Pioneer Valley Hospice & Palliative Care

“Based on record review, policy review and staff interview, the agency failed to 1.) ensure bereavement care plans were completed in a timely manner for 2 patients that had expired (#17 and #19), and 2.) ensure a care plan was updated every 15 days for 1 patient (#10), out of a total sample of 19 patients. Findings include: Review of the facility policy, entitled, Bereavement Services, revised April 2016, indicated the following: *A bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice. Information gathered will be incorporated into the plan of care and considered in the bereavement plan of care. *After a death has occurred, the bereavement assessment will be updated and the family/caregiver needs will be discussed at the next interdisciplinary group meeting. Review of the facility policy, entitled, The Plan of Care, revised April 2016, indicated the following: *The plan of care will be reviewed and revised as frequently as necessary, but not less often than every 15 days, by the interdisciplinary group, 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 of care. 1. Patient #17 was admitted to the agency in July 2024 with a diagnosis of lung cancer and the patient expired in July 2024 while on hospice services. Review of the clinical record did not contain any documentation that a bereavement care plan was updated to discuss the family/caregiver needs after the patient’s death. During an interview on 10/25/24 at 2:20 p.m., after reviewing the clinical record, the Quality and Control Coordinator said there was no bereavement care pan updated after the death of Patient #17, as required. 2. For Patient #19, the Bereavement Coordinator had not updated the bereavement care plan after the patient’s death. Patient #19 was admitted to the agency in June 2024 with a terminal diagnosis of Cerebral Atherosclerosis (plaque buildup in the arteries of the brain, that narrows and hardens them). The clinical record indicated the patient expired in July 2024. Review of the clinical record indicated a bereavement care plan was initiated when Patient#19 was admitted. Further review of the clinical record indicated the Bereavement Coordinator called and left voicemails on 7/17/24 and 8/8/24 for Patient #19’s Health Care Proxy (HCP), regarding the agency’s bereavement program. The clinical record did not include any further interventions, nor any bereavement care plan updates. During an interview on 10/25/24 at 2:30 P.M., the Quality and Compliance Coordinator said the Bereavement Coordinator had not updated the bereavement assessment and care plan, including any new interventions, after 8/8/24. She said the care plan had not been updated, as required. 3. For Patient #10, the Social Worker (SW) failed to ensure the care plan had been updated no less than every 15 days. Patient #10 was admitted to the agency in September 2024 with a terminal diagnosis of Severe Aortic Stenosis (narrowing of the valve in the large blood vessel branching off the heart, reducing blood flow to the body). Review of the clinical record indicated a care plan entitled, Deficit Related to Grief Process, was initiated 9/6/24, and last updated 9/23/24. Further review of the clinical record indicated interdisciplinary group (IDG) meetings were conducted on 9/17/24, 10/1/24 and 10/15/24. During an interview on 10/25/24 at 1:00 P.M., the Quality and Compliance Coordinator said the SW had not updated the Grief Process care plan, as required. During an interview on 10/25/24 at 2:30 P.M., Executive Director said that care plans are reviewed and updated when IDG meetings are held, and staff document when the care plan was last updated. She said the SW had not updated the Grief Process care plan.”

“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 3 patients (#8, #7 and #13), out of a total sample of 19 patients. Findings include: Review of the agency’s policy, entitled, The Plan of Care, revised April2016, indicated the following: *The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs. 1. For Patient #8, the facility failed to ensure A.) Medical Social Worker Visit (MSWV) and B.) Skilled Nurse Visit (SNV) were provided, as ordered. Patient #8 was admitted to the agency in June 2024 with a diagnosis of kidney cancer. Review of the Hospice POC with benefit dates 6/26/24 through 9/23/24 indicated the following: *MSWV monthly for 4 months and 5 visits, as needed (PRN), for psychosocial support. *SNV weekly and 5 PRN visits every 90 days. A. Review of the clinical record indicated a MSWV was not provided for the month of September, as ordered. B. Review of the clinical record indicated a SNV was not provided for the week of 9/29/24 through 10/5/24, as ordered. During an interview on 10/25/24 at 3:00 P.M., the Executive Director said the MSWV for September and the SNV for the week of 9/29/24 through 10/5/24 were not provided, as ordered. 2. For Patient #7, Home Health Aide visits (HHAVs) were provided without a physician order. Patient #7 was admitted the agency in October 2024 with a terminal diagnosis of Cerebral Atherosclerosis (a buildup of plaque in the arteries of the brain, making them narrowed and hardened). Review of the physician ordered Plan of Care for certification period 10/4/24 through 1/1/25, did not include an order for HHAVs. Review of the clinical record indicated a HHAV was provided on 10/24/24. During an interview on 10/25/24 at 9:20 A.M., the Quality and Compliance Coordinator said there was not an order for HHAV, and services were provided that were not included in the plan of care. 3. For Patient # 13, MSWVs were not provided as ordered in the plan of care. Patient #13 was admitted to the agency in June 2023 with a terminal diagnosis of Congestive Heart Failure (a chronic condition in which the heart doesn’t pump blood as well as it should). Review of the physician ordered Plan of Care for certification period 8/20/24 through 10/18/24, indicated the following: *MSWV once monthly and 5 PRN visits for 60 days. Review of the clinical record indicated there were no MSWVs between 8/20/24 and 10/6/24, and the only monthly visit was made on 10/7/24. During an interview on 10/25/24 at 9:50 A.M., the Quality and Compliance Coordinator said that the MSW had made several phones to the patient and/or family between 8/20/24 and 10/6/24, however those phone calls did not indicate they were replacements for monthly visits. She said the plan of care for monthly MSWVs had not been provided as ordered for the end of August and all of September 2024.”

“Based on record review and staff interview, the facility failed to ensure a communication occurred with the Chaplain, per the request of one Patient (#17), out of a total sample of 19 patients. Findings include: Patient #17 was admitted to the facility in June 2024 with a diagnosis of kidney cancer. Review of the clinical record indicated a SNV note, dated 7/29/24, that the patient seemed to think he/she was a burden and wished to talk to a priest. Further review of the clinical record did not contain any documentation that the chaplain had been notified of the patient’s request to be seen by the priest. During an interview on 10/25/24 at 1:00 P.M., with the Executive Director and Quality and Compliance Coordinator, both said the expectation would be for the agency to contact a priest per the patient wishes and there was no documentation in the clinical record that a priest had been notified.”

“Based on record review, policy review and interview, the agency failed to ensure there was communication shared with the physician when services were not provided, as ordered, for 4 Patients (#2, #12, #13, and #8), out a total sample of 19 patients. Findings include: Review of the agency’s policy entitled, Monitoring Patient’s Response/Reporting to Physician, dated April 2016, indicated the following: *Clinician will establish and maintain ongoing communication with the patient’s physician and the hospice Medical Director to ensure safe and appropriate care for the patient. *The patient’s physician and/or the hospice Medical Director will be contacted on the same day when any of the following occur: There is a problem implementing the plan of care. 1.Patient #2 was admitted to the agency in August 2023 with a terminal diagnosis of Amyotrophic Lateral Sclerosis (ALS-a nervous system disease that weakens muscles and impacts physical function). Review of the physician ordered Plan of Care for certification period 8/13/24 through 10/11/24, indicated the following: *Effective 8/13/24: Home Health Aide visits (HHAVs) 5 times a week for 60 days. Review of the clinical record included Missed HHAV notes for 9/9/24, 9/10/24, 9/11/24, 9/12/24 and 9/13/24. All 5 notes indicated the patient’s family declined the HHAVs and declined an alternate HHA. The notes did not included documentation that the physician was notified that the plan of care was not implemented as ordered, from 9/9/24 through 9/13/24, for the HHAVs. Review of the physician ordered Plan of Care for certification period 10/12/24 through 12/10/24, indicated the following: *Effective 10/12/24: HHAVs 5 times a week for 60 days. Review of the clinical record included Missed HHAV notes for 10/14/24 and 10/16/24. The 2 notes indicated services were not provided, but did not include physician notification of services not provided as ordered in the plan of care. During an interview on 10/25/24 at 10:30 A.M., the Quality and Compliance Coordinator said staff should have notified the physician and documented the notification of services not implemented as ordered in the plan of care. 2. Patient #12 was admitted to the agency in October 2024 with a terminal diagnosis of Cerebral Atherosclerosis (a buildup of plaque in the arteries of the brain, making them narrowed and hardened). Review of the physician ordered Plan of Care for certification period 10/13/24 through 1/10/25, indicated the following: *Effective 10/13/24: Home Health Aide visits (HHAVs) 2 times weekly. Review of the clinical record included a Missed HHAV note for 10/16/24, indicating the patient cancelled the visit. The note did not include documentation that the physician was notified that the plan of care was not implemented as ordered. During an interview on 10/25/24 at 2:30 P.M., the Quality and Compliance Coordinator said the physician had not been notified when the plan of care was not implemented on 10/16/24. 3. Patient #13 was admitted to the agency in June 2023 with a terminal diagnosis of Congestive Heart Failure (CHF-condition in which the heart doesn’t pump blood as well as it should). Review of the physician ordered Plans of Care for certification periods 8/20/24 through 10/18/24, and 10/19/24 through 12/17/24, indicated the following: *Medical Social Worker visit (MSWV) once monthly and 5 PRN visits for 60 days. Review of the clinical record indicated no MSWVs were provided 8/20/24 through 10/6/24. The record did not include any documentation that the physician had been notified that the plan of care had not been implement for MSWVs. During an interview on 10/25/24 at 9:50 A.M., the Quality and Compliance Coordinator said there was no documentation indicating that staff had notified the physician that the plan had not been implemented for MSWVs as ordered. During an interview on 10/25/24 at 3:00 P.M., the Executive Director said the services not provided as ordered in the plan of care are not reviewed with the physician during interdisciplinary group meetings. 4. Patient #8 was admitted to the agency in June 2024 with a diagnosis of kidney cancer. Review of the Hospice POC with benefit dates 6/26/24 through 9/23/24 indicated the following: *MSWV monthly for 4 months and 5 visits PRN, for psychosocial support. *SNV weekly and 5 visits PRN visits every 90 days. Review of the clinical record indicated a MSWV was not provided for the month of September, as ordered. Review of the clinical record indicated a SNV was not provided for the week of 9/29/24 through 10/5/24, as ordered. Further review of the clinical record did not include documentation that the physician had been notified of the missed MSWV and SNV. During an interview on 10/25/24 at 10:30 A.M., the Quality and Compliance Coordinator said there was no documentation in the clinical record that the staff had notified the physician of the missed visits and that the plan of care was not followed, as required.”

“Based on record review and interview, the agency failed to ensure that clinical documentation was complete, and appropriately authenticated and dated in accordance with currently accepted standards of practice for 6 Patients (#2, #9, #10, #13, #3 and #8), out of a total sample of 19 patients. Findings include: 5. Patient #3 was admitted to the agency in April 2024 with a diagnosis of leukodystrophy (a group of usually inherited disorders characterized by degeneration of the white matter in the brain). Review of the Hospice POC effective 7/22/24 through 10/18/24, indicated a SNV weekly times 13 weeks. Review of the clinical record indicated the following SNV notes that were signed/dated after the visit: *8/1/24 visit note was signed on 8/15/24. *8/22/24 visit note was signed on 8/25/24. *9/5/24 visit note was signed on 9/11/24. *9/11/24 visit note was signed on 9/16/24. *10/10/24 visit note was signed on 10/15/24. 6. Patient #8 was admitted to the agency in June 2024 with a diagnosis of kidney cancer. Review of the Hospice POC effective 6/26/24 through 9/23/24 indicated for a SNV weekly for 13 weeks and a MSWV once a month for 4 months. Review of the clinical record indicated the following: *8/28/24 SNV note was signed on 8/30/24. *8/28/24 MSWV note was signed on 8/30/24. During an interview on 10/25/24 at 2:30 P.M., the Quality and Compliance Coordinator said the SNV notes listed for Patient #3 and Patient #8 were signed late and the MSWV note listed for Patient #8 was signed late. 1.Patient #2 was admitted to agency in August 2023 with a terminal diagnosis of Amyotrophic Lateral Sclerosis (ALS-disease that weakens the muscles and impacts physical function). Review of the physician ordered Plan of Care for certification periods 8/13/24 through 10/11/24 and 10/12/24 through 12/10/24, indicated the following: *Skilled Nurse Visit (SNV) once weekly and 5 as needed (PRN) visits for 60 days. Review of the clinical record indicated the following SNV notes that were signed/dated after the visit: *9/13/24 visit note was signed on 9/25/24. *10/5/24 visit note was signed on 10/16/24. 2. Patient #9 was admitted to the agency in January 2024 with a terminal diagnosis of Parkinson’s disease (a disorder of the central nervous system that affects movement, and often includes tremors). Review of the physician ordered Plan of Care for certification period 7/24/24 through 9/21/24, indicated the following: *SNV once weekly and 5 PRN visits times 60 days. 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 9/20/24. 3. Patient #10 was admitted to the agency in September 2024 with a terminal diagnosis of Severe Aortic Stenosis (narrowing of the valve of the large blood vessel branching off the heart, reducing blood flow to the body). Review of the physician ordered Plan of Care for certification period 9/6/24 through 12/4/24, indicated the following: *SNV once weekly and 5 PRN visits times 90 days. Review of the clinical record indicated the following SNV note that was signed/dated after the visit: *9/6/24 visit note was signed on 9/8/24. 4. Patient #13 was admitted to the agency in June 2023 with a terminal diagnosis of Congestive Heart Failure (chronic condition in which the heart doesn’t pump blood as well as it should). Review of the physician ordered Plan of Care for certification period 8/20/24 through 10/18/24, indicated the following: *SNV once weekly and 5 PRN visits times 60 days. Review of the clinical record indicated the following SNV note that was signed/dated after the visit: *9/10/24 visit note was signed on 9/13/24. During an interview on 10/23/24 at 12:30 P.M., the Executive Director said staff are expected to sign and date their visit notes as completed within 24 hours of the visit. She said the above SNV notes were all signed and dated more than 24 hours after the visits, making them late.”

“Based on state requirements, personnel record review, and interview, the agency failed to provide documentation that Criminal Offender Record Information (CORI) background checks and/or Nurse Aide Registry (NAR) checks were conducted, prior to hire, for 14 Volunteers (#1, #2, #3 #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14), out of 28 Volunteer personnel records reviewed. 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 Volunteer #1’s personnel record on 10/25/24 indicated Volunteer #1 joined the volunteer program on 6/26/24 (date of hire). Further review of the file indicated the NAR check was conducted on 10/23/24, after the date of hire. Review of Volunteer #2’s personnel record on 10/25/24 indicated Volunteer #2 joined the volunteer program on 2/22/23 (date of hire). Further review of the file indicated the CORI check was conducted on 3/24/23 and the NAR check was conducted on 10/23/24, both were conducted after the date of hire. Review of Volunteer #3’s personnel record on 10/25/24 indicated Volunteer #3 joined the volunteer program on 3/26/18 (date of hire). Further review of the file indicated the CORI was conducted on 10/24/24, after the date of hire. Review of Volunteer #4’s personnel record on 10/25/24 indicated Volunteer #4 joined the volunteer program on 6/26/24 (date of hire). Further review of the file indicated a CORI check had not been conducted. Review of Volunteer #5’s personnel record on 10/25/24 indicated Volunteer #5 joined the volunteer program on 7/6/23 (date of hire). Further review of the file indicated the CORI was conducted on 10/24/24, after the date of hire. Review of Volunteer #6’s personnel record on 10/25/24 indicated Volunteer #6 joined the volunteer program on 3/29/17 (date of hire). Further review of the file indicated the CORI was conducted on 10/24/24, after the date of hire. Review of Volunteer #7’s personnel record on 10/25/24 indicated Volunteer #7 joined the volunteer program on 11/1/05 (date of hire). Further review of the file indicated the CORI was conducted on 10/24/24, after the date of hire. Review of Volunteer #8’s personnel record on 10/25/24 indicated Volunteer #8 joined the volunteer program on 12/5/23 (date of hire). Further review of the file indicated the NAR check was conducted on 10/24/24, after the date of hire. Review of Volunteer #9’s personnel record on 10/25/24 indicated Volunteer #9 joined the volunteer program on 7/26/23 (date of hire). Further review of the file indicated the NAR check was conducted on 10/24/24, after the date of hire. Review of Volunteer #10’s personnel record on 10/25/24 indicated Volunteer #10 joined the volunteer program on 9/13/13 (date of hire). Further review of the file indicated the CORI was conducted on 10/24/24, after the date of hire. Review of Volunteer #11’s personnel record on 10/25/24 indicated Volunteer #11 joined the volunteer program on 7/6/23 (date of hire). Further review of the file indicated the NAR check was conducted on 10/24/24, after the date of hire. Review of Volunteer #12’s personnel record on 10/25/24 indicated Volunteer #12 joined the volunteer program on 5/27/22 (date of hire). Further review of the file indicated the CORI was conducted on 10/23/24, after the date of hire. Review of Volunteer #13’s personnel record on 10/25/24 indicated Volunteer #13 joined the volunteer program on 7/6/23 (date of hire). Further review of the file indicated the NAR check was conducted on 10/24/24, after the date of hire. Review of Volunteer #14’s personnel record on 10/25/24 indicated Volunteer #14 joined the volunteer program on 2/22/23 (date of hire). Further review of the file indicated the NAR check was conducted on 10/24/24, after the date of hire. During an interview on 10/23/24 at 3:15 P.M., the Volunteer Coordinator said that CORI checks are done before the date of hire, but she was told by the previous Volunteer Coordinator that NAR checks were not required. During an interview on 10/23/24 at 3:45 P.M., the Executive Director (ED) said NAR checks were not being done due a miscommunication by the previous administrative team. During an interview on 10/25/24 at 11:30 A.M., the ED said the 14 Volunteers listed above should have had their CORI checks and/or NAR checks completed prior to hire, as required.”