VNA Care Hospice Inc.

“Based on record review and interview, the Condition of Participation related to initial and comprehensive assessment of the patient was reviewed and found to be out of compliance. The agency failed to ensure 1. an initial and comprehensive assessment identified and developed a plan of care (POC) related to a history of substance abuse for one patient (#13) and 2. the interdisciplinary group (IDG-in collaboration with the individual’s attending physician, if any) updated the comprehensive assessment and considered changes that have taken place since the initial assessment, for 15 Patients (#1, #2, #3, #7, #10, #12, #16, #17, #22, #5, #6, #8, #9, #20 and #11), out of a total sample of 27 patients Refer to L 524 and L 533.”

“Based on record review and staff interview, the hospice agency failed to ensure that the initial and comprehensive assessment identified a history of substance use and failed to develop a plan of care (POC) for 1 Patient (#13), out of a total sample of 27 patients. Findings include: Review of the facility policy entitled, “;Initial Assessment”, with the revision date of March 2024, indicated the following: *The purpose is to provide guidelines for initial assessment to evaluate the patients physical, psychosocial, and emotional needs and determine immediate care and support needs. *Admitting Registered Nurse uses an assessment scale/rating tool to assess for problems and establish a baseline status of each symptoms related. *Admitting Registered Nurse will determine the patients and caregivers primary concern, goals, and immediate care needs. *Admitting Registered Nurse will document interventions and teaching performed. *Based on the initial assessment, the plan of care will be initiated on the day of admission. Review of the facility policy entitled, “;Comprehensive Assessment”, with the revision date of March 2024, indicated the following: *During the comprehensive assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patients clinical record, including at least the following information, as relevant. *Patients past and present medical and psychosocial history including pertinent diagnoses and any co-morbid condition. *Medical, alcohol, and other drug history. Review of Manual for MassHealth Providers, 130 CMR 437.000: Hospice Services: Hospice Providers Regulation indicated the following: Massachusetts Regulations 130 CMR 437.422: Initial and Comprehensive Assessment of the Member. *The hospice provider must conduct and document in writing a member-specific comprehensive assessment that identifies the member’s need for hospice care and services, and the member’s need for physical, psychosocial, emotional, and spiritual care. This assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. *The comprehensive assessment must identify the physical, psychosocial, emotional, and spiritual needs related to terminal illness that must be addressed in order to promote the member’s well-being, comfort, and dignity throughout the dying process. The comprehensive assessment must take into consideration the following factors: -complications and risk factors that affect the care planning. Patient #13 was admitted to the agency in July 2024 with a diagnosis of cardiomyopathy (a condition in which makes it difficult for the heart to pump blood to other parts of the body). Review of the clinical record on 8/6/24 for certification period of 7/6/24 – 10/3/24, indicated that the initial assessment was conducted by Registered Nurse #1 (RN) on 7/6/24. The initial assessment indicated Patient #13 has his/her sister as his/her caregiver. The initial assessment also indicated that Patient #13 has a history of alcohol use, and an accidental overdose of benzodiazepines (a group of depressant medications used to treat anxiety disorders, seizure disorders and insomnia) in January 2024. The initial assessment also included education/understanding by the patient and caregiver of the illness (cardiomyopathy). The initial assessment did not address Patient #13s history of substance use, nor was education provided to Patient #13 and his/her caregiver regarding Patient #13s substance abuse history. Review of the Medical Social Workers initial assessment on 7/8/24 indicated that Patient #13 did not have a current or history of substance use. Review of the 7/8/24 hospice Interdisciplinary Group (IDG) Comprehensive Assessment and POC Update Report indicated that the IDG team identified Patient #13s history of substance uses but there was no evidence that the IDG had developed a plan of care or provided education to the patient and the caregiver for substance use. Review of the medical record indicated that on 7/10/24, that a family member call 911 (an emergency number used to reach immediate assistance from the police, fire department, or ambulance) and Patient #13 was transferred to the Emergency Department (ED) after drinking a bottle 15 milliliter (ml) of morphine (an opioid medication used to treat pain) oral solution from the comfort kit that was delivered to Patient #13s home from the pharmacy. This was witnessed by the caregivers daughter. The clinical record indicated that Patient #13 was shaky, had tachycardia (rapid heartbeat), was hypotensive (low blood pressure), and that Emergency Medical Services (EMS) had to administer Narcan (a medication used to treat an opioid overdose) to Patient #13 on route to the hospital. The clinical record also indicated that Patient #13s caregiver was not aware that morphine was in the comfort kit. During an interview on 8/6/24 at 2:00 P.M. via zoom at the IDG meeting, RN #1 said that she conducted the initial assessment of Patient #13 on 7/6/24. She acknowledged that Patient #13 had a history of substance use including an overdose of benzodiazepine this year, but it did not strike as a concern at the time of assessment because Patient #13 has his/her sister as a caregiver and Patient #13 is in much better living situation compared to before. RN #1 said that no education was provided to the patient or caregiver regarding Patient #13s history of substance use. During an interview on 8/8/24 at 8:40 A.M., the Executive Director said that managing and storing medications was part of the agencys booklet that the staff go through with the patient or caregiver and provide education/teaching. The Executive Director said that he could not find documentation indicating the staff provided education/teaching to Patient #13 or to the caregiver.”

“Based on clinical record review, policy review and interview, the agency failed to ensure the interdisciplinary group (IDG-in collaboration with the individual’s attending physician, if any) updated the comprehensive assessment and consider changes that have taken place since the initial assessment, for 15 Patients (#1 #2, #3, #7, #10, #12, #16, #17, #22, #5, #6, #8, #9, #20 and #11), out of a total sample of 27 patients. Findings include: 15. Patient #11 was admitted to the agency in June 2024 with a diagnosis of centrilobular emphysema (a chronic obstructive lung disease that occurs when there is damage to the center of the lungs). Review of the of the clinical record for certification period of 6/9/24 – 9/6/24, indicated a physician order for HHAVs 5 times a week for 12 weeks, effective 6/16/24. Review of the comprehensive care plan report indicated HHA service for assistance with personal care, hygiene, and activity of daily living. Review of the clinical record indicated no HHAVs were provided the weeks of 6/23/24, 6/30/24, 7/7/24, 7/14/24, 7/21/24, and 7/28/24. Review of the IDG meeting documentation, dated 6/25/24, 7/9/24, and 7/23/24 did not include a need to change the order for HHAVs, as they were not being provided, as ordered. During an interview on 8/8/24 at 8:30 A.M., the Executive Director said the HHAV order should have been updated to reflect the current status of unavailability of HHAVs. 10. Patient #5 was admitted to the hospice agency in June 2024 with a diagnosis of severe protein-calorie malnutrition. Review of the clinical record indicated the following order: *Effective 7/3/24: 5 HHAVs a week for 13 weeks. Further review of the Comprehensive Care Plan Report, undated, indicated an intervention: personal care services will be provided by hospice team members using an appropriate care plan based on ongoing nursing assessment: HHA services added 6/30/24 and ended 7/17/24, due to no HHA currently available. Review of the clinical record indicated no HHAVs were provided the weeks of 6/30/24, 7/7/24, and 7/14/24, due to HHA unavailability. Review of the IDG meeting documentation, dated 7/3/24, included a nursing note indicating the patient’s family would like to have HHAVs occur every Monday, Wednesday and Thursday. The clinical record did not indicate an updated HHAV order to reflect the family’s HHAV preference. Review of the IDG meeting documentation, dated 7/3/24 and 7/18/24, did not address the missed visits and there was no change in the order. During an interview on 8/8/24 at 8:30 A.M., the Executive Director said the HHAV order was not updated to reflect the current unavailability of HHAs, as required. 11. Patient #6 was admitted to the hospice agency in December 2023 with a diagnosis of Cerebrovascular Disease (medical conditions that affect the blood vessels of the brain and cerebral circulation). Review of the clinical record indicated the following order: *Effective 5/16/24: 3 HHAVs per week. Review of the clinical record indicated 2 HHAVs were provided for the weeks of 6/23/24, 6/30/24 and 7/14/24. Review of the IDG meeting documentation, dated 6/25/24, 7/9/24 and 7/23/24, indicated no updated review of HHA services not provided, as ordered. 12. Patient #8 was admitted to the hospice agency in June 2024 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease that damages the airways or other parts of the lung, making it difficult to breathe) with Lower Respiratory Infection. Review of the clinical record indicated the following order: *Effective 6/29/24: 5 HHAVs per week. Review of the clinical record indicated no HHAVs were provided the weeks of 6/30/24 and 7/7/24. Review of the clinical record indicated only 2 HHAVs were provided the week of 7/14/24 and 7/21/24. Review of the IDG meeting documentation, dated 7/2/24, indicated HHA services were not available, however, the order was not updated to reflect the unavailability of HHA services. Review of the IDG meeting documentation, dated 7/16/24, indicated the HHA services would be starting this week. Review of the IDG meeting documentation, dated 7/30/24, indicated HHA services were provided 3 times a week, not 5 times a week, as ordered. There was no updated review of the HHA services not provided, as ordered. 13. Patient #9 was admitted to the hospice agency in May 2024 with a diagnosis of Amyotrophic Lateral Sclerosis (ALS-a nervous system disease that weakens muscles and impacts physical function). Review of the clinical record indicated the following order: *Effective 6/12/24: 2 HHAVs per week. Review of the clinical record indicated 1 HHAV was provided during the weeks of 6/23/24, 6/30/24, 7/7/24, 7/14/24 and 7/21/24. Review of the IDG meeting documentation, dated 6/25/24, 7/9/24 and 7/23/24, indicated no updated review of HHA services not provided, as ordered. 14. Patient #20 was admitted to the hospice agency in May 2024 with a diagnosis of Chronic Kidney Disease (CKD) and Hypertensive Heart Disease (complications of high blood pressure that affect the heart). Review of the clinical record indicated the following orders: *Effective 6/2/24: HHAVs 2 times a week for 11 weeks. *Effective 7/3/24: HHAVs 5 times a week. Review of the clinical record indicated 1 HHAV was provided the weeks of 6/16/24 and 6/23/24. Review of the clinical record indicated 3 HHAVs were provided the week of 7/14/24. Review of the clinical record indicated 4 HHAVs were provided the week of 7/21/24. Review of the IDG meeting documentation, dated 6/27/24 and 7/25/24, indicated no updated review of HHA services not provided, as ordered. During an interview on 8/8/24 at 10:30 A.M, the Executive Director said the IDG meets every 2 weeks for review of patients. At that time, the IDG team would update the comprehensive care plan with new orders or changes to reflect a patient’s needs, and additionally, the nurse would update the IDG team members of services, not provided, as ordered. After reviewing the clinical records and IDG meeting notes for Patients #5, #6, #8, and #20, he said the IDG members had not been updated on HHAV services not provided, as ordered, and orders for those services had not been updated. Review of the agency’s policy entitled, Interdisciplinary Group (IDG) Membership and Responsibilities, date January 2024, included the following: *The IDG responsibilities include but are not limited to: A. Participation in the establishment of the plan of care (POC) for each patient admitted to the hospice services. B. Participation in periodic review and updating the POC for each patient receiving hospice services. C. Taking a proactive approach in developing/revising the POC by planning ahead for anticipated patient changes and needs, including appropriateness of visit frequency. Review of the agency’s policy entitled, The Plan of Care, dated May 2022, included the following: *The POC will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the IDG, with input from the attending physician, the patient, and the family/caregiver, based on ongoing comprehensive assessments of the patient and family/caregiver. Review of the plan of care will be documented in the clinical record. Revision dates will be noted on the plan care. *Any changes in the patient’s condition must result in a change in the POC, prior to implementation of the new service. *Care provided to the patient will be in accordance with the plan of care. 1. Patient #1 was admitted to the hospice agency in July with a diagnosis of metastatic breast cancer. Review of the clinical record indicated the following orders: *Effective 7/10/24: 2 Chaplin Visits (CHVs) a week for 1 week, 1 CHV a week for 2 weeks, 2 CHVs a week for 1 week, I CHV a week for 4 weeks, 2 CHVs a week for 1 week and 1 CHV a week for 1 week. *Effective 7/10/24: 6 Home Health Aide visits (HHAVs) a week for 1 week, 14 HHAVs a week for 1 week, 10 HHAVs a week for one week. *Effective 7/14/24: 9 Skilled Nursing Visits (SNVs) a week for 2 weeks. *Effective 7/21/24: 8 SNVs a week for 2 weeks. *Effective 7/21/24: 13 HHAVs a week for 1 week, 14 HHAVs a week for 1 week, 12 HHAVs a week for 1 week. Further review of the clinical record indicated a SNV and HHAV were not provided as ordered the week of 7/14/24, a SNV and HHAVs were not provided as ordered the week of 7/21/14, and a CHV was not provided as ordered the week of 7/28/24. Review of the IDG meeting documentation, dated 7/16/24 and 7/30/24, did not include an updated review of the services not provided as ordered, or the need to change SNVs HHAVs and/or CHVs orders. 2. Patient #2 was admitted to the hospice agency in July 2024 with a diagnosis of malignant neoplasm of the temporal lobe (glioblastoma-brain cancer). Review of the clinical record indicated the following orders: *Effective 7/8/24: 2 CHVs a week for 1 week, 1 CHV a week for 2 weeks, 2 CHVs a week for 1 week, 1 CHV a week for 4 weeks, 2 CHVs a week for 1 week, 1 CHV a week for 3 weeks, and 2 CHVs a week for 1 week. *Effective 7/8/24: 11 HHAVs a week for 1 week, and 14 HHAVs for 2 weeks. Review of the clinical record indicated a missed CHV the week of 7/8/24 (start of care) and a missed HHAVs the week of 7/14/24. Review of the IDG meeting documentation, dated 7/16/24 and 7/30/24, did not include an updated review of services not provided as ordered, or the need to change HHAVs and/or CHVs orders. 3. Patient #3 was admitted to the hospice agency in January 2024 with a diagnosis of Alzheimer’s Disease. Review of the clinical record indicated the following orders: *Effective 4/11/24: 1 HHAV a week for 1 week, 3 HHAVs a week for 12 weeks, and 1 HHAV a week for 1 week. *Effective 4/14/24: 2 Master of Social Work visits (MSWV) a week for one week, and 1 MSWV every 4 weeks for 8 weeks. *Effective 7/10/24: 3 HHAVs a week. *Effective 7/10/24: 1 CHV a week and 1 as needed (PRN) visit. Review of the clinical record indicated MSWVs were not provided as ordered the week of 4/14/24, HHAVs were not provided as ordered the weeks of 5/26/24, 6/23/24 and 7/7/24, and 7/14/24, and a CHV was not provided as ordered the week of 7/21/24. Review of the IDG meeting documentation, dated 4/23/24, 5/7/24, 5/21/24, 6/4/24, 6/18/24, 7/2/24, 7/16/24 and 7/30/24, did not include an updated review of services not provided as ordered, or the need to change MSWVs, HHAVs and/or CHVs orders. 4. Patient #7 was admitted to the hospice agency in June 2024 with a diagnosis of malignant neoplasm of a major salivary gland and melanoma. Review of the clinical record indicated the following orders: *Effective 7/7/24: 1 HHAV a week for 1 week, 2 HHAVs a week for 10 weeks, and 1 HHAV a week for 1 week. Review of the clinical record indicated HHAVs were not provided as ordered the weeks of 7/7/24, 7/14/24, 7/21/24, and 7/28/24. Review of the IDG meeting documentation, dated 7/2/24, and 7/16/24 did not include an updated review of services not provided as ordered, or the need to change HHAVs orders. Review of the IDG meeting documentation, dated 7/30/24, did not include an updated review of services not provided as ordered, but nursing requested HHAVs 5 times a week, and were awaiting HHA assignment. Further review of the record indicated the HHAVs order had not been changed by the physician. 5. Patient #10 was admitted to the agency in May 2024 with a diagnosis of systolic and diastolic heart failure. Review of the clinical record indicated the following orders: *Effective 5/9/24: 3 HHAVs a week, 2 MSWVs a month and 2 PRN visits, and 1 CHV a month and 1 PRN visit. *Effective 5/21/24: 2 HHAVs a week. Review of the clinical record indicated HHAVs were not provided as ordered the weeks of 5/12/14, 5/19/24, 5/26/24, 6/2/24 6/9/24, 6/16/24, 6/23/24, 6/30/24, 7/7/24, 7/14/24, and 7/21/24, a MSWV was not provided as ordered the week of 6/9/24, and a CHV was not provided as ordered the week of 6/23/24 and a monthly CHV was not provided in July 2024. Review of the IDG meeting documentation, dated 5/14/24, 5/28/24, 6/11/24, 6/25/24, 7/9/24 and 7/23/24 did not include an updated review of the services not provided as ordered, or the need to change HHAVs, MSWVs, and/or CHVs orders. 6. Patient #12 was admitted to the hospice agency in May 2024 with a diagnosis of malignant neoplasm of the endometrium ( cancer of the uterine lining). Review of the clinical record indicated the following orders: *Effective 5/7/24: 5 HHAVs a week, and I MSWV a month and 1 PRN visit. *Effective 5/21/24: 3 HHAVs a week. *Effective 7/16/24: 3 HHAVs a week, and 1 MSWV a month and 1 PRN visit. Review of the clinical record indicated HHAVs were not provided as ordered the weeks of 5/1/24 (start of care), 5/12/24, 5/26/24, and 7/21/24, and a MSWV was not provided as order during the month of July. Review of the IDG meeting documentation, dated 5/7/24, 5/21/24, 6/4/24, 6/18//24, 7/2/24 and 7/16/24, did not include an updated review of the services not provided as ordered, or the need to change HHAVs and/or MSWVs orders. Review of the IDG meeting documentation, dated 7/30/24, did not include an updated review of services not provide as ordered, since last meeting held on 7/16/14. 7. Patient #16 was admitted to the hospice agency in June 2024 with a diagnosis of atherosclerosis of the native artery of the right leg, and peripheral vascular disease. Review of the clinical record indicated the following orders: *Effective 6/4/24: 3 SNVs a week for 1 week, 4 SNVs a week for 1 week, and 4 SNVs a week for 11 weeks. *Effective 6/4/24: 1 MSWV a week for 4 weeks, 2 MSWVs a week for 1 week, 1 MSW every 2 weeks for 2 weeks, 1 MSWV as week for 2 weeks, 2 MSWVs every 2 weeks for 2 weeks. *Effective 6/4/24: 1 CHV a week for 2 weeks, 1 CHV every 2 weeks for 10 weeks. Review of the clinical record indicated a CHV and MSWV were not provided as ordered the week of 6/23/24, a MSWV was not provided as ordered the week of 7/14/24, a CHV was not provided as ordered the week of 7/21/21, a SNV was not provided as ordered the week of 7/28/24. Review of the IDG meeting documentation, dated 6/6/24, 6/20//24, 7/3/24, 7/18/24 and 8/1/24 did not include an updated review of the services not provided as ordered, or the need to change CHVs, SNVs and/or MSWVs orders. 8. Patient #17 was admitted to the hospice agency in May 2024 with a diagnosis of acute systolic heart failure. Review of the clinical record included the following orders: *Effective 5/30/24: 2 SNVs a week for 1 week, 5 SNVs a week for 1 week and 2 SNVs a week for 7 weeks. *Effective 5/30/24: 1 MSWV a week for 3 weeks, 1 MSWV every 4 weeks for 4 weeks, and 1 MSWV a week for 1 week. *Effective 6/9/24: 1 HHAV a week for 7 weeks. *Effective 6/16/24: 1 SNV a week for 6 weeks. *Effective 6/30/24: 2 SNVs a week for 1 week, and 1 SNV a week for 3 weeks. *Effective 7/29/24: 1 HHAV a week for 9 weeks. Review of the clinical record indicated MSWVs were not provided as ordered after the initial assessment completed on 5/30/24, SNVs were not provided as ordered the weeks of 6/2/24, 6/9/24, 6/23/24, and HHAVs were not provided as ordered the weeks of 7/21/24 and 7/28/24. Review of the IDG meeting documentation, dated 6/6/24, 6/20//24, 7/3/24, 7/18/24 and 8/1/24 did not include an updated review of the services not provided as ordered, or the need to change orders for SNVs, MSWVs and/or HHAVs orders. 9. Patient # 22 was admitted to the hospice agency in January 2024 with a diagnosis of brain cancer., Review of the clinical record indicated the following orders: *Effective 1/5/24: 2 SNVS a week for 1 week, 5 SNVS a week for 1 week, 2 SNVs a week for 11 weeks, and 1 SNV a week for 1 week. *Effective 1/7/24: 1 HHAV a week for 1 week, 2 HHAVs a week for 11 weeks, and 1 HHA a week for 1 week *Effective 1/7/24: 1 CHV a week for 1 week. *Effective 1/8/24: 1 MSWV a week and 1 PRN visit. *Effective 1/14/24: No SNVs this week *Effective 1/19/24: 1 MSWV and 1 CHV to be provided this day. *Effective 1/22/24: 2 MSWVs this day. Review of the clinical record indicated SNVs, MSWVs, HHAVs were provided not as ordered the week 1/7/24, HHAVs were not provided as ordered the weeks of 1/14/24 and 1/21/24, and SNVs, MSWVs and HHAVs were not provided as ordered the week of 1/28/24. Review of the IDG meeting documentation, dated 1/16/24 and 1/30/24, did not include an updated review of the serviced not provided as ordered, or the need to change orders for SNVs, MSWVs and/or HHAVs orders. During an interview on 8/8/24 at 10:30 A.M, the Executive Director said the IDG meets every 2 weeks for review patients, and at that time would update the comprehensive care plan with new orders or changes to reflect a patient’s needs, and additionally at IDG meetings the nurse would update the IDG team members of services not provided as ordered. After reviewing the clinical records and IDG meeting notes for Patients #1, #2, # #7, #10, #12, #16, #17 and #22, he said the IDG members had not been updated on SNVs, HHAS, MSWVs, and/or CHV services not provided as ordered and orders for those services had been not updated.”

“Based on record review and staff interview, the hospice agency failed to obtain a physicians order and update the plan of care in a timely manner to reflect changes of an indwelling urinary catheter size for 1 Patient (#11), in a total sample of 27 patients. Findings include: Patient #11 was admitted to the agency in June 2024 with a diagnosis of centrilobular emphysema (a chronic obstructive lung disease that occurs when there is damage to the center of the lungs). Review of the of the clinical record for certification period 6/9/24 – 9/6/24, indicated a physicians order on 6/9/24 for #16 French(Fr) urinary catheter (a flexible tube inserted into the bladder to empty the bladder and collect urine in a drainage bag) and 10 cubic centimeters (cc) balloon size. Review of the skilled nursing visit notes indicated the following: -On 6/27/24, the Registered Nurse (RN) removed Patient #11s #16 Fr catheter and 10 cc balloon size and replaced it with a #18 Fr catheter and 10 cc balloon size. There was no documentation that the physician was notified and that a physicians order was obtained to change the indwelling catheter size from #16 Fr catheter to a #18 Fr catheter. The plan of care (POC) was not updated until 7/1/24 to reflect changes of the indwelling urinary catheter size. -On 7/25/24, the RN removed Patient #11s #18 Fr catheter and 10 cc balloon size and replaced it with a #20 Fr catheter and 10 cc balloon size. There was no documentation that the physician was notified and that a physicians order was obtained to change the indwelling urinary catheter size from a #18 Fr catheter to a #20 Fr catheter. The POC was not updated until 7/31/24 to reflect changes of the indwelling urinary catheter size. -On 7/27/24, the RN removed Patient #11s #20 Fr catheter and 10 cc balloon size and replaced it with a #22 Fr catheter and 10 cc balloon size. There was no documentation that the physician was notified and that a physicians order was obtained to change the indwelling urinary catheter size from a #20 Fr catheter to a #22 Fr catheter. The POC was not updated until 7/31/24 to reflect changes of the indwelling urinary catheter size. During an interview on 8/8/24 at 8:40 A.M., the Executive Director said that he reviewed Patient #11s clinical record, including visit notes, and could not find any documentation that the physician was notified, and a physicians order was obtained, prior changing the size of the indwelling urinary catheter. He acknowledged that the POC was not updated in a timely manner.”

“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 6 patients (#1, #2, #3, #10, #12 and #16), out of a total sample of 27 patients. Findings include: Review of the agency’s policy entitled Missed Visits, dated March 2024, indicated the following: *If a visit is missed, the clinician should attempt to reschedule within the same week to support the hospice Plan of Care (POC) visit frequency is maintained. *If missed visits are not rescheduled. the clinician will: a. Communicate the missed visits to the Interdisciplinary Group (IDG) at the IDG Meeting. b. Documentation of missed visits is in the patient’s clinical record-Coordination note which includes the following information: Date and type of visit that was missed. Reason for the missed visit. Description of any unmet needs and how the patient’s needs were met. Any other follow-up needed. *If a home health aide visit is missed the aide will contact the case manager, the clinical manager or the designee and will take appropriate measures stated above. *If a patient is routinely refusing visits, the clinician and the IDG should evaluate the appropriateness of the plan of care and make adjustments to the plan of care with input from the patient and the IDG. 1. Patient #1 was admitted to the hospice agency in July with a diagnosis of metastatic breast cancer. Review of the Hospice POC with benefit dates 7/10/24 through 10/7/24, indicated the following orders: *Effective 7/10/24: 6 Home Health Aide visits (HHAVs) a week for 1 week, 14 HHAVs a week for 1 week, 10 HHAVs a week for one week. *Effective 7/14/24: 9 Skilled Nursing Visits (SNVs) a week for 2 weeks. *Effective 7/21/24: 8 SNVs a week for 2 weeks and 2 times a week for weeks. *Effective 7/21/24: 13 HHAVs a week for 1 week, 14 HHAVs a week for 1 week, 12 HHAVs a week for 1 week. Review of the clinical record indicated the following weeks when SNVs and HHAVs were not provided as ordered: The week of 7/14/24 through 7/20/24 indicated only 8 SNVs were provided. The week of 7/21/24 through 7/27/24 indicated only 7 SNVs were provided and only 11 HHAVs were provided. The week of 7/28/24 through 8/3/24 indicated only 13 HHAVs were provided. Further review of the clinical record indicated no documented reason why the visits were not provided as ordered. 2. Patient #2 was admitted to the hospice agency in July 2024 with a diagnosis of brain cancer. Review of the Hospice POC with benefit dates 7/8/24 through 10/5/24 indicated the following orders: *Effective 7/8/24: 2 Chaplin Home Visits (CHVs) a week, 1 CHV a week for 2 weeks, 1 CHV a week for 4 weeks, 2 CHVs a week for 1 week, 1 CHV a week for 3 weeks and 2 CHVs a week for 1 week. Review of the clinical record indicated the following weeks when a CHV was not provided as ordered. The week of 7/8/24 (start of care) through 7/13/24 only 1 CHV was provided. The week of 7/28/24 through 8/3/24 only 1 CHV was provided. Further review of the clinical record indicated no documented reason why the visits were not provided as ordered. 3. Patient #3 was admitted to the hospice agency in January 2024 with a diagnosis of Alzheimer’s disease. Review of the Hospice POC with benefits dates 4/11/24 through 7/9/24 indicated the following orders: *Effective 4/10/24; 1 SNV a week. *Effective 4/11/24: 1 HHAV a week for 1 week, 3 HHAVs a week for 12 weeks, and 1 HHAV a week for 1 week. *Effective 4/14/24: 2 Master of Social Worker visits (MSWVs) a week for 1 week and 1 MSWV every 4 weeks for 8 weeks. Review of the clinical record indicated the following weeks when MSWVs and HHAVs were not provided as ordered: Week of 4/14/24 through 4/20/24 indicated no MSWV was provided Week of 5/26/24 through 6/1/24 indicated 1 HHAV was provided. Week of 6/23/24 through 6/30/24 indicated 1 HHAV was provided. Further review of the clinical record indicated no documented reason why the visits were not provided as ordered. 4. Patient #10 was admitted to the hospice agency in May 2024 with a diagnosis of systolic and diastolic heart failure Review of the Hospice POC with benefits dates 5/9/24 through 8/624 indicated the following orders: *Effective 5/9/24: 3 HHAVs a week. *Effective 5/21/24: 2 HHAVs a week. Review of the clinical record indicated the following weeks when HHAVs were not provided as ordered: *Week of 5/12/24 through 5/18/24: no HHAVs were provided (only 5/15/24 and 5/17/24 had documented reasons for the missed visits). *Weeks of 5/26/24 through 6/1/24, 6/2/24 through 6/8/24, 6/9/24 through 6/15/24, and 6/16/24 through 6/22/24: only 1 HHAV was provided each week. *Week of 6/23/324 through 6/29/24, 6/30/24 through 7/6/24, 7/724 through 7/13/24, and 7/14/24 through 7/20/24: no HHAVs were provided (only 6/28/24, 7/5/24, 7/12/24, and 7/19/24 had documented reasons for the missed visits). Further review of the clinical record indicated no documented reason why the visits were not provided as ordered. 5. Patient # 12 was admitted to the hospice agency in May 2024 with a diagnosis of malignant neoplasm of the endometrium (cancer of the uterine lining). Review of the Hospice POC with benefits dates 5/1/24 through 7/29/24 indicated the following orders: *Effective 5/1/24: 5 HHAVs a week. *Effective 7/16/24: 3 HHAVs week. Review of the clinical record indicated the following weeks when HHAVs were not provided as ordered. *Weeks of 5/5/24 through 5/11/24, 5/19/24 through 5/25/24, 6/2/24 through 6/8/24, 6/9/24 through 6/15/24, 6/16/24 through 6/22/24. 6/23/24 through 6/29/24, 6/30/24 through 7/6/24 and 7/7/24 through 7/13/23: only 3 HHAVs were provided. * Weeks of 5/12/24 through 5/18/24, and 5/26/24 through 6/1/24: only 2 HHAVs were provided. Further review of the clinical record indicated no documented reason why the visits were not provided as ordered. 6. Patient #16 was admitted to the hospice agency in May 2024 with atherosclerosis of a native artery of the right leg and peripheral heart disease. Review of the Hospice POC with benefit dates 6/4/24 through 9/1/124 indicated the following orders: *Effective 6/4/24: 1 MSWV a week for 4 weeks, 2 MSWVs a week for 1 week, 2 MSWVs every 2 weeks for 2 weeks, 1 MSWV every 2 weeks for 2 weeks, 2 MSWVs every 2 weeks for 2 weeks. Review of the clinical record indicated the following weeks when MSWVs were not provided as ordered. *Weeks of 6/9/24 through 6/15/24, and 6/16/24 through 6/22/24: no MSWVs were provided. Further review of the clinical record indicated no documented reason why the visits were not provided as ordered. During an interview on 8/6/24 at 3:45 P.M., the Executive Director (ED) said that when visits are not provided as ordered, the clinician should document in the clinical record the reason why the visit could not be provided. He said if the missed visits were HHAs then the nurse should document the reasons for those missed visits. He said all missed visits should be reviewed at IDG meetings and if there are patterns to missed visits then the frequency order for them should be updated and changed by the physician. During a second interview on 8/8/24 at 10:30 A.M., the ED said, after reviewing the records for the patients not above, not all missed visits had documented reasons why they were missed and not all orders had been updated and changed.”

“Based on state requirements, personnel record review, and interview, the agency failed to provide documentation that Criminal Offender Record Information (CORI) background checks and Nurse Aide Registry checks were conducted, prior to hire, for 3 Volunteers (#1, #2, #3) personnel records reviewed. In addition, based on interview, 21 out of a total 58 active Volunteers, did not have CORI or Nurse Aide Registry check documentation on file. 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 the facility policy entitled, Volunteer Policy and Procedure, revised July 2024, included the following: Assessment of Volunteer Suitability: *Background checks may include: -Reference checks, -Criminal Offender Record Information (CORI)/ Aid Registry check. The agency failed to ensure that a CORI background check and Nurse Aide Registry documentation was conducted and on file for 3 Volunteers (#1, #2, #3), and 21 out of a total of 58 active Volunteers. Review of Volunteer #1 personnel record on 8/8/24 indicated Volunteer #1 joined the volunteer program on 11/17/20. Further review of the file failed to indicate a CORI or Nurse Aide Registry check was conducted. Review of Volunteer #2 personnel record on 8/8/24 indicated Volunteer #2 joined the volunteer program on 9/17/18. Further review of the file failed to indicate a CORI or Nurse Aide Registry check was conducted. Review of Volunteer #3 personnel record on 7/26/24 indicated Volunteer #3 joined the volunteer program on 4/7/23. Further review of the file failed to indicate a CORI or Nurse Aide Registry check was conducted. During an interview on 8/8/24 at 1:00 P.M., the Executive Director said that he checked with the Human Resource (HR) Department and was told that documentation of confirmation of CORI checks and CNA Registry checks for Volunteers #1, #2 and #3 were unable to be located. In addition, he said the agency has 58 active volunteers and 21 of them do not have confirmation of a CORI or CNA Registry check in their files, as required.”