Every finding on record at Hospice of the Good Shepherd, Inc.

Based on record review, policy review and interview, the agency failed to ensure the hospice interdisciplinary group (IDG) in collaboration with the individual's attending physician, (if any) must review, revise and document the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days, for 2 patients (#23 and #16), out of a total sample of 27 patients.Findings include: --- 2. Patient #16 was admitted to the agency in July 2025 with a diagnosis of cerebrovascular disease (any condition that affects the blood vessels supplying the brain).Review of the clinical record indicated the IDG held a care plan meeting on 9/25/25. Further review of the clinical record indicated an IDG care plan meeting was not held 15 days later, as required.During an interview on 10/15/25 at 2:30 P.M., the Director of Intake & Admissions said the review of the care plans at the IDG meeting held on 10/9/25 did not address Patient #16, as required.  Review of the agency's policy entitled Plan of Care, revised September 2020, indicated the following:-The plan of care is reviewed and updated by the interdisciplinary team at least every 14 days or more frequently if needed.1.Patient #23 was admitted to the agency in July 2025 with a diagnosis of senile degeneration of the brain and required hospice services.Review of the clinical record indicated the IDG held a care plan meeting on 9/25/25. Further review of the record indicated an IDG care plan meeting was not held 15 days later as required.During an interview on 10/16/25 at 3:00 P.M., the Vice President of Administration and Human Resources said Patient #23's care planning was missed on 10/9/25.

Based on record review, policy review and interview, the agency failed to ensure that the care and services are provided in accordance with the plan of care, for 2 Patients (#9 and#23), out of a total sample of 27 patients.Findings include: --- Review of the agency's policy entitled Plan of Care, revised September 2020, indicated the following:-During the admission process, an initial plan of treatment is established and is reviewed by the attending physician, hospice physician, and members of the interdisciplinary team.-The plan of care includes services and level of care required for the management of discomfort and symptom relief, including realistic and achievable goals and all physician orders.-All care provided to the patient is in accordance with the plan of care.1.Patient #9 was admitted to the agency in April 2025 with a diagnosis of senile degeneration of the brain and required hospice services.Review of the physician ordered Hospice Plan of Care, dated 10/10/25 through 12/8/25, did not include orders for social worker visits.Review of the clinical record indicated Patient #9 received visits from the social worker on 10/13/25 and 10/14/25.During an interview on 10/15/25 at 2:30 P.M., the Vice President of Nursing Operations said there was not an order for social worker visits in the current plan of care. She said services provided need to be ordered by the physician and part of the plan of care.2.Patient #23 was admitted to the agency in July 2025 with a diagnosis of senile degeneration of the brain and required hospice services.Review of the physician ordered Hospice Plan of Care, dated 7/11/25 through 10/8/25, indicated the following:-Home Care Aide (HCA) visits: 4 to 5 times a week times 13 weeks.Review of the clinical record indicated the following weeks when the plan of care order for HCA visits was not provided as ordered.-Week of 9/7/25: no HCA visits were provided.-Week of 9/14/25: only 2 HCA visits were provided.-Weeks of 9/21/25 and 9/28/25: only 1 HCA visit was provided each week.-Week of 10/5/25: no HCA visits were provided through 10/8/25.During an interview on 10/16/25 at 3:05 P.M., after reviewing Patient #23's record, the Vice President of Administration and Human Resources said the physician ordered HCA visits were not provided in accordance with the plan of care, as required, during the weeks noted above.

Based on record review and interview, the agency failed to ensure licensed practical nurse (LPN) supervision by a registered nurse (RN) occurred every 14 days to ensure services were provided, as per plan of care (POC), for 1 patient (#27), out of a total sample of 27 patients.Findings include: --- Review of the agency policy entitled, Nursing Services, revised September 2020, indicated the following:*When nursing services are delegated to a LPN:a. The LPN is supervised by an RN who is available at least by phone during the hours the LPN is providing services or is on call, andb. The RN makes at least bi-monthly home visits (once every 2 weeks) and documents that the LPN is routinely providing nursing services in accordance with the patient's plan of care.  Patient #2 was admitted to the agency in March 2025 with a diagnosis of degeneration of the brain.A. Review of the Hospice Plan of Care (POC) for certification period 3/25/25 through 6/22/25 indicated the following:-Skilled Nurse (SN) visit: 1-2 times a week for 14 weeks, 15 as needed (PRN) visits.Review of the clinical record indicated 22 LPN visits occurred during the certification period.B. Review of the Hospice POC for certification period 6/23/25 through 9/20/25 indicated the following:-SN visit: 1-2 times a week for 13 weeks, 10 PRN visits.Review of the clinical record indicated 19 LPN visits occurred during the certification period.C. Review of the Hospice POC for certification period 9/21/25 through 11/19/25 indicated the following:-SN visit: 1-2 times a week for 9 weeks, 9 PRN visits.Review of the clinical record on 10/15/25 indicated 3 LPN visits have occurred.Further review of the clinical record contained no RN documentation that any LPN supervision occurred during the 3 certification periods.During an interview on 10/15/25 at 4:00 P.M., after reviewing the clinical record, the Vice President of Nursing Operations said there was no RN documentation to indicate LPN supervision had occurred during the 3 certification periods, as required.

Based on record review, policy review and interview, the agency failed to ensure all entries must be legible, clear, complete, and appropriately authenticated and dated in accordance with hospice policy and currently accepted standards of practice for 6 patients (#13, #18, #23, #27, #25 and #7), out of a total sample of 27 patients.Findings include: --- 6. Patient #7 was admitted to the agency in September 2024 with a diagnosis of senile degeneration of the brain.Review of the clinical record included a physician signed Hospice POC for certification period 9/6/24 through 12/4/24. Further review of the POC indicated the physician had signed the POC on 12/20/24 and not within the agency required 21 days.During an interview on 10/15/25 at 4:23 P.M., the Vice President (VP) of Administration and Human Services said the POC should be signed by the physician within the required timeframe of 21 days.   5.  Patient #25 was admitted to the agency July 2025 with a diagnosis of senile degeneration of the brain.Clinical record review indicated that the physician signed the Hospice POC for the certification period of 7/25/25 through 10/22/25 on 8/18/25. Further clinical record review indicated that the physician had signed the POC 25 days after the start of care and not within the agency's required 21 days. 4. Patient #27 was admitted to the agency in March 2025 with a diagnosis of degeneration of the brain.Review of the clinical record included a physician signed Hospice POC for certification period 3/25/25 through 6/22/25. Further review of the POC indicated the physician had signed the POC on 10/15/25 and not within the agency required 21 days.  Review of the agency's policy entitled Physician Services-Ordered, revised September 2022, indicated the following:-Admission orders are documented in the initial plan of treatment and faxed to the attending physician's office to obtain the physician's dated signature, which must be returned within 21 days.1.Patient #13 was admitted to the agency in August 2025 with a diagnosis of chronic kidney disease and required hospice services.Review of the clinical record included a physician ordered Hospice Plan of Care (POC), dated 8/20/25 through 11/17/25. Further review of the POC indicated the physician signed it on 9/11/25, not within 21 days, as required, per the policy.2.Patient #18 was admitted to the agency in August 2025 with a diagnosis of rectal cancer and required hospice services.Review of the clinical record included a physician ordered Hospice POC, dated 8/21/25 through 11/18/25. Further review of the POC indicated the physician signed it on 9/30/25, not within 21 days, as required, per the policy.3.Patient #23 was admitted to the agency in July 2025 with a diagnosis of senile degeneration of the brain and required hospice services.Review of the clinical record indicated a physician ordered Hospice POC, dated 7/11/25 through 10/8/25, Further review of the POC indicated the physician signed it on 9/16/25, not with 21 days as required per the policy.

Based on record review, policy review and interview, the agency failed to ensure a discharge summary was forwarded to the patient's attending physician after the patient was discharged, for 1 Patient (#3), out of a total sample of 27 patients.Findings include: --- Review of the agency's policy entitled Discontinuation of Hospice Care, revised September 2022, indicated the following:-If services are discontinued for any reason (revocation, transfer, or discharge), a discharge summary is completed and forwarded to the attending physician.Patient #3 was admitted to the agency in July 2025 with a diagnosis of abnormal weight loss and required hospice services.Review of the clinical record indicated Patient #3 was discharged from the agency on 9/30/25, and a discharge summary was completed by a nurse on 10/1/25.Further review of the clinical record indicated no documentation of the discharge summary being forwarded to the attending physician.During an interview on 10/16/25 at 11:15 A.M., the Vice President of Administration and Human Resources said the agency had not forwarded the discharge summary to Patient #3's physician, as required.

Based on state requirements, personnel record review, and interview, the agency failed to provide documentation that Nurse Aide Registry checks were conducted prior to hire, for 2 Volunteers (#3 and #4), and 1 Home Care Aide (HCA) (#2), out of 7 personnel records reviewed.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.1. Review of Volunteer #3's personnel record indicated Volunteer #3 joined the volunteer program on 3/24/25. Further review of the record indicated a Nurse Aide Registry check was completed on 4/9/25.2. Review of Volunteer #4's personnel record indicated Volunteer #4 joined the volunteer program on 6/17/25. Further review of the record indicated a Nurse Aide Registry check was completed on 10/14/25.3. Review of HCA #2's personnel record indicated HCA #2 was hired on 1/6/25. Further review of the record indicated a Nurse Aide Registry check was completed on 1/9/25.During an interview on 10/16/25 at 9:00 A..M., the Vice President of Human Resources & Administration said the Nurse Aide Registry checks for Volunteers #3 and #4 and HCA #2 were completed after the date of hire and not prior to hire, as required.

Based on records reviewed and interviews, for one of three sampled Patients (Patient #1), the Facility failed to ensure Patient #1 was free from misappropriation when it was reported that Hospice Home Care Aide (HCA) #1 took a gold necklace from Patient #1s home without his/her consent. Findings Include: The Agency Policy titled Abuse, Neglect, Mistreatment, or Misappropriation of Property, revision date October 2024, indicated that all the Agency employees comply with all applicable state and federal mandatory reporting and processes. Patient #1 was admitted to Hospice in December 2023, diagnoses included chronic obstructive pulmonary disease and anxiety disorder. Review of Patient #1s Hospice Certification and Plan of Care for the period of 09/27/24 to 11/25/24, indicated he/she was to receive Hospice Home Care Aide (HCA) services three to four times a week for four weeks. The Hospice Certification and Plan of Care indicated that HCA services would be provided to Patient #1 for assistance with personal care, activities of daily living (ADLs), ambulation, grocery shopping, and housekeeping. Review of the Agency's Internal Investigation, dated 10/22/24, indicated that Family Member (FM) #1 called the Agency and spoke to the Home Care Aide Service Manager and reported following: - FM #1 said she thought that HCA #1 had taken a gold necklace, that she talked to HCA #1 and asked him to return the necklace in two hours. - FM #1 stated that on 10/22/24, she left HCA #1 and Patient #1 at home for the first time to attend a funeral. - FM # 1 said she noticed the room deodorizer spray, usually on top of the dresser, was missing. - FM #1 stated she looked at the waste basket next to the dresser to check to see if it fell into waste basket, because it usually does. - FM #1 said the waste basket bag was empty, and that HCA #1 usually removes this trash bag after changing Patient #1. - FM #1 stated while she was looking in the outside trash bag, she found her jewelry box in the trash, and the gold necklace was not there. - FM #1 stated that the jewelry box was always kept inside the dresser drawer. - While FM #1 was on the telephone with the Home Care Aide Service Manager FM #1 said someone was at her door, so she ended the call, but said would have to call back. - FM #1 called the Agency back and reported that HCA #1 had returned her gold necklace. During an interview on 11/19/24 at 2:30 P.M., the Home Care Aide Service Manager said on 10/22/24, she received a telephone call from Family Member (FM) #1, who was looking to reach HCA #1 and left a message for HCA #1. The Manager said the second time FM #1 called, she reported noticing a missing gold necklace, and reported that the last person who had access to the home was HCA #1, who provided care for Patient #1 earlier on 10/22/24. The Manager said that FM #1 reported that she had spoken to HCA #1 and told him if he returned the gold necklace, she would not report him, and the HCA #1 immediately returned the gold necklace to FM #1. The Manager said FM #1 was disappointed that HCA #1 had stolen from them, and said she did not want this to happen to another family. The Manager said she and the Vice President of Nursing Operations interviewed HCA #1 on 10/23/24 and when asked about the incident at first, HCA #1 denied taking the necklace. The Manager said that when they explained that FM #1 had called, HCA #1 then admitted that he had taken the necklace and returned it. The Manager said HCA #1 employment was terminated immediately. The Surveyor was unable to interview Home Care Aide #1 as he did not respond to the Department of Public Health's telephone call or letter requests for an interview.