Northern Light Home Care & Hospice

“Based on document review and interview, it was determined that the agency failed to ensure that all prefilled syringes containing controlled substances including morphine and lorazepam were labeled in accordance with currently accepted professional practice for six (6) of ten (10) patients (Patients #1, #4, #6 - #9). Findings:Northern Light Home Care and Hospice Policy and Procedure Ordering, Administering, Monitoring and Disposal of Medications, last revised 09/02/205, in part states, “…Scope: All Departments…Purpose: To establish a process for the safe and effective ordering, administration, monitoring and disposal of medications. To ensure compliance with State and Federal regulations and best practices. Policy: Northern Light Home Care & Hospice, hereinafter known as the Agency, requires that all drugs and biologicals be ordered, administered, monitored, and disposed of in accordance with accepted standards of practice as defined in State and Federal regulations and Home Care Best Practices. Procedure: Medication Ordering and Administration: Drugs and treatments are administered by Agency clinicians only as ordered by the practitioner…”Northern Light Home Care and Hospice Policy and Procedure Suspected Diversion of Narcotics, last revised 06/15/2026, in part states, “…Scope: All departments…Purpose: To provide guidelines and interventions for Agency workforce members in cases where suspected diversion of narcotics may be occurring, to provide a process to safely control and manage medications with a high potential for diversion, abuse, or misuse, to prevent unauthorized individuals from obtaining controlled medications, to ensure compliance with State and Federal regulations…The Agency will identify medications with a high potential for abuse and implement a process to manage them safely…Agency clinicians keep current and accurate records of the receipt and disposition of all controlled medications…”On 08/12/2026 at 12:52 PM, the survey team requested the policy and procedure addressing the labeling of syringes for controlled and non-controlled substances that is prefilled by the nurses and left in the patient homes to be administered to the patient. On 08/12/2026 at 1:03 PM, Vice President of Operations responded via email the following: “We do not have a specific policy on this.” A review of Patient #1’s medical record revealed the following:On 06/04/2026, Registered Nurse (“RN”) #1 documented in part the following “…Care Coordination: Prefilled syringe with lorazepam…”.On 06/082026, RN #1 documented in part the following “…Care Coordination: Prefilled syringes with lorazepam . No refills needed…” On 06/09/2026, RN #1 documented in part the following: “…Interventions: Prefill syringes with Morphin, lorazepam, haloperidol. Medication to be administered by self and wife…”.On 06/12/2026, RN #1 documented in part the following: “…Care Coordination: Prefilled morphine and Haldol syringes as needed…”.On 06/16/ 2026, RN #1 documented in part the following: “…admin [administer] 5mg [milligrams] morphine with excellent relief of pain and 0.5 mg lorazepam with excellent relief of anxiety. [instructed] spouse and PCG [Personal Care Giver]…Care Coordination…Syringes prefilled”.On 06/17/2026, RN #1 documented in part the following: “…[Instructed] PCG [Personal Care Giver] and spouse use of prn [as needed] lorazepam and morphine. Both v/u [verbal understanding]. Care Coordination: Prefilled syringes”.On 06/20/2026, RN #4 documented in part the following: “…Care Coordination: prefilled syringes with morphine, lorazepam, and Haldol…”.On 06/22/2026, RN #4 documented in part the following: “…Prefilled syringes with morphine, lorazepam, and Haldol…”.On 06/22/2026, RN #1 documented in part the following: “…Prefilled syringes…”.On 06/23/2026, RN #1 documented in part the following: “…Prefilled syringes…”.A review of Patient #4’s medical record revealed the following:On 05/14/2026, RN #5 documented in part the following: “…Filled multiple syringes with lorazepam and morphine for easy administration for family…”.On 05/16/2026, RN #6 documented in part the following: “…checked to see if enough meds are drawn up in syringes, patient’s wife states she has enough prefilled…”.A review of Patient #6’s medical record revealed the following:On 02/12/2026, RN #7 documented in part the following: “…labeled cups and placed pre-filled syringes in them…”.A review of Patient #7’s medical record revealed the following:On, 04/23/2026, RN #9 documented in part the following: “…opened up the comfort pack and prefilled some syringes of morphine, explained how to use it, what it’s for, and side effects of the medication… prefilled syringes…”On 05/19/2026, RN #8 documented in part the following: “…Oral syringes provided…”.A review of Patient #8’s medical record revealed the following:On 04/03/2026, RN #2 documented in part the following: “…had offered pre draw syringes yesterday… Agreeable to it perhaps once they have a PP [private pay] caregiver in home…”.On 04/04/2026, RN #5 documented in part the following: “…Planned to prefill syringes so [husband] could easily give if paid caregivers woke him to give them.… filled morphine, Haldol, and lorazepam syringes.”.A review of Patient #9’s medical record revealed the following:On 01/13/2026, RN #7 documented in part the following: “…This writer offered to pre-fill 1mL syringes…”.Hospice Staff interviews revealed the following: During an interview on 08/12/2026, at approximately 12:01PM, RN #1 was asked about their process for labeling prefilled syringes. RN #1 stated that if there were multiple syringes, they would label the container holding the syringes; when asked if the syringes are individually labeled, RN #1 stated, “Usually not.”During an interview on 08/12/2026, at approximately 1:07PM, Home Health Aide stated that one of their patients stores their syringes in the refrigerator at home and that during their previous visits, they have observed unlabeled medication located in this patient’s refrigerator.During an interview on 8/12/2026, at approximately 1:40PM, RN #2 confirmed that they do not individually label patient syringes and that patients can visually differentiate their medication, as morphine is blue and lorazepam is clear. At approximately 1:42PM, RN#2 stated, “To the best of my knowledge, I have not ever individually labeled every single syringe that I am drawing,” and that instead, they place patient syringes in a labeled cup with instructions.During an interview on 8/12/2026, at approximately 2:08PM, RN #3 stated that they have conducted visits in homes with pre-drawn syringes that have been unlabeled.On 08/12/2026, at approximately 12:52 PM, the Survey Team requested a policy and/or procedure addressing the labeling of syringes for controlled and non-controlled substances that are prefilled by nurses and left in patient homes to be administered to the patient. On 08/12/2026, at approximately 1:03 PM, Vice President of Operations responded via email and stated, “We do not have a specific policy on this.””

“Based on observation and interview, the Hospice care facility failed to maintain the proper shutoff mechanism for the preparing /cooking meals on commercial or residential equipment per NFPA 101, Life Safety Code, 2012 Edition, Chapter 18 Section 18.3.2.5.3 Finding: Based on interview and observation on 08/22/2024 between hours of 10:00 am and 1:00 pm. this surveyor accompanied with the Building owner and safety officer did observe the following: 1. The Stove in the Kitchen did not have the proper shutoff requirements per the code requirements set forth for cooking appliance. During interview it was confirmed with the safety officer, that the facility had removed the gas stove and replaced it with an electric stove and never reconnected the interlock which is required to turn off the electrical power to the new appliance when the suppression system activates nor has the facility added a safety switch in accordance with 18.3.2.5.3 (9) (A),(B) and (C). This deficient practice could affect the resident, visitors and staff. This was observed at the time by this surveyor along with the Building Owner and Safety Officer.”

“Based on observations and interview, the facility failed to ensure that the generator had a remote annunciator at a location that could be monitored 24 hours a day while facility was on auxiliary generator power Per NFPA 99, (2012) 6.4.1.1.17. Findings: Based on interview and observation on 08/22/2024 between hours of 10:00 am and 1:00 pm. this surveyor accompanied with Building Owner and Safety Officer did observe the following: 1. No generator annunciator panel at a readily observed location by operating personnel at a regular workstation such as a nurse’s station. When this surveyor asked the Safety Officer and Building Owner if they had a remote annunciator at any nurse’s station. The Safety Officer and Building Owner informed this surveyor that they did not have one. The surveyor confirmed these observations with the Safety Officer and Building Owner at the time of the observation.”

“K923 Gas Equipment - Cylinder and Container StorageBased on observation and interview, the facility failed to ensure that Cylinder and Container Storage areas were safeguarded in accordance with NFPA 99, Health Care Facilities code, 2012 edition, section 5.1.3.3.2 and 5.1.3.3.3 in 1 Oxygen storage closet inspected in the facility. Findings Include: Based on interview and observation on 08/22/2024 between hours of 10:00 am and 1:00 pm. this surveyor accompanied with the Safety Officer and Building Owner did observe the following: storage of oxygen exceeds the allotted quantity in the oxygen storage room located in the corridor next to the nurse’s station. 13 E tanks exceed 300 Cubic feet of storage for the room. This finding was verified by the Safety Officer and Building Owner at the time of the observation.”

“Based on document reviews and interviews, the hospice failed to ensure that the care and services were provided in accordance with the plan of care for one (1) of twenty-one (21) patients (Patient #8). Finding: The plan of care dated 5/26/2024 to 7/24/2024 ordered Skilled Nursing (SN) visits one (1) time a week for eight (8) weeks and Hospice Aide visits three (3) times a week for eight (8) weeks. There was no documentation that the week of 5/26/2024 that a SN visit was made and no documentation that the Hospice Aide visit was made. This finding was confirmed by the Clinical Manager 2 on 8/21/2024 at approximately 1:05 PM.”

“Based on document reviews and interviews, the hospice failed to ensure that a registered nurse made an on-site visit to the patient’s home no less frequently than every fourteen (14) days to assess the quality of care and services provided by the Hospice Aide for one (1) of fourteen (14) patients. (Patient #9) Finding: The review of the medical record for patient #9 revealed that the plan of care for 5/23/2024 to 8/20/2024 ordered Hospice Aide two (2) times a week for twelve (12) weeks and then on 8/18/2024 the frequency changed to one (1) time a week for the remainder of the certification period. The weeks of 6/16/2024, 6/30/2024, 7/14/2024, 7/28/2024 and 8/11/2024 there was no documentation that the Registered Nurse had made an on-site visit to the patient’s home to supervise the Hospice Aide. This was confirmed by the Clinical Manager 2 on 8/21/2024 at approximately 1:07 PM.”

“Based on document reviews, interviews, and observations, the hospice failed to ensure discharge summaries were sent to the physicians assuming responsibility for the patients care after discharge for two (2) out of ten (10) patient discharge summaries reviewed (Patient #18 & Patient #2-Discharge [“;Patient #2D”]). Findings: Northern Light Home Care & Hospices policy titled, “;Criteria for Patient Acceptance, Continuation of Services, & Discharge – Hospice,” dated 02/07/2023 states in part, “;...The purpose of the discharge plan is to coordinate the provision of services designed to meet the psychosocial and physical needs of the patient whose prognosis changes, no longer meets the admission criteria, is discharged for cause or revokes...” Northern Light Home Care & Hospices policy titled, “;Discontinuation of Services for Cause,” dated 02/07/2023 states in part, “;...If the Agency is able to identify other health care professionals who may be involved in in the patients care after discharge occurs these individuals will be notified of discharge, when it becomes imminent...” A review of Patient #18s medical record revealed that when Patient #18 discharged from hospice services on 09/01/2023, the patients discharge summary was sent to Hospice Physician #1, but the discharge summary was not sent to Patient #18s Primary Care Physician who would be assuming responsibility for the patients care after discharge. On 08/21/2024 at 1 PM, the Registered Nurse (“;RN”) Clinical Manager confirmed that per the medical record, when Patient #18 was discharged from hospice services on 09/01/2023, the patients discharge summary was forwarded to the Hospice Physician #1 instead of being forwarded to the patients Primary Care Physician who would be assuming responsibility for the patients care after discharge. The RN Clinical Manager confirmed on 08/21/2024 at 1:11 PM, that the patients discharge summary was only sent to Hospice Physician #1. A review of Patient #2Ds medical record revealed that when Patient #2D was discharged from hospice services on 03/04/2024, the patients discharge summary was sent to Hospice Physician #2, but the discharge summary was not sent to Patient #2Ds Oncologist who would be assuming responsibility for the patients care after discharge. On 08/21/2024 at 2:23 PM, the RN Clinical Manager confirmed that per the medical record, when Patient #2D was discharged from hospice services on 03/04/2024, the patients discharge summary was forwarded to the Hospice Physician #2 instead of being forwarded to the patients Oncologist who would be assuming responsibility for the patients care after discharge. On 08/21/2024 at 2:25 PM, the RN Clinical Manager confirmed that Patient #2Ds Oncologist did not receive a copy of the discharge summary when the patient was discharged.”