Every finding on record at Spectrum Home Health and Hospice Care, Inc

Based on clinical record review, policy review and interview, the agency failed to ensure services provided for wound care were part of the individualized written plan of care for 1 patient (#3), out of a total sample 19 patients.Findings include: --- Review of the agency's policy entitled Physician Orders, undated, indicated the following:*Nursing and other services that require a physician's order will be provided in accordance with a physician's order.Patient #3 was admitted to the agency in July 2025 with a diagnosis of Squamous Cell Cancer.Review of the physician ordered Hospice Plan of Care, dated 7/14/25 through 10/11/25, did not include orders for wound care.Review of a skilled nursing note dated 8/14/25, indicated the patient had a fall and sustained skin injuries to the right forearm and right elbow.Review of a skilled nursing note dated 8/21/25, indicated the patient had sustained another fall causing a left knee abrasion. Additionally, the note indicated wound care was provided to the left knee and right elbow.Review of a skilled nursing note dated 8/24/25, indicated the patient was provided with wound care to the right forearm and elbow.Further review of the clinical record did not include a physician's order for treatment of wounds.During an interview on 9/3/25 at 2:30 P.M., the Senior Director of Home and Community Services said all services provided by staff should have a physician's order. She said there were no orders to provide wound care for Patient #3, as required.

Based on record review, policy review and interview, the agency staff failed to A. develop and implement an individualized care plan to address wounds for 2 patients (#7 and #3) and B. update the Hospice Plan of Care upon receiving verbal physician orders for 1 patient (#6), out of a total sample of 19 patients.Findings include: --- 2. For Patient #3, the agency failed to develop and implement an individualized care plan after wounds were identified and treated.Patient #3 was admitted to the agency in July 2025 with a diagnosis of Squamous Cell Cancer.Review of a skilled nursing note dated 8/14/25, indicated the patient had a fall and sustained skin injuries to the right forearm and right elbow.Review of a skilled nursing note dated 8/21/25, indicated the patient had sustained another fall causing a left knee abrasion. Additionally, the note indicated wound care was provided to the left knee and right elbow.Review of a skilled nursing note dated 8/24/25, indicated the patient was provided with wound care to the right forearm and elbow.Further review of the clinical record did not include a wound care plan including treatment and goals for the new wounds the patient had sustained.During an interview on 9/3/25 at 2:30 P.M., the Senior Director of Home and Community Services said a care plan was not developed when wounds were identified and treated, as required.B. For Patient #6, the agency failed to update the plan of care upon receiving verbal physician orders.Review of the agency's policy entitled Physician Orders, undated, indicated the following:*Oral orders are put in writing, signed and dated with the date of receipt by a Registered Nurse (or qualified therapist) responsible for furnishing or supervising care. *Care and services provided will be provided according to the physician orders. Orders are current and updated.Patient #6 was admitted to the agency in May 2025 with a diagnosis of Intrahepatic (refers to structures or conditions within the liver) Bile Duct Cancer.Review of the clinical record indicated a verbal physician's order was obtained on 5/29/25 which included the following:*Admit to Hospice.*Discontinue routine weights, vitals, and labs unless otherwise ordered for medication administration.*Laxative/enema of choice as needed for constipation/impaction.*May insert Foley Catheter (thin flexible tube inserted into the bladder to drain urine) as needed for signs of retention and/or requested by the patient or caregiver.*May perform registered nurse (RN) pronouncement.*Oxygen by nasal canula at 2-4 liters per minute as needed for comfort.*Peritoneal (relates to the peritoneum; the serous membrane lining the abdominal cavity and covering most of the abdominal organs) drainage via Aspira Drainage System, drain abdomen as needed for comfort. Change dressing each time drain is accessed. Monitor abnormal drainage, redness, heat or cloudy return and any other signs/symptoms of acute infection.Further review of the verbal order indicated it was not signed by the nurse who obtained the order until 7/17/25 and was not signed by the physician until 7/18/25.Review of the physician ordered Hospice Plan of Care, dated 5/28/25 through 8/25/25, did not include all of the 5/29/25 ordered interventions, including the following:*Discontinue routine weights, vitals, and labs unless otherwise ordered for medication administration.*May insert Foley Catheter (thin flexible tube inserted into the bladder to drain urine) as needed for signs of retention and/or requested by the patient or caregiver.*May perform registered nurse (RN) pronouncement.*Oxygen by nasal canula at 2-4 liters per minute as needed for comfort.During an interview on 9/3/25 at 3:00 P.M., the Clinical Manager said the 5/29/25 verbal orders should have been signed and dated by the registered nurse when obtained and added to the Hospice Plan of Care when received, as required. A. Review of the agency policy entitled, Interdisciplinary Care Planning Process, undated, indicated the following:*An individualized written plan of care is developed for each patient. The plan of care reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments. The plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions.......1. Patient #7 was admitted to the agency in July 2025 with a diagnosis of acute systolic Congestive Heart Failure (a sudden and severe condition when the heart muscle is unable to pump enough blood to meet the body's needs).Review of the Registered Nurse (RN) Hospice Initial Assessment, dated 7/10/25, indicated Patient #7's skin was fragile with multiple areas of breakdown, including a Stage 3 pressure ulcer (a full thickness skin loss that extends into the layer of fat and connective tissue that lies beneath the skin but does not involve muscle, tendon, or bone) to the sacrum (a bone at the base of the spine) and the right buttock.Patient #7 resided in a nursing facility and wound care was provided by the facility staff. Review of the care plans in the clinical record did not contain any documentation that a Plan of Care addressing Patient #7's Stage 3 pressure ulcers was developed.During an interview on 9/3/25 at 2:00 P.M., the Senior Director of Home and Community Services, after reviewing the clinical record said a Plan of Care addressing Patient #7's wounds was not developed, as required.

Based on document review and interview, the agency failed to ensure the Volunteer cost savings program met the required 5 percent (%) minimum.Findings include: --- Review of the agency's monthly Percentage of Volunteer Hours to Direct Patient Care Staff Hours from January 2025 to June 2025 indicated the following percentages:*January - 2.9%, February - 4.8%, March - 3.6%, April 3.7%, May - 4.6%, June 4.3%.During an interview on 9/3/25 at 1:40 P.M., the Volunteer Coordinator said the Volunteer cost savings is less than the required 5% from January 2025 to June 2025.

Based on record review, policy review and interview, the agency failed to ensure entries were dated in accordance with hospice policy and currently accepted standards of practice, for 2 patients (#3 and #8), out of total sample of 19 patients.Findings include: --- Review of the agency's policy entitled Timely Submission of Patient Documentation, undated, indicated the following:*Itineraries, with all visit reports attached, are expected to be submitted within 48 hours but not to exceed 7 days.1.Patient #3 was admitted to the agency in July 2025 with a diagnosis of Squamous Cell Cancer.Review of the physician ordered Hospice Plan of Care, dated 7/14/25 through 10/11/25, indicated the following:*Chaplain visits: 1-2 times a month for 3 months.Review of the clinical record indicated a Chaplain visit was provided on 8/1/25. The documentation was completed and submitted on 9/1/25, and not within 7 days of the visit, as required.2. Patient #8 was admitted to the agency in August 2025 with a diagnosis Parkinson's Disease (neurodegenerative disease).Review of the physician ordered Hospice Plan of Care, dated 8/12/25 through 11/9/25, indicated the following:*Skilled Nursing visits: once a week for 13 weeks.Review of the clinical record indicated a Skilled Nursing visit was provided on 8/26/25. The documentation was completed and submitted on 9/3/25, and not within 7 days of the visit, as required.During an interview on 9/3/25 at 11:45 A.M., the Clinical Manager said staff are expected to complete and upload their visit notes within 48 hours of the visit but have up to 7 days to complete it. She said the visit documentation noted above were both completed late and the policy was not followed.

Based on interview and review, the Hospice Agency failed to provide documentation that the Quality Assessment and Performance Improvement (QAPI) program was addressed for two out of four last calendar quarters of 2021. --- Review of the Agency policy titled, Quality Assurance Performance Improvement, undated, included but not limited to: The QAPI team meets at least quarterly with the Medical Director and documentation of the meetings will be kept on file. During an interview and review of the Agency QAPI binder on 9/28/22 at 2:15 P.M. with the Hospice Director, she said the QAPI team meets quarterly. Review of a binder titled, QAPI, indicated documentary evidence of the QAPI program meetings for the first and second calendar quarters of 2022. Further review of the binder did not contain any evidence that the QAPI program was addressed during the third and fourth calendar quarters of 2021. The Hospice Director said the quarterly QAPI meetings were held for the the third and fourth quarters of 2021 but the employee that was responsible for the QAPI program resigned at the end of last year and she could not locate any documentary evidence that those meetings had occurred.

Based on observation and interview, the Agency Nurse failed to follow the standards of practice relative to handwashing after doffing (removing) gloves during one (Patient #3) of three home visits. --- Review of the Centers for Disease Control (CDC) article titled, Donning and Doffing Personal Protective Equipment (PPE): Proper Wearing and Removal; Disposal, included but not limited to: Don (put on) and use PPE properly to achieve the intended protection and minimize the risk of exposure. Doff (remove) PPE in a way that avoids self-contamination....... Always wash hands with soap and water before wearing and after removal of PPE. Dispose of all PPE in appropriate waste containers. Review of the Hospice Agency policy titled, Infection Control Measures, revised 3/2007, included but not limited to: Handwashing is indicated : a. After contact with blood/body fluids;b. In between patient contacts;c. Before clean procedure;d. After contact with contaminated items or surfaces;e. After removal of gloves. During a home visit observation on 9/27/22 at 9:00 A.M. for Patient #3, who resided in a long term care facility, Nurse #1 failed to follow standards of practice relative to hand washing after doffing gloves. Nurse #1 donned gloves and assessed Patient #3 vital signs. She doffed her gloves and donned a new pair of gloves. After donning gloves, Nurse #1 assisted Patient #3 to the bathroom by assisting with a transfer from the wheelchair and onto the toilet. She doffed her gloves and donned a new pair of gloves. She cleansed the patient after the patient had a bowel movement. She removed her gloves and donned a new pair of gloves. Nurse #1 did not cleanse her hands for three opportunities after doffing her gloves. During an interview on 9/27/22 at 9:20 A.M., Nurse #1 said she did not cleanse her hands after doffing, as required.

Based on policy review, personnel record review and interview, the Agency failed to ensure: 1) The Abuse Policy contained information consistent with the State regulations and 2) The Nurse Aide Registry check was completed during the hiring process for one (Employee #1) out of three personnel records reviewed. --- 1. The Agency failed to ensure the Abuse Policy was consistent with the State regulations relative to the reporting of abuse allegations. 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. Upon receiving such report, said supervisor or employer shall immediately notify the Department by oral communication, electronically transmitted report or facsimile in accordance with such guidelines as may be established by the Department...... Review of the Hosice Agency policy titled, Abuse and Neglect, dated 9/1/07, included but limited to: - Mandatory reporting requirements by state statute of suspected or known abuse, neglect, exploitation, mistreatment and misappropriation of client property by individuals known or related to the patient. -Misappropriation of patient or resident property: the deliberate misplacement, exploitation or wrongful temporary or permanent use of a patient's or resident's belongings or money without such patient's or resident's consent. - Mistreatment: the use of medications, or treatments, or isolation, or physical or chemical restraints that harm or are likely to cause harm to the patient or resident. -Any situation of the above is to be reported to a program supervisor/manager. The mandatory reporting procedure will then be followed. During an interview with the Hospice Director on 9/28/22 at 8:10 A.M., she said the Abuse Policy was very generic and the information in the policy was not consistent with the State regulations. She further said the policy did not contain the required reporting elements relative to an abuse allegation. 2. Review of the Massachusetts State Regulation 105.CMR.155.010 (E) indicated: (4) Except as provided in 105 CMR 155.014(A)(2), no facility, home health agency, homemaker agency or hospice program shall hire or employ an individual whose name appears in the Registry with a finding or adjudicated finding of patient or resident abuse, neglect, mistreatment or misappropriation of patient or resident property, or, if a sanction was imposed upon that individual, such individual may not be hired or employed until the terms of such sanction have been fulfilled. Furthermore, no facility, home health agency,homemaker agency or hospice program shall hire or employ an individual if such individual has been found guilty of, or pleaded guilty or nolo contendere to (a plea of no contest or no defense), or admitted to sufficient facts to support a guilty finding of patient or resident abuse, neglect, mistreatment or misappropriation of patient or resident property in a court of law. The Agency failed to complete a Nurse Aide Registry check during the hiring process for Employee #1. Employee #1 was hired on 2/25/20. Review of Employee #1 personnel file indicated the Nurse Aide Registry check was completed on 9/28/22. During an interview on 9/28/22 at 2:00 P.M., the Hospice Director said the Nurse Aide Registry check was completed late and not upon hire, as required.