Visiting Nurse & Community Care

“Based on record review, policy review and interview, the agency failed to ensure the interdisciplinary group (IDG), in consultation with the individual’s attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care, for 10 patients (#6, #7, #8, #11, #2, #4, #5, #9, #10 and #14), out of a total sample of 14 patients.Findings include: 9. Patient #10 was admitted to the agency in April 2024 with a diagnosis of senile degeneration of the brain and required hospice services. Clinical record review indicated that nursing completed an initial assessment on 4/22/24 at which time the patient/caregiver consented to hospice services. The assessment also indicated that the patient/caregiver initially consented to all hospice services but then later declined Chaplain services.Further clinical record review indicated that social services completed an initial assessment on 5/9/24 which was not within the required 5 calendar days of the election of hospice services. During an interview on 10/22/25 at 2:30 P.M. the CM said that the initial social services assessment was not completed within the required time frame.10. Patient #14 was admitted to the agency in January 2024 with a diagnosis of senile degeneration of the brain and required hospice services. Clinical record review indicated nursing completed an initial assessment on 1/9/24 at which time the patient/caregiver consented to hospice services.Further clinical record review indicated that the initial social services assessment was completed on 1/17/24, which was not within the required 5 calendar days of the election of hospice services.During an interview on 10/22/25 at 2:30 P.M. the CM said that the initial social services assessment was not completed within the required time frame. 5. Patient #2 was admitted to the agency in June 2024 with a diagnosis of senile degeneration of the brain and required hospice services.Review of the clinical record indicated nursing completed an initial assessment on 6/26/24 at which time the patient/caregiver consented to hospice services. The assessment also indicated that the patient’s family was open to all hospice services.Further review of the clinical record indicated that social services attempted to schedule an initial visit via telephone calls to the patient’s family on 6/27/24, 7/1/24, and 7/2/24 with no return phone call, however, the chaplain did not make attempts to contact the patient’s family until 7/3/24, which was not within the required time frame. During an interview on 10/21/25 at 4:08 P.M., the Administrator said the initial chaplain assessment was not completed within the required time frame.6. Patient #4 was admitted to the agency in August 2024 with a diagnosis of chronic kidney disease and heart failure.Review of the clinical record indicated nursing completed an initial assessment on 8/15/24 at which time the patient/caregiver consented to hospice services. The assessment also indicated that the patient welcomed all hospice services.Further review of the clinical record indicated social services completed an initial assessment on 8/27/25 which was not within the required 5 calendar days of the election of hospice services. Additionally, the chaplain did not make attempts to contact the patient/caregiver until 8/21/25, which was not within the required time frame. During an interview on 10/22/25 at 10:06 A.M., the CM said the social worker and chaplain’s initial assessments had not been completed within the required time frame.During an interview on 10/22/25 at 10:55 A.M., the CM said the patient/caregiver did not decline chaplain services and were open to all hospice services.7. Patient #5 was admitted to the agency in August 2025 with a diagnosis of severe protein-calorie malnutrition. Review of the clinical record indicated nursing completed an initial assessment on 8/21/25 at which time the patient/caregiver consented to hospice services. The assessment also indicated that the patient accepted medical social worker and chaplain services. Further review of the clinical record indicated social services completed an initial assessment on 8/29/25 which was not within the required 5 calendar days of the election of hospice services. Additionally, the chaplain did not make an attempt to contact the patient/patient’s family until 9/1/25, which was not within the required time frame. During an interview on 10/22/25 at 10:13 A.M., the CM said the social worker and chaplain’s initial visits had not been completed within the required time frame.8. Patient #9 was admitted to the agency in June 2025 with a diagnosis of Neurocognitive Disorder with Lewy Bodies (progressive brain disorder characterized by cognitive decline, movement problems, and fluctuations in alertness and attention).Review of the clinical record indicated nursing completed an initial assessment on 6/27/25 at which time the patient/caregiver consented to hospice services. The assessment also indicated that the patient was open to receiving chaplain services. Further review of the clinical record indicated that social services completed an initial assessment on 6/30/25, however the chaplain did not make an attempt to contact the patient/caregiver until 7/9/25, which was not within the required 5 calendar days of the election of hospice services.During an interview on 10/22/25 at 1:03 P.M., the CM said the chaplain did not reach out to the patient/caregiver until 7/9/25 and did not complete an initial assessment within the required timeframe. Review of the agency’s policy entitled, Comprehensive Assessment Of The Patient, revised November 2017, indicated the following:*The hospice IDG conducts and documents a patient-specific comprehensive assessment that identifies the patient’s need for hospice care, including medical, nursing, psychological, emotional and spiritual care.*The hospice nurse makes an initial assessment visit to the patient/caregiver within forty-eight hours after the patient elects hospice care in order to determine the patient’s immediate care and support needs.*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 calendar days after the patient elects the hospice benefit.Review of the agency’s policy entitled, Interdisciplinary Group (IDG), revised November 2017, indicated the following:*The IDG at the hospice agency includes, at minimum, the following individuals: -A doctor of medicine or osteopathy; -A registered nurse; -A social worker; and -A pastoral or other counselor.1.Patient #6 was admitted to the agency in August 2025 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease (an ongoing lung condition caused by damage to the lungs) and required hospice services.Review of the clinical record indicated nursing completed an initial assessment on 8/4/25 at which time the patient/caregiver consented to hospice services, and a chaplain phone call was made on 8/6/25 to the patient’s family who indicated they wanted chaplain services.Further review of the clinical record indicated social services completed an initial assessment on 8/7/25, however the chaplain completed an initial assessment on 8/19/25, which was not within the required 5 calendar days of the election of hospice services.During an interview on 10/22/25 at 10:00 A.M., the Clinical Manager (CM) said a nurse, a social worker, a chaplain and a physician are all part of the IDG, and are involved in completing the comprehensive assessment. She said the initial chaplain assessment was not completed within the required time frame.2.Patient #7 was admitted to the agency in May 2025 with a terminal diagnosis of Alzheimer’s Disease (brain disorder leading to dementia) and required hospice services.Review of the clinical record indicated nursing completed an initial assessment on 5/28/25 at which time the patient/caregiver consented to hospice service.Further review of the clinical record indicated social services completed an initial assessment on 6/2/25, however the chaplain completed an initial assessment on 6/20/25, which was not within the required 5 calendar days of the election of hospice services.During an interview on 10/22/25 at 10:00 A.M., the CM said the initial chaplain assessment had not been completed with the required time frame.3.Patient #8 was admitted to the agency in August 2025 with a terminal diagnosis of severe protein-calorie malnutrition and required hospice services.Review of the clinical record indicated nursing completed an initial assessment on 8/7/25 at which time the patient/caregiver consented to hospice services.Further review of the clinical record indicated social services completed an initial assessment on 8/14/25 which was not within the required 5 calendar days of the election of hospice services. Additionally, there was no chaplain assessment or evidence it had been declined by the patient/caregiver.During an interview on 10/22/25 at 12:15 P.M., the CM said the social service assessment was not completed within the required time frame. She also said chaplain services should have been ordered so an assessment could have been completed as part of the patient’s comprehensive assessment. 4.Patient #11 was admitted to the agency in May 2025 with a terminal diagnosis of Alzheimer’s Disease and required hospice services.Review of the clinical record indicated nursing completed an initial assessment on 5/12/25 at which time the patient/caregiver consented to hospice services, and a chaplain phone call was made on 5/19/25 to the patient’s family. A return call by the family on 5/20/25 indicated they wanted chaplain services.Further review of the clinical record indicated social services completed an initial assessment on 5/12/25, however the chaplain completed an initial assessment on 6/20/25, which was not within the required 5 calendars of the election of hospice services.During an interview on 10/22/25 at 3:15 P.M., the CM said the chaplain’s visit was not completed within the required time frame.”

“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 6 patients (#2, #9, #6, #11, #12, and #10), out of a total sample of 14 patients.Findings include: 6. Patient #10 was admitted to the agency in April 2024 with a diagnosis of senile degeneration of the brain and required hospice services. Clinical record review indicated the following:-Nursing initial assessment was completed on 4/22/24.-Social Service initial assessment was completed on 5/9/24.-Chaplain services declined by patient/caregiver.During an interview on 10/22/25 at 2:30 P.M. the CM said that the initial Bereavement Assessment may be completed by any of the Interdisciplinary Group team members, social services assessment was not completed within the required time frame. 3. Patient #6 was admitted to the agency in August 2025 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease (an ongoing lung condition caused by damage to the lungs) and required hospice services.Review of the clinical record indicated the following:-Nursing initial assessment was completed on 8/4/25.-Social Service initial assessment was completed on 8/7/25.-Chaplain initial assessment was completed on 8/19/25.Further review of these assessments and the clinical record indicated an initial bereavement assessment had not been completed, as required.During an interview on 10/22/25 at 1:15 P.M., after reviewing the clinical record for Patient #6, the CM said initial bereavement assessments had not been completed as required after the patients were admitted into hospice.4. Patient # 11 was admitted to the agency in May 2025 with a terminal diagnosis of Alzheimer’s Disease (brain disorder leading to dementia) and required hospice services.Review of the clinical record indicated the following:-Nursing and social service initial assessments were completed on 5/12/25.-Chaplain initial assessment was completed on 6/20/25.Further review of these assessments and the clinical record indicated an initial bereavement assessment had not been completed, as required.During an interview on 10/22/25 at 1:15 P.M., after reviewing the clinical record for Patient #11, the CM said initial bereavement assessments had not been completed as required after the patients were admitted into hospice.5. Patient #12 was admitted to the agency in September 2025 with a terminal diagnosis of Congestive Heart Failure (a syndrome caused by an impairment in the heart’s ability to fill and pump blood).Review of the clinical record indicated the following:-Nursing initial assessment was completed on 9/2/25.-Social Service initial assessment was completed on 9/5/25.-Chaplain initial assessment was completed on 9/6/25.Further review of these assessments and the clinical record indicated an initial bereavement assessment had not been completed, as required.During an interview on 10/22/25 at 1:15 P.M., after reviewing the clinical record for Patient #12, the CM said initial bereavement assessments had not been completed as required after the patients were admitted into hospice. Review of the agency’s policy entitled Bereavement Risk Assessment, revised 11/2017, indicated but was not limited to the following:*Hospice patients and family members, caregivers and significant others are assessed for grief and bereavement needs before and after the patient’s death.*During the comprehensive assessment of the patient, an initial bereavement assessment is conducted to determine the cultural, social, and spiritual factors that may impact the ability of the family members or other involved individuals to cope with the patient’s death.*Findings from the initial bereavement assessment are incorporated into the patient’s plan of care and considered in the bereavement plan of care.1. Patient #2 was admitted to the agency in June 2024 with a diagnosis of senile degeneration of the brain and required hospice services.Review of the clinical record indicated the following:-Nursing initial assessment was completed on 6/26/24.-Social Service initial assessment was not completed.-Chaplain initial assessment was not completed.Further review of these assessments and the clinical record indicated an initial bereavement assessment had not been completed, as required.During an interview on 10/22/25 at 10:22 A.M., the Clinical Manager (CM) said an initial bereavement assessment had not been completed, as required.2. Patient #9 was admitted to the agency in June 2025 with a diagnosis of Neurocognitive Disorder with Lewy Bodies (progressive brain disorder characterized by cognitive decline, movement problems, and fluctuations in alertness and attention).Review of the clinical record indicated the following:-Nursing initial assessment was completed on 6/27/25.-Social Service initial assessment was completed on 6/30/25.-Chaplain initial assessment was not completed.Further review of these assessments and the clinical record indicated an initial bereavement assessment had not been completed, as required.During an interview on 10/22/25 at 1:03 P.M., the CM said an initial bereavement assessment had not been conducted as required.”

“Based on record review, policy review and interview, the agency failed to ensure that the care and services are provided in accordance with the plan of care for 1 patient (#6), out of total sample of 14 patients.Findings include: Review of the agency’s policy entitled, Plan of Care, revised November 2017, indicated the following:-The care and services provided to patients and their families are in accordance with an individualized, written plan established by the hospice interdisciplinary group in collaboration with the patient’s attending physician (if any), and, if appropriate, the patient and/or his or her representative.1.Patient #6 was admitted to the agency in August 2025 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease (an ongoing lung condition caused by damage to the lungs) and required hospice services.Review of the physician ordered Hospice Plan of Care, dated 8/4/25 through 11/1/25, indicated the following services:-Skilled Nursing visits: 2 times a week for 13 weeks.-Home Care Aide visits: 4 times a week for 1 week, and 5 times a week for 12 weeks.Review of the clinical record indicated clergy visits were provided on 9/3/25 and 9/21/25.During an interview on 10/22/25 at 10:00 A.M., the Clinical Manager said the physician order for clergy services was not obtained until 10/11/25, but should have been obtained when services were provided. She said services should not be provided without a physician’s order, and included in the patient’s plan of care.”

“Based on record review, policy review, agency guidance review and 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 2 patients (#7 and #11), out of a total sample of 14 patients.Findings include: Review of the agency’s policy entitled, Interdisciplinary Group (IDG), revised November 2017, indicated the following:*The IDG is responsible for providing and coordinating care and services in accordance with the patient’s plan of care.*The IDG is responsible for communicating with the patient’s attending on a regular basis.Review of the agency’s protocol entitled, Notifying the Medical Doctor (MD) of Missed Visits, undated, indicated the following:*The following protocol is to be followed to notify the primary care physician (PCP) of any missed visits; Clinician eliminates the appointment in the electronic medical record (EMR) and notifies/documents notification of a missed visit to the attending MD; this creates a quick note detailing the reason for the missed visit and that the MD was notified.1.Patient #7 was admitted to the agency in May 2025 with a terminal diagnosis of Alzheimer’s Disease (brain disorder leading to dementia) and required hospice services.Review of the physician ordered Hospice Plan of Care, dated 7/27/25 through 9/24/25, indicated the following:-Skilled Nurse Visit (SNV): 2 times a week for 9 weeks, and 3 as needed (PRN) visits.-Home Care Aide Visit (HCAV): 5 times a week for 9 weeks.Review of a quick note dated 9/4/25 indicated a SNV was canceled for 9/5/25 because it was not necessary, but it did not indicate the physician was notified of the canceled service.Review of a quick note dated 9/10/25 indicated a HCAV was canceled for 9/10/25 because care was already provided, but it did not indicate the physician was notified of the canceled service.2.Patient #11 was admitted to the agency in May 2025 with a terminal diagnosis of Alzheimer’s Disease (brain disorder leading to dementia) and required hospice services.Review of the physician ordered Hospice Plan of Care, dated 8/10/25 through 11/7/25, indicated the following:-SNV: 2 times a week for 13 weeks.Review of a quick note dated 9/2/25 indicated a SNV was canceled for 9/10/25 because it was not necessary, but it did not indicate the physician was notified of the canceled service.During an interview on 10/22/25 at 3:15 P.M., the Clinical Manager said that when staff cancel physician ordered visits, a quick note is completed by that staff member. She said staff should indicate why the visit was not provided and that the physician was notified. She said for Patients #7 and #11, staff had not notified the physician, as required, when services ordered were not provided.”

“Based on document review and staff interview, the agency failed to provide volunteers in a day-to-day administrative and/or direct patient care service position in an amount that, at a minimum, equals five (5) percent of the total patient care hours of all paid hospice employees and contract staff.Findings include:* Review of the Volunteer Cost Saving Report between 1/1/25 and 10/22/25 indicated the following:-Paid patient hospice hours = 16313-Volunteer hours = 236-Volunteer hours represent 1.45% cost savings to total patient care hours.* Review of the Volunteer Cost Saving Report between 10/22/24 and 10/22/25 indicated the following:-Paid patient hospice hours = 20445-Volunteer hours = 283-Volunteer hours represent 1.38% cost savings to total patient care hours.During an interview on 10/22/25 at 9:23 A.M., the Volunteer Coordinator said the agency did not provide volunteers in a day-to-day administrative and/or direct patient care service position in an amount that, at a minimum, equals 5% of the total patient care hours of all paid hospice employees and contract staff, as required.”

“Based on record review, policy review and interview, the agency failed to ensure a discharge summary was forwarded to the patient’s attending physician after the patient was discharged, for 1 patient (#1), out of a total sample of 14 patients.Findings include: Review of the agency’s policy titled Revocation of the Medicare Hospice Benefit (revised 11/2017) indicated the following:-When a revocation occurs, the RN Case Manager or designee notifies the patient’s attending physician of the revocation decision and effective date, and the hospice sends a discharge summary to the attending physician.Patient #1 was admitted to the agency in March 2025 with a diagnosis of Alzheimer’s Disease.Clinical record review indicated the patient/caregiver elected to revoke Hospices Services as of 5/8/25 and a discharge summary was completed by a nurse on 5/8/25.Further clinical record review indicated no documentation that the discharge summary had been sent/forwarded to the attending physician.During an interview on 10/21/25 at 12:15 P.M., the Administrator said the agency had not forwarded/sent the discharge summary to Patient #1’s physician, as required, but should have.”

“Based on state requirements, policy review, personnel record review, and interview, the agency failed:1. to provide documentation that Nurse Aide Registry checks were conducted prior to hire, for two Volunteers (#1 and #2), two Registered Nurses (RN) (#3 and #4), two Home Care Aides (HCA) (#5 and #6), and one Medical Social Worker (MSW) (#7) out of 7 personnel records reviewed and 2. to provide documentation that a Criminal Offender Record Information (CORI) check was conducted prior to hire, for one HHA (#5) out of 7 personnel records reviewed. Findings include: 1.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 indicated he/she joined the volunteer program on 3/24/25. Further review of the record did not indicate a Nurse Aide Registry check had been completed.- Review of Volunteer #2’s personnel record indicated he/she joined the volunteer program on 9/10/24. Further review of the record did not indicate a Nurse Aide Registry check had been completed.- Review of RN #3’s personnel record indicated he/she was hired on 10/30/23. Further review of the record indicated that a Nurse Aide Registry check was completed on 6/27/25.- Review of RN #4’s personnel record indicated he/she was hired on 8/12/25. Further review of the record indicated that a Nurse Aide Registry check was completed on 9/23/25.- Review of HHA #5’s personnel record indicated he/she was hired on 2/27/24. Further review of the record indicated that a Nurse Aide Registry check was completed on 6/27/25.- Review of HHA #6’s personnel record indicated he/she was hired on 9/8/25. Further review of the record indicated that a Nurse Aide Registry check was completed on 9/23/25.- Review of MSW #7’s personnel record indicated he/she was hired on 7/28/25. Further review of the record indicated that a Nurse Aide Registry check was completed on 9/23/25.2. Review of the agency’s policy entitled Criminal Offender Record Information (C.O.R.I), last reviewed 11/4/19, indicated but was not limited to the following: * Visiting Nurse and Community Care respects the dignity of each client/patient through vigorous promotion of human and civil rights which, in part, strive to keep clients/patients free from abuse, mistreatment, crimes of violence, and theft. This policy is aimed at establishing standardized procedures for conducting checks on the criminal records of candidates being considered for employment, promotion or lateral transfer who provide unsupervised care to clients/patients of Visiting Nurse and Community Care* CORI checks shall be performed on all Visiting Nurse and Community Care candidates for any position. * The provisions of this policy shall apply to any personnel transaction (effective 2/1/96) involving new hires, promotions, or lateral transfers into positions that entail contact with clients/patients.* Hired Employees – upon receipt of the written confirmation that the criminal record investigation has been completed, the applicable manager(s)/supervisor may then designate the candidate as a hired employee.During an interview on 10/22/25 at 1:39 P.M., the Administrator and Director of Human Resources said Nurse Aide Registry checks and CORI checks should have been completed upon hire and prior to patient care being provided but wasn’t. During an interview on 10/22/25 at 4:01 P.M., the Administrator said all seven staff members had provided direct care prior to Nurse Aide Registry and/or CORI checks being completed.”