Every finding on record at Sudbury Pines Hospice

Based on record review and interview, the agency failed to ensure the Plan of Care (POC) included a detailed statement of the scope and frequency of Skilled Nursing (SN) services necessary to meet the specific patient and family needs for 1 patient (#2), out of a total sample of 9 patients.Findings include: --- Review of the agency policy entitled, Interdisciplinary Group (IDG) Care Plan Development and Updating, revised 1/24/19, indicated the following:*The Initial Plan of Care will be developed before care is provided. The Initial Plan of Care will be developed by a Registered Nurse, coordination with the Medical Director and at least one other member of the Interdisciplinary Group. The initial plan will be reviewed and ratified at the next Interdisciplinary Group Meeting.*The Plan of Care, including specific actions to be taken by members of the IDG, their scope and frequency of services, will be reviewed at least on a bi-weekly basis. Each problem past and present will be reviewed, and new problems will be addressed as they arise. *The Plan of Care shall include, but not be limited to:-Plan to assess identified needs including scope of services required.-Identification of anticipated frequency of services needed.-Identification of the disciplines involved in each deliverable service.-Procedure for follow-up to determine if goals were met and for assessment as needed. Patient #2 was admitted to the agency in July 2025 with a diagnosis of heart failure.Review of the Hospice POC, dated 7/29/25, did not include details of the scope and frequency of SN services necessary to meet the patient and family’s hospice needs.Review of the Interdisciplinary Group Meeting (IDG) notes, dated 7/31/25, 8/28/25, 9/11/25, and 9/25/25, did not indicate a review of the frequency of SN services.During an interview on 10/7/25 at 12:04 P.M., the Hospice Director said the IDG meeting minutes did not include documentation of a review of SN visit frequency.During an interview on 10/8/25 at 8:40 A.M., the Hospice Director said SN was not care planned for Patient #2 specific to the scope and frequency of SN services necessary to meet the patient and family’s hospice needs but should have been.

Based on record review and interview, the agency failed to ensure that care and services were provided in accordance with the plan of care (POC) for 1 patient (#2), out of a total sample of 9 patients.Findings include: --- Review of the agency policy entitled, Interdisciplinary Group Care Plan Development and Updating, revised 1/24/19, indicated the following:*The initial Plan of Care will be developed before care is provided. The initial Plan of Care will be developed by a Registered Nurse, coordination with the Medical Director and at least one other member of the Interdisciplinary Group. The initial plan will be reviewed and ratified at the next Interdisciplinary Group Meeting.*The Plan of Care, including specific actions to be taken by members of the IDG, their scope and frequency of services, will be reviewed at least on a bi-weekly basis. Each problem past and present will be reviewed, and new problems will be addressed as they arise.  *The Plan of Care shall include, but not be limited to:-Identification of anticipated frequency of services needed.-Identification of the disciplines involved in each deliverable service. Patient #2 was admitted to the agency in July 2025 with a diagnosis of heart failure. Review of the Initial Certification of Terminal Illness with benefit dates 7/29/25 through 10/26/25, Hospice POC, dated 7/29/25, and Interdisciplinary Group Meeting (IDG) notes, dated 7/31/25, 8/28/25, 9/11/25, and 9/25/25, did not indicate the frequency of SN services necessary to meet the specific patient and family needs. Review of the Insurance Data Form, dated 7/29/25, and nursing Comprehensive Hospice Assessment, dated 7/30/25, indicated the following:-Skilled Nursing Visits, 1-2 visits per week Review of the clinical record indicated the following:-(Week of 8/10/25 through 8/16/25), SN visits on 8/12/25, 8/13/25, and 8/14/25-(Week of 8/17/25 through 8/23/25), SN visits on 8/19/25, 8/20/25, 8/21/25-(Week of 9/7/25 through 9/13/25), SN visits on 9/8/25, 9/10/25, 9/11/25-(Week of 9/21/25 through 9/27/25), SN visits on 9/22/25, 9/23/25, 9/24/25, 9/25/25-(Week of 9/28/25 through 10/4/25), SN visits on 9/29/25, 9/30/25, 10/1/25, 10/2/25, 10/3/25 Further review of the clinical record indicated SN visits were not provided as ordered by the physician. During an interview on 10/7/25 at 12:04 P.M., the Hospice Director said a physician’s order is needed if SN visits exceed the prescribed amount. She said there was no order for PRN (as needed) visits and said the IDG meeting minutes did not include documentation of a review of or change in SN visit frequency.

Based on record review, the agency policy review, and staff interview, the agency failed to ensure bereavement services were made available for 1 patient’s (#9) family member, out of a total sample of 9 patients. Findings Include: --- Review of the agency policy, titled Sudbury Pines Hospice Bereavement Policy and Procedure, revised date 1/24/2019, indicated the following: Policy: Sudbury Pines Hospice will provide an organized bereavement program supervised by a qualified Bereavement Coordinator for up to one (1) year following the death of the patient. *Hospice monitors family, caregiver and significant others receiving bereavement care for thirteen months following the death of a hospice patient. *Bereavement interventions will be reflective of the family/caregiver’s choice to participate in the bereavement program. Review of the Bereavement Follow up form indicated the following: Cards and letters offered through Sudbury Pines:-        Sympathy Card-        2-week letter-        3-month letter-        6-month letter-        9-month letter-        13-month letter-        Holiday letter Patient #9 was admitted to the agency in December 2024 with a certification period of 12/13/24 through 3/12/25.  The patient expired on 2/11/25. Review of Patient #9’s Bereavement Follow-up form indicated a sympathy card was sent to the family on 2/18/25.   Further review of the Bereavement Follow- up form did not indicate any further letters were initiated and sent to the family. Review of the Social Service note written on 2/11/25 indicated the mother of the patient was happy with the services provided to the patient and family support was in place. There was no documented evidence in the note that the mother/family declined bereavement services. During an interview on 10/8/25 at 8:45 A.M., the Bereavement Coordinator said the Social Worker was responsible for reaching out to the family for the first initial contact. She said Patient #9’s family did not want any further bereavement services. The Bereavement Coordinator said there should have been documentation in the clinical record indicating no further bereavement services.

Based on record reviews and interview, the Agency staff failed to conduct an initial Bereavement Assessment of the needs of the patient's family that may potentially impact their ability to cope with the patient's death for three Patients (#3, #4 and #6), out of 11 patient records reviewed. --- Review of the Agency policy titled, Sudbury Pines Hospice Bereavement Policy and Procedure, revised 1/24/19, included but not limited to: - A bereavement risk assessment will be completed by the hospice social worker within five days of admission to hospice. This assessment is part of the Psychosocial Assessment. Information gathered will be incorporated into the bereavement plan of care. 1. Patient #3 was admitted to Hospice services in November 2021 with a diagnosis of Failure To Thrive (FTT-a decline resulting in a downward spiral of poor nutrition, weight loss, inactivity, depression and decreasing functional ability). Review of the medical record contained no evidence that a Bereavement Risk Assessment was completed upon admission to Hospice services. 2. Patient #4 was admitted to Hospice services in November 2021 with a diagnosis of stroke and Stage 4 decubitus (a deep wound that reaches the muscles, ligaments or bone). Review of the medical record indicated that a Bereavement Risk Assessment was completed on the day the Patient expired and not upon admission to Hospice services. 3. Patient #6 was admitted to Hospice services in April 2022 with a diagnosis of frontotemporal Dementia (a type of Dementia that causes problems with behavior and language). Review of the medical record contained no evidence that a Bereavement Risk Assessment was completed upon admission to Hospice services. During an interview on 10/13/22 at 11:40 A.M., the Director of Nurses (DON) said the initial Bereavement Risk Assessment was not completed for Patients #3 and #6. She further said the Bereavement Risk Assessment was completed late for Patient #4 and not upon admission, as required.

Based on record review and interview, the Agency failed to develop an individualized Bereavement Plan of Care to address any grief/loss issues for the patient families of two Patients (#10 and #11), out of nine bereavement records reviewed. --- Review of the Agency policy titled, Sudbury Pines Hospice Bereavement Policy and Procedure, revised 1/24/19, included but not limited to: - After the bereavement risk assessment is completed, a plan will be developed to address, the kind of services to be offered and the frequency of services... 1. Patient #10 was admitted to Hospice services in May 2020 with a diagnosis of Alzheimers Disease. The Patient expired in May 2020. Review of the clinical record did not contain evidence that a Bereavement Care Plan had been developed. 2. Patient #11 was admitted to Hospice services in November 2019 with a diagnosis of Dementia with Lewy bodies (a disease associated with abnormal deposits of a chemical in the brain which can lead to problems with thinking, movement, behavior and mood). The Patient expired in April 2020. Review of the medical record did not contain evidence that a Bereavement Care Plan had been developed. During an interview on 10/13/22 at 11:40 A.M., the Director of Nurses (DON) said there were no Bereavement Care Plans developed for Patients #10 and #11, as required.

Based on record reviews and interview, the Agency staff failed to develop and implement an individualized Bereavement Care Plan to address any grief/loss issues of the patient's family for three Patients (#3, #4, and #6), out of 11 patient records reviewed. --- Review of the Agency to be offered and the frequency of the services. titled, Sudbury Pines Hospice Bereavement Policy and Procedure, revised 1/24/19, included but not limited to: - After the bereavement risk assessment is completed, a plan will be developed to address, the kind of services to be offered and the frequency of the services. The Bereavement Coordinator and Bereavement Staff will monitor the evolving bereavement needs of the patient/caregiver during Interdisciplinary Group (IDG) meeting while the patient is active on the program. 1. Patient #3 was admitted to Hospice services in November 2021 with a diagnosis of Failure To Thrive (FTT-a decline resulting in a downward spiral of poor nutrition, weight loss, inactivity, depression and decreasing functional ability). Review of the medical record did not contain an initial Bereavement Risk Assessment and the Bereavement Care Plan was not individualized to meet the grief/loss needs of the patient/caregiver. 2. Patient #4 was admitted to Hospice services in November 2021 with a diagnosis of a stroke and Stage 4 decubitus (a deep wound that reaches the muscles, ligaments or bone). Review of the medical record indicated that a Bereavement Risk Assessment was completed on the day the Patient expired and the Bereavement Care Plan was not individualized to meet the grief/loss needs of the patient/caregiver. 3. Patient #6 was admitted to Hospice services in April 2022 with a diagnosis of frontotemporal Dementia (a type of Dementia that causes problems with behavior and language). Review of the medical record did not contain an initial Bereavement Risk Assessment and the Bereavement Care Plan was not individualized to meet the grief/loss needs of the patient/caregiver. During an interview on 10/13/22 at 11:40 A.M., the Director of Nurses (DON) said the Bereavement Care Plans created for Patients #3, #4 and #6 were not individualized, as required.

Based on record review and interview, the Agency failed to ensure Skilled Nurse services were provided according to the plan of care for one Patient (#11), out of 11 patient records reviewed. --- Review of the Agency policy titled, Interdisciplinary Group Care Plan Development and Updating, revised 1/24/19, included but not limited to: - The Plan of Care, including specific actions to be taken by members of the Interdisciplinary Group (IDG), their scope and frequency of services, will be established and reviewed at least on a bi-weekly basis.... Patient #11 was admitted to Hospice services in November 2019 with a diagnosis of Dementia with Lewy bodies (a disease associated with abnormal deposits of a chemical in the brain which can lead to problems with thinking, movement, behavior and mood). The Patient expired in April 2020. Review of the medical record indicated the plan of care for a Skilled Nurse to visit one to two times a week. Further review of the medical record indicated a Skilled Nurse visit did not occur during the week of 3/1/20 to 3/7/20 and the week of 3/8/20 to 3/14/20. During an interview on 10/13/22 at 12:00 P.M., the Director of Nurses (DON) said Patient #11 had no Skilled Nurse visits from 3/1/20 to 3/14/20, as required per plan of care.

Based on observation, record review and interview, the Agency Nurse failed to follow Standard Precautions during a visit to one Patient (#1), out of one home visit observed. --- Review of the Centers for Disease Control (CDC) article, Precautions to Prevent Transmission of Infectious Agents, Standard Precautions, included but not limited to: - Standard Precautions include a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any setting in which healthcare is delivered. These include: hand hygiene; use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure; and safe injection practices. Also, equipment or items in the patient environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission of infectious agents (e.g., wear gloves for direct contact, contain heavily soiled equipment, properly clean and disinfect or sterilize reusable equipment before use on another patient). The nursing facility that Patient #1 resides in has one current positive Covid-19 resident. Patient #1 was admitted to Hospice services in October 2022 with a diagnosis of senile degeneration of the brain. During an observation of a Skilled Nurse visit on 10/12/22 at 1:15 P.M., Nurse #1 entered Patient #1's room and placed her stethoscope on the Patient's bed. She hung her goggles on the bathroom doorknob. She did not cleanse the stethoscope or goggles prior to using them on Patent #1 after placing both items on contaminated surfaces. During an interview on 10/12/22 at 1:30 P.M., Nurse #1 said she did not maintain infection control practice when she placed her stethoscope on the patient's bed and bedside stand. She said she should not have hung her goggles on the bathroom door. She further said she did not cleanse the stethoscope and goggles prior to using them on the patient.