Masonicare Home Health and Hospice Inc.

“Based on clinical record reviews, reviews of agency documentation and interviews with agency personnel, for one of one patients reviewed (Patient #1), the hospice agency failed to ensure care coordination with the patient’s caregivers for the management of end of life symptoms and pain control. The findings include: Patient #1 elected the hospice benefit on 05/15/2026 with a terminal diagnosis of senile degeneration of the brain and resided in a secure memory care unit at an Assisted Living Facility (ALF). The physician orders for the certification period of 05/15/2026 identified hospice nursing visits weekly for assessments, indwelling urinary catheter care and management of the symptoms of the terminal illness. Additionally, the Patient would receive social work, home health aide and pastoral services. Review of the hospice physician’s orders dated 05/15/2026 identified Patient #1 was to receive the following hospice comfort medications Acetaminophen 160 milligrams (mg) / 5 milliliters (ml) oral suspension as needed for pain or fever three (3) times per day, Acetaminophen 650 mg rectal suppository one (1) every four (4) hours as needed for fever, Ibuprofen 100 mg/5 ml oral suspension four (4) times per day as needed for pain or fever, Levsin 0.125 mg one (1) tablet every four (4) hours as needed for congestion or excessive secretions, Lorazepam 0.5 mg one (1) tablet every hour as needed for anxiety agitation or restlessness and Morphine 100 mg/5 ml oral solution every twenty (20) minutes as needed for pain or respiratory distress. Review of a nursing note dated 06/25/2026 at 10:08 AM by Hospice Licensed Practical Nurse (LPN) #1 identified that Patient #1 received assistance from a private duty aide at night and at this visit was not presenting with uncontrolled symptoms. Review of a nursing note dated 06/29/2026 at 3:49 PM by Hospice Registered Nurse (RN) #1 identified that Patient #1 remained free from uncontrolled symptoms at this time and also identified that as of 06/25/2026, Patient #1’s Hospice comfort medications were being managed and ordered by the ALF nursing staff. Hospice RN #1 indicated s/he and a ALF nurse destroyed the unused Hospice agency’s comfort kit medications at the time the visit. Interview with Hospice LPN #1 on 07/21/2026 at 12:15 PM identified that during a visit with Patient #1 on 06/25/2026, s/he asked ALF LPN #1 if Patient #1’s Hospice comfort kit medications could be removed from the locked cabinet in the Patient’s apartment, and relocated in the patient’s closet for ease of staff accessibility. ALF LPN #1 indicated that other hospice agencies had stored Hospice comfort kit medications in the closet to improve accessibility for the hospice staff and private duty aides.Hospice LPN #1 contacted the Hospice’s Supervisor of Clinical Services (SCS) #1 who approved the transfer of the patient’s Hospice comfort kit medications from the locked cabinet to the Patient’s closet. Interview with Assistant Hospice Director (AHD) on 07/21/2026 at 1:00 PM, identified on 06/29/2026 the Supervisor of Assisted Living Services Agency (SALSA) at the ALF contacted the Hospice agency and advised that per the Hospice agency policy, all narcotic/hospice comfort kit medications were required to be stored in a double-locked cabinet located in the patient’s apartment. The AHD further indicated that Hospice LPN #1 was not aware of the ALF’s narcotic medication storage policy at that time of the request for relocation. Additionally, the AHD was unable to identify Hospice LPN #1 provided documentation identifying the relocation of the Hospice comfort medications for the assurance of care coordination between the agencies and caregiver.”

“Based on review of agency documentation and interviews with hospice personnel, for one of three patients (Patient #1) who received hospice services, the hospice agency failed to manage the patient’s pain and symptoms related to the terminal illness in a timely manner. The findings include: Patient #1 elected the hospice benefit on 11/09/25 with diagnoses that included severe protein-calorie malnutrition, dementia and dysphagia. The physician’s orders dated 11/09/25 included nursing services twice weekly for assessments and symptom management, hospice aide services, social work and chaplain services.Physicians’ orders included Oxycodone 5 mg/5 ml (milligrams/milliliter) by mouth every four hours as needed for pain and Lorazepam Intensol 2mg/ml, 0.25 ml by mouth every six hours as needed for anxiety.Additionally, on 12/02/25, Morphine 20 mg/5ml, take 5 mg by mouth every four hours as needed for pain was ordered.Review of agency documentation dated 12/02/25 identified a concern from a family member requesting Registered Nurse /RN #1 to obtain Morphine medication locally rather than obtaining the Morphine through the Hospice pharmacy. Additionally, the family called back RN #1 at 5:28 PM and indicated that the Morphine had not been delivered, RN #1 called the Hospice pharmacy and verified the delivery left at 4:30 PM.Review of RN #2’s communication note dated 12/02/25 at 1:20 PM indicated receiving a call from the next of kin identifying that the patient was now having abdominal pain, the Oxycodone was not effective and requested Morphine be called into a local pharmacy. RN #2 offered to visit the patient but the next of kin declined the visit. RN #2 called the Supervisor of Clinical Services/SCS and was instructed to call the Hospice Physician for a stat delivery of Morphine. The order was received from the Hospice Physician for Morphine 0.25 ml every four hours as needed for pain and Oxycodone 5 mg every four hours as needed for pain. The stat order was then called into the Hospice pharmacy for delivery.Review of RN #2’s call log for 12/02/25 identified at 1:20 PM, the next of kin called RN #2 and at 1:21 PM, the Hospice pharmacy was called.Review of electronic mail dated 12/31/25 from the family member identified that the Morphine did not arrive until 6:30 PM.Review of the agency documentation with the Hospice Program Director indicated that she received the complaint, spoke with RN #3 who indicated visiting the patient on 12/01/25, the patient denied pain, but was short of breath with talking and turning, but symptoms were relieved with oxygen as needed. After the family’s request for Morphine on 12/02/25, the SCS recommended RN #2 call the Hospice Physician for a stat Morphine order and indicated there was Oxycodone available until the arrival of Morphine, therefore, a local fill of the medication was not warranted. The Hospice Program Director indicated that the agency expectations for a stat order for medication delivery was within three hours in December 2025, but has now been changed to four hours.Interview with the Associate Hospice Director on 1/05/26 at 1:30 PM failed to ensure education and coordination with the family to encourage an “as needed visit” be completed on 12/02/25 at 1:20 PM to assess the patient’s immediate needs, and change in condition and failed to ensure timely delivery of medications within the three-hour timeframe for the management of the patient’s symptoms.Review of the agency Hospice Local Fill Standard Work document directed when the patient has insufficient supply to last until a STAT order can be delivered then a local pharmacy is contacted to obtain the medication. The Medical Director will be contacted to sign the medication prescription, and the nurse will contact the local pharmacy to ensure the medication is ready for pick up.”

“Based on review of clinical records, agency documentation, and staff interviews for one (1) of one (1) patients’ (Patient #1) who received hospice services, the hospice agency failed to ensure management of the patient’s hospice comfort medication for the control of symptoms related to a terminal illness. The findings include: Patient #1 who resided in a skilled nursing facility (SNF), elected the hospice benefit on 04/06/2024 with diagnoses of ovarian cancer, schizoaffective disorder, bipolar II disorder, type II diabetes and pain. The physician’s orders for the recertification period of 05/31/2025 to 7/29/2025 included nursing services three (3) times per week.Physician’s orders included Morphine Concentrate 20 milligrams (mg)/milliliters (ml) take 40 mg by sublingual route every four (4) hours as needed for pain and Lorazepam Intensol 2 mg/ml oral concentrate take 4 mg by oral route every four (4) hours for anxiety or agitation and Fentanyl 50 micrograms (mcg)/hour transdermal patch for pain to be applied every seventy-two (72) hours. Review of the patient’s clinical record identified on 7/9/25 the hospice agency took control of the management of Patient #1’s hospice medications with the hospice Medical Director (MD) prescribing the hospice comfort medications (a set of prescribed medications that are kept on hand to quickly relieve symptoms related to the terminal illness).Review of a hospice nursing visit note dated 07/16/2025, identified a hospice visit was completed, but did not identify documentation of the completion of a controlled substances count within the clinical record, as it related to tracking/reordering of the controlled substances.Review of a hospice nursing note dated 07/23/2025, identified Patient #1 was sleeping upon the nurse’s arrival, but arousable. The Patient presented with audible wheezing and was prescribed Prednisone 40 mg daily. The nursing documentation did not identify the completion of a count of the patient’s-controlled substances in the clinical record. Review of a hospice case communication report dated 07/26/2025, identified a call was placed to the skilled nursing facility to check on Patient #1’s status, the nursing supervisor identified the Patient’s mentation was at baseline and he/she had slight upper airway congestion. The case communication documentation did not identify the completion of a current count of the patient’s-controlled substance medications in the clinical record. Review of a nursing note dated 07/29/2025, identified Hospice RN #2 received a call from one of the SNF’s nurses, identifying that Patient #1 “ran out’ of Lorazepam Intensol. The last dose was identified as being administered on 07/26/25 at 1:00 PM and identified twelve (12) subsequent, scheduled doses between the dates of 07/26/2025 to 07/28/2025 of Lorazepam Intensol 4 mg were not administered per the physician’s/MD order, due to no medication availability. During the call, the SNF nurse identified a refill of the Lorazepan Intensol was obtained and delivered on 7/28/25 from the SNF’s in-house pharmacy, with the patient being administered the medication on 07/28/2025 at 6:50 PM, 72 hours after the last dose. Review of the agency’s investigation document dated 07/31/2025, identified on 07/25/2025 Hospice RN #1 had obtained a provider order for an “as needed” nursing visit for 07/26/2025, for the assessment of Patient #1 and the monitoring of the amount of hospice comfort medications remaining, including the Lorazepam Intensol 2 mg/ml, (which was projected to “run out” on 07/28/2025). The investigation documentation identified that Patient #1 did not receive a nursing visit as scheduled on 7/26/25 but was seen on 07/29/2025 (3 days later) by Hospice RN #2 due to a schedule change as a result of agency staffing. The nursing documentation of 7/29/25 identified at the time of the nursing visit, the Patient was found to be in a highly combative, agitated state and was striking staff during care. Review of a nursing visit note dated 07/31/2025, identified Patient #1 was alert, irritable and angry. The Patient was hallucinating, striking staff, declining meals and medications and had increased agitation and anxiety. The SNF staff identified a request for a psychiatric provider evaluation due to the increase in Patient’s behaviors. RN #1 placed a call to the hospice’s medical director to report the Patient’s behavior, with no change in the Patient’s orders identified. Review of the nursing visit note did not identify any other assessments or interventions were completed as a result of a change in condition, and the 12 missed doses of the scheduled Lorazepam Intensol 2mg/ml medication from 7/26/25 to 7/28/25. The investigation further identified that on 07/22/2025, the pharmacy documentation identified the Patient’s medications had been delivered to the SNF, but during a subsequent pharmacy record review it was found that only two (2) of the three (3) medications were delivered to the SNF, the Fentanyl patches, and Morphine Concentrate, not the Lorazepam Intensol, as had been previously reported to the SNF staff. The Hospice agency documentation further identified the hospice agency’s physician/MD advised they would no longer prescribe the Patient’s routine and controlled substance medications in the hospice comfort medications, therefore, on 08/04/2025 the skilled nursing facility appropriated (took control) of the prescribing, administration, reordering and counting of the controlled substances within the hospice comfort medications along with the Patient’s routine medication.Interview and review of Patient #1’s clinical record with Supervisor of Clinical Services (SCS #1) on 08/28/2025 at 11:00 AM, identified Patient #1 resided at a SNF, and the facility had a history of not ordering the patient’s comfort medication timely. On 7/9/25 the hospice agency assumed control and management for the hospice comfort medication including the counting of the controlled substances, and the reordering of the Lorazepam Intensol 2mg/ml. SCS #1 further identified the nursing visit scheduled for 7/26/25 was not completed and was rescheduled for 7/29/25 (2 days after the projected Lorazepam Intensol 2mg/ml depletion), due to a staffing issue, which resulted in a delay in a review of the patient’s meds, the reordering of the necessary medication and the subsequent medication depletion and 12 missed doses of medication. Interview with the Hospice Program Director on 08/28/2025 at 11:45 AM, identified the hospice agency was responsible for the Patient’s hospice comfort medications from 7/9/25 through 8/4/25, which was atypical. The Hospice Program Director identified that typically a SNF patient’s hospice comfort medications were ordered by the Hospice Medical Director, administered by the SNF nursing staff and reordered by the SNF. Additionally, the SNF nursing staff would perform controlled substance counts of the hospice comfort medications. The Hospice Program Director identified on two (2) separate occasions the SNF failed to reorder the Patient’s Lorazepam Intensol, therefore, on 07/09/2025 the hospice agency assumed control over prescribing, reordering and performing the controlled substance counts of the hospice comfort medications upon each visit.The Hospice Director further identified as a result of the hospice agency personnel rescheduling the nursing visit from 7/26/25 to 7/29/2025, the patient experienced a lapse in the medication availability from 7/26/25 to 7/28/2025, a 72 hour period, 12 doses of Lorazepam (Intersol) and failed to identify the hospice agency provided professional management and oversight for the timely reordering and delivery of the patients controlled medications for the effective management of pain and symptom control of a terminal illness. Review of Patient #1’s hospice plan of care dated 05/31/2025 -7/29/25 identified no revisions/notations to reflect the hospice agency’s responsibility for assuming control of the patient’s hospice comfort medications as of 07/09/2024 from the SNF.Review of the hospice agency’s protocol for the provision of routine and respite hospice level of care services, between Masonicare Home Health Care and Hospice Inc. and New London Health and Rehab. dated 10/22/2024, identified the hospice agrees to provide all drugs and pharmaceuticals related to the management of the terminal illness and related conditions which are specified in the hospice plan of care. Hospice assumes responsibility for professional management of the resident’s hospice services provided in accordance with the hospice plan. The hospice and the skilled nursing facility or the home agree to communicate, establish and agree upon a coordinated plan of care that reflects hospice philosophies. The staff of the hospice and the skilled nursing facility would work together to ensure that ordering, renewal, delivery and administration of medications to each hospice patent was achieved in such a way to assure optimal symptom relief and minimal delay.”

“Based on clinical record reviews, reviews of agency documentation and interviews with agency personnel, for three of twenty-three patients (Patient’s #5, 8 & 11) in the survey sample, the hospice agency failed to follow the physician’s orders. The findings include: a. Patient #5 elected the Hospice Benefit on 3/14/25 and resided at home. The patient’s diagnoses included severe protein-calorie malnutrition, dementia, and heart failure. The physician’s orders for the certification period from 6/12/25 through 9/9/25 included nursing services twice a week, medical social work services (MSW) twice a month, spiritual services twice a month, volunteer services three to four times a month, and massage therapy twice a month.Review of the clinical record for Patient #5 between 6/12/25 through 8/26/25 failed to identify nursing visits were made twice weekly to Patient #5 during the weeks of: 6/22 through 6/28, 6/29 through 7/5, 7/13 through 7/19, and 7/27 through 8/1 because were missed visits on 6/27, 7/3, 7/16, and 8/1. Interview and review of the clinical record for Patient #5 with the Associate Executive Director of Hospice on 8/27/25 at 12:30 PM failed to identify the provision of nursing services in accordance with the physician’s orders and in response to the patient’s needs. The Associate Executive Director of Hospice indicated the nursing visits on 6/23, 7/3, 7/16, and 8/1 were considered missed visits, were subsequently cancelled, and there was no documentation regarding the reason for the missed visits and of any attempts to reschedule the missed visits. b. Patient #11 elected the Hospice Benefit on 11/16/24 and resided at home. The patient’s diagnoses included Alzheimer’s disease with early onset and dementia in other diseases classified elsewhere, severe, with agitation. The physician’s orders for the certification period from 5/15/25 through 7/13/25 included nursing services once a week, hospice aide services twice a week, medical social work services (MSW), and spiritual services. The subsequent physician orders dated 5/21/25 directed MSW services to be provided once a month and as needed (PRN). The physician’s orders for the certification period between 7/14/25 through 9/11/25 included nursing services once a week, hospice aide services twice a week, medical social work services (MSW), and volunteer services.Review of the clinical record for Patient #11 reflected no documentation that MSW visits were made between 5/15/25 through 8/26/25. Interview and review of Patient #11’s clinical record with the Associate Executive Director of Hospice on 8/26/25 at 2:15 PM failed to identify MSW visits were made and the provision of social work services between 5/13/25 through 8/26/25 in accordance with the physician’s orders and in response to the patient and family’s needs. Subsequent to surveyor inquiry, a case communication note dated 8/27/25 at 9:15 AM identified the MSW communicated with Patient #11’s family on 8/11/25, the family declined to schedule a follow-up visit from the MSW and declined MSW services. Review of the agency Plan of Care Policy dated 5/7/25 directed the care and services provided to the patient and their families are in accordance with an individualized, written plan of care established by all clinical staff involved in the patient’s care and in collaboration with patient’s attending physician, the patient and/or his or her representative. Patient #8 elected the Hospice Benefit on 7/17/25 and resided in a skilled nursing facility/SNF. The patient’s diagnoses included severe protein-calorie malnutrition, dysphagia, depression and congestive heart failure. The physician’s orders dated 7/17/25 included nursing services two times a week, hospice aide services two times a week, medical social worker/MSW, chaplain and massage therapy services. Review of the clinical record from 7/17/25 to 8/23/25 identified only one hospice aide visit the weeks of 7/20/25 to 7/26/25, 8/10/25 to 8/16/25 and 8/17/25 to 8/23/25. Interview and review of Patient #8’s clinical record with the Administrator on 8/28/25 at 10:30 AM identified documentation of hospice aide missed visits on 8/19/25 (one out of four missed visits) indicating the regular hospice aide was unavailable but lacked documentation of rescheduling the hospice aide to meet the physician’s ordered frequency of twice weekly and lacked documentation of physician notification of the three other missed visits in accordance with agency policies. Review of agency policy for Missed Visit Process directed at the end of the frequency week, missed visit forms are faxed to the physician via email by the scheduler and can be sent daily if the visit will not be rescheduled. A missed visit fax form is completed with the patient’s name and the date of the missed visit and addressed to the patient’s physician and listed from case manager.”

“Based on clinical record review, review of agency documentation, and staff interviews, for one (1) of one (1) patients (Patient #1) who received hospice services, the hospice agency failed to revise the plan of care to reflect the patient’s needs and to ensure the coordination of services and interventions provided to the patient. The findings include: Patient #1 who resided in a skilled nursing facility, elected the hospice benefit on 04/06/2024 with diagnoses of ovarian cancer, schizoaffective disorder, bipolar II disorder, type II diabetes and pain. The physician’s orders for the recertification period of 05/31/2025 to 7/29/2025 included nursing services three (3) times per week. Review of the Provision of Service agreement between the agency and SNF dated 10/22/24 identified the hospice agency was responsible for prescribing the hospice comfort medications (a set of prescribed medications that are kept on hand to quickly relieve symptoms related to the terminal illness) and the skilled nursing facility was responsible for administering the Patient’s medications, counting the controlled substances and re-ordering the medications.Physician’s orders included Morphine Concentrate 20 milligrams (mg)/milliliters (ml) take 40 mg by sublingual route every four (4) hours as needed for pain and Lorazepam Intensol 2 mg/ml oral concentrate take 4 mg by oral route every four (4) hours for anxiety or agitation and Fentanyl 50 micrograms (mcg)/hour transdermal patch for pain to be applied every seventy-two (72) hours. Review of the patient’s clinical record identified on 7/9/25 the hospice agency took control of the management of Patient #1’s hospice medications with the hospice Medical Director (MD) prescribing the hospice comfort medications (a set of prescribed medications that are kept on hand to quickly relieve symptoms related to the terminal illness), due to missed medication doses.Review of a hospice nursing visit note dated 07/16/2025, identified a hospice visit was completed, but did not identify documentation of the completion of a controlled substances count within the clinical record, as it related to tracking/reordering of the controlled substances.Review of a hospice nursing note dated 07/23/2025, identified Patient #1 was sleeping upon the nurse’s arrival, but arousable. The Patient presented with audible wheezing and was prescribed Prednisone 40 mg daily. The nursing documentation did not identify the completion of a count of the patient’s-controlled substances in the clinical record. Review of a hospice case communication report dated 07/26/2025, identified a call was placed to the skilled nursing facility to check on Patient #1’s status, the nursing supervisor identified the Patient’s mentation was at baseline and he/she had slight upper airway congestion. The case communication documentation did not identify the completion of a current count of the patient’s-controlled substance medications in the clinical record. Review of a nursing note dated 07/29/2025, identified Hospice RN #2 was contacted by one of the SNF’s nurses, identifying that Patient #1 “ran out’ of Lorazepam Intensol. The last dose being administered on 07/26/25 at 1:00 PM and identified twelve (12) subsequent, scheduled doses between the dates of 07/26/2025 to 07/28/2025 of Lorazepam Intensol 4 mg were not administered per the physician’s/MD order, due to no medication availability. During the call, the SNF nurse identified a refill of the Lorazepan Intensol was obtained and delivered on 7/28/25 from the SNF’s in-house pharmacy, with the patient being administered the medication on 07/28/2025 at 6:50 PM, 72 hours after the last dose. Review of the agency’s investigation document dated 07/31/2025, identified on 07/25/2025 Hospice RN #1 had obtained a provider order for an “as needed” nursing visit for 07/26/2025, for the assessment of Patient #1 and the monitoring of the amount of hospice comfort medications remaining, including the Lorazepam Intensol 2 mg/ml, (which was projected to “run out” on 07/28/2025). The investigation documentation identified that Patient #1 did not receive a nursing visit as scheduled on 7/26/25 but was seen on 07/29/2025 (3 days later) by Hospice RN #2 due to a schedule change as a result of agency staffing. The nursing documentation of 7/29/25 identified at the time of the nursing visit, the Patient was found to be in a highly combative, agitated state and was striking staff during care. Review of a nursing visit note dated 07/31/2025, identified Patient #1 was alert, irritable and angry. The patient was hallucinating, striking staff, declining meals and medications and had increased agitation and anxiety. The SNF staff identified a request for a psychiatric provider evaluation due to the increase in Patient’s behaviors. RN #1 placed a call to the hospice’s medical director to report the Patient’s behavior, with no change in the Patient’s orders identified. Review of the nursing visit note did not identify any other assessments or interventions were completed as a result of a change in condition, and the 12 missed doses of the scheduled Lorazepam Intensol 2mg/ml medication from 7/26/25 to 7/28/25. The investigation identified that on 07/22/2025, the pharmacy documentation identified the Patient’s medications had been delivered to the SNF, but during a subsequent pharmacy record review it was found that only two (2) of the three (3) medications were delivered to the SNF, the Fentanyl patches, and Morphine Concentrate, not the Lorazepam Intensol, as had been previously reported to the SNF staff. The Hospice agency documentation further identified the hospice agency’s physician/MD advised they would no longer prescribe the Patient’s routine and controlled substance medications in the hospice comfort medications, therefore, on 08/04/2025 the skilled nursing facility appropriated (took control) of the prescribing, administration, reordering and counting of the controlled substances within the hospice comfort medications along with the Patient’s routine medication.Interview and review of Patient #1’s clinical record with Supervisor of Clinical Services (SCS #1) on 08/28/2025 at 11:00 AM, identified Patient #1 resided at a SNF, and the facility had a history of not ordering the patient’s comfort medication timely. On 7/9/25 the hospice agency assumed control and management for the hospice comfort medication including the counting of the controlled substances, and the reordering of the Lorazepam Intensol 2mg/ml. SCS #1 further identified the nursing visit scheduled for 7/26/25 was not completed and was rescheduled for 7/29/25 (2 days after the projected Lorazepam Intensol 2mg/ml depletion), due to a staffing issue, which resulted in a delay in a review of the patient’s meds, the reordering of the necessary medication, and the subsequent medication depletion and 12 missed doses of medication. Interview with the Hospice Program Director on 08/28/2025 at 11:45 AM, identified the hospice agency was responsible for the Patient’s hospice comfort medications from 7/9/25 through 8/4/25, which was atypical. The Hospice Program Director identified that typically a SNF patient’s hospice comfort medications were ordered by the Hospice Medical Director, administered by the SNF nursing staff and reordered by the SNF. Additionally, the SNF nursing staff would perform controlled substance counts of the hospice comfort medications. The Hospice Program Director identified on two (2) separate occasions the SNF failed to reorder the Patient’s Lorazepam Intensol, therefore, on 07/09/2025 the hospice agency assumed control over prescribing, reordering and performing the controlled substance counts of the hospice comfort medications upon each visit.The Hospice Director further identified as a result of the hospice agency personnel rescheduling the nursing visit from 7/26/25 to 7/29/2025, the patient experienced a lapse in the medication availability from 7/26/25 to 7/28/2025, a 72 hour period, 12 doses of Lorazepam (Intersol) and failed to identify the hospice agency provided professional management and oversight for the timely reordering and delivery of the patients controlled medications for the effective management of pain and symptom control of a terminal illness. Review of Patient #1’s hospice plan of care dated 05/31/2025 -7/29/25 identified no revisions/notations to reflect the hospice agency’s responsibility for assuming control of the patient’s hospice comfort medications as of 07/09/2024 from the SNF.Review of the hospice agency’s protocol for the provision of routine and respite hospice level of care services, between Masonicare Home Health Care and Hospice Inc. and New London Health and Rehab. dated 10/22/2024, identified the hospice agrees to provide all drugs and pharmaceuticals related to the management of the terminal illness and related conditions which are specified in the hospice plan of care. Hospice assumes responsibility for professional management of the resident’s hospice services provided in accordance with the hospice plan. The hospice and the skilled nursing facility or the home agree to communicate, establish and agree upon a coordinated plan of care that reflects hospice philosophies. The staff of the hospice and the skilled nursing facility would work together to ensure that ordering, renewal, delivery and administration of medications to each hospice patent was achieved in such a way to assure optimal symptom relief and minimal delay.”

“Based on clinical record reviews, reviews of agency documentation and interviews with agency personnel, for one of twenty-three patients (Patient #2) in the survey sample, the hospice agency failed to ensure care and services were provided in accordance with the care plan. The finding includes: Patient #2 elected the Hospice Benefit on 6/03/25 and resided in a skilled nursing facility/SNF. The patient’s diagnoses included brain cancer, Alzheimer’s disease, dementia, type II diabetes mellitus and congestive heart failure. The physician’s orders dated 6/03/25 included nursing services two times a week, hospice aide services two times a week, medical social worker/MSW and chaplain services. Review of the clinical record from 6/03/25 to 6/28/25 failed to identify hospice aide services were being provided per the physician’s order by the agency staff. Review of Patient #2’s clinical record with the Administrator on 8/28/25 at 10:30 AM failed to identify the provision of hospice aide services in accordance with the physician’s orders and in response to the patient’s care needs. On 8/28/25, subsequent to the interview, review of the nursing note identified that it was noted that the SNF was meeting the patient’s care needs and hospice aide services were discontinued. Review of the agency Plan of Care Policy directed the care and services provided to the patient and their families are in accordance with an individualized, written plan of care established by all clinical staff involved in the patient’s care and in collaboration with patient’s attending physician, the patient and/or his or her representative.”

“Based on a review of clinical records, agency documentation, and staff interviews, for one (1) of one (1) patients (Patient #1) who received hospice services, the hospice agency failed to provide professional management of the patient’s symptoms of the terminal illness in a timely manner, and failed to coordinate care to assure all services and interventions were provided to the patient. The finding includes: Patient #1 who resided in a skilled nursing facility, elected the hospice benefit on 04/06/2024 with diagnoses of ovarian cancer, schizoaffective disorder, bipolar II disorder, type II diabetes and pain. The physician’s orders for the recertification period of 05/31/2025 to 7/29/2025 included nursing services three (3) times per week. The hospice agency was responsible for prescribing the hospice comfort medications (a set of prescribed medications that are kept on hand to quickly relieve symptoms related to the terminal illness) and the skilled nursing facility was responsible for administering the Patient’s medications, counting the controlled substances and re-ordering the medications.Physician’s orders included Morphine Concentrate 20 milligrams (mg)/milliliters (ml) take 40 mg by sublingual route every four (4) hours as needed for pain and Lorazepam Intensol 2 mg/ml oral concentrate take 4 mg by oral route every four (4) hours for anxiety or agitation and Fentanyl 50 micrograms (mcg)/hour transdermal patch for pain to be applied every seventy-two (72) hours. Review of the patient’s clinical record identified on 7/9/25 the hospice agency took control of the management of Patient #1’s hospice medications with the hospice Medical Director (MD) prescribing the hospice comfort medications (a set of prescribed medications that are kept on hand to quickly relieve symptoms related to the terminal illness).Review of a hospice nursing visit note dated 07/16/2025, identified a hospice visit was completed, but did not identify documentation of the completion of a controlled substances count within the clinical record, as it related to tracking/reordering of the controlled substances.Review of a hospice nursing note dated 07/23/2025, identified Patient #1 was sleeping upon the nurse’s arrival, but arousable. The Patient presented with audible wheezing and was prescribed Prednisone 40 mg daily. The nursing documentation did not identify the completion of a count of the patient’s-controlled substances in the clinical record. Review of a hospice case communication report dated 07/26/2025, identified a call was placed to the skilled nursing facility to check on Patient #1’s status, the nursing supervisor identified the Patient’s mentation was at baseline and he/she had slight upper airway congestion. The case communication documentation did not identify the completion of a current count of the patient’s-controlled substance medications in the clinical record. Review of a nursing note dated 07/29/2025, identified Hospice RN #2 received a call from one of SNF’s nurses, identifying that Patient #1 “ran out’ of Lorazepam Intensol. The last dose was identified as being administered on 07/26/25 at 1:00 PM and identified twelve (12) subsequent, scheduled doses between the dates of 07/26/2025 to 07/28/2025 of Lorazepam Intensol 4 mg were not administered per the physician’s/MD order, due to no medication availability. During the call, the SNF nurse identified a refill of the Lorazepan Intensol was obtained and delivered on 7/28/25 from the SNF’s in-house pharmacy, with the patient being administered the medication on 07/28/2025 at 6:50 PM, 72 hours after the last dose. Review of the agency’s investigation document dated 07/31/2025, identified on 07/25/2025 Hospice RN #1 had obtained a provider order for an “as needed” nursing visit for 07/26/2025, for the assessment of Patient #1 and the monitoring of the amount of hospice comfort medications remaining, including the Lorazepam Intensol 2 mg/ml, (which was projected to “run out” on 07/28/2025). The investigation documentation identified that Patient #1 did not receive a nursing visit as scheduled on 7/26/25 but was seen on 07/29/2025 (3 days later) by Hospice RN #2 due to a schedule change as a result of agency staffing. The nursing documentation of 7/29/25 identified at the time of the nursing visit, the Patient was found to be in a highly combative, agitated state and was striking staff during care. Review of a nursing visit note dated 07/31/2025, identified Patient #1 was alert, irritable and angry. The patient was hallucinating, striking staff, declining meals and medications and had increased agitation and anxiety. The SNF staff identified a request for a psychiatric provider evaluation due to the increase in Patient’s behaviors. RN #1 placed a call to the hospice’s medical director to report the Patient’s behavior, with no change in the Patient’s orders identified. Review of the nursing visit note did not identify any other assessments or interventions were completed as a result of a change in condition, and the 12 missed doses of the scheduled Lorazepam Intensol 2mg/ml medication from 7/26/25 to 7/28/25. The investigation identified that on 07/22/2025, the pharmacy documentation identified the Patient’s medications had been delivered to the SNF, but during a subsequent pharmacy record review it was found that only two (2) of the three (3) medications were delivered to the SNF, the Fentanyl patches, and Morphine Concentrate, not the Lorazepam Intensol, as had been previously reported to the SNF staff. The Hospice agency documentation further identified the hospice agency’s physician/MD advised they would no longer prescribe the Patient’s routine and controlled substance medications in the hospice comfort medications, therefore, on 08/04/2025 the skilled nursing facility appropriated (took control) of the prescribing, administration, reordering and counting of the controlled substances within the hospice comfort medications along with the Patient’s routine medication.Interview and review of Patient #1’s clinical record with Supervisor of Clinical Services (SCS #1) on 08/28/2025 at 11:00 AM, identified Patient #1 resided at a SNF, and the facility had a history of not ordering the patient’s comfort medication timely. On 7/9/25 the hospice agency assumed control and management for the hospice comfort medication including the counting of the controlled substances, and the reordering of the Lorazepam Intensol 2mg/ml. SCS #1 further identified the nursing visit scheduled for 7/26/25 was not completed and was rescheduled for 7/29/25 (2 days after the projected Lorazepam Intensol 2mg/ml depletion), due to a staffing issue, which resulted in a delay in a review of the patient’s meds, the reordering of the necessary medication and the subsequent medication depletion and 12 missed doses of medication. Interview with the Hospice Program Director on 08/28/2025 at 11:45 AM, identified the hospice agency was responsible for the Patient’s hospice comfort medications from 7/9/25 through 8/4/25, which was atypical. The Hospice Program Director identified that typically a SNF patient’s hospice comfort medications were ordered by the Hospice Medical Director, administered by the SNF nursing staff and reordered by the SNF. Additionally, the SNF nursing staff would perform controlled substance counts of the hospice comfort medications. The Hospice Program Director identified on two (2) separate occasions the SNF failed to reorder the Patient’s Lorazepam Intensol, therefore, on 07/09/2025 the hospice agency assumed control over prescribing, reordering and performing the controlled substance counts of the hospice comfort medications upon each visit.The Hospice Director further identified as a result of the hospice agency personnel rescheduling the nursing visit from 7/26/25 to 7/29/2025, the patient experienced a lapse in the medication availability from 7/26/25 to 7/28/2025, a 72 hour period, 12 doses of Lorazepam (Intersol) and failed to identify the hospice agency provided professional management and oversight for the timely reordering and delivery of the patients controlled medications for the effective management of pain and symptom control of a terminal illness. Review of Patient #1’s hospice plan of care dated 05/31/2025 -7/29/25 identified no revisions/notations to reflect the hospice agency’s responsibility for assuming control of the patient’s hospice comfort medications as of 07/09/2024 from the SNF.Review of the hospice agency’s protocol for the provision of routine and respite hospice level of care services, between Masonicare Home Health Care and Hospice Inc. and New London Health and Rehab. dated 10/22/2024, identified the hospice agrees to provide all drugs and pharmaceuticals related to the management of the terminal illness and related conditions which are specified in the hospice plan of care. Hospice assumes responsibility for professional management of the resident’s hospice services provided in accordance with the hospice plan. The hospice and the skilled nursing facility or the home agree to communicate, establish and agree upon a coordinated plan of care that reflects hospice philosophies. The staff of the hospice and the skilled nursing facility would work together to ensure that ordering, renewal, delivery and administration of medications to each hospice patent was achieved in such a way to assure optimal symptom relief and minimal delay.”

“Based on clinical record review, review of agency documentation and interviews with hospice personnel, for one of three patients (Patient #1) who received hospice services, the hospice agency failed to manage the patient’s pain and symptoms related to the terminal illness in a timely manner. The findings include: Patient #1 elected the hospice benefit on 4/21/25 with diagnoses of end stage liver disease, hepatic cirrhosis and ascites. The physician’s orders dated 4/21/25 included nursing services three times weekly for assessments and management of the left abdominal drain three times a week, home health aide services, social work and chaplain services. Physician’s orders included Hydromorphone 2 milligrams/mg by mouth three times a day for pain, Hydromorphone 1 milligram/milliliter (mg/ml) take 1ml by mouth every four hours as needed for pain, Atropine 1 % drops, 2 drops sublingually every two hours as needed for terminal secretions and Haloperidol Lactate 2mg/ml, take 0.5 ml by mouth every six hours as needed for agitation. Review of agency documentation dated 5/22/25 identified a concern from the next of kin indicating that Patient #1 suffered the last day of life, medications ran out, the Hospice nursing visit was delayed after a reported change in condition by the family and the family identified they did not feel supported by the Hospice team. Review of Registered Nurse/RN #1’s on-call communication note dated 5/22/25 at 5:09 AM indicated receiving a call from the spouse concerning increased bronchial congestion, with recommendations to administer atropine drops and a plan to have an on-call nurse visit for symptom management. On 5/22/25 at 5:31 AM, RN #2 conducted an on-call visit and documented that the patient was actively dying, moaning, restless, dyspneic at rest with labored breathing and mild congestion. RN #2 documented administering Haloperidol, Hydromorphone and Atropine drops with good effect and educated the spouse and next of kin on signs and symptoms of dying and repositioning of patient to alleviate secretions. Upon her departure, at 5:47 AM, the patient was resting comfortably. At approximately 7:45 AM, RN #2 received two additional calls from the spouse indicating symptoms of increased secretions, respirations and moaning had returned. RN #2 called MD #1 and Hydromorphone was increased to 6 mg every six hours around the clock for pain or shortness of breath, Lorazepam Intensol 2mg/ml, take 1 ml every 2 hours for anxiety and Haloperidol Lactate 2mg/ml, take 1 mg by mouth every six hours as needed for agitation. The medication orders were faxed to the Hospice pharmacy STAT at 8 AM (to be delivered within 4 hours). The spouse was notified of the updated medication orders, and a follow up nursing visit was requested. Interview and review of the Hospice pharmacy medication delivery receipt with the Hospice Program Director on 8/11/25 at 2:18 PM indicated that the medication receipt verified that the medications were delivered to the patient’s home at 11:38 AM, but identified that the medications should have been ordered through the local pharmacy to ensure faster delivery to the patient residence and failed to ensure timely pain and symptom management.Patient #1 was pronounced on 5/22/25 at 12:39 PM by RN #3.”

“Based on clinical record reviews, review of agency policies, interviews with hospice personnel and review of agency documentation, for one of three patients (Patient #1) in the survey sample, the hospice nurse failed to provide the necessary assessment. The findings include: Patient #1 elected the hospice benefit on 4/21/25 with diagnoses of end stage liver disease, hepatic cirrhosis and ascites. The physician’s orders dated 4/21/25 included nursing services three times weekly for assessments and management of the left abdominal drain three times a week, home health aide services, social work and chaplain services. Review of agency documentation dated 5/22/25 identified a concern from the next of kin indicating that Patient #1 suffered the last day of life, the requested nursing visit was delayed after a reported change in condition and the nurse inaccurately completed the death certificate. Review of RN #1’s on-call communication note dated 5/22/25 at 5:09 AM indicated receiving a call from the spouse concerning increased bronchial congestion, with recommendations to administer atropine drops and a plan to have on-call nurse visit for management. On 5/22/25 at 5:31 AM, RN #2 conducted an on-call visit and documented that the patient was actively dying, moaning, restless, dyspneic at rest with labored breathing and mild congestion. RN #2 documented administering Haloperidol, Hydromorphone and Atropine drops with good effect and educated the spouse and next of kin on signa and symptoms of dying and repositioning to alleviate secretions. Upon her departure, at 5:47 AM, the patient was resting comfortably. At approximately 7:45 AM, RN #2 received two calls from the spouse indicating symptoms of increased secretions, respirations and moaning had returned. RN #2 called MD #1 and Hydromorphone was increased to 6 mg every six hours around the clock for pain or shortness of breath, Lorazepam Intensol 2mg/ml, take 1 ml every 2 hours for anxiety and Haloperidol Lactate 2mg/ml, take 1 mg by mouth every six hours as needed for agitation. The medication orders were faxed to the Hospice pharmacy STAT at 8 AM (to be delivered within 4 hours). The spouse was notified of the updated medication orders, and a follow up nursing visit was requested. Review of the agency timeline documentation dated 5/22/25 identified at 8:03 AM, RN #3 was notified of the need to visit Patient #1 as soon as possible (ASAP), which was confirmed by RN #3 at 8:34 AM. At 9 AM, Licensed Practical Nurse/LPN #1, who visited the patient frequently prior to 5/22/25, reported to RN #3 that she received a call from the next of kin that the patient was uncomfortable and may need continuous care. At 11 AM, the Hospice Program Director reassigned LPN #1 to the visit. . At 11:13 AM, the visit was removed from RN #3’s assignment to LPN #1’s assignment. Upon LPN #1 arrival at the residence, a review of the patient’s communication notes was conducted and indicated that the patient had passed away while LPN #1 was in transit to the patient residence. LPN #1 notified the Hospice Program Director and at 12:02pm RN #3 was notified of the patient’s passing. Subsequently RN # 3 had arrived at the patient’s residence and was parked in the driveway, not entering the home until 12:26 PM. Interview with RN #3 on 8/12/25 at 11:19 AM identified never seeing the text from the office to visit Patient #1 “ASAP” (as soon as possible), and indicated that he/she already had Patient #1 on his/her visit schedule but was enroute to visit patients in the skilled nursing facility first, and would see Patient #1 after. RN # 3 further identified that he/she arrived at Patient #1’s home at 12:02 PM and was delayed in entering the patient’s home until 12:26PM as he/she was on the phone in the driveway with the Hospice educator reviewing the pronouncement visit documentation process prior to entering the patient’s home. Patient #1 was pronounced on 5/22/25 at 12:39 PM by RN #3. Interview and review of the agency documentation with the Hospice Program Director on 8/11/25 at 1:30 PM indicated that RN #3 should have seen Patient #1 as soon as she was notified on 5/22/25 at 8:03am of the urgent visit, but failed to ensure the timely arrival, assessment and management of the patients symptoms and families end of life needs. Review of agency policy for Hospice and Palliative Care Specialty Registered Nurse, directed ensure quality and safe delivery of hospice and palliative nursing services and can be depended upon to report to work on time.”

“Based on clinical record reviews, review of agency policies, interviews with hospice personnel and review of agency documentation, for one of three patients (Patient #1) in the survey sample, the hospice nurse failed to ensure a complete and accurate record. The findings include: Patient #1 elected the hospice benefit on 4/21/25 with diagnoses of end stage liver disease, hepatic cirrhosis and ascites. The physician’s orders dated 4/21/25 included nursing services three times weekly for assessments and management of the left abdominal drain three times a week, home health aide services, social work and chaplain services. Review of agency documentation dated 5/22/25 identified a concern from the next of kin indicating that Patient #1 suffered the last day of life, the requested nursing visit was delayed after a reported change in condition and the nurse inaccurately completed the death certificate. Review of RN #3’s personnel file identified documentation dated 5/27/25 from Patient #1’s Funeral Home Director that RN #3 did not affirm/certify the death certificate (a box is on the death certificate to be checked off by the pronouncing nurse) and noted the wrong “Cause of Death” thus holding up the cremation of the patient. Interview and review of the agency documentation with the Hospice Program Director on 8/11/25 at 1:30 PM indicated that RN #3 failed to ensure accurate and complete information was documented on the death certificate. Review of agency policy for Hospice and Palliative Care Specialty Registered Nurse directed demonstrates timely and accurate computer documentation of patient information.”