reviewing all the clinical records for Patients #2, #4, #6, #7 and #13, the DO said the physician was not notified of any visits that occurred without an order or that were not provided as per plan of care, as required. Review of the agency's policy entitled, The Plan of Care, undated, indicated the following: *Review of, and changes to the plan of care are documented and communicated to the members of the interdisciplinary group (IDG). Review of the agency's policy entitled, Charting Error, undated, indicated the following: *Charting Error: a discrepancy in charting, examples include, but not limited to, omission of important information, incorrect entries, inconsistent information, or visit frequency error. *The nurse reviewing the chart will notify the Clinical Director immediately upon the discovery of the charting error. The Clinical Director will conduct a follow-up assessment within 24 hours of notification to the charting error, including documentation on the reason for the missed visit. 1. Patient #12 was admitted to the agency in June 2024 with a terminal diagnosis of End Stage Heart Failure. Review of the physician ordered Plan of Care for certification period 6/7/24 through 9/4/24, indicated the following: *HAVs: 3 times a week. *SNV: 1 time a week. Review of the clinical record indicated no HAVs were provided for the weeks of 7/7/24 through 7/13/24, 7/14/24 through 7/20/24, and 7/21/24 through 7/27/24, and a SNV was not provided for the week of 9/21/24 through 9/27/24. 2. Patient #14 was admitted to the agency in September 2024 with a terminal diagnosis of End Stage Heart Failure. Review of the physician ordered Plan of Care for certification period 9/24/24 through 12/22/24, indicated the following: *HAVs: 2 times a week. Review of the clinical record indicated only one HAV was provided for the weeks of 9/24/24 through 9/28/24, and 9/29/24 through 10/5/24. 3. Patient #16 was admitted to the agency in March 2024 with a terminal diagnosis of Senile Degeneration of the Brain (Dementia). Review of the physician ordered Plan of Care for certification period 9/25/24 through 11/23/24, indicated the following: *HAVs: 3 times a week. *SCV: 1 time every 4 weeks and 2 as needed (PRN) visits. Review of the clinical record indicated only 2 HAVs were provided for the week of 10/13/24 through 10/19/24, not 3 as ordered, and no SCVs were provided in October. 4. Patient #18 was admitted to the agency in November 2023 with a terminal diagnosis of Dementia. Review of the physician ordered Plan of Care for 11/1/23 through 1/9/24, indicated the following: *Effective 11/5/23: HAVs 3 times a week. Review of the clinical record indicated only one HAV was provided (11/15/23) between 11/5/23 and 11/21/23. 5. Patient #19 was admitted to the agency in April 2024 with a terminal diagnosis of Malignant Neoplasm (cancer) of the brain. Review of the physician ordered Plan of Care for 4/25/24 through 7/23/24, indicated the following: *Effective 5/22/24: HAV 1 time a week and 2 PRN visits. Review of the clinical record indicated no HAV was provided between 5/22/24 and 5/25/24. During an interview on 11/6/24 at 2:15 P.M., the Director of Operations (DO) said when visits are not provided as ordered, the missed visit is documented in the clinical record, including a reason why it was not provided as ordered, and that information is then provided to the attending physician. She said for the Patients #12, #14, #16, #18 and #19 there were no missed visit documentation, and the physician(s) had not been notified that the plan of care was not implemented as ordered.

Based on documentation review and interview with the Executive Director, it was determined the agency failed to implement and maintain an effective, ongoing, hospice-wide, data-driven Quality Assessment and Performance Improvement (QAPI) program. This has the potential to affect the 14 patients who are currently receiving hospice services and all future hospice patients. Findings include: The agency failed to analyze the quality indicators from all aspects of operation. Refer to L0562. The agency failed to ensure QAPI committee meetings were routinely held. Refer to L0565. The agency failed to ensure identified Performance Improvement Projects (PIPs) were documented, developed and evaluated for progress and performance. Refer to L0573

Based on review of the Quality Assessment and Performance Improvement (QAPI) documentation, policy review, and staff interview, the agency failed to analyze the quality indicators from all aspects of operation which would enable the Hospice to assess quality of care and hospice services provided. Findings include: --- Review of the agency policy, entitled, QAPI-Program and Activities, undated, included the following: *Ongoing planning of the QAPI program includes a focus on demonstrating measured improvements in indicators related to palliative outcomes and hospice services. *The QAPI committee, in collaboration with hospice leadership, establishes a framework for determining appropriate quality indicators to monitor clinical and non-clinical components of the hospice's operations. *Selected quality indicators related to adverse events and other aspects performance are measured, analyzed, and tracked in order to assess processes of care, hospice services and operations. *Performance improvement activities: -focus on high-risk, high-volume, and problem prone areas; -consider incidence, prevalence, and severity of problems in high risk, high volume and problem areas, and -affect palliative outcomes, patient safety and quality of care. *When improvement opportunities are identified through quality assessment activities, the hospice takes action to improve performance, including education, modification of systems and processes, or formal performance improvement projects. *After implementing actions to improve performance, the hospice continues to monitor the related quality indicators in order to measure success and ensure that improvements are sustained. During an interview on 10/30/24 at 4:30 P.M., the Executive Director and surveyor reviewed the facility QAPI documentation binder. The binder contained documentation from two Quarterly QAPI meetings that occurred on 1/23/24 and 4/23/24. The 1/23/24 QAPI meeting documentation indicated a current Performance Improvement Plan (PIP) for insurance forms at sign-in visits that are not being fully completed. The 4/23/24 QAPI meeting documentation indicated a PIP for secondary insurance documentation. There was no documentation of a specific quality measure that was being measured, analyzed and tracked specific to patient care. The Executive Director said there has been no quarterly QAPI meetings since April due to the Quality Director of Compliance has been working from home due to an illness and there has been major changes in leadership at the agency. She further said there was no documentation to indicate quality indicators were measured, tracked, analyzed by the agency.

Based on Quality Improvement and Assessment Improvement (QAPI) documentation, policy review and staff interview, the agency failed to ensure QAPI committee meetings were held quarterly. Findings include: --- Review of the agency policy, entitled, QAPI-Quality Assessment and Performance Improvement Projects, undated, indicated the following: *A QAPI Committee, whose members are appointed by the Hospice Administrator will assist the Administrator with overall operation of the QAPI program. The committee will meet regularly, no less than 4 times per year. The agency failed to ensure Quarterly QAPI meetings were held, as required. Review of the QAPI documentation indicated Quarterly QAPI meetings were only held on 1/23/24 and 4/23/24. During an interview on 10/30/24 at 4:30 P.M., the Executive Director said there were no other Quarterly QAPI meetings held this year. She further said the Quality Director has been working from home due to an illness and there have been major leadership changes in the agency and no other Quarterly QAPI meetings have occurred, as required.

Based on Quality Assessment and Performance Improvement (QAPI) documentation and interview, the agency failed to ensure four Performance Improvement Projects (PIPs) identified were documented, developed, implemented, and evaluated for progress and improvement performance. Findings include: --- Review of the agency policy, entitled, QAPI-Performance Improvement Projects, undated, indicated the following: *The number of performance improvement projects conducted each year is based on identified needs and consistent with the size, complexity, and past performance of the hospice's services and operations. *The QAPI Committee makes recommendations for potential performance improvement projects based on the results of quality monitoring throughout the hospice and patient care priorities. *The QAPI Committee involves members of appropriate departments, disciplines, and programs in the planning, implementation, and evaluation of selected performance improvement activities and projects. *All performance improvement projects, the reasons for selecting specific projects and the measurable progress achieved of all activities and projects are documented and communicated throughout the hospice and the hospice's Board of Directors. *Progress and improvement achieved through selected performance improvement activities and projects are evaluated to assess sustainability. Review of the documentation of the 1/23/24 Quarterly QAPI meeting indicated the following: *PIP addressing diversity was being planned and a meeting with a staff member was to occur. *PIP addressing pain that was continuing with data collection a little longer. *PIP addressing dyspnea. *PIP addressing bowel medications. Review of the documentation of the 4/23/24 Quarterly QAPI meeting indicted the following: *PIP addressing diversity was ongoing with 2 staff members. *PIP addressing dyspnea. *PIP addressing anxiety. *PIP addressing medication errors. No documentation was found in the QAPI binder for any of the PIP projects identified in the 1/23/24 and 4/23/24 Quarterly QAPI meeting minutes. During an interview with the Executive Director on 11/6/24 at 2:00 P.M., she said she could not provide any additional documentation on the PIP projects identified in the four Quarterly QAPI meetings.

Based on volunteer personnel record review, state regulation review, and staff interview, the agency failed to ensure Abuse training was provided during the orientation process for 3 of 3 volunteers. Findings include: --- Review of the 105 CMR 155.000: Patient and Resident Abuse Prevention, Reporting, Investigation, Penalties and Registry Section: 155.010: Responsibilities of the Facility, Home Health Agency, Homemaker Agency and Hospice Program included the following: (A) Each facility, home health agency, homemaker agency and hospice program shall develop and adopt, through an interdisciplinary team, written policies and procedures for preventing patient or resident abuse, neglect, mistreatment and misappropriation; and reporting and responding to suspected cases of patient or resident abuse, neglect, mistreatment or misappropriation of patient or resident property prior to submitting an application for a license. Each facility, home health agency, homemaker agency and hospice program shall implement, and review and revise through an interdisciplinary team as needed but no less than once a year, its written policies and procedures. A facility, home health agency, homemaker agency and hospice program shall ensure that all staff, including temporary staff and volunteers, are trained and determined to be competent as needed for their duties on the policies and procedures developed. At a minimum, these written policies and procedures shall include provisions to meet the requirements of 105. CMR.010, and the following areas: (1) Screening; (2) Training; (3) Prevention; (4) Identification; (5) Investigation; (6) Protection, and (7) Reporting and Response. Review of Volunteer #1 personnel record on 10/30/24 indicated Volunteer #1 joined the volunteer program on 7/7/24. Further review of the personnel file did not contain documentation that Abuse training was provided during the orientation process. Review of Volunteer #2 personnel record on 10/30/24 indicated Volunteer #2 joined the volunteer program on 7/13/24. Further review of the personnel file did not contain documentation that Abuse training was provided during the orientation process. Review of Volunteer #3 personnel record on 10/30/24 indicated Volunteer #3 joined the volunteer program on 7/13/24. Further review of the personnel file did not contain documentation that Abuse training was provided during the orientation process. During an interview on 10/30/24 at 1:50 P.M., the Volunteer Coordinator said she could not find any documentation that Volunteers #1, #2 and #3 had received Abuse training during the orientation process, as required. During an interview on 10/30/24 at 4:00 P.M., the Executive Director said there was no documentation that the volunteers in the agency had received Abuse training during the orientation process, as required. Help shape the future of iQIES. Click Here to participate in iQIES HCD Rese

Based on record review, policy review, and interview, the agency failed to ensure that clinical documentation was complete, and appropriately authenticated and dated in accordance with the hospice agency policy and with currently accepted standards of practice for 12 Patients (#1, #8, #10, #12, #14, #16, #18, #19, #7, #11, #13, and #17), out of a total sample of 19 patients. Findings include: --- 9. Patient #7 was admitted to the agency in July 2024 with a diagnosis of lung cancer. Review of the Combined Disciplinary Plan of Care, for certification period 10/15/24 through 1/12/25, indicated the following: *SNV; once a week. Review of the clinical record indicated a SNV on 10/16/24 and the visit note was signed/dated on 10/23/24. 10. Patient #11 was admitted to the facility in August 2024 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD-a group of ling diseases that block airflow and make it difficult to breathe). Review of a physician order, dated 8/20/24, indicated for a HAV, once a week. Review of a physician order, dated 10/15/24, indicated for 2 HAVs per week. Review of the clinical record indicated for HAVs that occurred between 8/29/24 through 11/1/24, there were 15 notes signed/dated after the visit. These notes included: *8/29/24 visit note was signed/dated on 9/1/24. *9/6/24 visit note was signed/dated on 9/24/24. *10/4/24 visit note was signed/dated17 on 10/31/24. 11. Patient #13 was admitted to the agency in June 2024 with a diagnosis of Alzheimer's Disease. a. Review of a physician order, dated 6/3/24, indicated the following: *SNV; once a week. Review of the clinical record indicated the following SNV notes that were signed/dated after the visit: *6/12/24 visit note was signed/dated on 6/16/24. *6/28/24 visit note was signed/dated on 7/1/24. *8/9/24 visit note was signed/dated on 8/12/24. b. Review of a physician order, dated 6/3/24, indicated the following: *HAV; 3 times a week. Review of the clinical record indicated for HAVs that occurred between 6/6/24 through 8/15/24, there were 26 visit notes that were signed/dated after the visit. These notes included: *6/25/24 visit note was signed/dated on 7/14/24. *7/2/24 visit note was signed/dated on 7/15/24. *8/7/24 visit note was signed/dated 9/1/24. 12. Patient #17 was admitted to the agency in June 2024 with a diagnosis of neoplasm of the bladder (cancer). a. Review of a physician order, dated 6/4/24, indicated the following: *SCV; one visit every 4 weeks. Review of the clinical record indicated the following: *6/10/24 visit note was signed/dated on 7/8/24. *7/5/24 Spiritual Care call note to the patient was signed/dated on 7/8/24. *7/25/24 visit note was signed/dated on 7/30/24. *8/19/24 visit note was signed/dated on 821/24. *9/27/24 visit note was signed/dated on 9/30/24. b. Review of a physician order, dated 6/4/24, indicated the following: *Medical Social Worker Visit (MSWV); 2 visits every 4 weeks. Review of the clinical record indicated a MSWV occurred on 9/18/24 and the visit note was signed/dated on 9/18/24. c. Review of a physician order, dated 6/12/24, indicated the following: *HAV-2 visits per week. Review of the clinical record indicated for HAVs that occurred between 6/10/24 and 10/29/24, there were 36 visit notes that were signed/dated after the visit. These notes included: *6/14/24 visit note was signed/dated on 6/24/24. *7/16/24 visit note that was signed/dated on 8/2/24. *8/8/24 visit note that was signed/dated on 9/1/24. During an interview on 11/6/24 at 11:490 A.M., the DO said, after reviewing the clinical records, documentation of visits should be completed within 24 hours of the visit. She further said the visit documentations completed for Patients #7, #11, #13 and#17 were all late and not within the required 24 hour timeframe. Review of the agency's policy entitled, Documentation Requirements, undated, indicated the following: *Documentation is completed by all hospice staff and volunteers whenever patient/family visits occur. *Documentation must be legible, grammatically correct, accurate and timely. 1. Patient #1 was admitted to the agency in September 2024 with a terminal diagnosis of End Stage Heart Failure. Review of the physician ordered Plan of Care for certification period 9/27/24 through 12/25/24, indicated the following: *Spiritual Care Visit (SCV) once every 4 weeks and 2 as needed (PRN) visits. Review of the clinical record indicated the following SCV notes that was signed/dated after the visit: *9/30/24 visit note was signed on 10/15/24. 2. Patient #8 was admitted to the agency in June 2024 with a terminal diagnosis of Heart Failure. Review of the clinical record indicated the following SCV notes that were signed/dated after phone calls to the family. *6/27/24 phone call note was signed 7/8/24. *6/28/24 phone call note was signed on 8/21/24. 3. Patient #10 was admitted to the agency in May 2024 with a terminal diagnosis of Toxic Encephalopathy (a brain disease that occurs when brain's structure or functions is altered by exposure to toxins or other factors). Review of the physician ordered Plan of Care for certification period 5/16/24 through 7/14/24, indicated the following: *SCV once every 4 weeks and 2 as needed (PRN) visits. Review of the clinical record indicated the following SCV notes that was signed/dated after the visit: *5/20/24 visit note was signed on 8/27/24. 4. Patient #12 was admitted to the agency in June 2024 with a terminal diagnosis of End Stage Heart Failure. Review of the physician ordered Plan of Care for certification period 6/7/24 through 9/4/24, indicated the following: *Skilled Nurse Visit (SNV) 1 time a week, and 2 PRN visits. *Hospice Aide Visit (HAV) 3 times a week. Review of the clinical record indicated the following SNV and HAV notes that were signed/dated after the visit: *6/7/24 SNV note was signed on 6/10/24. *6/13/24 and 6/18/24 HAV notes were both signed on 6/24/24. *6/21/24 and 6/28/24 SNV notes were signed on 7/1/24. *7/16/24, 7/17/24 and 7/18/24 HAV notes were signed on 8/1/24. 4. Patient #14 was admitted to the agency in September 2024 with a terminal diagnosis of End Stage Heart Failure. Review of the physician ordered Plan of Care for certification period 9/24/24 through 12/22/24, indicated the following: *SCV once every 4 weeks and 2 PRN visits. *HAV 2 times a week. Review of the clinical record indicated the following HAV and SCV notes that were signed/dated after the visit: *10/3/24 and 10/7/24 HAV notes were both signed on 10/31/24. *10/18/24 SCV note was signed on 10/22/24. 5. Patient #16 was admitted to the agency in March 2024 with a terminal diagnosis of Senile Degeneration of the Brain (Dementia). Review of the physician ordered Plan of Care for certification period 6/27/24 through 9/24/24, indicated the following: *SCV 1 visit every 4 weeks and 2 PRN visits. Review of the clinical record indicated the following SCV note that was signed/dated after the visit: *9/13/24 SCV note was signed on 9/16/24. Review of the physician ordered Plan of Care for certification period 9/25/24 through 11/23/24, indicated the following: *SNV 1 time a week and 2 PRN visits. *HAV 3 times a week and 2 PRN visits. Review of the clinical record indicated the following SNV and HAV notes that were signed/dated after the visit: *9/27/24 HAV note was signed on 10/2/24 *11/1/24 SNV note was signed on 11/4/24. 6. Patient #18 was admitted to the agency in November 2023 with a terminal diagnosis of Dementia. Review of the physician ordered Plan of Care for certification period 11/1/23 through 1/29/24, indicated the following: *SNV 1 time a week and 2 PRN visits Review of the clinical record indicated the following SNV note that was signed/dated after the visit: *11/9/23 SNV note was signed on 11/13/23. 7. Patient #19 was admitted to the agency in April 2024 with a terminal diagnosis of Malignant Neoplasm (cancer) of the Brain. Review of the physician ordered Plan of Care for certification period 4/25/24 through 7/23/24, indicated the following: *SCV 1 visit every 4 weeks and 2 PRN visits. *Effective 6/5/24: HAV 3 times a week. Review of the clinical record indicated the following SCV and HAV notes that were signed/dated after the visit. *4/29/24 SCV note was signed on 5/21/24 *6/5/24 HAV note was signed on 6/12/24. *6/6/24 HAV note was signed on 6/13/24. During an interview on 11/6/24 at 8:30 A.M., the Director of Operation (DO) said that staff are expected to complete their visit note on the day of the visit, or within 24 hours of the visit. During an interview on 11/6/24 at 11:40 A.M., Certified Nurse Aide (CNA) #1 said that he completes his documentation of visits he makes at the end of each day. During an interveiw on 11/6/24 at 2:30 P.M., the DO and the Executive Director both said that based on the surveyors review some staff are not completing their documentation timely as required.

Based on record review and interview the agency failed to ensure that the Medical Director participated in 2 of 4 quarterly Quality Assurance/Performance Improvement (QAPI) meetings during the past year. Findings include: Review of the agency's QAPI Program Policy, undated, indicated, "The QAPI Committee, which includes representatives from all disciplines, assists in the management of the on-going performance improvement process through regularly scheduled meetings." Review of the Quarterly QAPI Report for January 1, 2021 - March 31, 2021, indicated that the Medical Director was absent from the meeting. Review of the Quarterly QAPI Report for April 1, 2021 - June 30, 2021, indicated that the Medical Director was absent from the meeting. During an interview with the QAPI Director on 12/13/21 at 3:10 P.M., she said that the QAPI meetings are held quarterly by teleconference. She further said that the Medical Director does not always participate in the meetings and usually only asks for an update after the missed meeting.

Based on review of nine employee personnel record files and an interview with the Director of Operations, the Hospice Agency failed to ensure a Massachusetts Criminal Offender Record Information (CORI) check was completed prior to hire, as required, for one Employee (#1). Findings include: Employee #1 was hired on 6/17/19. Review of Employee #1's personnel file documentation indicated the CORI check was completed on 6/18/19. During an interview on 12/14/21 at 2:45 P.M., the Director of Operations said the CORI check for Employee #1 was not completed prior to hire, as required.

Based on review of nine employee personnel record files and an interview with the Director of Operations, the Hospice Agency failed to contact the Nurse Aide Registry prior to hire, as required, for three Employees (#1, #2 and #3). Findings include: 1. Employee #1 was hired on 6/17/19. Review of the personnel record indicated a Nurse Aide Registry check was completed on 7/31/19. 2. Employee #2 was hired on 5/23/21. Review of the personnel record indicated a Nurse Aide Registry check was not completed. 3. Employee #3 was hired on 11/10/20. Review of the personnel record indicated a Nurse Aide Registry check was not completed. During an interview on 12/14/21 at 2:45 P.M., the Director of Operations said the Nurse Aide Registry check for Employee #1 was not completed prior to hire, as required. She further said the Nurse Aide Registry checks for Employees #2 and #3 were not completed prior to hire, as required.