Hospice Services of Western & Central Mass

“Based on record review and interview, the agency failed to ensure the comprehensive assessment was completed by the hospice interdisciplinary group (IDG) no later than 5 calendar days after the election of hospice care for 3 Patients (#4, #11 and #5), out of a total sample of 19 patients.Findings include: 3. Patient #5 was admitted to the agency in July 2025 with a diagnosis of chronic obstructive pulmonary disease (COPD- group of lung diseases that block airflow and make it difficult to breathe).Review of the clinical record indicated the following:-Initial Skilled Nurse Visit note, dated 7/8/25-MSW Admission Visit Summary, dated 7/10/25-Initial Chaplain assessment, dated 7/14/25.During an interview on 8/14/25 at 9:30 A.M., the Clinical Manager, after reviewing the clinical record for Patient #5, said the Comprehensive Assessment was not completed within five calendar days after the Patient was admitted to the agency, as required. Review of the agency policy entitled, Assessment-Comprehensive Assessment of the Patient, dated 12/2/2008, indicated the following:*The hospice IDG conducts and documents a patient-specific comprehensive assessment that identifies the patient’s needs for hospice care, including medical, nursing, psychosocial, emotional and spiritual care.*The comprehensive assessment of the patient is completed by designated members of the IDG in consultation with the patient’s attending physician no later than five (5) calendar days after the patient elects the hospice benefit.1. Patient #4 was admitted to the agency in April 2025 with a diagnosis of liver cancer.Review of the clinical record indicated the following:-Skilled Nurse Visit note, dated 4/18/25.-Medical Social Worker (MSW) Admission Visit Summary, dated 4/20/25. -Initial Chaplain Assessment, dated 4/28/25.During an interview on 8/14/25 at 9:30 A.M., the Clinical Manager, after reviewing the clinical records for Patient #4, said the Comprehensive Assessments were not completed within the five calendar days after the patients were admitted to the agency, as required. 2. Patient #11 was admitted t the agency in June 2025 with a diagnosis of Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL-when the thickening of blood vessel walls blocks the flow of blood to the brain).Review of the clinical record indicated a MSW Admission Visit Summary, dated 6/17/25.During an interview on 8/14/25 at 9:30 A.M., the Clinical Manager, after reviewing the clinical records for Patient #11, said the Comprehensive Assessments were not completed within the five calendar days after the patients were admitted to the agency, as required.”

“Based on record review 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 two patients (#8 and #17), out of a total sample of 19 patients.Findings include: Review of the agency policy entitled, Bereavement-Care Services, dated 12/2/2008, indicated the following:*A bereavement care plan is developed for identified family members and other involved individuals after the patient’s death.*During the initial bereavement assessment, the interdisciplinary group (IDG) identifies family members, caregivers, or significant others who may be significantly impacted by the patient’s death. The initial bereavement assessment is updated during IDG meetings throughout the course of the patient’s care.1. Patient #8 was admitted to the agency in October 2024 with a diagnosis of Huntington’s Disease (an inherited condition in which nerve cells in the brain break down over time).Review of the clinical record did not contain documentation indicating that an initial Bereavement Assessment was completed on admission.During an interview on 8/14/25 at 9:30 A.M, the Clinical Manager (CM) after reviewing the clinical record, said the initial bereavement assessment was not completed, as required.2. Patient #17 was admitted to the agency in February 2025 with a diagnosis of systolic Congestive Heart Failure (CHF-heart is weakened and cannot forcefully contract enough to pump an adequate amount of blood through the body).Review of the clinical record indicated a Medical Social Worker (MSW) Admission Visit Summary, dated 2/28/25, that a bereavement assessment is not necessary as the patient has a legal guardian that is unrelated to the patient.During an interview on 8/14/25 at 1:12 P.M., the CM after reviewing the clinical record, said the initial bereavement assessment should have been completed regardless if the legal guardian was related or not related to the patient.”

“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 4 patients (#3, #6, #2 and #14), out of a total sample of 19 patients.Findings include: Review of the agency policy entitled, Plan of Care, dated 12/2/2008, indicated the following:* Hospice care and services provided to patients and their families are in accordance with an individualized, written plan of care (POC) established by the hospice interdisciplinary group (IDG) in collaboration with the patient’s attending physician (if any), and, if appropriate, the patient or representative and the primary caregiver.*The patient’s plan of care specifies the care and services necessary to meet the needs of the patient/caregiver as identified in the initial, comprehensive and updated assessments of the patient.1. For Patient #3, the facility failed to ensure Home Care Aide Visit (HCAV) was provided, as ordered.Patient #3 was admitted to the agency in December 2024 with a diagnosis of senile degeneration of the brain.Review of the Hospice POC with benefit dates 5/18/25 through 7/16/25 indicated the following:-HCAV twice weekly for 8 weeks.Review of the clinical record indicated a HCAV was not provided for the week of 6/22/25 through 6/28/25, as ordered.During an interview on 8/14/25 at 9:30 A.M., the Clinical Manager (CM), after reviewing the clinical records for Patient #3, said HCAVs were not provided the week of 6/22/25 through 6/28/25, as ordered.2. For Patient #6, the facility failed to ensure Home Care Aide Visit (HCAV) was provided, as ordered.Patient #6 was admitted to the agency in May 2025 with a diagnosis of Chronic Kidney Disease (CKD) Stage 3 (indicates moderate kidney damage and reduced function).Review of the Hospice POC with benefit dates 5/1/25 through 7/29/25 indicated the following:-HCAV-once a week for one week, twice a week for 13 weeks.Review of the clinical record indicated a HCAV was not provided for the week of 6/22/25 through 6/28/25, as ordered.During an interview on 8/14/25 at 9:30 A.M., the Clinical Manager (CM), after reviewing the clinical records for Patient #6, said HCAVs were not provided the week of 6/22/25 through 6/28/25, as ordered. 3. For Patient #2, the facility failed to ensure Volunteer Visits were provided as ordered.Patient #2 was admitted to the agency in October 2023 with a diagnosis of cerebral atherosclerosis.Review of the Hospice POC interim orders with benefit dates 2/11/25 through 4/11/25 indicated the following:-Volunteer: once a month x three months, PRN (as needed) x 7, verbal order provided by the physician on 2/11/25.Review of Patient Quick Notes indicated a Volunteer Visit was not provided for the month of March 2025, as ordered.Review of the Hospice POC interim orders with benefit dates 6/11/25 through 8/9/25 indicated the following:-Volunteer: once a month x three months, PRN x 4, verbal order provided by the physician on 6/11/25.Review of the medical record indicated a Volunteer Visit was not provided for the month of July 2025, as ordered.During an interview on 8/13/25 at 3:30 P.M., Patient #2’s Health Care Proxy (HCP – legal document where you name someone to make medical decisions for you if you’re unable to do so yourself) said the Volunteer was coming once a month but then told him/her that her job got in the way and would come visit when she could. The HCP said he/she could not remember when the last visit was.During an interview on 8/13/25 at 3:40 P.M., the Office Manager said the missed March Volunteer visit was not reported by the Volunteer to agency staff, therefore, no attempts were made to reschedule. She said there was no documentation in the medical record of the missed July visit but there should have been and said all visits should have been conducted per the patient’s plan of care.4. For Patient #14, the facility failed to ensure a physician’s order was obtained prior to Volunteer home visits being provided.Patient #14 was admitted to the agency in March 2025 with a diagnosis of Alzheimer’s Disease.Review of the Hospice Revision to the Plan of Care with benefit dates 6/1/25 through 8/29/25 indicated the following:-Volunteer: twice a month x one month (8/14/25 to 8/29/25), PRN x 4Review of the medical record indicated Volunteer home visits were provided on 6/18/25, 7/3/25, and 7/27/25.During an interview on 8/14/25 at 12:05 P.M., the Clinical Manager said there was an order for Volunteer Visits throughout the certification period, but it was never signed off by the physician, as required. Review of the agency policy entitled, Plan of Care, dated 12/2/2008, indicated the following:* Hospice care and services provided to patients and their families are in accordance with an individualized, written plan of care (POC) established by the hospice interdisciplinary group (IDG) in collaboration with the patient’s attending physician (if any), and, if appropriate, the patient or representative and the primary caregiver.*The patient’s plan of care specifies the care and services necessary to meet the needs of the patient/caregiver as identified in the initial, comprehensive and updated assessments of the patient.1. For Patient #3, the facility failed to ensure Home Care Aide Visit (HCAV) was provided, as ordered.Patient #3 was admitted to the agency in December 2024 with a diagnosis of senile degeneration of the brain.Review of the Hospice POC with benefit dates 5/18/25 through 7/16/25 indicated the following:-HCAV twice weekly for 8 weeks.Review of the clinical record indicated a HCAV was not provided for the week of 6/22/25 through 6/28/25, as ordered.During an interview on 8/14/25 at 9:30 A.M., the Clinical Manager (CM), after reviewing the clinical records for Patient #3, said HCAVs were not provided the week of 6/22/25 through 6/28/25, as ordered.2. For Patient #6, the facility failed to ensure Home Care Aide Visit (HCAV) was provided, as ordered.Patient #6 was admitted to the agency in May 2025 with a diagnosis of Chronic Kidney Disease (CKD) Stage 3 (indicates moderate kidney damage and reduced function).Review of the Hospice POC with benefit dates 5/1/25 through 7/29/25 indicated the following:-HCAV-once a week for one week, twice a week for 13 weeks.Review of the clinical record indicated a HCAV was not provided for the week of 6/22/25 through 6/28/25, as ordered.During an interview on 8/14/25 at 9:30 A.M., the Clinical Manager (CM), after reviewing the clinical records for Patient #6, said HCAVs were not provided the week of 6/22/25 through 6/28/25, as ordered.3. For Patient #2, the facility failed to ensure Volunteer Visits were provided as ordered.Patient #2 was admitted to the agency in October 2023 with a diagnosis of cerebral atherosclerosis.Review of the Hospice POC interim orders with benefit dates 2/11/25 through 4/11/25 indicated the following:-Volunteer: once a month x three months, PRN (as needed) x 7, verbal order provided by the physician on 2/11/25.Review of Patient Quick Notes indicated a Volunteer Visit was not provided for the month of March 2025, as ordered.Review of the Hospice POC interim orders with benefit dates 6/11/25 through 8/9/25 indicated the following:-Volunteer: once a month x three months, PRN x 4, verbal order provided by the physician on 6/11/25.Review of the medical record indicated a Volunteer Visit was not provided for the month of July 2025, as ordered.During an interview on 8/13/25 at 3:30 P.M., Patient #2’s Health Care Proxy (HCP – legal document where you name someone to make medical decisions for you if you’re unable to do so yourself) said the Volunteer was coming once a month but then told him/her that her job got in the way and would come visit when she could. The HCP said he/she could not remember when the last visit was.During an interview on 8/13/25 at 3:40 P.M., the Office Manager said the missed March Volunteer visit was not reported by the Volunteer to agency staff, therefore, no attempts were made to reschedule. She said there was no documentation in the medical record of the missed July visit but there should have been and said all visits should have been conducted per the patient’s plan of care.4. For Patient #14, the facility failed to ensure a physician’s order was obtained prior to Volunteer home visits being provided.Patient #14 was admitted to the agency in March 2025 with a diagnosis of Alzheimer’s Disease.Review of the Hospice Revision to the Plan of Care with benefit dates 6/1/25 through 8/29/25 indicated the following:-Volunteer: twice a month x one month (8/14/25 to 8/29/25), PRN x 4Review of the medical record indicated Volunteer home visits were provided on 6/18/25, 7/3/25, and 7/27/25.During an interview on 8/14/25 at 12:05 P.M., the Clinical Manager said there was an order for Volunteer Visits throughout the certification period, but it was never signed off by the physician, as required.”

“Based on record review and interview, the agency failed to ensure that care and services were provided based on a determination of post bereavement needs for one patient (#16), out of a total sample of 19 patients.Findings include:Review of the agency policy titled, Bereavement-Risk Assessment, revised 11/17/2008, indicated the following:*Each person designated to receive bereavement services is categorized according to level of risk for complicated grief reactions and receives appropriate interventions according to identified need.*The intervention associated with the three levels of risk are as follows:a. Low risk – initial sympathy call from Interdisciplinary Group (IDG) member, invitations to bereavement support groups and memorial services, and mailings at 1, 3, 6, 9, 11, and 13 months following the patient’s death.Patient #16 was admitted to the agency in October 2024 and had a diagnosis of senile degeneration of the brain.Review of the clinical record indicated the following:-Bereavement Risk Factor – Low Risk-Patient #16 expired in January 2025-Clergy for Bereavement Phone Call Visit Summary, dated 3/11/25Further review of the clinical record did not contain documentation indicating that an initial sympathy call was made to the bereaved to assess their potential need for bereavement care and services to be provided after Patient #16’s death until 3/11/25.During an interview on 8/14/25 at 2:13 P.M., the Clinical Manager, after reviewing the clinical record, said he could not locate documentation that at least two initial sympathy phone call attempts were made.”

“Based on record review and interview, the agency failed to ensure licensed practical nurse (LPN) supervision by a registered nurse (RN) occurred every 14 days to ensure services were provided as per the plan of care (POC) for 2 patients (#3 and #6), out of a total sample of 19 patients.Findings include: Review of the agency policy entitled, Nursing Services, dated 12/2/2008, included the following:*Nursing services are directed and staffed to assure that the nursing needs of all patients are met as identified in the patient’s comprehensive and updated assessments. services*When nursing services are delegated to a LPN:a. The LPN is supervised by an RN who is available at least by phone during the hours the LPN is providing services or is on call; and b. The RN makes at least bi-monthly home visits (once every 2 weeks) and documents that the LPN is routinely providing nursing services in accordance with the patient’s POC.1.Patient #3 was admitted to the agency in December 2024 with a diagnosis of senile degeneration of the brain.Review of the Hospice POC with benefit dates 7/17/25 through 9/14/2025 indicated the following:-Skilled Nurse Visit (SNV) one time for one week (7/17/25 to 7/19/25) and two times a week for 9 weeks (7/20/25 to 9/14/25).Review of the clinical record indicated documentation that RN supervision occurred on 7/17/25 and the next RN supervision on 8/8/25, over the 14 day timeframe.2. Patient #6 was admitted to the agency in May 2025 with a diagnosis of Chronic Kidney Disease (CKD) Stage 3 (indicates moderate kidney damage and reduced function).Review of the Hospice POC with benefit dates 5/1/25 through 7/29/25 indicated the following:-SNV twice a week for 14 weeks and 5 as needed (PRN) visits.Review of the clinical record indicated documentation that RN supervision occurred on 7/17/25 and the next RN supervision on 8/8/25, over the 14 day timeframe. During an interview on 8/14/25 at 9:30 A.M., the Clinical Manager, after reviewing the clinical records, said there was no RN supervision provided for Patients #3 and #6 every 14 days, as required.”

“Based on record review and interview, the agency failed to ensure Registered Nurse (RN) supervision of Hospice Aide occurred every 14 days to ensure the plan of care (POC) was followed for 4 patients (#3, #6, #12 and #14), out of a total sample of 19 patients.Findings include: 3. Patient #12 was admitted to the facility in April 2025 and had a diagnosis of Parkinson’s disease (disorder of the central nervous system that affects movement).Review of the Hospice POC with benefit dates 4/3/25 through 7/1/25 indicated the following:-HCA: twice a week x 14 weeks.Review of the clinical record indicated documentation that HCA #1 conducted a home visit on 6/16/25 and 6/18/25.Further review of the clinical record indicated that RN supervision for HCA #1 occurred on 7/8/25, greater than 14 days later.Review of the Hospice POC with benefit dates 7/2/25 through 9/29/25 indicated the following:-HCA: twice a week x 12 weeks.Review of the clinical record indicated documentation that HCA #1 conducted a home visit on 7/21/25.Further review of the clinical record indicated that RN supervision for HCA #1 occurred on 8/6/25, greater than 14 days later.During an interview on 8/14/25 at 9:34 A.M., the Clinical Manager, after reviewing the clinical record, said the RN supervisory visits for HCA #1 were not completed within 14 days as required. 4. Patient #14 was admitted to the agency in March 2025 with a diagnosis of Alzheimer’s disease.Review of the Hospice POC with benefit dates 6/1/25 through 8/29/25 indicated the following:-HCA: twice a week x 13 weeks.Review of the clinical record indicated documentation that HCA #1 conducted a home visit on 6/18/25.Further review of the clinical record failed to indicate RN supervision for HCA #1.During an interview on 8/14/25 at 12:05 P.M., the Clinical Manager, upon review of the clinical record, said a RN supervisory visit for HCA #1 did not occur as required. Review of the agency policy entitled, Hospice Aide Supervision, dated 12/2/2008, indicated the following:*Hospice aides are supervised by a RN in a manner and frequency that assures the safety of patients and the quality of aide services provided.*A RN makes an on-site visit to the patient’s home no less frequently than every 14 days to ensure that the services ordered by the interdisciplinary group (IDG) and provided by the aide are meeting the patient’s need. 1. Patient #3 was admitted to the agency in December 2024 with a diagnosis of senile degeneration of the brain.Review of the Hospice POC with benefit dates 7/17/25 through 9/14/2025 indicated the following:-Home Care Aide (HCA) one time for one week (7/17/25 to 7/19/25) and two times a week for 9 weeks (7/20/25 to 9/14/25).Review of the clinical record indicated documentation that RN supervision occurred on 7/17/25 and the next RN supervision on 8/8/25, over the 14 day timeframe.During an interview on 8/14/25 at 9:30 A.M., the Clinical Manager, after reviewing the clinical records, said there was no RN supervision provided for Patient #3 every 14 days, as required.2. Patient #6 was admitted to the agency in May 2025 with a diagnosis of Chronic Kidney Disease (CKD) Stage 3 (indicates moderate kidney damage and reduced function).Review of the Hospice POC with benefit dates 5/1/25 through 7/29/25 indicated the following:-HCA one tome a week for one week, two times a week for 13 weeks.Review of the clinical record indicated documentation that RN supervision occurred on 7/17/25 and the next RN supervision on 8/8/25, over the 14 day timeframe. During an interview on 8/14/25 at 9:30 A.M., the Clinical Manager, after reviewing the clinical records, said there was no RN supervision provided for Patient #6 every 14 days, as required.”

“Based on record review and interview, the agency failed to ensure each patient’s record included clinical notes for two patients (#2 and #14).Findings include:Review of the facility’s policy titled, Volunteers-Documentation, undated, indicated the following:*Hospice volunteers use the Volunteer Progress Note for documentation of any and all contact with hospice patients and their caregivers (including visits and telephone calls).*Upon completion of a patient/caregiver visit (or phone contact), the volunteer completes the Volunteer Progress Note and brings or mails the completed documentation to the Volunteer Coordinator.*All volunteer documentation is submitted within one week after the end of the month after patient contact for incorporation into the patient’s clinical record.1. Patient #2 was admitted to the agency in October 2023 and had a diagnosis of cerebral atherosclerosis (condition in which the arteries in the brain become narrowed and hardened due to the buildup of plaque).Review of the medical record failed to indicate Volunteer visit notes for the months of April, May, and June 2025.During an interview on 8/14/25 at 4:15 P.M., the Office Manager and Clinical Manager said the process for volunteer documentation was not followed and the clinical record was not maintained as required.2. Patient #14 was admitted to the agency in October 2024 and had a diagnosis of senile degeneration of the brain.Review of the medical record indicated Volunteer home visits were provided on 6/18/25, 7/3/25, and 7/27/25.Further review of the medical record indicated the Volunteer visit notes were not incorporated into the clinical record.During an interview on 8/14/25 at 1:07 P.M., the Office Manager said the Volunteer visit notes were not maintained in the clinical record as required.”