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“Based on interview, record review and facility document review, the Hospice agency failed to meet the Condition of Participation (CoP) for Interdisciplinary Group, Care Planning and Coordination of Services when the agency failed to accurately assess pain, prescribe pain medications appropriately, and use all available interventions to treat one of five patients (Patient (P)17) reviewed for Methadone use out of a total sample of 23 and failed to ensure the patient care plans incorporated measurable data elements to assess if progress toward expected outcomes were being met for 13 out of 14 active patients reviewed for care plans (P1, P2, P3, P4, P6, P7, P8, P9, P10, P11. P12. P13, and P14) out of a total sample of 23. This deficient practice had the potential to affect all 73 patients receiving services from the Hospice Agency.The agency was notified of an Immediate Jeopardy (IJ) at L549 on 08/06/2025 at 6:52 PM related to the failure to accurately assess pain, prescribe pain medications appropriately, and use all available interventions when signs and symptoms of overdose were noted for P17. An acceptable removal plan was provided on 08/07/2025 which included the assessment of all patients receiving Methadone to ensure safe doses, signs and symptoms of toxicity, and adverse reactions; the creation of Methadone specific care plans for those patients; staff education on pain assessments and pain relief guides; and the development of a policy related to best practices for the use of Methadone. The survey team verified implementation of the facility’s IJ removal plan, and the IJ was lifted on 08/07/2025 at 5:40 PM.Findings include: 1. The agency failed to accurately assess pain, prescribe pain medications appropriately, and use all available interventions when signs and symptoms of overdose were noted for one of five patients (Patient (P) 17) reviewed for Methadone use out of a total sample of 23. Methadone was ordered for P17, a narcotic naïve patient, without indication for use and was ordered in an inappropriate dose of Methadone 20 milligrams (mg) twice daily. P17 showed signs and symptoms of Methadone overdose, and the hospice agency failed to administer Naloxone (Narcan, used to reverse the effects of opioids). Cross Reference: L549.2. The agency failed to ensure patient care plans incorporated measurable data elements to assess if progress toward expected outcomes were being met for 13 out of 14 active patients (P1, P2, P3, P4, P6, P7, P8, P9, P10, P11, P12, P13, and P14) reviewed for care plans. Cross Reference: L548.”

“Based on interview, record review, and document review, the hospice agency failed to complete the Social Services Initial Assessment and Initial Bereavement Assessment within five days after the election of hospice care for one of 23 sampled patients (Patient (P) 4). This failure had the potential to cause P4 to not receive services that might be needed.Findings include: Review of the agency’s policy titled, “Interdisciplinary Group Membership,” dated 04/2019, indicated, “. . . The interdisciplinary group responsibilities include [sic] but are not limited to: A. Consulting with the patient’s attending physician (if any), completes the initial comprehensive assessment within five (5) calendar days after the election of hospice care…”Review of P4’s agency provided “General Patient Details” indicated P4 was admitted to hospice services on 10/18/2024 with the terminal illness of atherosclerotic heart disease of native coronary artery without angina.Review of P4’s “Documents,” located in the electronic medical record (EMR), indicated the “Election of Hospice Benefits” was signed by the Power of Attorney (POA) for P4 on 10/18/2024.Review of P4’s “Social Services-Admission,” located under the “Clinical Charting” in the EMR, indicated the Social Services Admission Assessment and the initial Bereavement Assessment were completed by the Social Worker on 10/25/2024.During an interview on 08/06/2025 at 1:56 PM, the Social Worker stated, “I was confused in the beginning about the time period for the admission assessment to be completed in. I thought that I could talk to the patient or family member within the first five days. I found out differently and since then, I have been completing the admission assessment within the first five days.”During an interview on 08/07/2025 at 3:00 PM, the Branch Manager (BM) confirmed P4 was not assessed by the social worker and the initial Bereavement Assessment was not completed within five days of the start of care.”

“Based on interview, record review and facility document review, the agency failed to ensure the patient care plans incorporated measurable data elements to assess if progress toward expected outcomes were being met for 13 out of 14 active patients reviewed for care plans (P1, P2, P3, P4, P6, P7, P8, P9, P10, P11, P12, P13, and P14) out of a total sample of 23. This deficient practice had the potential to affect all 73 patients receiving services from the Hospice Agency.Findings include: 1. Review of P1’s “Plan of Care,” located under the “Certification” tab in the electronic medical record (EMR), indicated the Chaplain started P1’s care plan on 05/07/2025 that included “Continued spiritual comfort, acceptance of dest [sic], utilization of spiritual resources, and statement of 5 [sic] or less in scale of 1-10 [sic] satisfaction with spiritual status.”The Registered Nurse (RN) started P1’s care plan on 05/21/2025 that included “Patient will achieve and maintain optimal physical comfort through achieving a pain score of (3/10) [sic] with an appropriate scale (Numerical, PAINAD) to meet patients [sic] comfort desire.”The Social Worker started P1’s care plan on 6/4/2025 that included “Family/patient obtain service and burial of their choice.”The care plan did not include measurable data elements to monitor the progress toward the expected outcomes and goals.2. Review of P2’s “Plan of Care,” located under the “Certification” tab in the EMR, indicated the Social Worker started P2’s care plan on 04/28/2025 that included “To facilitate normal grief process through hospice services, [sic] of social worker visits and provide materials as needed or requested by patient/family throughout hospice stay.”The Chaplain started P2’s care plan on 05/07/2025 that included “Chaplain will provide at least 1 x [time] [sic] monthly visits for companionship and support throughout hospice stay.”The RN started P2’s care plan on 05/01/2025 that included “Remain free of falls.”The care plan did not include measurable data elements to monitor the progress toward the expected outcomes and goals.3. Review of P3’s “Plan of Care,” located under the “Certification” tab in the EMR, indicated the RN started P3’s care plan on 06/17/2025 that included “Patient will achieve optimal breathing patterns, airway patency, and comfort through oxygen saturations above 88% [percent]. Respiratory rate between 12-20 and stating SOB [shortness of breath] on a scale of 1-10 to patient satisfaction throughout hospice stay.”The Social Worker updated P3’a care plan on 06/21/2025 that included “[P3] will have increased coping with her current situation and report less than 5 [sic] on a scale of 1-10 of how they are coping throughout hospice stay.”The Chaplain updated P3’s care plan on 06/19/2025 that included “Affirmation of Present Spiritual Comfort [sic], Acceptance [sic] of Death [sic], and Utilization [sic] of Spiritual Resources [sic].”The care plan did not include measurable data elements to monitor the progress toward the expected outcomes and goals.4. Review of P4’s “Plan of Care,” located under the “Certification” tab in the EMR, indicated the RN updated P4’s care plan on 06/03/2025 that included “Patient will achieve and maintain optimal physical comfort through achieving a pain score of 2 or less with PAINAD scale to meet patient’s comfort desire throughout hospice stay.”The Social Worker updated P3’s care plan on 05/31/2025 that included “[P4’s] PCG [patient care giver] will identify ways to reduce stress through help from the IDG [Interdisciplinary Group] and SW [social worker].”The Chaplain updated P4’s care plan on 05/10/2025 that included “Deficit related to affirmation of present spiritual comfort, acceptance of death, and utilization of spiritual resources.”The care plan did not include measurable data elements to monitor the progress toward the expected outcomes and goals.5. Review of P5’s “Plan of Care,” located under the “Certification” tab in the EMR, indicated the Chaplain started P5’s care plan on 08/04/2025 that included “Patient will receive spiritual comfort, acceptance of death, and utilization of spiritual resources.”The RN started P5’s care plan on 08/01/2025 that included “Patient will achieve and maintain optimal physical comfort through achieving a pain score of (3/10) [sic] with an appropriate scale (Numerical, PAINAD) to meet patients [sic] comfort desire.”The care plan did not include measurable data elements to monitor the progress toward the expected outcomes and goals.6. Review of P6’s “Plan of Care,” located under the “Certification” tab in the EMR, indicated the RN updated P6’s care plan on 04/22/2025 that included “Client will pass food and or [sic] fluids safely from mouth to stomach and be free of complications throughout hospice care.” The Social Worker updated P6’s care plan on 01/29/2025 that included “Caregiver will engage in appropriate leisure activities/respite during the 5 [sic] day length of stay.”The care plan did not include measurable data elements to monitor the progress toward the expected outcomes and goals.7. Review of P7’s “Plan of Care,” located under the “Certification” tab in the EMR, indicated the Chaplain started P7’s care plan on 02/13/2025 that included “Chaplain will provide at least 1 x [sic] monthly visits for companionship and support to patient.”The RN updated P7’s care plan on 01/30/2025 that included “Patient will maintain adequate cardiac/circulatory function and fluid volume as long as possible with HR [heart rate] between 60-100, edema manageable less than 2+ [plus] and no symptoms of fluid overload.”The Social Worker updated P7’s care plan on 02/04/2025 that included “Family/patient obtain services and burial of their choice.”The care plan did not include measurable data elements to monitor the progress toward the expected outcomes and goals.8. Review of P8’s “Plan of Care,” located under the “Certification” tab in the EMR, indicated the RN started P8’s care plan on 06/05/2025 that included “Patient will achieve and maintain optimal physical comfort through achieving a pain score of less than 5 [sic] with an appropriate scale (specify FLACC [Face, Legs, Activity, Cry, and Consolability],Verbal 1-10, PAINAD) to meet patients [sic]comfort desire throughout the hospice stay.”The care plan did not include measurable data elements to monitor the progress toward the expected outcomes and goals.9. Review of P10’s “Plan of Care,” located under the “Certification” tab in the EMR, included the Social Worker updated P10’s care plan on 04/27/2025 that included “[P10’s] family will identify effective ways to cope through support from the IDG team.”The RN updated P10’s care plan that included “Patient will achieve and maintain optimal physical comfort through achieving a pain score of 5/10 [five out of 10] [sic] with an appropriate scale Numerical [sic] to meet patients [sic] comfort desire throughout hospice stay.”The care plan did not include measurable data elements to monitor the progress toward the expected outcomes and goals.10. Review of P11’s “Plan of Care,” located under the “Certification” tab in the EMR, included the RN updated P11’s care plan on 06/24/2025 that included “Patient will maintain blood glucose levels within the normal range of 90-120 for as long as possible while under hospice care.”The Social Worker updated P11’s care plan on 05/11/2025 that included “Family/patient obtain service and burial of their choice prior to patient passing.”The Chaplain updated P11’s care plan on 06/07/2025 that included “ Affirmation of Present Spiritual Comfort [sic], Acceptance [sic] of Death [sic], and Utilization [sic] of Spiritual Resources [sic].”The care plan did not include measurable data elements to monitor the progress toward the expected outcomes and goals.11. Review of P12’s “Plan of Care,” located under the “Certification” tab in the EMR, indicated the RN updated P12’s care plan on 07/22/2025 that included “Promote optimal patient safety and prevention of injury with no falls throughout the hospice stay.”The Chaplain update P12’s care plan on 07/12/2025 that included “ Affirmation of Present Spiritual Comfort [sic], Acceptance [sic] of Death [sic], and Utilization [sic] of Spiritual Resources [sic].”The care plan did not include measurable data elements to monitor the progress toward the expected outcomes and goals.12. Review of P13’s “Plan of Care,” located under the “Certification” tab in the EMR indicated the Social Worker updated P13’s care plan on 05/27/2025 that included “Patient’s daughter will choose funeral home for arrangements.”The RN updated P13’s care plan on 05/31/2025 that included “Patient will achieve and maintain optimal physical comfort through achieving a pain score of less than 5 [sic] with an appropriate scale (specify FLACC [Face, Legs, Activity, Cry, and Consolability], Verbal 1-10, PAINAD) to meet patients [sic]comfort desire throughout the hospice stay.”The care plan did not include measurable data elements to monitor the progress toward the expected outcomes and goals.13. Review of P14’s “Plan of Care,” located under the “Certification” tab in the EMR, indicated the Chaplain updated P14’s care plan on 06/20/2025 that included “Chaplain will provide at least 1 x [sic] monthly visits for companionship and support to patient throughout hospice stay.”The RN updated P14’s care plan on 06/18/2025 that included “Client will remain safe and receive appropriate care, [sic] as the physical decline increases throughout hospice stay. The client will be free from injuries.”The Social Worker updated P14’s care plan on 06/20/2025 that included “Patient adjusts to facility to extent possible [sic] by reporting on a scale of 1-10 satisfaction and understanding of long term [sic] care placement throughout hospice stay.”The care plan did not include measurable data elements to monitor the progress toward the expected outcomes and goals.During an interview on 08/07/2025 at 1:00 PM, the Chaplin confirmed the goals in the patient’s care plans were not measurable. The Chaplain stated, “Now that I know about this, I will start making the goals measurable by using data elements.”During an interview on 08/07/2025 at 1:56 PM, the Social Worker confirmed the patient’s goals in the care plans were not measurable. The Social Worker stated, “I have never been told about this. I will start making the goals measurable.”During an interview on 08/07/2025 at 2:00 PM, the Clinical Manager-Registered Nurse (CM-RN) confirmed the goals in the patient’s care plans were not measurable.”

“Based on interview, record review, and document review, the hospice agency failed to accurately assess pain, prescribe pain medications appropriately, and use all available interventions when signs and symptoms of overdose were noted for one of five patients (Patient (P) 17) reviewed for Methadone use out of a total sample of 23. Methadone was ordered for P17, a narcotic naïve patient, without indication for use and was ordered in an inappropriate dose of Methadone 20 milligrams (mg) twice daily. P17 showed signs and symptoms of Methadone overdose, and the hospice agency failed to administer Naloxone (Narcan, used to reverse the effects of opioids). The agency was notified of an Immediate Jeopardy (IJ) at L549 on 08/06/25 at 6:52 PM related to the failure to accurately assess pain, prescribe pain medications appropriately, and use all available interventions when signs and symptoms of overdose were noted for P17. An acceptable removal plan was provided on 08/07/25 which included the assessment of all patients receiving Methadone to ensure safe doses, signs and symptoms of toxicity, and adverse reactions; the creation of Methadone specific care plans for those patients; staff education on pain assessments and pain relief guides; and the development of a policy related to best practices for the use of Methadone. The survey team verified implementation of the facility’s IJ removal plan, and the IJ was lifted on 08/07/25/25 at 5:40 PM. Findings include: Review of the hospice agency’s policy “Pain Assessment” dated April 2019 indicated, “. . . When the patient or the clinician identifies pain, the following in-depth pain assessment information will be obtained whenever possible . . . Pain intensity using a rating scale (on scale of 0-10: 0 = no pain, 10 = unbearable pain). Pain intensity should include current pain, worst pain, and least pain using the scale. The patient will be reassessed every visit for the existence and intensity of pain and the effectiveness of interventions to relieve pain . . . Pain location and frequency . . . Pain quality, patterns of radiation, and character . . . Pain onset, duration, variations, and patterns . . . Alleviating and aggravating factors . . . Present pain management regimen and effectiveness . . . Pain management history, to include a medication history, presence of common barriers to reporting pain and using analgesics, past interventions and response, and manner of expressing pain . . . Effects of pain. These include impact on daily life, function, sleep, appetite, relationships with others, emotions, concentration, etc. . . . The patient’s pain goal, including pain intensity and goals related to function, activities, and quality of life . . . Physical exam or observation of the site of pain . . . Secondary symptoms related to pain such as nausea, vomiting, respiratory distress, or nutritional compromise . . . Non-pharmacological interventions will be considered for the treatment of pain . . .” Review of P17’s agency provided “General Patient Details” indicated P17 was admitted to hospice services on 06/02/2023 with the terminal illness of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of P17’s agency provided “Physician Orders,” dated 06/02/2023, revealed an order for Gabapentin 100 milligrams (mg) one capsule one time a day for pain and Tylenol Extra Strength 500 mg two tablets every six hours as needed for pain/fever. Review of P17’s agency provided “Comprehension Admission Assessment,” dated 06/02/2023, P17 was noted to be alert and oriented times one and was able to ambulate using a walker to go outside of the assisted living facility to smoke several times a day. P17 had a history of lower back pain which was described as mild to moderate which could occur occasionally. It was recorded P17 had been taking Tylenol Extra Strength as needed (prn) for pain relief. Review of P17’s “Skilled Nursing Visit,” dated 11/10/2023 and located under the “Clinical Charting” tab of the electronic medical record (EMR), revealed no documented evidence P17 was experiencing increased pain that was not controlled with the current pain medication. It was recorded that the nurse assessed R17’s pain using the “PAINAD” scale, which required the patient to rate their pain on a zero to 10 scale. It was recorded that the patient reported the level pain was “0.” Review of P17’s “Charting Notes,” provided by the assisted living facility, revealed: 11/11/2023 at 1:05 PM - “…Resident isn’t complaining of any pain from her fall yesterday…’ 11/12/2023 at 9:34 PM - “…resident seem [sic] to be doing alright, resident did not complaint about any pain from the fall…” 11/13/2023 at 9:05 PM - “…Resident had an unwitness [sic] fall today…asked resident if she is in any pain resident said no…called her hospice but the nurse just came in the building so I told her about it…” Review of P17’s agency provided “Physician Order,” dated 11/13/2023, indicated an order for Methadone 10 milligrams (mg) take two tablets by mouth twice daily. The order was signed by the Medical Director (MD) and Registered Nurse (RN) 1. The Methadone dose was four times the recommended starting dose for an opioid naïve patient. Review of P17’s “Charting Notes,” provided by the assisted living facility, revealed: 11/1420/23 at 12:55 PM - “… not complaint of any pain today from her fall. [He/She] did come out of [his/her] room without [his/her] walker…was directed back…so [he/she] could get [his/her] walker…” 11/15/2023 at 1:25 PM - “…The resident has had no complains [sic] of pain…” Review of P17’s “Skilled Nursing Visits,” located under the “Clinical Charting” tab in the EMR and dated 11/15/2023, revealed no documented evidence to reflect P17 was having increased pain that was not being relieved with the current pain medications P17 was prescribed. The nurse documented P17 was assessed for pain using a verbal scale type for chronic pain related to their condition. The pain was documented as being “0.” It was recorded, “…has been more confused of late [sic] and more word salad…” Review of P17’s “Medication Administration Record (MAR),” dated 11/15/2023 at 8:00 PM and provided by the assisted living facility, revealed P17 received two tablets of Methadone 10 mg, for a total of 20 mg. Review of P17’s “Charting Notes,” dated 11/15/2023 at 9:49 PM and provided by the assisted living facility, revealed, “…seem to be doing alright. Resident has not complain [sic] about any pain…” Review of P17’s “MAR,” dated 11/16/2023 at 8:00 AM and provided by the assisted living facility, revealed P17 received two tablets of Methadone 10 mg. Review of P17’s “Charting Notes,” provided by the facility, revealed: 11/16/2023 at 1:15 PM - “…started Methadone last night for back pain. Today [he/she] has been very sleepy and shaky. [he/she] was woken up to take [his/her] medications, but then [he/she] went back to bed and missed breakfast. [he/she] pushed [his/her] pendant around 1130, and [he/she] was still in bed. Team members tried to help her get up and get dressed but [he/she] said that [he/she] was dizzy when [he/she] stood up and wanted to lay back down. [he/she] hospice nurse was notified. [he/she] stated to keep watching [P17] and if [he/she] continues to be dizzy and sleepy, [his/her]…Methadone will be discontinued . . .” 11/16/2023 at 9:06 PM - “…Resident been [sic] asleep thru out the shift. Resident was unable to take her meds [medications] due to her being so sleepy… attempted multiple times resident just opens her eyes but then she loses them right away…notified [his/her] hospice that she refused her meds. Will continue to monitor the resident…” Review of P17’s “MAR,” dated 11/17/2023 at 8:00 AM and provided by the assisted living facility, revealed P17 received two tablets of Methadone 10 mg. Review of P17’s “Pharmacy Documentation,” provided by the pharmacy and dated 11/17/2023, indicated, “[Name of Registered Nurse (RN)] notified as prescription was written incorrectly - pt [patient] is receiving double the intended dose. MD [Medical Director] notified. Narcan on hand prn [as needed]. States pt sedated but otherwise okay. Discussed need for increase monitoring: N/V [nausea/vomiting], decreased respiratory rate, sweating, worsening sedation, palpations [sic]. Kinetics discussed…Stated they are delignating monitoring. 11/20/2023 Follow up with [name of RN]. States pt ok - not showing s/s [signs/symptoms] of Methadone toxicity. Didn’t change overall condition…” Review of P17’s “SN [Skilled Nurse] PRN Visit Notes,” dated 11/17/2023 and provided by the facility, indicated, “…[P17] showed no SS [signs/symptoms] of pain…pain was assessed using the ‘PAINAD’ method which indicated [P 17]’s breathing was normal, there was no vocalization, no expression or inexpression and body language was relaxed…” The nurse documented, “…[Name of Assisted Living Facility] called to say [P17] had a change in condition and was very sleepy. [P17] was started on Methadone 2 [sic] days ago and could be reacting to the medications. Meds [medication] was stopped. Q 2-checks [Every 2-hour checks] were ordered…RN checked for any injury from the previous fall…” Review of P17’s “Charting Notes,” provided by the assisted living facility revealed: 11/17/2023 at 12:25 PM – “…Spoke with Hospice nurse [Clinical Manager/Registered Nurse (CM-RN) 1]. [He/She] stated the case worker for [P17] had wrote the order for… [his/her] Methidone[sic] wrong. It should have been 2.5 mg not 20 mg. [P17] received 3 doses before it was dc’d [discontinued]. They talked about doing Narcan but decided to wait and see how [he/she] does…” 11/17/2023 at 1:03 PM – “…Resident was dripping sweat and was really confused when the MA [Medication Aide] went…to give [his/her] meds to [him/her]. MA helped [him/her] to [his/her] chair and as [him/her] was walking [him/her] was stumbling and really weak…At approx. [approximately] 11:04 . . . went into [him/her] room to check on [him/her] and called a code f [fall] . . . [him/her] is okay other then [sic] a scrape on [his/her] rib cage and [him/her] right tricep. [him/her] also had some bruising on [his/her] backside as well as her ribcage. Hospice was notified…” 11/17/2023 at 9:32 PM – “…was ok tonight…was a little weak moving but was assisted to bed…” 11/18/2023 at 1:30 PM – “…has been resting in her chair all morning…hasn’t really ate much and has been sleeping most of the day…” 11/20/2023 at 12:27 PM – “…spoke with [CM-RN1] (hospice nurse) today…is still not able to sit up on [his/her] own…will only take about 2 of [his/her] meds and then can’t swallow. I asked if they planned on sending a hospital bed because it is taking 3 team members to sit [him/her] up to take [his/her] meds…said [he/she] will ask the case manager if [he/she] ordered one… I was told again that they had thought about giving [him/her] Narcan but decided not to…she is still very sweaty…” 11/20/2023 at 1:10 PM – “…was only able to take [his/her] Losartan and [his/her] Clopidogrel…tried multiple times to swallow another pill, but [he/she] kept falling asleep, and [he/she] couldn’t focus on how to drink from a straw…kept blowing bubbles. Hospice was notified…” 11/21/2023 at 1:40 PM – “…[family member] asked for [P17’s] medication to not be given this morning…stated that [[he/she] could not wake [him[her] up enough to keep [him/her] awake and [he/she] was afraid that [he/she] would choke. Hospice notified. [His/Her] nurse came and assessed [him/her] and they feel like [he/she] had a stroke…nurse stated [he/she] is starting to have the ‘death rattle’ and [his/her] lungs sound congested…” 11/21/2023 at 3:00 PM – “…I spoke with [family member] and [he/she] told me that hospice told [him/her] that it would take about 5 days for the medication to wear off. I spoke with [CM-RN1] and [he/she] told me that [he/she] and [Former Hospice Medical Director] spoke about giving Narcan again and decided not to. [He/She] stated that they think [P17] had another stroke and this was not the symptoms from the medication…” P17 passed away on 11/22/2023 at 1:30 AM. During an interview on 08/06/2025 at 10:48 AM, CM-RN1stated, “I don’t know why this patient was started on Methadone, I don’t think [Pl7] needed it for not having any documentation of increased pain. If [P17’s nurse] had come to me as her manager, or ran this by me, I would not have suggested Methadone for any reason.” CMRN1 was asked if Narcan had been administered to P17 and the CMRN1 stated, “No, because the patient was able to be aroused and respond to us.” CMRN1 confirmed P17 had more of a decline after Methadone had been given as P17 was not able to ambulate as P17 had prior to the use of the medication. During an interview on 08/07/2025 at 11:00 AM, the Pharmacist had called the hospice agency and spoke to the nurse in the office on 11/17/2023. The Pharmacist discussed with the office nurse that the order for Methadone was double the amount of Methadone the patient should be receiving, and discussions were held concerning if Narcan was available on hand and the signs and symptoms of Methadone toxicity, the need for increased monitoring and the kinetics of Methadone. The Pharmacist had called on 11/20/2023 and was told that the patient (P17) was “okay” and not showing signs/symptoms of Methadone toxicity and the overall condition of the patient had not changed. P17’s nurse could not be interviewed as he/she the nurse was no longer employed at the hospice agency. The Medical Director, who had ordered the Methadone, could not be interviewed due to expiring in May 2025. Review of the National Library of Medicine article titled, “Practical Guide for Using Methadone in Pain and Palliative Care Practice,” located at https://pmc.ncbi.nlm.nih.gov/articles/PMC5806302/, revealed, “. . . Based on limited research evidence and clinical experience, the practical advice is to initiate methadone at low doses, individualize the treatment based on indication and prior opioid exposure status, titrate slow, and monitor patients for adverse effects such as sedation . . . Before starting methadone, complete an individualized medical and behavioral risk/benefit evaluation . . . Initiating methadone as a first line opioid in an opioid-naïve patient is not a common practice. It is strongly recommended to consult with a pain and palliative care consultant in such situations . . . Method . . . ‘Start low and go slow’ method . . . Starting dose: Start with 2.5 mg orally every 12 or 8 [hours] . . . In elderly or frail patients, start as low as 1 mg orally once per day . . .” Review of the website, https://professionals.wrha.mb.ca/old/professionals/files/PDTip_AnalgesicLadder.pdf, indicated the “World Health Organization (WHO) Analgesic Ladder” states there are “. . . three main principles of the WHO analgesic ladder are: By the clock, By the mouth, By the ladder [sic]… By the ladder: If pain occurs there should be prompt administration of drugs in the following order: non-opioids (e. g. [sic] acetaminophen) as necessary, mild opioids (e. g. [sic] codeine) then strong opioids (e, g, [sic] morphine or hydromorphone) until the patient is free of pain...” Review of the Centers for Disease Control article titled, “5 Things to Know About Naloxone [Narcan],” dated 05/02/24 and located at https://www.cdc.gov/overdose-prevention/reversing-overdose/about-naloxone.html, revealed, “. . . Naloxone can reverse the effects of an overdose from opioids, including . . . Methadone . . . Naloxone can be administered by bystanders and is available as a(n): Nasal Spray: Prefilled devices that spray medication into the nose . . . Naloxone will not harm someone if you give it to them and they are not overdosing on an opioid. Naloxone can be given safely to people of all ages, from infants to older adults . . . Naloxone quickly reverses an overdose by blocking the effects of opioids. Review of the Mayo Clinic’s article titled, “Methadone,” located at https://www.mayoclinic.org/drugs-supplements/methadone-oral-route/description/drg-20075806, revealed, “. . . Methadone is used to treat moderate to severe pain when around-the-clock pain relief is needed for a long period of time. This medicine should not be used to treat pain that you only have once in a while or “as needed”. . . elderly patients are more likely to have age-related heart, kidney, liver, or lung problems, which may require caution and an adjustment in the dose for patients receiving methadone . . . If you think you or someone else may have taken an overdose of this medicine, get emergency help at once. . . Signs of an overdose include: change or loss of consciousness . . . decreased awareness or responsiveness, extreme dizziness or weakness, increased sweating, irregular, fast, or slow, or shallow breathing . . . sleepiness or unusual drowsiness. . . trouble breathing. Call your doctor right away if you notice these symptoms . . .””

“Based on interview and document review, the hospice agency failed to perform quality improvement activities to track adverse patient events, analyze the causes, and implement preventive actions and mechanisms to prevent further episodes from occurring. The deficient practice had the potential to affect all 73 patients receiving hospice services. Findings include: Review of P17’s agency provided “General Patient Details “indicated P17 was admitted to hospice services on 06/02/2023 with the terminal illness of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of P17’s agency provided “Physician Order,” dated 11/13/2023, indicated an order for Methadone 10 mg (milligrams) take two tablets by mouth twice daily. P17 had received a total of three doses beginning 11/15/2023 at 8:00 PM, 11/16 and 11/17 at 8:00 AM. Review of P17’s “Skilled Nursing Visits,” located under the “Clinical Charting” tab in the electronic medical record (EMR) and dated 11/10/2023 and 11/15/2023, did not have documentation to reflect P17 was having increased pain that was not being relieved with the current pain medications P17 was prescribed. The nurse documented for both visits that P17 was assessed for pain using a verbal scale type for chronic pain related to his/her condition. The pain was documented as being “0”. On 11/15/2023, the nurse documented P17 “. . . has been more confused of late [sic] and more word salad . . .” Review of P17’s “Pharmacy Documentation,” which was provided by the pharmacy and dated 11/17/2023, indicated, “[Name of Registered Nurse (RN)] notified as prescription was written incorrectly - pt [patient] is receiving double the intended dose. MD [Medical Director] notified. Narcan on hand prn [as needed]. States pt [patient] sedated but otherwise okay. Discussed need for increase monitoring: N/V [nausea/vomiting], decreased respiratory rate, sweating, worsening sedation, palpations [sic], Kinetics discussed . . . Stated they are delignating monitoring. 11/20/23 Follow up with [name of RN]. States pt ok - not showing s/s [signs/symptoms] of Methadone toxicity. Didn’t change overall condition.” During an interview on 08/06/2025 at 12:15 PM, the Administrator stated, “As soon as we discovered the patient was getting the wrong dose of Methadone, we started an investigation.” Review of the agency provided “Adverse Events Tracking Sheet [name of office],” dated 11/17/2023, indicated the “Summary of Occurance [sic]” stated, “Patient was started on 20 mg of methadone [sic] BID [twice a day] instead of 2.5 mg BID. Nurse ordered the incorrect dosage. Facility notified us [hospice agency] a change in condition with the patient and the error in dosage was found. Due to change in condition and medication review [sic] it was revealed there was a medication error.” The Medical Doctor (MD) was notified on 11/17/2023 at 5:30 PM. The MD response or recommendation indicated, “Stop the medication, place patient on Q2 [every two] hour checks with the facility. Patient was started on daily nursing visits.” Family was notified on 11/17/2023 at 5:50 PM. “Outcome” was documented, “Patient was able to stabilize but eventually passed away on 11/22/2023.” “Evaluation” indicated “Employee was written up and education was given to the nursing staff regarding safe dosages. Education was given regarding. “ Review of agency provided “Nursing Medication Education” dated November 21, 2023, indicated: “Medication Error Protocol -Report to management upon discovery -Notify MD of error -Notify family of error Safe Dosages -All meds need to be verified with MD to confirm safe dosage -Double check dosages with another RN [Registered Nurse] and MD if unsure Side Effects of Methadone -Increased drowsiness -n/v [sic] [nausea/vomiting] -Hallucinations” During an interview on 08/06/2025 at 1:00 PM, the Administrator was asked if the information provided was all of the investigation and education that had been provided to the nursing staff after the discovery of the wrong dose of Methadone for P17. The Administrator stated, “We talked about it in the QAPI [Quality Assurance Program Improvement] meeting on 02/19/2023 and we provided education to the to the nursing staff on 11/21/2023.” During an interview on 08/06/2025 at 10:48 AM, the Clinical Manager-Registered Nurse (CM-RN)1 was asked if there was a medication review of all the residents that were on Methadone at the time of this medication error. The CM-RN1 stated, “None of the other patients were having any problems with their Methadone, only this patient [P17]. We review the medications every two weeks in the IDG [Interdisciplinary Group] meetings.””

“Based on record review and interview, the hospice agency failed to ensure the administrator and pharmacist immediately investigated the medication discrepancy for one of 23 sampled patients (Patient (P)17) who received an inappropriate dose of Methadone (a pain medication). The deficient practice had the potential to affect the five residents that were currently being administered Methadone at the time of this event. Findings include: Review of P17’s agency provided “General Patient Details” indicated P17 was admitted to hospice services on 06/02/2023 with the terminal illness of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of P17’s agency provided “Physician Order,” dated 11/13/2023, indicated an order for Methadone 10 mg (milligrams) take two tablets by mouth twice daily. P17 had received a total of three doses beginning 11/15/2023 at 8:00 PM, 11/16 and 11/17 at 8:00 AM. Review of P17’s “Pharmacy Documentation,” which was provided by the pharmacy and dated 11/17/2023, indicated, “[Name of Registered Nurse (RN)] notified as prescription was written incorrectly - pt [patient] is receiving double the intended dose. MD [Medical Director] notified. Narcan on hand prn [as needed]. States pt [patient] sedated but otherwise okay. Discussed need for increase monitoring: N/V [nausea/vomiting], decreased respiratory rate, sweating, worsening sedation, palpations [sic]. Kinetics discussed... Stated they are delignating monitoring. 11/20/2023 Follow up with [name of RN]. States pt ok - not showing s/s [signs/symptoms] of Methadone toxicity. Didn’t change overall condition.” Review of the agency provided “Adverse Events Tracking Sheet [name of office],” dated 11/17/2023, indicated the “Summary of Occurrence [sic]” stated, “Patient was started on 20 mg of methadone [sic] BID [twice a day] instead of 2.5 mg BID. Nurse ordered the incorrect dosage. Facility notified us [hospice agency] a change in condition with the patient and the error in dosage was found. Due to change in condition and medication review [sic] it was revealed there was a medication error.” The Medical Doctor (MD) was notified on 11/17/2023 at 5:30 PM The MD response or recommendation indicated “Stop the medication, place patient on Q2 [every two] hour checks with the facility. Patient was started on daily nursing visits.” Family was notified on 11/17/23 at 5:50 PM. “Outcome” was documented, “Patient was able to stabilize but eventually passed away on 11/22/2023.” “Evaluation” indicated “Employee was written up and education was given to the nursing staff regarding safe dosages. Education was given regarding.” During an interview on 08/06/2025 at 1:00 PM, the Administrator was asked if the information provided was all of the investigation and education that had been provided to the nursing staff after the discovery of the wrong dose of Methadone for P17. The Administrator stated, “We talked about it in the QAPI [Quality Assurance Program Improvement] meeting on 02/19/2023 and we provided education to the to the nursing staff on 11/21/2023.” During an interview on 08/06/2025 at 10:48 AM, the Clinical Manager-Registered Nurse (CM-RN)1 was asked if there was a medication review of all the residents that were on Methadone at the time of this medication error. The CM-RN1 stated, “None of the other patients were having any problems with their Methadone, only this patient [P17]. We review the medications every two weeks in the IDG [Interdisclipinary Group] meetings.” During an interview on 08/07/2025 at 6:00 PM, the Administrator stated, “There has been a lot of things learned from the process of this survey on this incident. We wish we had reported it to the state and had conducted a more in-depth investigation into this.””