Every finding on record at Overlook Hospice Services

Based on state requirements, personnel record review, and interview, the agency failed to provide documentation that Criminal Offender Record Information (CORI) background checks and/or Nurse Aide Registry (NAR) checks were conducted, prior to hire, for 4 volunteers (#1, #2, #3 and #4), out of 6 volunteer 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.Review of Volunteer #1's personnel record on 7/25/25 indicated Volunteer #1 joined the volunteer program on 9/1/24 (date of hire). Further review of the file indicated the CORI check was conducted on 9/6/24 and the NAR check was conducted on 11/20/24, both after the date of hire.Review of Volunteer #2's personnel record on 7/25/25 indicated Volunteer #2 joined the volunteer program on 4/13/24 (date of hire). Further review of the file indicated the CORI check was conducted on 5/20/24, after the hire date, and the NAR check was not conducted.Review of Volunteer #3's personnel record on 7/25/25 indicated Volunteer #3 joined the volunteer program on 9/1/24 (date of hire). Further review of the file indicated the CORI check was conducted on 10/25/24 and the NAR check was conducted on 10/31/24, both after the hire date.Review of Volunteer #4's personnel record on 7/25/25 indicated Volunteer #4 joined the volunteer program on 9/1/24 (date of hire). Further review of the file indicated a NAR check was not conducted.During an interview on 7/25/25 at 11:00 A.M., the Director of Employee, Relations and Benefits said the 4 Volunteers listed should have had their CORI checks and/or NAR checks completed prior to hire, as required.

Based on review of quality improvement records, review of the "Board of Directors Meeting Minutes" and interview, it was determined the hospice failed to: 1) develop, implement and maintain an ongoing hospice-wide data driven quality assessment and performance improvement (QAPI) program (see L560), 2) failed to measure, analyze and track quality indicators from all aspects of performance to enable the hospice to assess quality of care and hospice operations (see L562), 3) failed to ensure the frequency and detail of the QAPI program was reviewed, approved and monitored by the hospice's governing body (see L565), and 4) failed to implement and maintain documentation of performance improvement projects (PIP) being conducted currently, the reasons for conducting these projects, and any measurable progress achieved on these projects (see L573). This has the potential to affect the 40 patients who are currently receiving hospice services and all future hospice patients. Findings include: There was no documented evidence that the Hospice utilized data collection to examine all facets of a hospice's operation ... Refer to L560. There was no documented evidence that patient services and activities that could impact patient/family care were evaluated as part of the QAPI program ... Refer to L562 There was no documented evidence the hospice's governing body was responsible for ensuring that an ongoing program for quality improvement is defined, implemented, maintained and evaluated annually ... Refer to L565. There was no documented evidence the hospice used data collection to identify opportunities and priorities for improvement .... Refer to L573.

1. Based on review of quality improvement records and interview, it was determined the Agency failed to develop, implement and maintain an ongoing hospice-wide data driven quality assessment and performance improvement (QAPI) program. This had the potential to affect the 40 patients who are currently receiving hospice services and all future hospice patients. Findings include: Review of the Agency's documentation of the quality program failed to demonstrate action taken by the hospice to improve hospice performance based on indicators related to improved palliative outcomes or care delivery. There was no documented evidence that the hospice had developed a QAPI program that included patient assessment data elements, review of clinical records, effectiveness of care delivery, hospice operating systems or hospice outcome measures. During an interview on 7/6/22 at 10:35 A.M., the Executive Director said the information indicated the 2021 QAPI Plan was "jumbled". She said the information listed for the QAPI Plan 2022 did not contain specific performance improvements projects but rather the purpose, the description of the multidisciplinary team members and description of the elements of a QAPI plan. The Executive Director said that the hospice quality committee meets quarterly, but there were no meeting minutes or signature sheets for March 2021, September 2021 and June 2022 committee meetings. She said the QAPI Manager for Hospice works part time for the Agency and was not available for an interview during the recertification survey.

2. Based on review of quality improvement records and interview, it was determined the Hospice failed to analyze the quality indicators from all aspects of performance which would enable the hospice to assess quality of care and hospice operations. This had the potential to affect the 40 patients who were currently receiving hospice services and all future hospice patients. Findings include: Review of the documentation in the QAPI PLAN binder failed to demonstrate action taken by the hospice to improve hospice performance based on indicators related to improve palliative outcomes or care delivery . There was no documented evidence that the hospice had developed a quality assessment and performance improvement (QAPI) program that included, and was built on the analysis of quality indicators. There were no adverse events identified and there was no data available for review. During an interview on 7/6/22 at 10:35 A.M., the Executive Director said the information in the 2021 QAPI Plan was "jumbled". She further said there was no analysis of the quality indicators to improve quality of care for patients.

3. Based on staff interview and review of the "Combined Board of Directors Meeting Minutes", it was determined that the hospice failed to ensure the frequency and detail of the quality assessment and performance improvement (QAPI) program was reviewed, approved and monitored by the hospice's governing body. This had the potential to affect all 40 patients who were currently receiving hospice services and future hospice patients. Findings include: Review of the Combined Board of Directors Annual Meeting Minutes, dated 1/21/22, and monthly meetings on 2/25/22, 3/25/22, 4/22/22 and 5/20/22 did not contain documentation that the Hospice QAPI program was reviewed and approved by the hospice governing body. During an interview on 7/6/22 at 12:41 P.M., the Executive Director said there was no evidence that the Hospice QAPI program was presented at the Board of Directors meetings because they were not clinical meetings.

4. Based on review of quality assessment and performance improvement (QAPI) records and staff interview, it was determined the hospice failed to implement and maintain documentation of performance improvement projects (PIPs) being conducted, the reasons for conducting these projects, and any measurable progress achieved on these projects. This deficient practice had the potential to affect all 40 patients who were currently receiving hospice services and future hospice patients. Findings include: A review of QAPI documents in the QAPI PLAN 2022 binder revealed a PIP with no specific start date but indicating the PIP was ongoing from 2021, for staff visit frequencies compliance. The PIP indicated weekly audits and staff education. No audits or documentation that education was done as stated, was provided to the surveyor. During an interview on 7/6/22 at 10:35 A.M., the Director of Quality Assurance and Performance Improvement said the PIP for staff visit frequencies was identified in the last recertification survey, dated 7/2018, and the Agency was still working on the PIP. Review of the PIP, dated 6/22/22, indicated the area for improvement was for aide supervision by the nurse. Education and weekly audits were to be completed. There was no documented evidence the hospice had identified, implemented and monitored any other specific performance improvement projects based on the results of their quality monitoring.

Based on record review, policy review and interview, the Agency failed to ensure: 1) a Nurse Aide Registry check was completed upon hire for one out of 6 personnel files reviewed and 2) that the Abuse Policy contained the required timeframe for reporting an abuse allegation. Findings included: 1. Review of the Agency policy titled, New Hire Screening and Verification, revised 10/25/16, included but was not limited to: The following must be completed and/or verified within the time frames listed within this policy for all new hires and any rehires who left employment more than three months ago. Employment is contingent upon the results and completion of verification and screenings. - The Massachusetts (and/or appropriate state) Nurse Aide Registry must be verified prior to the first day of employment. This will be done when an employee is rehired and and when a new Certified Nursing Assistant (CNA) becomes certified. The Nurse Aide Registry reviews will be kept in the employee's personnel file. A review of Employee #3's personnel file indicated the date of hire for the Registered Nurse was 11/19/21. Further review of the file indicated the Nurse Aide Registry check was completed on 2/9/22 and not upon hire. During an interview on 7/5/22 at 1:15 P.M., the Director of People and Culture said the Nurse Aide Registry check for Employee #3 was completed after the date of hire and not upon hire, as required. 2. The facility failed to ensure that the Abuse Policy contained reporting timelines 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.... Review of the Facility Abuse Policy, dated 7/15/20, indicated: When care is provided in a facility, hospice personnel are required to report all alleged abuse, mistreatment and/or exploitation by anyone unrelated to the hospice to the nursing facility administrator within 24 hours of becoming aware of the alleged violation. During an interview with the Executive Director on 7/5/22 at 3:55 P.M., she said the Abuse Policy should reflect to immediately report abuse and the policy needed to be updated to reflect this information.