Legacy Lifecare Hospice and Palliative Care

“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 2 patients (#10 and #5), out of a total sample of 14 patients.Findings include: 2. Patient # 5 was admitted to the agency in July 2025 with a diagnosis of Malignant Melanoma (cancer) of the skin and required hospice services.Review of the clinical record indicated the election of hospice care was 7/24/25.Further review of the clinical record indicated the chaplain completed the initial comprehensive assessment on 7/30/25, 6 days after the start of hospice care, not within 5 days as required.During an interview on 10/29/25 at 10:00 A.M., the Clinical Director said that nursing (in conjunction with the physician), social service, and spiritual service (chaplain) are required to complete the initial comprehensive assessment of the patient within the first 5 days of starting hospice services. She said that for Patient #5, the initial chaplain assessment was not completed timely as required. Review of the agency policy entitled, Initial Assessment/Comprehensive Assessment, undated, indicated the following:*The Hospice IDG, in consultation with the patient’s attending physician (if any), must complete the comprehensive assessment no later than 5 calendar days after patient’s election of Hospice care.1. Patient #10 was admitted to the agency in July 2025 with a diagnosis of cardiac disease (conditions that affect the heart and blood vessels).Review of the clinical record indicated the Comprehensive Assessment was completed on 7/17/25.During an interview on 10/29/25 at 11:45 A.M., after reviewing the clinical record, the Clinical Director said the Comprehensive Assessment was not completed within the 5 calendar days after the patient was 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 5 patients (#10, #11, #13, #8 and #2), out of a total sample of 14 patients.Findings include: 5. Patient #2 was admitted to the hospice agency in October 2025 with a diagnosis of moderate protein-calorie malnutrition and required hospice services.Review of the clinical record did not contain documentation that an initial Bereavement Risk Assessment had been completed upon admission to the agency.During an interview on 10/28/25 at 2:55 P.M., the Clinical Director after reviewing the clinical record, said the initial Bereavement Risk Assessment had not been completed, as required. 4. Patient #8 was admitted to the hospice agency in September 2025 with a diagnosis of malignant neoplasm (cancer) of the bronchus or lung and required hospice services.Review of the clinical record did not contain documentation indicating that an initial Bereavement Risk Assessment was completed upon admission to the agency.During an interview on 10/29/25 at 10:37 A.M., the Clinical Director after reviewing the clinical record, said the initial Bereavement Risk Assessment was not completed upon admission, as required. 2. Patient #11 was admitted to the agency in February 2025 with a diagnosis of Parkinson’s Disease (a progressive neurological disorder that affects movement and balance) and required hospice services.Review of the clinical record did not indicate an initial Bereavement Risk Assessment had been completed by any of the interdisciplinary team (IDT) members, after being admitted into hospice care.3. Patient #13 was admitted to the agency in August 2025 with a diagnosis of heart disease.Review of the clinical record did not indicate an initial Bereavement Risk Assessment had been completed by any of the IDT members, after being admitted into hospice care.During an interview on 10/29/25 at 10:45 P.M., the Clinical Director said that any IDT member could complete the initial Bereavement Risk Assessment, and that it was usually completed by the chaplain or social worker. She said that for Patients #11 and #13, the initial Bereavement Risk Assessments had not been completed as required, after both were admitted into hospice care. Review of the agency policy entitled, Bereavement Services, undated, indicated the following:*An initial Bereavement Risk Assessment will be performed as a part of the Comprehensive Assessment. Depending on the initial assessment, a plan of care will be developed to include specific counseling to patient and family members to be provided by the Social Worker, Chaplain or Bereavement Counselor. The plan of care will reflect family needs, as well as a clear delineation of services to be provided and the frequency of service delivery.1. Patient #10 was admitted to the agency in July 2025 with a diagnosis of cardiac disease (conditions that affect the heart and blood vessels).Review of the clinical record did not contain documentation indicating that an initial Bereavement Risk Assessment was completed upon admission to the agency.During an interview on 10/29/25 at 10:45 A.M., the Clinical Director after reviewing the clinical record, said the initial Bereavement Risk Assessment was not completed upon admission, as required.”

“Based on record review, policy review, and staff interview, the agency failed to ensure ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement, for one Patient (#6), out of a total sample of 14 patients.Findings include: Review of the facility’s policy entitled Coordination of Patient Care, undated, indicated, but was not limited to, the following:*Staff provides the physician, Medical Director and IDG (interdisciplinary group) with patient information on an ongoing basis regarding:-Missed Hospice visits. Patient #6 was admitted to the agency in October 2025 with a diagnosis of Alzheimer’s disease (brain disorder leading to dementia) and required hospice services. Review of the physician ordered Hospice Plan of Care, dated 10/10/25 through 1/7/26, indicated the following:-Home Health Aide (HHA): 4-5 times weekly for 12 weeks; 2-3 times weekly for 1 week Review of missed visit notes, dated 10/20/25, 10/21/25, 10/22/25, 10/23/25, and 10/24/25, indicated HHA visits were cancelled due to the aide being out, but they did not indicate the physician was notified of cancelled services.During an interview on 10/29/25 at 10:22 A.M., the Clinical Director (CD) said when entered as a missed visit, a box needs to be checked off in the electronic record system for the physician to receive notification via fax the next business day of the missed visit. She said this was not done for the 10/20/25 through 10/24/25 HHA visits and the physician was not notified of any missed visits, as required. The CD further said an IDG meeting was held on 10/22/25 but she could not provide documentation that the physician had been notified of the 10/20/25, 10/21/25, and 10/22/25 missed HHA visits.”

“Based on record review and interview, the agency failed to ensure the clinical record contained complete Home Health Aide (HHA) visit documentation for 7 patients (#3, #7, #10, #4, #9, #8 and #2), out of a total sample off 14 patients.Findings include: 7. Patient #8 was admitted to the agency in September 2025 with a diagnosis of malignant neoplasm of the bronchus or lung and required hospice services.Review of the physician ordered Hospice POC for certification period 9/17/25 through 12/15/25 indicated the following:-HHA Visit: once a week for 1 week; 2-3 times weekly for 12 weeks; once a week for 1 week.Review of the clinical record indicated Home Health Aide (HHA) visits were provided on 9/22/25, 9/24/25, 9/26/25, 9/29/25, 10/1/25, 10/3/25, 10/6/25, 10/8/25, 10/10/25, 10/13/25, 10/15/25, and 10/17/25.Further review of the clinical record indicated the Homecare HHA Flowsheets were incomplete as they did not indicate what type of services had been provided to the patient by the HHA.During an interview on 10/29/25 at 1:28 P.M., the Clinical Director said the HHA Flowsheets were not completed and entered into the clinical record as required. 6. Patient #2 was admitted to the agency October 2025 with a diagnosis of moderate protein calorie malnutrition and required hospice services.Review of the physician ordered Hospice POC for certification period 10/10/25 through 1/8/26 indicated the following:-HHA Visits: 1-2 times a week for 12 weeks, once a week for one week.Review of the clinical record indicated the HHA provided visits on 10/14/25, 10/16/25, 10/21/25 and 10/23/25.Further review of the clinical record indicated that the Homecare HHA flow sheets were incomplete as they did not indicate what type of services had been provided to the patient by the HHA.During an interview on 10/29/25 at 1:00 P.M. the Clinical Director said that although the documentation on the Homecare HHA flow sheets indicated that visits were provided on the above dates, they did not indicate what type of services were provided to the patient, as required. 4. Patient #4 was admitted to the agency in August 2025 with a diagnosis of Cerebral Atherosclerosis (fatty plaque buildup in the arteries of the brain causing reduced blood flow) and required hospice services.Review of the physician ordered Hospice POC, dated 8/5/25 through 10/15/25, indicated the following:-HHA Visit: 1 to 2 times a week for 10 weeks.Review of the clinical record indicated the HHA provided visits on 9/23/25 and 9/25/25.Further review of the clinical record indicated the Homecare HHA Flowsheet was incomplete for the week of 9/21/25, as there was no documentation completed for what services were provided on 9/25/25.During an interview on 10/29/25 at 9:00 A.M., after reviewing Patient #4’s record, the Clinical Director said the HHA visit documentation was incomplete and did not indicate the services that were provided as required.5. Patient #9 was admitted to the agency in June 2024 with a diagnosis of Atrioventricular Block (impaired electrical signal between the chambers of the heart) and required hospice services.Review of the physician ordered Hospice POC, dated 8/7/25 through 10/5/25, indicated the following:-HHA Visit: 2 to 3 times a week for 9 weeks.Review of the physician ordered Hospice POC, dated 10/6/25 through 12/4/25, indicated the following:-HHA Visit: 1 to 2 times a week for 1 week.-HHA Visit: 2 to 3 times a week for 8 weeks.Review of the clinical record indicated the HHA provided visits on 9/2/25, 9/3/25, 9/5/25, 9/8/25, 9/10/25, 9/12/25, 9/15/25, 9/17/25, 9/19/25, 9/22/25, 9/24/25, 9/26/25, 9/29/25, 10/1/25, 10/3/25, 10/6/25, 10/7/25, 10/9/25, 10/13/25, 10/14/25, and 10/16/25.Further review of the clinical record indicated the Homecare HHA Flowsheets were incomplete as they did not indicate what type of services had been provided to the patient by the HHA for any of the visits noted above.During an interview on 10/29/25 at 9:00 A.M., after reviewing Patient #9’s record, the Clinical Director said the HHA visit documentation was incomplete and did not indicate the services that were provided as required. Review of the agency policy entitled, Hospice Aide Documentation, undated, indicated the following:*The Hospice Aide will document services rendered to the patient on the appropriate Hospice Aide charting form.*The Hospice Aide will be responsible for reporting any changes in the patient’s condition and/or other pertinent observations to the supervising registered nurse (RN).*The Manager of Patient Services, RN or designee is responsible for reviewing the Hospice Aide’s charting.*The original documentation will be filed in the medical record within seven (7) days of the visit.1. Patient #3 was admitted to the agency in October 2025 with a diagnosis of Alzheimer’s disease. Review of the physician ordered Hospice Plan of Care (POC) for certification period 10/10/25 through 12/8/25 indicated the following:-Hospice Health Aide (HHA) Visit: 2-3 times a week for 8 weeks, once a week for one week.Review of the clinical record indicated the HHA provided visits on 10/13/25, 10/14/25, 10/15/25, 10/22/25, 10/23/25, 10/24/25, 10/27/25 and 10/28/25.Further review of the clinical record indicated the Homecare HHA Flowsheets were incomplete as they did not indicate the specific dates the services had been provided to the patient by the HHA.During an interview on 10/29/25 at 1:36 P.M., after reviewing the clinical records for Patient #3, the Clinical Director said the Homecare HHA Flowsheets were incomplete as they did not contain the specific dates the services were provided for Patient #3, as required.2. Patient #7 was admitted to the agency in May 2025 with a diagnosis of prostate cancer.Review of the physician ordered Hospice POC for certification period 8/17/25 through 11/14/25 indicated the following:-HHA Visit: 2-3 times a week for 13 weeks.Review of the clinical record indicated the HHA provided visits on 9/2/25, 9/3/25, 9/5/25, 9/8/25, 9/10/25, 9/12/25, 9/15/25, 9/17/25, 9/19/25, 9/22/25, 9/25/25, 9/26/25, 9/29/25, 10/1/25, 10/3/25, 10/6/25, 10/8/25, 10/10/25, 10/13/25, 10/15/25, 10/17/25, 10/20/25, 10/22/25, and 10/24/25.Further review of the clinical record indicated the Homecare HHA Flowsheets were incomplete as they did not indicate what type of services had been provided to the patient by the HHA.During an interview on 10/29/25 at 1:36 P.M., after reviewing the clinical record for Patient #7, the Clinical Director said the Homecare HHA Flowsheets were incomplete as they did not contain the specific types of services that were provided for Patient #7, as required.3. Patient #10 was admitted to the agency in July 2025 with a diagnosis of cardiac disease (conditions that affect the heart and blood vessels).Review of the physician ordered POC for certification periods 7/8/25 through 10/5/25 and 10/6/25 through 1/3/26 indicated the following:-HHA Visit: 2-3 times a week for 13 weeks.Review of the clinical record indicated that the HHA provided visits on 9/2/25, 9/3/25, 9/4/25, 9/9/25, 9/10/25, 9/11/25, 9/17/25, 9/18/25, 9/24/25, 9/25/25, 9/26/25, 9/30/25, 10/1/25, 10/2/25, 10/6/25, 10/8/25, 10/9/25, 10/13/25, 10/15/25, 10/16/25, 10/22/25, 10/23/25, and 10/24/25.Further review of the clinical record indicated the Homecare HHA Flowsheets were incomplete as they did not indicate the specific dates the services had been provided to the patient by the HHA.During an interview on 10/29/25 at 1:36 P.M., after reviewing the clinical record for Patient #10, the Clinical Director said the Homecare HHA Flowsheets were incomplete as they did not contain the specific dates the services were provided for Patient #10, as required.”

“Based on record review, policy review, and staff interview, the agency failed to ensure clinical documentation was complete and appropriately authenticated and dated in accordance with currently accepted standards of practice for 2 patients (#8 and #2), out of a total sample of 14 patients.Findings include: 2. Patient #2 was admitted to the agency October 2025 with diagnosis including moderate protein calorie malnutrition and required hospice services.Review of the physician ordered Hospice POC for certification period 10/10/25 through 1/7/26, indicated the following:*SNV: once weekly for 13 weeks.Review of the clinical record indicated the following:*10/11/25 SNV note was signed on 10/22/25.During an interview on 10/29/25 at 2:00 P.M., the CD said all staff are expected to sign/complete their notes within seven days of the visit and that the nurse had not signed/completed the visit note within 7 days, as required by the agency. Review of the facility’s policy entitled Timely Submission of Patient Documentation, undated, indicated but was not limited to the following:*Hospice will ensure the timely and proper submission of patient documentation.*Itineraries, with all visit reports attached, are expected to be submitted within 48 hours, but not to exceed seven (7) days. All patient visit reports from contract personnel must be submitted within three (3) business days from the date of the visit, e.g., PT, SLP, etc.1. Patient #8 was admitted to the hospice in September 2025 with a diagnosis of malignant neoplasm of the bronchus or lung and required hospice services.Review of the physician ordered Plan of Care (POC) for certification period 9/17/25 through 12/15/25 indicated the following:*Skilled Nursing Visits (SNV) once weekly for 12 weeks.Review of the clinical record indicated the following:*10/9/25 SNV note was signed on 10/29/25.During an interview on 10/29/25 at 1:28 P.M., the Clinical Director (CD), after reviewing the clinical record for Patient #8, said staff are expected to sign their notes within seven days. She said the nurse did not sign the note within seven days making the note late.”

“Based on policy review, personnel file review, and interview, the agency failed: to provide confirmation/ documentation that a Nurse Aide Registry check and a Criminal Offender Record Information (CORI) check were completed prior to hire, for one of two volunteer’s (Volunteer #1), out of a total of 7 personnel files reviewed. Findings include: Review of the agency’s policy titled Personnel Records (revised March 2018) indicated, but was not limited to, the following:-Personnel files will be established and maintained for all staff.-New Hire process: Once a candidate has been identified as someone the agency would like to bring on board, the pre-placement process begins. All steps must be completed prior to the new hire starting orientation.-Pre-Employment Checks: Criminal Offender Record Information (CORI)-Processed after an offer has been extended to applicant.-CORI acknowledgment forms must be signed and completed by the applicant.-Certified Nursing Assistant (CNA) Registry: All new hires are checked against Department of Public Health’s (DPH’s) Nurse Aide Registry System, regardless of position.-After all checks have been completed, notify the hiring manager of successful completion of the preplacement process and reconfirm for orientation.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 file indicated that he was hired as a volunteer on 10/13/21.Further review of his personal file indicated no documentation that a Nurse Aide Registry check or a CORI check had been completed prior to being hired.During an interview on 10/29/25 at 3:00 P.M. the Clinical Director said that the Nurse Aide Registry Check and the CORI check should have been completed prior to hire as required but could not provide confirmation/documentation that the checks were completed prior to Volunteer #1 being hired.”