Every finding on record at Seasons Hospice & Palliative Care of Massachusetts, LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) clinical records reviewed of a patient who received continuous oxygen therapy, the agency did not ensure that the patient's drug profile included the patient's current medications and other alternative treatments that could affect drug therapy. CLINICAL RECORD 7: The patient elected the hospice benefit on 06/25/2025 with a terminal diagnosis of lung cancer and chronic obstructive pulmonary disease (COPD). The initial nursing assessment dated 06/25/2025, documented that the patient was on 5 liters of oxygen continuously per nasal cannula. On 07/25/2025, during a nursing assessment, the RN documented that the patient was on 6 liters of oxygen continuously. The patient's drug profile did not include documentation of oxygen. During an interview on 07/31/2025, the Administrator reported that the oxygen was not entered into the medication profile, which is how the order would be generated, and confirmed that there were no additional orders for the continuous oxygen located elsewhere in the record. The Administrator stated that an order was being entered now.

It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. The hospice advises the patient and family of spiritual counseling services and documents the acceptance or refusal of services. This standard was not met as evidenced by clinical record review and interview. In 1 of 26 (4%) clinical records reviewed, the agency did not ensure that the patient's spiritual needs were provided according to the patient and family's acceptance and that the acceptance or refusal of services was documented. CLINICAL RECORD 20: The patient elected hospice care on 04/11/2024 with a diagnosis of anoxic brain injury. The plan of care effective from 03/07/2025 to 05/05/2025 ordered "3 PRN (as needed) visits for spiritual support, crisis management." On 05/02/2025, the Chaplain entered an order, "This CH (Chaplain) would like to request a PRN visit for today." No SC PRN visits were completed, and there was no additional documentation to support why another PRN visit was needed or requested. The patient was discharged on 05/05/2025 with an extended prognosis. During an interview on 07/30/2025, the Administrator reported that the order was 'approved' late on 05/03/2025 and said that since the patient wasn't discharged until 05/05/2025, there would still have been time for a visit, if needed. The Administrator also confirmed that the Chaplain had orders for 3 PRN visits, which had not been utilized and would not have needed to obtain an additional order or await approval. The Administrator said, "We will be providing the Chaplains with more education on this process."

It is required that a registered nurse makes an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy #HOS 3-008 "Hospice Aide Training" (last reviewed 06/28/2024) stated in part, "The organization shall perform an annual competency evaluation to ensure the competency of the hospice aide...Documentation in the Hospice Aide personnel file shall include ... Annual Competency Evaluation." In 1 of 1 (100%) personnel records reviewed of a Hospice Aide employed over one year, the agency did not ensure that an annual on-site visit by a Registered Nurse (RN) was completed per agency policy. PERSONNEL RECORD 7: The Hospice Aide was hired on 09/27/2021 and provided care in the agency's inpatient care facility. The personnel record included on-site evaluations, performed by an RN, on 01/21/2024, 04/22/2025, and 07/22/2025. For the calendar year of 2023 (the CMS Public Health Emergency (PHE) Waiver specified that for the annual aide onsite visit with aide- May postpone these visits during the PHE. Visits must be completed within 60 days of the end date of the PHE, which was May 11, 2023. There was no documented evidence of an on-site competency evaluation performed by an RN within 60 days of 05/11/2023 or during the remainder of 2023. On 07/31/2025, the Director of Operations, who was present during the review of the personnel records, confirmed that there was no documented evidence that the annual competency evaluation was completed for 2023. At the time of the exit conference, the Administrator reported that they were unable to locate documented evidence of the annual competency evaluation.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A review of the volunteer productivity reports for the past year revealed that the agency did not ensure that the administrative and patient care hours provided by hospice volunteers equaled at least 5% of the total patient care hours of all paid and contract staff. VOLUNTEER HOUR REPORT: The agency's volunteer productivity report for the year 2024 (January 2024 to December 2024) documented that the volunteer hours, including both administrative and direct patient care hours, equaled 2% of total patient care hours. The volunteer productivity report also documented that, for the past rolling 12 months (07/24/2024 to 07/24/2025), the average of administrative and direct patient care hours provided by volunteers was 3% of the total patient care hours provided by paid staff. During an interview on 07/29/2025, the Volunteer Coordinator (VC) (Personnel Record 12) confirmed that the volunteer hours have not met the level of at least 5% of the total clinical hours for the past year. The VC also stated that, since taking the volunteer coordinator position in February 2025, they have undertaken many additional recruitment efforts and have increased the total number of hours provided by volunteers. A review of the volunteer productivity reports for the past year revealed that the agency did not ensure that the administrative and patient care hours provided by hospice volunteers equaled at least 5% of the total patient care hours of all paid and contract staff.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) clinical records reviewed of a patient who received continuous oxygen therapy, the agency did not ensure that physician orders for the oxygen administration were present. CLINICAL RECORD 7: The patient elected the hospice benefit on 06/25/2025 with a terminal diagnosis of lung cancer and chronic obstructive pulmonary disease (COPD). The initial nursing assessment dated 06/25/2025, documented that the patient was on 5 liters of oxygen continuously per nasal cannula. On 07/25/2025, during a nursing assessment, the RN documented that the patient was on 6 liters of oxygen continuously. The plan of care, dated 06/25/2025 to 09/23/2025, did not include orders for continuous oxygen, nor was oxygen included in the medication profile. The patient's clinical record did not include documented evidence of physician orders for the oxygen. During an interview on 07/31/2025, the Administrator reported that the oxygen was not entered into the medication profile, which is how the order would be generated, and confirmed that there were no additional orders for the continuous oxygen located elsewhere in the record. The Administrator stated that an order was being entered now.

Observed in Building Tour. In 6 of 8 CLDs, The hospice nurse surveyor noted through discussions with staff, tracer activities and documentation review that leadership and the governing body should have reasonably known about requirement for COP 418.100 and 418.110. This was confirmed with the executive director.;

Observed in Building Tour. In 6 of 8 CLD, The hospice nurse surveyor noted that the organization had no evidence that there was a person responsible for the evaluation and maintenance for the environmental and Life safety needs of the facility. The surveyor noted that there was no evidence that environmental inspections were performed on a routine base or that environmental tours were conducted. Also, the Life Safety drawings provided, did not accurately describe the building. For example, the firewall ended in an egress and there was no indication on the drawing of a corridor B smoke barrier door. A fire watch process was implement on site for all Life safety deficiencies. The surveyor did not receive documentation of the generator load testing time and percentage of load run, verification of the fire wall rating and expanse. This was confirmed with the executive director. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy: Observed in Building Tour. In 15 of 15 patient rooms, The hospice nurse surveyor noted that fifteen (15) patient rooms with exit doors to closed patios, were not labelled as NO EXIT. The surveyor noted that one patio had no signage and the remaining rooms that had some signage on the door were not visible as the doors had a shade pulled down and blocking the sign. Aa fixed railing blocking the egress to a clear area. This has not been corrected and a fire watch remains in place. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy: Observed in Building Tour. In 1 of 1 cld, The hospice nurse surveyor noted that there was greater than 1/8 inch gap between the fire doors in both the A and B corridor doors and the base of both doors had a gap greater than 3/4 inches. The surveyor noted that the corridor B door had a gap greater than one inch both between the doors and at the floor. This was confirmed with the director and a fire watch was instituted on site. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy: Observed in Building Tour. The hospice nurse surveyor noted a penetration of a pipe and cabling, into the ceiling of the IT room ceiling that were caulked; however there was no evidence or available documentation to confirm that it was fire rated caulking. A fire watch was instituted on site until resolved. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy:

Observed in Individual Tracer. In 4 of 20 patient records reviewed, The hospice nurse surveyor noted (ARR#1) that the comprehensive assessment was incomplete and did not include an assessment of the severity of the patient's symptom of seizures, currently being treated with intravenous Keppra. Also, there was no evidence that a nutritional assessment was completed or indication as to whether or not the patient was taking oral nutrition. In (HV#1), the surveyor noted that the assessment indicated that the patient had orthostatic hypotension and hallucinations; however, there was no documentation of the severity. In (HV#2), there was no assessment of the severity of seizures and agitation. In (HV#4), there was no assessment of the severity of spasms, agitation or hallucinations. This was confirmed with the director.

Observed in Individual Tracer. In 20 of 20 patient records reviewed, The hospice nurse surveyor noted in (HV#1) that the patient plan of care goals did not include any measurable outcomes or time frames for achieving outcomes, since admission. The surveyor noted that in (HV#2), (HV#3), (HV#4) and (HV#5) the plan of care did not include any outcome measures or time frames. There were no outcome measures in 19 of 20 records reveiw and there were no time frames noted in 20 of 20 records reviewed. This was confirmed with the director.

Observed in Individual Tracer. In 3 of 20 patient records reviewed, The hospice nurse surveyor noted (HV#4) that there were no orders for the Baclofen pump, oxygen or amount and frequency for prn catheter irrigation. Also, in (ARR#5) and (ARR#6), the assessment and visit notes indicated that the patient was on oxygen however, there were no oxygen orders on the plan of care or in the order documentation. This was confirmed with the director.

Observed in Individual Tracer. In 4 of 5 home visits conducted, The hospice nurse surveyor noted (HV#2) that the nurse did not follow organizational policy #4004 and manufacturer's guidelines when using Sani-wipes to disinfect equipment before returning it to the bag. The manufacturer's guidelines require a two (2) minute wet time; however the equipment was cleansed and left to dry and did not stay wet, as required. Also, in (HV#3) and (HV#4), the nurses did not maintain the wet-time and in (HV#5) the nurse disinfected the equipment and immediately returned the equipment to the bag, while still wet. This was confirmed with the director.

Observed in Tracer Activities. The hospice nurse surveyor noted through discussion s with staff, tracer activities and documentation review that leadership and the governing body should have reasonably known about requirement for COP 418.100 and 418.110. This was confirmed with the executive director.

Observed in Individual Tracer. In 1 of 20 patient records reviewed, The hospice nurse surveyor noted (HV#4) that the medication profile was incomplete and did not include medication delivered through the Baclofen pump; however it was not included on the medication list and had not been listed since the patient was admitted with it in 2021. This was confirmed with the director.

Observed in Medication Management Tracer. The hospice nurse surveyor noted that the nurse failed to label the medication and there was a break in the break in process. The nurse prepared a medication at the nurses' station and extracted liquid haloperidol from its original container into a syringe. The nurse did not label the syringe and carried it down the hall and into the patient's room. The nurse handed the syringe to another person in the room while she attended to settling the patient, and then administered the medication. This was confirmed with the director.

Observed in Building Tour. The hospice nurse surveyor noted that the organization had no evidence that there was a person responsible for the evaluation and maintenance for the environmental and Life safety needs of the facility. The surveyor noted that there was no evidence that environmental inspections were performed on a routine base or that environmental tours were conducted. Also, the Life Safety drawings provided, did not accurately describe the building. For example, the firewall ended in an egress and there was no indication on the drawing of a corridor B smoke barrier door. A fire watch process was implement on site for all Life safety deficiencies. The surveyor did not receive documentation of the generator maintenance and testing, fire extinguisher annual maintenance, or any utility maintenance reports while on site. This was confirmed with the director. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy: Observed in Building Tour. In 16 of 16 patient patio exits, The hospice nurse surveyor noted that sixteen (16) patient rooms with exit doors to closed patios, were not labelled as NO EXIT. The surveyor noted that each patio had a fixed railing blocking the egress to a clear area. This has not been corrected and a fire watch was instituted. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy: Observed in Building Tour. In 2 of 2 fire barrier door checks, The hospice nurse surveyor noted that there was >1/8 inch gap between the fire doors in both the A and B corridor doors and the base of both doors had a gap >3/4 inches. The surveyor noted that the corridor B door had a gap greater than one inch both between the doors and at the floor. This was confirmed with the director and a fire watch was instituted on site. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy: Observed in Building Tour. The hospice nurse surveyor noted a penetration of a pipe into the ceiling of the large storage room that was not caulked and penetrated the ceiling smoke barrier. A fire watch was instituted on site until resolved. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy: Observed in Building Tour. The hospice nurse surveyor noted that there was a missing escutcheon plate on the sprinkler head in the large storage room in a smoke barrier ceiling. A fire watch was instituted until corrected. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy: Observed in Building Tour. In 2 of 2 corridor egresses, The hospice nurse surveyor noted that both the A and B patient care corridor egresses were blocked with computer terminals, laundry carts and bedside table. The corridors were cleared and corrected on site. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.

Observed in Building Tour. In 3 of 3 years, The hospice nurse surveyor noted that there was no available documentation of water temperature testing in the patient rooms for the last three years. This was confirmed with the director.

Observed in Individual Tracer. In 1 of 20 patient records reviewed, The hospice nurse surveyor noted (HV#3) that the plan of care for this patient residing in a skilled nursing facility did not indicate who was responsible for the provision of care and treatments. The surveyor noted that the form in the hospice binder to identify the task responsibilities was also blank. This was confirmed with the team manager.