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.”