VNA of Care New England

“Based on record review and staff interview it has been determined that the agency failed to immediately take action to prevent further potential violations while an alleged violation is being conducted in accordance with established procedures for 2 of 2 allegations of abuse reviewed, Patient ID #s 20 and 21. Findings are as follows: Review of an agency policy titled, “;Abuse and/or Neglect- 60 years and older” revealed in part: “;...The purpose of this Abuse and/or Neglect of Elder- 60 years and older policy is to describe the VNA of Care New England protocol and/or law for all professional and non-professional employees in reporting suspicion or actual abuse and/or neglect of an elder 60 years of age or older... ...All health care professionals and paraprofessionals are responsible for adhering to the elder abuse/ neglect reporting procedure... ...Allegation of abuse by a licensed home care agency or nursing facility should be reported to the Department of Health Facilities and Regulation and the Alliance of Better Long-Term Care... ...The report must contain... The name, address, telephone number, occupation, and employers address and the phone number of the person reporting... The name and address of the patient [pt] or resident who is believed to be the victim of the abuse, mistreatment, or neglect... The details, observations, and beliefs concerning the incident(s)... Any statement regarding the incident made by the patient or resident and to whom they were made... The date, time, and place of the incident... The name of any individual(s) believed to have knowledge of the incident... The name of any individual(s) believed to have been responsible for the incident... Duty To Report...medical profession or health officer or any person within the scope of their employment at a Home Nursing Care or Home Care Provider or in their professional capacity who has knowledge of or reasonable cause to believe that a patient or resident receiving or being assessed for services has been abused, mistreated or neglected shall make within 24 [hours] or by the end of the next business day a telephone or fax report to the licensing agency for those incidents involving home nursing, home care and in health care facilities... Allegations of Abuse/neglect by Licensed Agency/Facility... For allegations of abuse by a home care or other licensed facility the Rhode Island Department of Health (DOH) must be reported within 24 hours of discovery...” 1) Record review of the Hospice Plan of Care for Patient ID #20 revealed a start of care date of 10/16/2024. It further revealed in part, “;Patient Strengths/ Long Term Goals: Safe Personal Care with Dignity Throughout the Certification Period...” Record review of a social worker visit note dated 12/13/2024, revealed documentation that the patient expressed that the facility had “;mistreated” him/her. The patient had further stated “;I do not want to get anyone in trouble” and “;I just want to forget it.” The documentation further reveals that the patient had said to his/her family member, “;She lifted the sheet, that [s/he] thinks [s/he] has a girlfriend.” Record review of a care coordination note dated 12/14/2024, revealed in part, “;...a wellness check on the patient and caregiver...the caregiver reported that the patient is doing well after revealing [his/her] experiences, using client language sexual assault and way to friendly’...Additionally, [nursing home name redacted]...contacted the...Police on Friday night, regarding the allegation of sexual abuse...” Review of the record in the presence of the Director of Organizational Excellence and the Director of Hospice on 2/28/2025 failed to reveal evidence that the Agency had reported the allegation of abuse to the Department of Health. It further failed to reveal evidence that the agency had conducted a thorough investigation of the abuse allegation. During a surveyor interview on 3/3/2025 at approximately 12:00 PM with the Director of Organizational Excellence and the Director of Hospice, they acknowledged that they had failed to report the above incident of suspected abuse to the Department of Health. They further were unable to provide evidence that a thorough investigation was conducted by the agency regarding the alleged abuse of Patient ID #20. 2) Record review of the Hospice Plan of Care for Patient ID #21 revealed a start of care date of 6/27/2024. It further revealed in part, “;Long Term Goals...Patient will be maintained in a safe environment...” Record review of a patient care coordination note dated 8/19/2024, revealed that the patients family member called the agency to report that the patient left the family member a voicemail stating that s/he was abused by the staff that put him/her to bed. It further revealed that the family member was very upset. Record review of a nursing visit note dated 8/19/2024 revealed documentation that the visit was made due to the allegation of abuse. It revealed that the patient reported that a bigger woman was rough with him/her when putting him/her to bed 2 nights ago. It further revealed that the patient had a healing skin tear, but the patient was unsure how s/he obtained it. Review of the record in the presence of the Director of Organizational Excellence and the Director of Hospice failed to reveal evidence that the Agency had reported the allegation of abuse to the Department of Health. During a surveyor interview on 3/3/2025 at approximately 12:00 PM with the Director of Organizational Excellence and the Director of Hospice, they acknowledged that they had failed to report the above incident of suspected abuse to the Department of Health.”

“Based on surveyor observation, record review, staff and patient interview it has been determined that the agency failed to develop an individualized written plan of care that reflects patient and family goals and interventions identified in the initial, comprehensive and updated comprehensive assessments relative to ensuring that medications are administered according to the patients plan of care for 2 of 4 patients visits, Patient ID #s 3 and 4. Findings are as follows: Review of the agency policy titled, “;Medication Reconciliation” revealed in part, “;...To develop, reconcile, and maintain an accurate patient medication list... This policy applies to all...clinicians and patients with an active medication list in Home Health and Hospice services... Medication reconciliation- process of comparing the medications a patient is taking, including prescribed and over the counter medications, with newly ordered medications... The qualified clinician is responsible for conducting medication reconciliation by comparing the discharge medication list from the referral source with medications preset in the home and entering the medications into the...electronic record... Once medication reconciliation is confirmed then clinicians shall evaluate for any new, discontinued, or changed meds at all future visits... Clinicians will update both the electronic Medication Profile and the patients medication list as needed when conducting the medication reconciliation process. Medications in the electronic profile and the patients medication list in the home must match...” 1) Record review of the agency provided medication list for Patient ID #3, who resides in a Skilled Nursing facility (SNF) revealed the following orders: - order dated 3/14/2024 for Enulose 10 gram(gm)/15 milliliters (ml) (medication prescribed to treat constipation), take 90 ml two times daily. Review of the patients current orders provided by the SNF revealed the following: -order dated 10/23/2024 for Enulose 10 gm/15 ml, take 90 ml once daily During a surveyor interview on 2/26/2025 at approximately 2:30 PM with Registered Nurse, Staff A, she indicated that she was unaware of the discrepancy. 2) Record review of the agency provided medication list for Patient ID #4 revealed the following orders: -order dated 1/16/2024 for Advair Diskus (inhaler- prescribed to treat asthma) 250 micrograms (mcg)- 50 mcg, inhale 1 puff 2 times daily -order dated 10/3/2024 for clonazepam (medication prescribed to treat anxiety) 0.5 milligram (mg) take one tablet every 6 hours and one tablet 3 times a day as needed. -order dated 3/25/2024 for Haldol (medication prescribed to treat severe agitation/ hallucinations) 1 mg every 6 hours as needed. - order dated 10/2/2024 for Senna Plus 8.6 mg- 50 mg (medication prescribed to treat constipation) one tablet daily. - order dated 1/16/2024 for Spiriva Respimat 2.5 mcg (medication prescribed to treat Asthma) once daily. During a surveyor interview on 2/25/2025 at 3:00 PM of the patient, in the presence of the Chaplin, s/he revealed the following: - s/he has not taken the Advair Diskus for over two years -s/he takes the clonazepam 0.5 mg every four hours as needed. -the Haldol was prescribed to him/her approximately two years ago while s/he was hospitalized. The patient stated that s/he has never taken this medication. -s/he takes two tablets daily of the Senna Plus. S/he stated that taking one tablet a day didnt work for him/her. -s/he hasnt taken the Spiriva Respimat for 2 years. During a surveyor interview on 2/26/2025 at approximately 2:30 PM with Registered Nurse, Staff B, she acknowledged that the medication list should have been updated. She could not provide evidence that she had updated the medication list. During a surveyor interview on 2/26/2025 at 3:10 PM with the Director of Hospice, she revealed that she would expect the nurse to reconcile the patients medications during the home visits.”

“Based on record review and staff interview, it has been determined that the agency failed to ensure that care and services are provided in accordance with the plan of care for 1 of 1 patient reviewed relative to weekly measurements and assessments of pressure wounds, Patient ID #5. Findings are as follows: Review of the agency policy, titled “;Process: Use of the Wound Addendum” states in part, “;...The clinician will document all wound characteristics by completing each section of the Wound Addendum at each visit. Open wounds will be measured weekly on the first of the week...” Review of the plan of care, for recertification period 1/14/2025 through 3/14/2025, revealed a start of care date of 9/22/2023. Further review revealed s/he has a stage 3 pressure ulcer (a wound with full thickness skin loss, involving damage or death to the tissue under the skin that may extend down to, but not through underlying tissues and muscles) to his/her coccyx (a small triangular bone at the base of the spinal column) that originated on admission. In addition, s/he has a stage 2 pressure ulcer (a wound with partial-thickness skin loss, typically breaking through the top layer of the skin and part of the layer below) to the left thigh with an onset date of 8/7/2024. Additional review of the plan of care revealed interventions for the skilled nurse to assess the wounds weekly if the agency is performing wound care. Review of the weekly wound reports from 2/2/2025 through 2/22/2025 revealed the following: - 2/2/2025 through 2/8/2025: weekly skilled nurse visit was cancelled without a documented reason; therefore, no wound report, measurements nor wound assessments were completed. - 2/9/2025 through 2/15/2025: failed to reveal evidence of measurements to either the coccyx or thigh wounds. - 2/16/2025 through 2/22/2025: failed to reveal evidence of measurements or assessments to the coccyx or thigh wounds During a surveyor interview on 2/27/2025 at approximately 11:00 AM with the Wound Specialist, she acknowledged that the wound measurements and/or assessments were not completed for the above-mentioned weeks and indicated her expectation would be that the nurse would have either completed this documentation or documented the reason as to why it was not done. Furthermore, her expectation would be that a reason would be documented as to why the nurse visit was cancelled for the week of 2/2/2025 through 2/8/2025 and that the missed visit would have been rescheduled. During a surveyor interview 2/27/2025 at approximately 3:30 PM with the Director of Hospice, she was unable to provide evidence that the patients plan of care and the agency policy were followed.”

“Based on surveyor observation, record review, and staff interview, it has been determined that the hospice failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases for 1 of 1 patient reviewed, relative to the proper positioning of a Foley catheter and the maintenance of enhanced barrier precautions, Patient ID #3. Findings are as follows: 1. Review of the agency policy, titled “;Indwelling urinary catheter (Foley) care and management” states in part, “;...Ensure that the drainage bag is maintained below the level of the bladder to prevent backflow of urine into the bladder, which increases the risk of CAUTI [catheter-associated urinary tract infection]...” Surveyor observation of Certified Nursing Assistant (CNA), Staff C, providing ADL (activities of daily living) care to the patient while in bed on 2/26/2025 at 8:48 AM, revealed that while emptying the patients Foley catheter Staff C held the drainage bag above the level of the bladder and the urine in the tubing was observed back flowing into the tube leading to his/her bladder. During a surveyor interview with Staff C on 2/26/2025 at 10:00 AM, she acknowledged positioning the drainage bag above the patients bladder while emptying his/her Foley catheter. During a surveyor interview with the Director of Hospice on 2/26/2025 at 3:00 PM, she indicated that her expectation would be that the policy would be followed regarding maintaining the patients drainage bag below the level of his/her bladder. 2. Review of the agency policy, titled “;Infection Surveillance Policy” states in part, “;...Process measures may include, but are not limited to...Adherence to published standards, recommendations from stated accredited bodies...proper management of invasive medical devices...” According to the 3/20/2024 Centers for Disease Control (CDC) infection control guidance regarding enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms that indicates targeted gown and glove use during high contact resident care activities) are implemented during high-contact care activities for residents of skilled nursing facilities with indwelling medical devices. Surveyor observation of Patient ID #3’s room on 2/26/2025 at approximately 8:48 AM revealed a sign stating that the patient was on EBP. Surveyor observation of CNA, Staff C, on 2/26/2025 at 8:48 AM revealed she entered the patients room and washed her hands in the bathroom. Next, she proceeded to go to the hallway, donned gloves and a gown and then walked down the hallway to gather linen. Upon returning to the patients room, Staff C provided ADL care and emptied the patient’s Foley catheter while wearing the same PPE. Further surveyor observation revealed after completing care and while still wearing the same PPE, Staff C exited the patient’s room with a bag of soiled linen to place in a bin in the hallway. She then returned to the patient’s room to discard her PPE. During a surveyor interview with Staff C on 2/26/2025 at 10:00 AM, she acknowledged wearing PPE in the hallway, touching multiple items, and then providing catheter care to the patient. She further acknowledged wearing the dirty PPE in the hallway to place the patient’s linen into a bin. During a surveyor interview with the Director of Hospice on 2/26/2025 at 3:00 PM, she indicated that her expectation would be that the CNA would not wear PPE in the hallway of the skilled nursing facility. Additionally, she indicated that the dirty PPE and soiled linens should be disposed of prior to exiting the patients room.”

“Based on record review and staff interview, it has been determined that the hospice failed to ensure that bereavement services are available to families and other individuals in the bereavement plan of care up to 1 year following the death of the patient for 2 of 3 patient’s reviewed, relative to bereavement services, Patient ID #s 17 and 18. Findings are as follows: Record review of an agency policy titled, “;Bereavement Program” dated 4/10/2024, revealed in part, “;...The purpose of this Bereavement Program Policy...is to describe the provisions of timely and professional help for patients/families to cope with grief and loss issues at time of hospice admission, during the illness, after the death, and through the bereavement period... At the time of death, needs are further assessed, a plan of care is established... The Bereavement Coordinator, Social Worker, Spiritual Care Coordinator or specially trained volunteer will make a bereavement contact (a telephone call) seven days for bereaved with high bereavement risk, fourteen days for bereaved with a moderate bereavement risk, thirty days for bereaved with a low bereavement risk... The Hospice RN and/or other team members place a condolence call within 24/48 hours after death... A personalized Bereavement plan of care is written for individuals depending on the needs of the bereaved party... Ongoing bereavement services are offered (unless declined by bereaved) for a minimum of 13 months after the patients death and include... Description of bereavement services offered... Follow-up phone calls and visits as needed or outlined in bereavement plan of care... Support groups (in person/virtual)... Individual counseling or referral for counseling if needed... Mailings detailing bereavement groups, seminars, memorial service (in person/virtual)... Volunteer support with telephone calls and home visits... Education and support materials... All bereavement contact is documented in the patient record...” 1) Record review for Patient ID #17 revealed his/her date of death was on 9/29/2024. Review of the patients record revealed that a family member was chosen to receive bereavement services. Record review in the presence of the Bereavement Coordinator on 2/27/2025 at approximately 2:30 PM, failed to reveal evidence that the family member had received any bereavement services after the patient passed away. He was unable to provide evidence of an opt out form indicating that the family declined bereavement services. Further he was unable to provide any documentation that the family member had declined bereavement services. During a surveyor interview on 2/27/2025 at the time of the above observation with the Bereavement Coordinator, he revealed that the bereavement plan for the family member was initiated on 9/29/2024 and was discharged on 10/1/2024. He acknowledged that there failed to be any documentation of calls, mailings or contacts for the patients family member. Further, he was unable to provide evidence that the patients family member declined bereavement services. 2) Record review for Patient ID #18 revealed his/her date of death was on 10/13/2024. Review of the patient’s record revealed that a family member was chosen to receive bereavement services. Record review in the presence of the Bereavement Coordinator on 2/27/2025 at approximately 2:30 PM, revealed that discharge from bereavement services was documented on 11/12/2024. He was unable to provide evidence of an opt out form indicating that the family declined bereavement services. Further he was unable to provide any documentation that the family member had declined bereavement services. During a surveyor interview on 2/27/2025 at the time of the above observation with the Bereavement Coordinator, he acknowledged that there failed to be any documentation indicating that the patient’s family member declined bereavement services, or that an opt out form was completed by the family member. During a surveyor interview on 2/27/2025 at approximately 3:30 PM with the Director of Hospice, she revealed that she would expect for an opt out form to be filled out, or a note to be written that the family declined bereavement services.”