Constellation Home Care

“Based on clinical record reviews, agency documentation and staff interviews, for one of three patients reviewed, (Patient #1) the hospice agency failed to assign a registered nurse/RN as a member of the interdisciplinary group, and failed to provide supervisory oversight for the coordination and management of all services provided. The findings include: Patient #1 elected the Hospice Benefit on 7/09/25 and resided at home. The patient’s diagnoses included end stage heart failure, chronic kidney disease, and adult failure to thrive. The physician’s orders dated 7/09/25 included nursing services one time weekly for thirteen weeks and eighteen as needed visits for assessments and pain management, hospice aide services three times a week for assistance with personal care and a medical social worker/MSW evaluation.Physician’s orders included Morphine oral concentrate 20 milligrams/ ml (mg/ml) give 0.25 ml every three hours as needed for mild to moderate pain or shortness of breath and 0.5 ml for severe pain or shortness of breath, Lorazepam 0.5 mg every four hours as needed for anxiety and agitation and Haldol 2mg/ml, give 0.5 ml every three hours as needed for agitationReview of RN #5 ‘s nursing note dated 7/13/26 at 9:45 AM indicated that the patient was observed with physical and mental decline. The family reported that the patient was agitated and anxious during the night, using accessory muscles for breathing and had audible wheezes throughout the lungs. The patient received Morphine Sulfate liquid 10 milligrams/0.5 ml (mg/ml) every three hours, Lorazepam 0.5 mg every three hours and Haldol 0.5 milliliters every three hours with little effect. The physician/MD #1 was notified and Morphine was increased to 0.5 ml every four hours and every three hours as needed for pain or shortness of breath, Lorazepam 1 mg every four hours and every three hours as needed for anxiety, the family was educated on the new orders and the on-call RN #6, in collaboration with RN #5, indicated that Continuous Care will be initiated that evening at 8 PM.On 7/13/25 at 8 PM, Licensed Practical Nurse/LPN #1 was assigned the 8 PM to 8 AM shift and sent an electronic mail/email on 7/14/25 at 8:07 AM to the Supervisor of Clinical Services/SCS and RN #5 indicating that Person #1 expressed much frustration with care since 7/09/25 and indicated that Patient #1 was never assigned a “regular primary nurse” (Case Manager) and wanted to know if RN #5 was the patient’s Case Manager.Review of the Electronic Medical Record/EMR with the Administrator and Hospice Program Director on 5/27/26 at 9:50 AM indicated documentation of the assignment of RN #1’s as Patient #1’s Case Manager, although, the Administrator indicated that RN #1 was on family leave, and would not have been the Case Manager assigned for the area that Patient #1 lived. Interview and review of the email sent on 7/14/26 by LPN #1 with the SCS on 5/28/26 at 11:09 AM indicated, she would have assigned a Case Manager to the patient after seeing the email, but never followed up on the concern. The SCS indicated for every new patient admission, it is the responsibility of the Team Assistant and/or Supervisor for assigning a primary nurse/Case Manager to the patient.Interview and review of the agency documentation with the Administrator and Hospice Program Director on 5/28/26 at 12:25 PM did not ensure the assignment of a Case Manager for to the patient, and failed to ensure supervisory oversight for the coordination and management of all care and services provided to the hospice patient. Review of agency policy for Care/Service Coordination directed each patient will be assigned a Case Manager upon admission by the Clinical Director or Clinical Supervisor. It will be the responsibility of the Case Manager to facilitate communication about changes to the patient status among assigned personnel. The name of the Case Manager will be clearly documented in the clinical record.Review of agency job description for Clinical Supervisor directed the clinical supervisor id responsible for ensuring that patient care is coordinated and managed appropriately. Responsibilities include, in part, receiving case referrals and assigning appropriate hospice personnel to a case as needed.Review of the agency job description for Team Assistant directed the team assistant will be responsible for providing clinical, clerical and administrative support necessary to ensure efficient delivery of care for the patients and staff of the home care interdisciplinary team. Performs patient centered scheduling duties, utilizing the scheduling system, and assigns cases to appropriate interdisciplinary team members.”

“Based on clinical record review, agency documentation and staff interviews, for one of three patients reviewed (Patient #2), the hospice aide failed to complete provide services as assigned. The findings include: Patient #2 elected the Hospice Benefit on 6/12/25 and resided at home. The patient’s diagnoses included malignant neoplasm of the ampulla of Vater and type II diabetes mellitus. The physician’s orders for the certification periods of 2/07/26 to 4/06/26 included nursing services one to two times weekly for assessments and pain management and hospice aide services six to seven times a week for one hour, 9-10 AM, to assist with personal care, companionship and care giver relief.Review of agency documentation dated 5/14/26 identified a concern from the family that Hospice aide #2 only stayed 20 minutes on Saturday 4/11/26 and “did not show” on 4/12/26, as assigned.Review of the clinical record identified missed hospice aide visits on 4/11/26 and 4/12/26.Interview and review of the clinical record with the Hospice Program Director and Home Health Aide/HHA Supervisor on 5/27/26 at 2:40 PM indicated, upon investigation, Hospice Aide #2 documented a start to the visit on 4/11/26, but did not provide a close/end to the visit, and could not provide the visit was conducted. (yet she was there for 20 minutes according to the family) and never showed for her visit on 4/12/26. The HHA Supervisor indicated that she called the aide and left several messages without a return call. The aide was removed from the schedule and then terminated after not returning any calls. Review of the agency job description for Certified Hospice Aide directed the hospice aide is responsible for observing the patient, reporting these observations and documenting observations and care performed. Responsibilities include performing personal care needs after given a patient’s assignment and attending to his/her requests promptly. If unable to perform a certain task, report to the Case Manager immediately.”

“Based on clinical record reviews, agency documentation and staff interviews, for one of three patients reviewed (Patient #2) the hospice aide failed to report the changes in the care plan to the registered nurse. The findings include: Patient #2 elected the Hospice Benefit on 6/12/25 and resided at home. The patient’s diagnoses included malignant neoplasm of the ampulla of Vater and type II diabetes mellitus. The physician’s orders for the certification periods of 2/07/26 to 4/06/26 included nursing services one to two times weekly for assessments and pain management and hospice aide services six to seven times a week for one hour, 9-10 AM, to assist with personal care, companionship and care giver relief.Review of agency documentation dated 5/12/26 identified a concern from the family that on 4/11/26, Hospice aide #1 was scheduled for 9 AM but did not arrive at the patient’s home until 11:30 AM and only stayed 25 minutes. Person #2 was also upset that Hospice aide #1 was on her phone and texting when she arrived and never bathed the patient due to patient refusal.Review of the clinical record identified on 3/21/26, Hospice aide #1 arrived at 11:30 AM, 2.5 hours late (scheduled to arrive at 9 AM) and only stayed 25 minutes.Interview and review of the clinical record with the Hospice Program Director and Home Health Aide Supervisor on 5/27/26 at 2:30 PM indicated, upon investigation of Person #2’s concern, Hospice Aide #1 indicated that the patient refused personal care but after the family arrived, accepted the bed bath.Hospice aide #1 received verbal counseling for arriving 2.5 hours after the scheduled time without notifying a supervisor or the family, for not notifying a supervisor of the refusal of care, for not staying the hour and for being on her phone during patient care time. Review of agency Code of Ethics/Conduct directed examples of misconduct which may result in discipline up to and including discharge include violation of the company’s policies, poor attendance and leaving work premises during work time without permission.”

“Based on clinical record reviews, reviews of agency documentation and interviews with agency personnel, for one of three patients reviewed (Patient #1), the agency failed to ensure care and services were provided in accordance to the patient’s care plan. The findings include: Patient #1 elected the Hospice benefit on 2/02/26. Patient #1’s diagnoses included hypertensive heart disease with failure and stage IV pressure ulcer of the sacral region. Physician’s orders dated 2/02/26 included nursing services three times weekly, Mondays/Wednesdays/Fridays, for assessments and wound care to the stage IV sacral pressure ulcer, home health aide and chaplain services.Review of agency complaint documentation dated 2/17/26 identified a concern from the next of kin regarding the patient’s schedule for three times a week wound care and the delay in nursing services and a visit requests due to a change in condition. Review of the documentation identified a skilled nursing visit with wound care was completed on Monday 02/02/26, with the next nursing visits to be completed on 02/04/26 and 02/06/26. Review of the documentation indicated on 2/04/26 at 3:04 PM, the next of kin placed a call to the agency indicating a nurse had not called to schedule, or had performed a visit for that day. The next of kin indicated after two (2) additional calls to the agency, Registered Nurse/RN #6 called the next of kin at 5:42 PM and indicated s/he would send a nurse out to complete the visit. Documentation identified on 2/4/26 at 9:15 PM, RN #1 arrived at the patient’s home and provided wound care to the patient. Agency documentation identified that the next skilled nursing visit was due 2/6/26, but review of the patients’ schedule showed no skilled visits were scheduled and an agency communicated was sent by RN #1 to make sure they added someone to the patient’s schedule to perform a visit. Review of the visit notes of 2/5/26 identified a nursing visit and wound care were performed, with the next nursing visit scheduled for Monday 2/9/26. The next of kin indicated questioning the nurse regarding a 4 day delay in wound care, and being told the nurse could teach the aide to perform the care on 2/7/26, which was performed.Interview and review of the clinical record with the Administrator and Hospice Program Director on 3/10/26 at 10:15 AM indicated that nursing visits should have been scheduled for Monday, Wednesday and Friday as indicated on the physician’s orders and agency personnel failed to follow the physician certified plan of care.Review of agency policy for Plan of Care directed all clinical services are provided only in accordance with a plan of care established by a physician’s written orders. The plan of care is based on assessment of the patient’s immediate and long-term needs and must include treatment orders and patient treatment goals.”

“Based on clinical record review, review of agency documentation and staff interviews, for one of three patients reviewed (Patient #1), the agency licensed personnel failed to complete the assigned provision of care to meet the patient’s needs, and failed to follow the agency expectations/policies for on-call services. The findings include: Patient #1 elected the Hospice benefit on 2/02/26. Patient #1’s diagnoses included hypertensive heart disease with failure and stage IV pressure ulcer of the sacral region. Physician’s orders dated 2/02/26 included nursing services three times weekly for assessments and wound care to the stage IV sacral pressure ulcer, home health aide and chaplain services.a. Review of agency documentation dated 2/17/26 identified a concern from the next of kin regarding the patients nursing services scheduled three times a week for wound care. On 2/04/26 at 3:04 PM, s/he placed a call to the agency indicating a nurse had not called, or completed a visit that day. At 5:42 PM, RN #6 called the next of kin back and indicated s/he would send a nurse. At 9:15 PM, RN #1 arrived at the patient’s home and provided wound care.Interview and review of the clinical record and the next of kins concern with the Administrator and Hospice Program Director on 3/10/26 at 10:25 AM indicated that the agency expectation for on-call nursing visits is an arrival time within one (1) hour from the request and indicated that RN #1 did failed to follow the agency expectations.b. On 2/14/26 at 12:10 PM, the next of kin indicated that the patient’s breathing had become more labored and his/her oxygen level was fluctuating and placed a call to the agency. RN #4 returned the call to the next of kin, and instructed him/her to increase the oxygen flow to 3.5-4 liters, and indicated a nurse (RN #1) would be sent to check on the patient’s status. The documentation indicated that no nursing staff performed a visit, or called the next of kin for a follow up assessment.Interview with RN #1 on 3/10/26 at 11:32 AM indicated that there was a miscommunication concerning which nurse was going to see Patient #1. RN #1 stated they were in a different area and requested the visit be reassigned to another nurse.Interview and review of the next of kins concern with the Administrator and Hospice Program Director on 3/10/26 at 11:45 AM indicated that the visit was assigned to RN #1, and s/he should have conducted the visit as scheduled, and failed to follow the agency expectation for the visit completion. On 2/15/26 at 8:50 AM, the next of kin indicated the patient had become more agitated, moving arms about and moaning. The agency was called at 8:57 AM, RN #5 instructed the next of kin to administer two Lorazepam (anti-anxiety medication) tablets and a nurse would be sent to check on the patient. The documentation indicated the next of kin called the agency a second time, spoke with RN #4 and informed her that a nurse had not shown up yet. At 5 PM, RN #5 called the next of kin and indicated she was enroute to evaluate the patient, arriving at 5:40 PM (approximately 8 hours after the initial call).Interview and review of the next of kins concern with the Administrator and Hospice Program Director on 3/10/26 at 10:25 AM indicated that the nursing staff did not adhere to the agency expectation for on-call nursing visit arrival time of within one hour, and indicated the patient did not receive a timely response from the on-call agency staff. Review of agency On Call policy directed all calls to the agency outside the usual hours of office operation are referred to a telephone answering service. The answering service takes a message from the caller and calls the on-call scheduling coordinator. The on-call scheduling coordinator will return any calls pertaining to clinical issues with direct verbal contact to the caller. Return calls are expected within thirty minutes.”

“Based on clinical record review, review of agency documentation and staff interviews for one of three patients reviewed (Patient #1) the agency failed to ensure completion of a nursing note after a visit was conducted. The findings include: Patient #1 elected the Hospice benefit on 2/02/26. Patient #1’s diagnoses included hypertensive heart disease with failure and stage IV pressure ulcer of the sacral region. Physician’s orders dated 2/02/26 included nursing services three times weekly for assessments and wound care to the stage IV sacral pressure ulcer, home health aide and chaplain services. Review of agency documentation dated 2/17/26 identified a concern from the next of kin regarding nursing services scheduled three times a week for wound care. On 2/04/26 at 3:04 PM, the next of kin placed a call to the agency indicating a nurse had not called to schedule a visit that day. At 5:42 PM, RN #6 called the next of kin indicating that s/he would send a nurse to complete a visit. At 9:15 PM, RN #1 arrived at the patient’s home conducted a nursing visit and provided wound care. Review of the clinical record documentation did not identify completion of the 2/04/26 nursing visit and wound care completion. Interview with RN #1 on 3/10/26 at 10:04 AM indicated that she conducted the nursing visit on 2/04/26 at 9:15 PM but forgot to write a note. Interview and review of the agency documentation and clinical record with the Administrator and Hospice Program Director on 3/10/26 at 10:25 AM indicated that all clinical notes should be completed after the visit completion and the agency staff failed to follow agency policies. Review of agency policy for Patient Record Management directed personnel will participate in preparation of the plan of care/service: submit weekly documentation of services provided including clinical notes, schedule of visits and patient evaluations/assessments and participate in case conferences when a patient in their caseload is being discussed.”

“Based on clinical record reviews, interviews with hospice agency personnel, review of agency documentation and hospice agency policies, for one of nine patients (Patient #14) in the survey sample who received hospice services, the Hospice agency failed to provide timely and effective management of a patient’s symptoms related to the terminal illness. The findings include: Patient #14 elected the hospice benefit on 04/09/2025 with diagnoses of liver cell carcinoma, chronic obstructive pulmonary disease, congestive heart failure, chronic kidney disease, type two diabetes, anxiety and resided in a skilled nursing facility. The physician orders for the certification period of 04/09/2025 to 7/9/2025 identified hospice nursing visits one to two times per week for the assessment and management of symptoms of the terminal illness. Additionally, the Patient would receive home health aide services for assistance with activities of daily living, social work, and pastoral services. Review of the nursing start of care assessment summary dated 04/09/2025, identified Patient #14 had a wound to the dorsal portion of the right foot. Review of Hospice Registered Nurse (RN) #1’s nursing note dated 04/17/2025, identified Patient #14 was seen for a scheduled nursing visit at the skilled nursing facility, he/she was received in bed with his/her eyes closed, no response to verbal or physical stimuli, presented with increased lethargy, wheezing was heard to the right and left upper lung fields and skin was intact. Hospice RN #1 recommended increasing the frequency of Morphine 0.25 milliliters (ml) from every six hours as needed for pain and/or shortness of breath to every four hours. Review of a text message communication from Patient #14’s caregiver to Hospice RN #1 dated 04/19/2025 at 06:34 AM, identified Patient #14 was experiencing increased secretions. Hospice RN #1 directed the Patient’s caregiver to call the hospice agency’s on-call nurse who was available all weekend and off hours. Review of Hospice RN #2’s on-call communication note dated 04/19/2025 at 3:32 PM, identified Patient #14’s caregiver called the hospice agency’s on-call service at 3:32 PM, reported the Patient had drained copious amounts of secretions today and continued to have increased secretions draining from his/her mouth. Hospice RN #2 provided education on repositioning the Patient and planned a hospice nurse visit for 04/19/2025. Review of Hospice RN #2’s nursing note dated 04/19/2025, identified he/she arrived at the skilled nursing facility at 9:00 PM (five hours and twenty-eight minutes after Patient #14’s caregiver initially contacted the hospice agency) and received Patient #14 lying in bed in a supine position. Hospice RN #2 indicated that the Patient had no response to physical or verbal stimuli, presented with oral congestion and had swelling to the abdomen and right hand secondary to the accumulation of bodily fluids. Hospice RN #2 recommended adding an additional Scopolamine patch (a transdermal patch indicated to reduce saliva secretion) to the Patient. Patient #14 was scheduled for a follow-up visit on 04/20/2025. Review of the hospice agency’s on-call communication notes dated 04/20/2025 at 07:03 AM, identified the skilled nursing facility notified the hospice agency that Patient #14 had passed away. Interview with Hospice RN #2 on 04/24/2025 at 1:06 PM, identified he/she received a call from Patient #14’s caregiver on 04/19/2025 at 3:32 PM related to the Patient’s increased secretions. Hospice RN #2 indicated he/she provided education on repositioning the Patient, but the Patient’s caregiver declined to have the Patient repositioned as it caused pain and distress. Hospice RN #2 identified visiting Patient #14 on 04/19/2025 at 9:00 PM and indicated that the Patient had oral congestion. The Patient’s caregiver declined repositioning the Patient due to pain from opened wounds to his/her buttocks area and declined an assessment of the Patient’s skin. Hospice RN #2 recommended applying a second Scopolamine patch to the Patient and scheduled a nursing visit for 04/20/2025. Interview and review of Patient #14’s clinical record with the Director of Hospice on 04/24/2025 at 1:30 PM, failed to identify the hospice agency provided Patient #14 with a timely nursing visit on 04/19/2025 (five hours and twenty-eight minutes after Patient #14’s caregiver initially contacted the hospice agency at 3:32 PM to report a change in Patient #14’s condition) to ensure effective symptom management of the terminal illness. Review of the agency’s Inpatient Services Agreement identified hospice would retain responsibility for coordinating, evaluating and administering the hospice program, as well as ensuring the continuity of care for hospice patients which would include coordination of inpatient services and evaluation of the care rendered by the facility. Review of the agency’s Care/Service Coordination policy identified the purpose of the policy was to ensure that timely and ongoing communication was the responsibility of each team member and would be appropriate to the needs and abilities of the patient, and relevant to the care/service provided. The clinician would be responsible for facilitating communications about changes in the patient’s status among the assigned personnel.”

“Based on clinical record review, review of agency policy and interview with hospice personnel, for two of twenty-seven patients (Patient #5 and #6) in the survey sample, the hospice nurses failed to follow the physician-certified plan of care. The findings include: Patient #5 had a hospice election date of 03/12/2025 with diagnoses that included sepsis due to right pyelonephritis, senile dementia, metabolic encephalopathy, hypertension and anemia. The physician’s orders for the certification period of 03/12/2025 to 06/09/2025 included nursing services two to three times per week for assessments, home health aide services five to seven times per week for assistance with personal care, Chaplin services for spiritual needs, and medical social work. Review of a nursing note for Patient #5 dated 03/12/2025, identified the Patient was admitted to hospice earlier that day and required an evening nursing visit to provide the Patient’s caregiver with nephrostomy tube management education. The Patient’s caregiver was able to return demonstrate the irrigation of the nephrostomy tube with ten milliliters (ml) of saline. Interview and review of Patient #5’s clinical record with the Director of Hospice on 04/24/2025 at 12:30 PM, identified the Patient’s caregiver irrigated the nephrostomy tube, but failed to identify an initial physician’s order for the irrigation and dressing change of the nephrostomy tube was included in the Patient’s care plan dated 03/12/2025. The Director of Hospice further, identified a verbal order was obtained on 04/10/2025 which included a right nephrostomy dressing change every week and flush with 10 cc of normal saline weekly by the clinician or caregiver. Review of the agency’s Patient Plan of Care policy identified the plan of care would include the Patient’s treatment orders and patient/caregiver teaching needs. Patient #6 elected the Hospice benefit on 4/05/25. The patient’s diagnoses included hypertensive heart disease with failure, left lower extremity wounds and peripheral vascular disease. Physician’s orders dated 4/05/25 included nursing services one to two times a week for assessments and wound care to the left lower extremities distal lateral calf wound and medial shin wound using Medi-honey and kerlix wrap every other day, home health aide services one to two times a week, social worker, chaplain and volunteer services.Patient #6 resided in a skilled nursing facility/SNF.Interview and review of the nursing notes from 4/06/25 to 4/22/25 (6 visits) with the Director of Hospice on 4/24/25 at 10 AM failed to identify wound care was provided in accordance with physician’s orders.”

“Based on clinical record reviews, interviews with hospice agency personnel, review of agency documentation and hospice agency policies, for one of nine patients (Patient #14) in the survey sample who received hospice services, the Hospice agency failed to provide timely and effective management of a patient’s symptoms related to the terminal illness and failed to follow the agency’s comprehensive assessment policy following a change in condition. The findings include: Patient #14 elected the hospice benefit on 04/09/2025 with diagnoses of liver cell carcinoma, chronic obstructive pulmonary disease, congestive heart failure, chronic kidney disease, type two diabetes, anxiety and resided in a skilled nursing facility. The physician orders for the certification period of 04/09/2025 to 7/9/2025 identified hospice nursing visits one to two times per week for the assessment and management of symptoms of the terminal illness. Additionally, the Patient would receive home health aide services for assistance with activities of daily living, social work, and pastoral services. Review of the nursing start of care assessment summary dated 04/09/2025, identified Patient #14 had a wound to the dorsal portion of the right foot. Review of Hospice Registered Nurse (RN) #1’s nursing note dated 04/17/2025, identified Patient #14 was seen for a scheduled nursing visit at the skilled nursing facility, he/she was received in bed with his/her eyes closed, no response to verbal or physical stimuli, presented with increased lethargy, wheezing was heard to the right and left upper lung fields and skin was intact. Hospice RN #1 recommended increasing the frequency of Morphine 0.25 milliliters (ml) from every six hours as needed for pain and/or shortness of breath to every four hours. Review of a text message communication from Patient #14’s caregiver to Hospice RN #1 dated 04/19/2025 at 06:34 AM, identified Patient #14 was experiencing increased secretions. Hospice RN #1 directed the Patient’s caregiver to call the hospice agency’s on-call nurse who was available all weekend and off hours. Review of Hospice RN #2’s on-call communication note dated 04/19/2025 at 3:32 PM, identified Patient #14’s caregiver called the hospice agency’s on-call service at 3:32 PM, reported the Patient had drained copious amounts of secretions today and continued to have increased secretions draining from his/her mouth. Hospice RN #2 provided education on repositioning the Patient and planned a hospice nurse visit for 04/19/2025. Review of Hospice RN #2’s nursing note dated 04/19/2025, identified he/she arrived at the skilled nursing facility at 9:00 PM (five hours and twenty-eight minutes after Patient #14’s caregiver initially contacted the hospice agency) and received Patient #14 lying in bed in a supine position. Hospice RN #2 indicated that the Patient had no response to physical or verbal stimuli, presented with oral congestion and had swelling to the abdomen and right hand secondary to the accumulation of bodily fluids. Hospice RN #2 recommended adding an additional Scopolamine patch (a transdermal patch indicated to reduce saliva secretion) to the Patient. Patient #14 was scheduled for a follow-up visit on 04/20/2025. Review of the hospice agency’s on-call communication notes dated 04/20/2025 at 07:03 AM, identified the skilled nursing facility notified the hospice agency that Patient #14 had passed away. Interview with Hospice RN #2 on 04/24/2025 at 1:06 PM, identified he/she received a call from Patient #14’s caregiver on 04/19/2025 at 3:32 PM related to the Patient’s increased secretions. Hospice RN #2 indicated he/she provided education on repositioning the Patient, but the Patient’s caregiver declined to have the Patient repositioned as it caused pain and distress. Hospice RN #2 identified visiting Patient #14 on 04/19/2025 at 9:00 PM and indicated that the Patient had oral congestion. The Patient’s caregiver declined repositioning the Patient due to pain from opened wounds to his/her buttocks area and declined an assessment of the Patient’s skin. Hospice RN #2 recommended applying a second Scopolamine patch to the Patient and scheduled a nursing visit for 04/20/2025. Interview and review of Patient #14’s clinical record with the Director of Hospice on 04/24/2025 at 1:30 PM, failed to identify the hospice agency provided Patient #14 with a timely nursing visit on 04/19/2025 (five hours and twenty-eight minutes after Patient #14’s caregiver initially contacted the hospice agency at 3:32 PM to report a change in Patient #14’s condition) to ensure effective symptom management of the terminal illness and failed to identify Hospice RN #2 had documented the caregiver’s report of wounds to the Patient’s buttocks area. Review of the agency’s Initial and Comprehensive Assessment policy, identified a comprehensive assessment would occur at the initial start of care and for a significant change in condition which would determine a patient’s problems, needs and care preferences. Review of the agency’s Inpatient Services Agreement identified hospice would retain responsibility for coordinating, evaluating and administering the hospice program, as well as ensuring the continuity of care for hospice patients which would include coordination of inpatient services and evaluation of the care rendered by the facility. Review of the agency’s Care/Service Coordination policy identified the purpose of the policy was to ensure that timely and ongoing communication was the responsibility of each team member and would be appropriate to the needs and abilities of the patient, and relevant to the care/service provided. The clinician would be responsible for facilitating communications about changes in the patient’s status among the assigned personnel.”

“Based on clinical record review, review of agency policies and interviews with the agency personnel, for two of sixteen (Patients #7 and #18) sampled patients who received nursing and home health aide services, the hospice agency failed to complete home health aide supervisions no less frequently than every fourteen (14) days to assess the quality of care and services provided by the home health aide. The findings include: Patient #7 elected the Hospice benefit on 2/21/25. The patient’s diagnoses included Parkinson’s disease, dementia, hypertension, stage III pressure ulcer of the coccyx and atrial fibrillation. Physician’s orders dated 2/21/25 included nursing services one to two times a week for assessments and wound care to the coccyx cleansing with normal saline followed by Santyl ointment and a clean dry dressing daily, home health aide services one to two times a week for grooming and assistance with activities of daily living, social worker and chaplain services.Interview and review of the clinical record from 2/21/25 to 4/22/25 with the Director of Hospice on 4/24/25 at 11:30 AM identified home health aide services were increased on 3/17/25 to four to five times a week but failed to identify documentation of any home health aide supervisions by the Registered Nurses/RN’s every fourteen days to assess quality of care and services provided by the home health aides. Review of agency policy for home health aide supervisions directed the frequency of supervisory visits will be based upon the needs of the patient but no less frequently than every fourteen days by the RN or Therapist. Patient #18 elected the Hospice benefit on 2/13/25 for start of care on 2/14/25. The patient’s diagnoses included Parkinsonism, Alzheimer’s disease, vascular dementia, hypertension, diabetes mellitus, and epilepsy. Physician’s orders dated 2/14/25 included nursing services one to two times a week for assessments and evaluations, home health aide services two to three times a week for grooming and assistance with activities of daily living, social worker and chaplain services.Patient #18 resided in a skilled nursing facility/SNF.Interview and review of the clinical record from 2/14/25 to 4/22/25 with the Director of Hospice on 4/24/25 at 12:00 PM identified home health aide services were received two to three times a week but failed to identify documentation of any home health aide supervisions by the Registered Nurses/RN’s every fourteen days to assess quality of care and services provided by the home health aides.”

“Based on clinical record reviews, reviews of agency policies and interviews with hospice personnel for two of ten patients (Patient’s # 1 & # 6), who resided in a Skilled Nursing Facility, the Hospice agency failed to maintain professional management of the Hospice care. The findings include: Patient #6 elected the Hospice benefit on 4/05/25. The patient’s diagnoses included hypertensive heart disease with failure, left lower extremity wounds and peripheral vascular disease. Physician’s orders dated 4/05/25 included nursing services one to two times a week for assessments and wound care to the left lower extremities distal lateral calf wound and medial shin wound using Medi-honey and kerlix wrap every other day, home health aide services one to two times a week, social worker, chaplain and volunteer services.Patient #6 resided in a Skilled Nursing Facility/SNF.Interview and review of the nursing notes from 4/06/25 to 4/22/25 (6 visits) with the Director of Hospice on 4/24/25 at 10:15 AM identified on 4/06/25 and 4/07/25 the patient refused wound care, on 4/11/25, 4/14/25, 4/18/25 and 4/22/25 no wound care was documented and failed to ensure professional management of the wound care and coordination with the SNF nurses to ensure the hospice nurses’ performance of wound care and measurements at least once weekly to evaluate effectiveness of the treatment ordered. Review of the agency policy for Wound Assessment directed wounds will be assessed during each skilled visit with measurement of the wound done weekly unless acute changes are noted and then, more frequently including size of the wound, using a measuring tool, length x width x depth. Patient #1 had a hospice election date of 03/03/2025 with a diagnosis of senile degeneration of the brain. The physician’s orders for the certification period of 03/03/2025 to 05/01/2025 included nursing services one to two times per week for assessments and wound care to stage two pressure ulceration to the midline medial buttocks which included cleansing with normal saline, pat dry, apply barrier cream followed by a protective foam dressing. Additionally, Patient #1 received home health aide services four to five times per week for personal care. Patient #1 resided in an Assisted Living Facility in the secured memory care unit. Interview and review Patient #1’s clinical record with the Director of Hospice on 04/24/2025 at 12:55 PM, identified the Patient’s stage two pressure ulceration to the midline medial buttock was measured during the admission visit on 03/03/2025 but had not been measured weekly in accordance with the agency’s policies in seven weeks following the admission.”

“Based on clinical record review, review of agency policies and interview with the agency personnel, for four of four patients (Patient’s #1, #6, #7 & #12) requiring wound care, the agency licensed personnel failed to follow agency policies and the Regulations of Connecticut State Agencies. The findings include: a. Patient #6 elected the Hospice benefit on 4/05/25. The patient’s diagnoses included hypertensive heart disease with failure, left lower extremity wounds and peripheral vascular disease. Physician’s orders dated 4/05/25 included nursing services one to two times a week for assessments and wound care to the left lower extremities distal lateral calf wound and medial shin wound using Medi-honey and kerlix wrap every other day, home health aide services one to two times a week, social worker, chaplain and volunteer services.Patient #6 resided in a skilled nursing facility/SNF.Interview and review of the nursing notes from 4/06/25 to 4/22/25 (6 visits) with the Director of Hospice on 4/24/25 at 10:05 AM failed to identify weekly measurements of the patient’s wounds according to agency policies.b. Patient #7 elected the Hospice benefit on 2/21/25. The patient’s diagnoses included Parkinson’s disease, dementia, hypertension, stage III pressure ulcer of the coccyx and atrial fibrillation. Physician’s orders dated 2/21/25 included nursing services one to two times a week for assessments and wound care to the coccyx cleansing with normal saline followed by santyl ointment and a clean dry dressing daily, home health aide services one to two times a week, social worker and chaplain services.Interview and review of the nursing notes from 2/21/25 to 4/22/25 with the Director of Hospice on 4/24/25 at 11 AM failed to identify an initial measurement of the patient’s stage III coccyx wound and failed to identify a coccyx wound measurement the week of 3/02/25 according to agency policies. c. Patient #12 elected the Hospice benefit on 3/08/25. The patient’s diagnoses included lung cancer, Alzheimer’s disease, acute kidney failure and congestive heart failure. Physician’s orders dated 3/08/25 included nursing services one to two times a week for assessments and wound care to the stage III coccyx wound applying Triad paste twice daily and social worker services. Interview and review of the nursing notes from 3/08/25 to 4/16/25 with the Director of Hospice on 4/24/25 at 11:15 AM identified a stage II-III coccyx wound but failed to identify an initial measurement of the patient’s coccyx wound and failed to identify a coccyx wound measurement the weeks of 3/16/25, 3/23/25, 4/06/25 and on 4/16/25, the coccyx wound measurement of 0.5 centimeters/cm x 0.2 cm but failed to include a depth measurement according to agency policies. Review of the agency policy for Wound Assessment directed wounds will be assessed during each skilled visit with measurement of the wound done weekly unless acute changes are noted and then, more frequently including size of the wound, using a measuring tool, length x width x depth. Patient #1 had a hospice election date of 03/03/2025 with a diagnosis of senile degeneration of the brain. The physician’s orders for the certification period of 03/03/2025 to 05/01/2025 included nursing services one to two times per week for assessments and wound care to stage two pressure ulceration to the midline medial buttocks which included cleansing with normal saline, pat dry, apply barrier cream followed by a protective foam dressing. Additionally, Patient #1 received home health aide services four to five times per week for personal care. Patient #1 resided in an Assisted Living Facility in the secured memory care unit. Interview and review Patient #1’s clinical record with the Director of Hospice on 04/24/2025 at 12:55 PM, identified the Patient’s stage two pressure ulceration to the midline medial buttock was measured during the admission visit on 03/03/2025 but had not been measured weekly in accordance with the agency’s policies in seven weeks following the admission.”

“Based on clinical record reviews, interviews with agency personnel, review of agency documentation and Hospice agency policies, for one of two clients (Client #16) the Hospice agency failed to ensure effective management of a patients pain and symptoms of a terminal illness. The findings include: a. Patient #16 was admitted to Hospice services on 03/05/2024 with diagnoses that included, end-stage cirrhosis of the liver, chronic kidney disease, and coronary artery disease. Patient#16s Hospice plan of care dated 03/05/2024, identified Hospice nursing visits three times per week for one week and six to seven times per week for two weeks for the assessment and management of symptoms of the terminal illness. Additionally, the Patient would receive home health aide services three to four times per week for thirteen weeks for assistance with activities of daily living, Hospice Social Worker, and Pastoral services monthly. Review of Patient #16s hospital discharge summary dated 03/05/2024, identified the Patient was admitted to the hospital on 02/25/2024 with a diagnosis of acute cystitis with hematuria (blood in urine) and end-stage cirrhosis of the liver. During the Patients hospital admission, he/she received Valium 10 milligrams (mg) via intravenous (IV) push for anxiety, Haloperidol (Haldol) 1 mg via IV push for agitation, and Morphine 2 mg via IV push for pain. Patient #16 received the last dose of Morphine on 3/05/2024 and was discharged to home with Hospice services. Review of the Hospice agencys Hospital Liaison Registered Nurse (RN) #1s communication note dated 03/05/2024 at 10:17 AM, identified Patient #16s physician and responsible caregivers agreed to admit the Patient to Hospice services on 03/05/2024 with a terminal diagnosis of end-stage cirrhosis of the liver. Review of Patient #16s initial nursing visit note dated 03/05/2024 at 7:30 PM, identified Patient #16 was received at home in a hospital bed, lethargic and nonresponsive. RN #2 further identified the Patient appeared to be transitioning (actively approaching the end of life). RN #2 identified the comfort kit medications (Lorazepam 0.5 mg every six hours for anxiety/agitation, Morphine 0.25 ml every three hours for pain, Haldol 0.5 ml every six hours for agitation) would be ordered and delivered by the pharmacy. RN #2 failed to identify the Patients pain level and/or signs or symptoms of pain. Review of on-call Hospice RN #3s communication note dated 03/05/2024 at 8:31 PM, identified RN #2 contacted RN #3 to report the Patients responsible caregiver expected the comfort kit medications earlier that evening. RN #3 contacted the pharmacy who had not received an order for the Patients comfort kit medications. RN #3 ordered the comfort kit medications to be delivered to the Patients between 9:00 PM and 10:00 PM. Review of on-call Hospice RN #3s communication note dated 03/05/2024 at 9:47 PM, identified Patient #16s responsible caregiver contacted the Hospice to report the comfort kit medications had not arrived. Review of on-call Hospice RN #3s communication note dated 03/06/2024 at 02:58 AM, identified Patient #16 received the comfort kit medications but the Patient was in pain, agitated and the Morphine was ineffective. Review of on-call Hospice RN #3s communication note dated 03/06/2024 at 06:32 AM, identified Patient #16s responsible caregiver reported the Patient remained in pain and was agitated. RN #3 indicated a nursing visit was scheduled for later that morning. i. Interview and review of the agencys investigation with the Director of Hospice on 04/30/2024 at 12:45 PM, identified Hospital Liaison RN#1 verified she was to order Patient #16s comfort kit medications prior to his/her discharge from the hospital on 03/05/2024, but failed to submit the medication order with the pharmacy. Additionally, the Director of Hospice identified the agency failed to provide the Patient with a nursing visit after the responsible caregiver reported the Patient remained in pain on 03/06/2024 at 02:58 AM. Review of the Hospice agencys On-Call policy identified the on-call supervisor would be expected to utilize his/her professional nursing judgement for action taken on all requests for care outside of the agencys usual hours of operation. Review of the Hospice agencys Pain Assessment policy identified all patients would receive pain assessments. Pain assessments would be documented to facilitate regular reassessments and follow-up by the clinicians. The following in-depth pain assessment information would be obtained whenever possible, pain intensity using a rating scale of 0-10, location, onset, duration, variation, patterns, alleviating and aggravating factors, present pain management regimen and effectiveness. Review of the Hospice agencys Hospital Liaisons position description, identified the nurse liaison would be directly involved in managing the multiple elements that comprise a persons successful transition from one level of care to another in doing so, demonstrates exemplary communication and organization skills. Furthermore, the nurse liaison would be responsible for following up with patients through skilled nursing stay and may manage transitions along the care continuum prior to discharge to home health services.”

“Based on clinical record reviews, review of agency policies and interview with hospice personnel for one of two patients (Patient #16), the Hospice agency failed to maintain professional management of the Hospice care. The findings include: a. Patient #16 was admitted to Hospice services on 03/05/2024 with diagnoses that included, end-stage cirrhosis of the liver, chronic kidney disease, and coronary artery disease. Patient#16s Hospice plan of care dated 03/05/2024, identified Hospice nursing visits three times per week for one week and six to seven times per week for two weeks for the assessment and management of symptoms of the terminal illness. Additionally, the Patient would receive home health aide services three to four times per week for thirteen weeks for assistance with activities of daily living, Hospice Social Worker, and Pastoral services monthly. Review of Patient #16s hospital discharge summary dated 03/05/2024, identified the Patient was admitted to the hospital on 02/25/2024 with a diagnosis of acute cystitis with hematuria (blood in urine) and end-stage cirrhosis of the liver. During the Patients hospital admission, he/she received Valium 10 milligrams (mg) via intravenous (IV) push for anxiety, Haloperidol (Haldol) 1 mg via IV push for agitation, and Morphine 2 mg via IV push for pain. Patient #16 received the last dose of Morphine on 3/05/2024 and was discharged to home with Hospice services. Review of the Hospice agencys Hospital Liaison Registered Nurse (RN) #1s communication note dated 03/05/2024 at 10:17 AM, identified Patient #16s physician and responsible caregivers agreed to admit the Patient to Hospice services on 03/05/2024 with a terminal diagnosis of end-stage cirrhosis of the liver. Review of Patient #16s initial nursing visit note dated 03/05/2024 at 7:30 PM, identified Patient #16 was received at home in a hospital bed, lethargic and nonresponsive. RN #2 further identified the Patient appeared to be transitioning (actively approaching the end of life). RN #2 identified the comfort kit medications (Lorazepam 0.5 mg every six hours for anxiety/agitation, Morphine 0.25 ml every three hours for pain, Haldol 0.5 ml every six hours for agitation) would be ordered and delivered by the pharmacy. RN #2 failed to identify the Patients pain level and/or signs or symptoms of pain. Review of on-call Hospice RN #3s communication note dated 03/05/2024 at 8:31 PM, identified RN #2 contacted RN #3 to report the Patients responsible caregiver expected the comfort kit medications earlier that evening. RN #3 contacted the pharmacy who had not received an order for the Patients comfort kit medications. RN #3 ordered the comfort kit medications to be delivered to the Patients between 9:00 PM and 10:00 PM. Review of on-call Hospice RN #3s communication note dated 03/05/2024 at 9:47 PM, identified Patient #16s responsible caregiver contacted the Hospice to report the comfort kit medications had not arrived. Review of on-call Hospice RN #3s communication note dated 03/06/2024 at 02:58 AM, identified Patient #16 received the comfort kit medications but the Patient was in pain, agitated and the Morphine was ineffective. Review of on-call Hospice RN #3s communication note dated 03/06/2024 at 06:32 AM, identified Patient #16s responsible caregiver reported the Patient remained in pain and was agitated. RN #3 indicated a nursing visit was scheduled for later that morning. i. Interview and review of the agencys investigation with the Director of Hospice on 04/30/2024 at 12:45 PM, identified Hospital Liaison RN#1 verified she was to order Patient #16s comfort kit medications prior to his/her discharge from the hospital on 03/05/2024, but failed to submit the medication order with the pharmacy. Additionally, the Director of Hospice identified the agency failed to provide the Patient with a nursing visit after the responsible caregiver reported the Patient remained in pain on 03/06/2024 at 02:58 AM. Review of the Hospice agencys On-Call policy identified the on-call supervisor would be expected to utilize his/her professional nursing judgement for action taken on all requests for care outside of the agencys usual hours of operation. Review of the Hospice agencys Pain Assessment policy identified all patients would receive pain assessments. Pain assessments would be documented to facilitate regular reassessments and follow-up by the clinicians. The following in-depth pain assessment information would be obtained whenever possible, pain intensity using a rating scale of 0-10, location, onset, duration, variation, patterns, alleviating and aggravating factors, present pain management regimen and effectiveness. Review of the Hospice agencys Hospital Liaisons position description, identified the nurse liaison would be directly involved in managing the multiple elements that comprise a persons successful transition from one level of care to another in doing so, demonstrates exemplary communication and organization skills. Furthermore, the nurse liaison would be responsible for following up with patients through skilled nursing stay and may manage transitions along the care continuum prior to discharge to home health services.”