Every finding on record at New England Hospice II LLC

Observed in Record Review. In 2 of 16 patient records reviewed, The HCO staff failed to provide patient care at the ordered frequency. For example, the surveyor noted on RR #5, the hospice aide made two visits for the week of 11/20/22-11/26/26, although the visit frequency on the plan of care date 09/20/22-12/18/22 order aide visits for 3-4 times a week and 3 as needed. On RR #10, the registered nurse made one visit the week of 09/18/22 – 09/24/22 when the visit frequency for the plan of care for 09/13/22-12/11/22 order nurse visits at 2 times a week and 3 as needed. There was no communication documentation or physician orders, addressing the deviations. Standards require patient care be provided according to the patient’s individualized plan of care. These findings were reviewed discussed and validated with the organization’s Administrator and Clinical Services Director.

Observed in Record Review. In 5 of 16 patient records reviewed, The organization did not ensure the registered nurse complete hospice aide supervisory visits as required. For example, the surveyor noted there were periods greater than 14 days where the registered nurse documented a hospice aide supervisor visit, including on HV #1/RR #1, 11/21/22-12/08/22 and 12/20/22-01/06/23; on HV #2/RR#2, 08/16/22-09/02/22, 12/13/22-01/01/23, 01/04/23-01/20/23, and 03/03/23-03/23/23; on HV #3/RR #3, 08/19/22-09/16//22, 01/16/23-02/06/23, and 03/20/23-04/12/23; on HV #4/RR #4, 01/16/23-02/01/23, 02/27/23-03/13/23, and 04/02/23-04/18/23; and on RR #5 12/01/22-04/04/23. Standards require the registered nurse supervise the hospice aide no less frequently than every 14 days. These findings were reviewed, discussed, and validated by the Administrator and the Clinical Services Director.

Observed in Record Review. In 1 of 16 patient records reviewed, The HCO did not ensure an initial certification of terminal illness (CTI) was completed on the patient’s admission to hospice services. For example, the surveyor noted on RR #6, there was no documentation of a completed CTI contained within the health record for the patient’s initial hospice admission Standards require the medical director or designee provide written certification of the determination of the patient’s life expectancy. These finding were reviewed, discussed and confirmed with the Administrator and Clinical Services Director.