Baystate Hospice

“Based on record review and interview, the agency failed to ensure that care and services were provided in accordance with the plan of care for 6 Patients (#3, #5, #6, #22, #24 and #26), out of total sample of 27 patients. Findings include: 4. Patient #22 was admitted to the agency in May 2024 with a diagnosis of anemia (deficiency of red blood cells). Review of the physician ordered, Hospice Recertification Plan of Care, dated 7/29/24, for certification period 8/13/24 through 11/10//24, indicated the following: *Effective 8/13/24: MSWV one visit every 3 weeks times 3 weeks, one visit every 4 weeks for 8 weeks, 3 visits, as needed (PRN), for additional support. Review of the clinical record for the week of 8/25/24 indicated a MSWV was missed on 8/30/24 and no documentation indicating why the visit was not provided. During an interview on 10/22/24 at 12:40 P.M., the CM said the plan of care was not followed when the MSWV on 8/30/24 was not provided and there was no documentation to indicate why it was missed. 5. Patient #24 was was admitted to the agency in September 2024 with a diagnosis of malignant neoplasm (cancer) of the liver and intrahepatic bile duct (tubes connecting liver and gallbladder to the the small intestine). Review of the physician order, dated 9/4/24, indicated the following: *Effective 9/4/24: MSWV once a week for one week, once a week for one week, one visit every 2 weeks for ten weeks and 3 PRN visits for additional support. Review of the clinical record for the week of 9/8/24 indicated no MSWV was provided, as ordered, and no documentation indicating why the visit was missed. During an interview on 10/11/24 at 1:48 P.M., the CM said the plan of care was not followed when the MSWV was missed and not provided, as ordered, due to a scheduling error and the MSWV not being assigned to anyone. 6. Patient #26 was admitted to the agency in August 2024 with a diagnosis of Alzheimer’s Disease. Review of the physician order, dated 8/12/24 indicated the following: *Effective 8/12/24: MSWV once a week for one week, one visit every 7 weeks for 7 weeks, one visit every 5 weeks for five weeks. Review of the clinical record indicated for the week of 9/29/24 indicated no MSWV was provided, as ordered, and no documentation indicating why the visit was missed. During an interview on 10/11/24 at 2:15 P.M., the CM said the plan of care was not followed when the MSWV was missed and not provided, as ordered. 1. Patient # 3 was admitted to the agency in July 2024 with a terminal diagnosis of Multiple Sclerosis (a chronic neurological disorder that affects the central nervous system). Review of the physician ordered Hospice Certification and Plan of Care, dated 7/2/24 through 9/7/24, indicated the following: *Effective 8/2/24: Home Health Aide visit (HHAV) 3 times a week for 8 weeks. Review of the clinical for the week of 8/4/24 through 8/10/24, indicated HHAVs were provided on 8/5/24 and 8/7/24. A third HHAV was not provided as ordered, and there was no documentation indicating why the visit was not provided. During an interview on 10/11/24 at 9:35 A.M., the Clinical Manager (CM) said the third HHAV was missed the week of 8/4/24 through 8/10/24, and there was not a missed visit note. She said the plan care was not followed as ordered for the HHAV that week. 2. Patient #5 was admitted to the agency in March 2024 with a terminal diagnosis of malignant neoplasm (cancer) of the colon. Review of the physician ordered Hospice Certification and Plan of Care, dated 3/6/24 through 6/3/24, indicated the following: *Effective 3/6/24: Chaplin visit (CV) once a week for 13 weeks. Review of the clinical record indicated no CVs were provided for the weeks of 3/10/24 through 3/16/24, and 4/7/24 through 4/13/24. There were no documented missed visit notes for these 2 weeks indicating why the visits were not provided. During an interview on 10/11/24 at 9:45 A.M., the CM said the weekly CVs were missed the weeks noted above, and the Chaplin did not document why the visits were missed. She said the plan of care was not followed as ordered for the CVs. 6. Patient #6 was admitted to the agency in February 2024 with a terminal diagnosis of severe protein-calorie malnutrition. Review of the physician ordered Hospice Certification and Plan of Care, dated 2/16/24 through 5/15/24, indicated the following: *Effective 2/18/24: 1 Medical Social Worker visit (MSWV) a week for 1 week, 1 visit a week for 1 week, and 1visit every 2 weeks for 10 weeks. Review of the clinical record indicated only 1 MSWV was provided between 2/18/24 and 3/13/24 (when Patient #6 was discharged from the agency). During an interview on 10/11/24 at 9:50 A.M., the CM said MSW visits were missed and there was no documentation indicating why the visits were not provided. She said the plan of care was not followed as ordered for the MSWVs.”

“Based on record review, policy review and interview, the agency failed to ensure that a registered nurse (RN) made an on-site visit to the patient’s home, no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs, for 1 Patient (#21), out of a total sample of 27 patients. Findings include: Review of the agency’s policy entitled, Supervision of Home Care Aide/Hospice Aide, dated 10/13/22, indicated the following: *The primary clinician is responsible for: Conduct supervisory visit in the patient’s home either when the aide is present to observe and demonstrate, or when the aide is absent to assess relationships and determine whether goals are being met. Document aide supervision at least every 14 days in the patient’s home. Patient #21 was admitted to agency in September 2024 with a terminal diagnosis of malignant neoplasm (cancer) of the colon. Review of the physician ordered Hospice Certification and Plan of Care, dated 9/22/24 through 12/20/24, included the following: *Home Health Aide visit (HHAV) once a week for 1 week, and 2 times a week for 12 weeks. Review of the clinical record indicated HHAVs were provided on 9/26/24, 10/3/24, 10/8/24 and 10/10/24. Review of the clinical record from 9/22/24 and 10/10/24 indicated that no HHA supervisory visits were completed by the RN. During an interview on 10/11/24 at 10:15 A.M., the Clinical Manager said the RN had not completed the required HHA supervisory visits.”

“Based on record review and staff interview, the facility failed to ensure care and/or services were provided, as ordered, for 3 patients (#5, #11 and #14), out of a total sample of 27 patients. Findings include: 3. Patient #14 was admitted to the agency in July 2024 with a terminal diagnosis of Hypertensive Heart Disease with Congestive Heart Failure. Review of a physician order, dated 9/28/24, indicated for HHAVs 3 times a week for the week of 9/28/24. Review of the clinical record indicated HHAV were not provided, as ordered, for the week of 9/28/24. On 10/11/24 at 10:30 A.M., the surveyor and CM reviewed the HHAV order in the clinical record. The CM said the HHAV in the patient’s calendar for the week of 9/28/24 indicated 3 HHA PRN visits. The CM further said the physician order should have been clarified to indicate PRN visits and not 3 visits for the week. 1. Patient #5 was admitted to the agency in March 2024 with a terminal diagnosis of malignant neoplasm (cancer) the colon. Review of the physician ordered Hospice Certification and Plan of Care, dated 3/6/24 through 6/3/24, indicated the following: *4 Medical Social Worker visits (MSWVs) a week for 1 week, 1 visit every 8 weeks for 8 weeks, and 1 visit every 4 weeks for 4 weeks. Review of the clinical record indicated only 1 MSWV was provided between 3/6/24 and 3/9/24. On 10/11/24 at 9:45 A.M., the Clinical Manager (CM) and the surveyor reviewed the MSWV order and the clinical record. The CM said the MSW indicated in the patient’s calendar for as needed (PRN) visits for the first week. She said the physician order should have been clarified to indicate PRN visits, not 4 visits a week. 2. Patient #11 was admitted to the agency November 2023 with a terminal diagnosis of Hypertensive Heart Disease with Heart Failure and Chronic Kidney Disease. Review of the physician ordered Hospice Recertification and Plan of Care, dated 9/6/24 through 11/4/24, indicated the following: *Effective 9/29/24: 3 Home Health Aide visits (HHAVs) for one week. Review of the clinical record indicated no HHAVs were provided, and the patient’s calendar had HHAVs plotted for this week as PRN visits. On 10/11/24 at 9:35 A.M., the CM and the surveyor reviewed the clinical record and the patient’s calendar for HHAVs. She said the initial HHAV order, effective 9/29/24, should have been clarified as PRN visits, not 3 visits a week. The intention was for PRN visits the first week and that was the way they were plotted in the calendar for visits.”

“Based on record review, policy review and interview, the agency failed to ensure clinical documentation was complete, and appropriately authenticated and dated in accordance with hospice policy and currently accepted standards of practice for 5 Patients (#19, #20, #10, #15 and #16), out of a total sample of 27 patients. Findings include: 3. Patient #10 was admitted to the agency in August 2024 with a diagnosis of non rheumatic aortic (valve) stenosis (narrowing of the valve). Review of the physician order, Hospice Certification and Plan of Care, dated 8/23/24 through 11/20/24, indicated the following: *SNV: one visit a week for one week, one visit a week for 13 weeks, 5 PRN visits for symptom management. Review of the clinical record indicated the following SNV note that was signed/dated after the visit: *9/17/24 visit note was signed on 9/19/24. 4. Patient #15 was admitted to the agency in June 2024 with a diagnosis of malignant neoplasm (cancer) of the ovary. Review of the physician order, Hospice Certification and Plan of Care, dated 9/2/24 through 11/30/24, indicated the following: *SNV: twice a week for one week, once a week for 13 weeks and 5 PRN visits. Review of the clinical record indicated the following SNV note that was signed/dated after the visit: *9/20/24 visit note was signed on 9/22/24. 5. Patient #16 was admitted to the agency in July 2024 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). Review of the physician order, Hospice Certification and Plan of Care, dated 7/11/24 through 9/8/24, indicated the following: *SNV- twice a week for 9 weeks and 5 PRN visits. Review of the clinical record indicated the following SNV notes that were were signed/dated after the visit: *7/12/24 visit note was signed on 7/15/24. *7/16/24 visit note was signed on 7/18/24. *7/19/24 visit note was signed on 7/23/24. *7/23/24 visit note was signed on 7/25/24. *8/6/24 visit note was signed on 8/8/24. *8/9/24 visit note was signed on 8/12/24. Review of the physician order, Hospice Certification and Plan of Care, dated 9/2/24 through 11/30/24, indicated the following: *SNV-once a week for 13 weeks, and 5 PRN visits. Review of the clinical record indicated the following SNV notes that were were signed/dated after the visit: *9/12/24 visit note was signed on 9/18/24. During an interview on 10/11/24 at 10:30 A.M., the CM said the SNV notes listed for Patients #10, #15 and #16 were signed late and not in a timely manner, as required. Review of the agency’s policy entitled, Medical Record Documentation/Professional Staff, dated November 2023, indicated the following: *Documentation will be completed by the end of the clinician’s shift. Any exceptions need to be approved by the clinical manager. *Electronic Medical Record (EMR) system auto-authenticable date and time, and time of all entries. 1. Patient #19 was admitted to the agency in September 2024 with a terminal diagnosis of Cerebrovascular Disease (disease affecting blood vessels and blood flow in the brain). Review of the physician order Hospice Certification and Plan of Care, dated 6/21/24 through 9/18/24, indicated the following: *Effective 7/7/24: Volunteer visit (VV) once a week for hair cut or as needed (PRN). Review of the clinical record indicated the following VV notes that were signed/dated after the visit: *8/1/24 visit note was signed 8/6/24. *8/28/23 visit note was signed 8/30/32. *9/4/24 visit note was signed on 9/9/24. *9/11/24 visit note was signed on 9/17/24. During an interview on 10/11/24 at 11:20 A.M., the Volunteer Coordinator said volunteers should be signing and dating their visit notes on the day of the visit. 2. Patient #20 was admitted to the agency in July 2024 with a terminal diagnosis of bladder cancer. Review of the physician ordered Hospice Certification and Plan of Care, dated 7/3/24 through 9/30/24, indicated the following: *Skilled Nursing visit (SNV) once a week for 13 weeks and 5 as needed visits (PRN). Review of the clinical record indicated the following SNV note that was signed/dated after the visit: *8/18/24 visit note was signed on 8/21/24. During an interview on 10/11/24 at 12:30 P.M., the Clinical Manager said nursing staff are expected to sign and date their notes on the day of the visit, or within 24 hours of the visit. She said the 8/18/24 SNV note was documented late and was not timely as required.”

“Based on state requirements, personnel record review, and interview, the agency failed to ensure Nurse Aide Registry checks were conducted for 4 employees (#1, #6, #7, and #8), prior to hire, out of a total of 9 personnel records reviewed. Findings include: Review of the 105 CMR 155.000: Patient and Resident Abuse Prevention, Reporting, Investigation, Penalties and Registry Section: 105CMR 155.010 (E) (3) included the following: -All facilities shall contact the Registry prior to hiring any employee to ascertain of 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. -All home health agencies, homemaker agencies, and hospice programs shall contact the Registry prior to hiring an individual who will provide direct patient 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. Employee #1 was hired as a Volunteer on 2/23/24. Review of the personnel record contained evidence that a Nurse Aide Registry check was completed on 10/4/23 and not prior to hire. Employee #6 was hired as a Social Worker on 5/30/23. Review of the personnel record did not contain any evidence that a Nurse Aide Registry check was completed upon hire. Employee #7 was hired as a Home Health Aide on 8/9/21. Review of the personnel record contained evidence that a Nurse Aide Registry check was completed on 2/21/22 and not prior to hire. Employee #8 was hired as a Bereavement Coordinator on 4/15/24. Review of the personnel record did not contain any evidence that a Nurse Aide Registry check was completed upon hire. During an interview on 10/11/24 at 4:00 P.M., the Operations Manager said the Nurse Aide Registry checks for Employees #1 and #7 were completed late and not prior to hire, as required. She further said for Employees #6 and #8, there was no evidence that Nurse Aide Registry checks were completed prior to hire, as required.”