Every finding on record at Peoplefirst Homecare & Hospice of Massachusetts, LLC

Upon patient record review 2 of 19 (Patient #6, #12) did not have evidence in the patient record that the hospice interdisciplinary group, 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. Patient 6: The initial spiritual assessment was completed on 8/21/25 with start of care 8/13/25. Patient #12: The initial spiritual assessment was completed on 2/4/25 with start of care 1/29/2025.

Upon patient record review 2 of 19 (Patient #11, #14) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #11: There was no evidence of an initial comprehensive spiritual assessment. Patient #14: There was no evidence of an initial comprehensive spiritual assessment.

Upon patient record review, 2 of 19 (Patients #5, #13) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #5: The medication profile contained duplicate Keppra entries with differing doses and differing administration routes of oral and PEG tube. The medication profile also contained an order for MiraLax, however there were no mixing instructions for this medication. The medication profile also contained an order for Famotidine tablets to administer via PEG tube, however there were no instructions how to prepare medication for PEG tube administration. Corrected on site with order clarification and medication profile updated. Patient #13: During medication reconciliation, the facility and hospice medications did not match. The facility medication profile contained acetaminophen with administration route as suppository. The hospice medication profile contained acetaminophen with administration route as oral. The hospice medication profile also contained PRN orders for guaifenesin and Milk of Mag, but these medications were absent from facility medication profile.

Upon patient record review, 2 of 19 (Patient #2, #5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2: The medical record indicated patient has a skin tear to left lower arm with foam border dressing in place. There is no evidence of a wound care order. Patient #5: There were duplicate Keppra orders with differing doses and differing administration routes of oral and PEG tube. The order for MiraLax did not have mixing instructions for this medication. The order for Famotidine tablets to administer via PEG tube, however there were no instructions to prepare medication for PEG tube administration. Corrected on site with order clarification and medication profile updated.

Upon patient record review, 4 of 19 (Patient #3, #5, #6, #11) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 3: The medical record contained nursing documentation upon admission identifying patient use of gel mattress. There was no evidence of orders for the DME included in the plan of care. Corrected on site with orders received. Patient 5: The medical record contained DME order for O2. There was no evidence of need or physician order for O2. Corrected on site with DME order discontinued. Patient 6: The medical record contained nursing documentation upon admission identifying patient use of bed rails. There was no evidence of orders for the DME included in the plan of care. Corrected on site with orders received. Patient 11: The medical record contained DME order for O2. There was no evidence of need or physician order for O2. Corrected on site with DME order discontinued.

Upon client record review, 1 of 19 (Patient #12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 12: There was an order for nurse visit frequency of twice weekly. There was no evidence of second visit made week of 11/2/25. The medical record also contained an order for chaplain visit frequency of once monthly. There was no evidence of a visit in October.

Upon patient record review 3 of 19 (Patient #6, #8, #12) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 6: The medical record contained an order for aide visits three times weekly. There was no evidence of third visit made weeks of 10/12/25 and10/19/25. Patient 8: The medical record contained an order for aide visits three times weekly. There was only one visit made week of 10/5/25. Patient 12: The medical record contained an order for aide visits two times weekly. There was no evidence of second visit made week of 11/23/25.

Upon patient client record review, 1 of 19 (Patient #9) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 9: The election form identified the patient elected to receive the Notification of Hospice Non-Covered items upon admission 3/29/25. There was no evidence the patient received the requested addendum.

Upon client record review, 2 of 19 (Patient #5, #13) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 5: There was an order for nurse visit frequency of twice weekly. There was no evidence of second visit made weeks of 11/9/25 and 11/16/25. Patient 13: There was an order for chaplain visit frequency of three visits a month. There was no evidence of third visit made in October.

Upon client record review, 1 of 19 (Patient #5) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 5: The record indicates the patient has a PEG tube, however the care plan did not indicate who was responsible for the care of the Peg tube. Corrected on site with orders received and care plan updated.

Upon personnel record review, 3 of 15 (Personnel #13,#14,#15) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel 13,14,15: There was no evidence of criminal background checks completed for all states the individuals may have lived in within the past 3 years. Agency contacted the contracted agency to inquire, however they only run state criminal background checks.

Upon patient record review 1 of 13 (Patient #7) did not have evidence in the patient record that the hospice interdisciplinary group, 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. Patient 7: Patient admitted on 10/19/2022, psychosocial and spiritual assessment completed on 10/25/2022.

Upon patient record review, 2 of 13 (Patient #2, #8) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 2: Duplicate drug orders on the med profile. 3 separate Trazodone orders all written on 10/21/2022 - 1) Trazodone 25mg 1/2 tab 2 times daily PRN for anxiety. 2) 25mg 1/2 tab 2 times daily for depression. 3) 50mg 1 tab at bedtime for anxiety. Patient 8: Order entered on 10/05/2022 for Miralax 17 grams daily per J-tube. No evidence of a diluent entered on the med profile.

Upon patient record review, 1 of 13 (Patient #1) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 1: Admit diagnosis changed from COPD to Alzheimer's. No evidence of neurological/Alzheimer's goals and interventions added to the plan of care.

Upon patient record review, 2 of 13 (Patient #2,#8) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 2: Duplicate medications orders. 3 separate Trazodone orders all written on 10/21/2022 - 1) Trazodone 25mg 1/2 tab 2 times daily PRN for anxiety. 2) 25mg 1/2 tab 2 times daily for depression. 3) 50mg 1 tab at bedtime for anxiety. Patient 8: Order entered on 10/05/2022 for Miralax 17 grams daily per J-tube. No evidence of a diluent entered on the order.

Upon patient record review 7 of 13 (Patient #1,#2,#3,#5,#7,#11,#12) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 1: Aide frequency 3 times weekly per POC, no evidence that 3 visits were completed for the week of 10/20/2022. Patient 2: Aide POC has nail care ordered weekly. Nail care being completed on all aide visits 3x week. Patient 3: Aide POC has nail care ordered weekly. Nail care being completed on all aide visits 3x week. Patient 5: Aide POC has to give a bath and shampoo at every visit. Both being completed by the aide weekly, not at every visit as ordered in the POC. Aide frequency ordered 2 times for week1, then 3 times weekly per POC. No evidence that aide visits occurred at all for the first 3 weeks of the benefit period. No evidence that 3 visits occurred weekly from 08/21/2022-11/16/2022. Patient 7: Aide missed the 10/21/22 visit. Entered a missed visit note for the visit that only had the templet in the note, no information was entered on the templet as to why the visit was missed. Aide ordered as twice a week, no evidence of a second visit, refusal or order for second visit due to the incomplete missed visit note. Patient 11: Aide POC has to give a bath and shampoo weekly. Both being completed by the aide at every visit 3x week. Patient 12: Aide POC has to shampoo weekly, clean nails weekly. Both were completed by the aide at every visit 2x week.

Upon patient client record review, 1 of 13 (Patient #2) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 2: POA elected to receive the "Notice of Non-covered Items" upon admit. No evidence that it was provided within first 5 days.

Upon client record review, 7 of 13 (Patient #1,#2,#3,#4,#5,#6,#13) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 1: Volunteer services ordered to start weekly on 10/18/2022. No evidence that volunteer visits occurred before 11/03/2022. RN visits ordered twice per week. No evidence that 2 visits occurred on the weeks of 10/09/2022, 10/30/2022, 11/13/2022, and 11/20/2022. Patient 2: RN visits ordered once wk1, then twice weekly per POC. No evidence that 2 visits occurred on the weeks of 10/30/2022, 11/06/2022, 11/13/2022, and 11/21/2022. Patient 3: RN visits ordered once wk1, then 3 times on wk2, then twice weekly per POC. No evidence that 2 visits occurred on the weeks of 09/04/2022, 09/11/2022, 09/25/2022, 10/02/2022, 10/09/2022, 10/23/2022, 10/30/2022, 11/06/2022, and 11/13/2022. Patient 4: RN visits twice a week per POC. No evidence that 2 visits occurred on the weeks of 09/18/2022 and 10/16/2022. Patient 5: Volunteer services declined on SOC. Order written on 08/20/2022 ordered to start twice monthly. No evidence of volunteer visits for the month of September. Volunteer visit documented on 08/13/2022 before the order was written on 08/20/2022. RN visits ordered twice a week. No evidence that 2 visits occurred on the following weeks 09/15/2022, 10/02/2022, 10/09/2022, 10/23/2022. Patient 6: RN visits twice a week per POC. No evidence that 2 visits occurred on the week of 11/06/2022. Patient 13: RN visits twice a week per POC. No evidence that 2 visits occurred on the weeks of 10/09/2022, 10/30/2022, 11/13/2022, 11/20/2022 and 11/27/2022.