Hopehealth Hospice & Palliative Care

“Based on surveyor observation, clinical record review, patient and staff interviews, the agency failed to ensure that medications were prepared and administered in a safe and accurate manner, in accordance with professional standards of care. Specifically, for 1 of 1 patient reviewed, Patient ID #2 who self-administered morphine sulfate prefilled syringes that were prepared with the incorrect concentration of morphine by hospice staff, Registered Nurse (RN), Case Manager, Staff A. Additionally, the agency failed to report a medication error in accordance with its established policies and procedures for 1 of 1 medication error reviewed, Patient ID #2. Findings are as follows:Review of an agency-reported incident submitted to the Rhode Island Department of Health on 4/14/2026 revealed that a medication error occurred involving Patient ID #2. Staff A, prefilled syringes with an incorrect dose of morphine sulfate solution for Patient ID #2.Record review revealed that Patient ID #2 was admitted to hospice services in March of 2026, with a diagnosis including, but not limited to, Chronic Obstructive Pulmonary Disease.1. According to the Institute for Healthcare Improvement, “…to reduce medication errors and harm…use the “five rights”: the right patient, the right drug, the right dose, the right route, and the right time…”Record review revealed a physician’s order with a start date of 3/30/2026 for Morphine 10 milligrams (mg) / 5 milliliters (mL) oral solution, administer 2 mg (1mL) by mouth or sublingual every hour as needed.Review of a Hospice Care Coordination Note dated 4/8/2026 at 9:40 AM revealed that the assisted living facility where Patient ID #2 resides called and was requesting a return call from the hospice RN Case Manager regarding the patient’s morphine orders. This request was forwarded to the RN Hospice Case Manager, Staff A, for follow-up. Review of a progress note authored by Staff A indicates that on 4/6/2026, the patient was seen for a home visit. During this visit, Staff A opened a new bottle of morphine sulfate and discarded the previous one. The note further documents that “12 prefilled syringes of 20 mg/1 mL of morphine were prepared.” However, the prescribed concentration for the patient was 2 mg/mL, indicating that the prefilled syringes contained a morphine solution at a concentration that is ten times higher than what was ordered.Review of a progress note authored by Staff A on 4/8/2026 at 11:30 AM, revealed that the patient reported not feeling well, lightheaded, weak with a dry mouth, and difficulty with voiding. The patient is contributing these symptoms to his/her morphine. Staff A indicated that there were 5 syringes left from the 12 syringes Staff A prefilled on 4/6/2026 and the patient was concerned with the morphine dosage and its effects on him/her. Per the documentation Staff A prefilled 10 new syringes from a new morphine bottle that was delivered by the agency’s contracted pharmacy.Per the documentation, Staff A indicated that during a morning visit on 4/8/2026, she identified two separate morphine bottles with differing concentrations in the patient’s possession. One bottle contained morphine 10 mg/5 mL and was supplied by the contracted pharmacy, while the second bottle contained morphine 20 mg/1 mL and was unlabeled. Staff A further documented that she intended to discard the remaining prefilled syringes prepared on 4/6/2026; however, the patient requested to retain them at that time, stating s/he did not intend to use them. Staff A reported that the five syringes with the higher concentration of morphine, along with the associated bottle, were placed in a zip-top bag and stored separately from the prefilled syringes of morphine that she prepared during the visit on 4/8/2026.Review of the hospice agency’s internal investigation revealed that Staff A prepared 1 mL syringes of morphine concentrate during the 4/6/2026 visit using a 20 mg/mL morphine concentrate bottle presented by the patient, which was unlabeled. Staff A did not verify the medication dose against the active physician’s order to ensure accuracy and did not recognize that a medication error was occurring.The investigation further indicated that the patient reported Staff A removed the morphine bottle from his/her pocket during the 4/6/2026 visit. Staff A stated that the patient was in possession of the morphine; however, the agency’s investigation did not identify any active prescription supporting the 20 mg/mL concentration of morphine.Review of a photograph provided by the hospice agency revealed a bottle of morphine concentrate 20mg/ml. The bottle did not contain appropriate directions for use or required cautionary warnings associated with the medication. During a surveyor interview on 4/23/2026 at 1:25 PM, Staff A stated that the bottle used on 4/6/2026 was not labeled with the patient’s name, dosage, indication for use, or cautionary instructions. Staff A further reported that she found the bottle on the resident’s table in his/her room.Staff A indicated that she prefilled 12 syringes from the unlabeled bottle and left the remaining bottle with the patient. She further acknowledged that she did not follow the five rights of medication administration when preparing morphine sulfate for Patient ID #2, including verification of the correct dose.Additionally, Staff A stated that the patient was administered 20 mg of morphine instead of the prescribed 2 mg dose on seven separate occasions. During a surveyor interview on 4/23/2026 at approximately 2:20 PM, with the Senior Director of Quality and Compliance, she acknowledged that the morphine concentrate 20mg/ml bottle was utilized for the patient on 4/6/2026 and that the patient received 20 mg of morphine instead of the prescribed 2 mg dose on seven separate occasions. 2. Review of the agency’s policy titled “INCIDENTS” last revised in June 2025, states in part, “…An Incident Report is completed by an employee who performs, discovers, witness, or becomes aware of circumstances indicative of an unexpected event involving a patient…Major Incidents: the manager responsible for investigating the major incident will initiate an Incident Investigation Report, call their manager or AOC [Administrator On Call] immediately…”Record review indicated that Staff A became aware of the above-referenced medication error during the patient visit on 4/8/2026 at 10:00 AM. Documentation further reflected a subsequent communication with the pharmacist on 4/8/2026 at 3:37 PM. However, there was no evidence in the record to indicate that Staff A notified her supervisor or the Administrator on Call (AOC) regarding the incident.Record review indicated that on 4/8/2026 at 5:33 PM, Registered Nurse (RN) Staff B completed a patient-requested visit related to concerns regarding prefilled syringes. Upon arrival, the patient reported symptoms including brain fog, pruritus, dry mouth, decreased appetite, tremors, decreased urinary output, generalized weakness, and increased sleepiness throughout the day.Staff B observed two separate bottles of morphine with differing dosages in the patient’s room. The patient further reported that s/he had taken five of the prefilled syringes containing the incorrect dose of morphine. Staff B subsequently notified the AOC, the evening supervisor, and the provider of the incident.During a surveyor interview on 4/23/2026 at 1:25 PM, with Staff A, she revealed that she was aware of the medication error and created a plan with the patient going forward related to ordering the patients morphine. Additionally, she revealed that she did not notify her manager, AOC or provider of the medication error.During a surveyor interview on 4/23/2026 at approximately 2:20 PM, with the Senior Director of Quality and Compliance, she was unable to provide evidence that Staff A followed the agency policy regarding the notification of the incident and failed to file an incident report in accordance with agency policy.”

“Based on record review and staff interview, the agency failed to provide necessary in-service training and education following identified adverse events for 2 of 3 incidents reviewed. A. Review of an agency-reported incident submitted to the Rhode Island Department of Health on 4/14/2026 revealed that a significant medication error occurred involving Patient ID #2. Hospice Registered Nurse (RN) Case Manager, Staff A, inappropriately prefilled syringes with an incorrect dose of morphine sulfate solution.B. Record review of an agency-reported incident submitted to the Rhode Island Department of Health on 3/20/2026 revealed that hospice volunteer, Staff C, entered a patient’s room and engaged in inappropriate physical contact by hugging a visitor on two separate occasions.Further review of agency documentation confirmed that both incidents were investigated, resulting in the termination of Staff A and Staff C.However, record review failed to demonstrate that the agency implemented any in-service education, competency validation, or targeted staff training following these serious incidents. Specifically, there was no evidence of education related to safe medication administration practices, controlled substance management, abuse prevention, recognition, or mandatory reporting requirements.During a surveyor interview conducted on 4/22/2026, the Senior Director of Quality and Compliance acknowledged that no staff education or retraining was provided in response to these incidents, reflecting a failure by the agency to take necessary corrective actions to prevent recurrence and ensure staff competency.”

“Based on surveyor observation, clinical record review, and patient and staff interviews, the facility failed to ensure that drugs and biologicals were stored in accordance with currently accepted professional standards for 1 of 1 patient reviewed, Patient ID #2, who self-administered morphine sulfate solution. Findings are as follows:Review of an agency-reported incident submitted to the Rhode Island Department of Health on 4/14/2026 revealed that a medication error occurred involving Patient ID #2. Hospice Registered Nurse (RN), Case Manager, Staff A, prefilled syringes with an incorrect dose of morphine sulfate solution for Patient ID #2.Review of a agency policy titled, “MEDICATION – LABELING, STORAGE OF DRUGS AND BIOLOGICALS AND SAFEGUARDING” last revised 7/2021, states in part, “…Drugs and biologicals are labeled in accordance with currently accepted professional practice that includes appropriate usage and cautionary instructions as well as an expiration date…”Record review revealed that Patient ID #2 was admitted to hospice services in March of 2026, with a diagnosis including, but not limited to, Chronic Obstructive Pulmonary Disease.Record review revealed a physician’s order with a start date of 3/30/2026 for Morphine 10 milligrams (mg) / 5 milliliters (mL) oral solution, administer 2 mg (1mL) by mouth or sublingual every one hours as needed.Review of a progress note authored by Staff A indicates that on 4/6/2026, the patient was seen for a home visit. During this visit, Staff A opened a new bottle of morphine sulfate and discarded the previous one. The note further documents that “12 prefilled syringes of 20 mg/1 mL of morphine were prepared.” However, the prescribed concentration for the patient was 2 mg/mL, indicating that the prefilled syringes contained a morphine solution at a concentration ten times higher than what was ordered. Review of a progress note authored by Staff A on 4/8/2026 at 11:30 AM, revealed that the patient reported not feeling well, lightheaded, weak with a dry mouth, difficulty and voiding. The patient is contributing these symptoms to his/her morphine. Staff A indicated that there were 5 syringes left from the 12 syringes Staff A prefilled on 4/6/2026 and the patient was concerned with the morphine dosage and its effects on him/her. Per the documentation Staff A prefilled 10 new syringes from a new morphine bottle that was delivered by the agency’s contracted pharmacy.Review of a progress note authored by Staff A on 4/8/2026 at 3:37 PM revealed that Patient ID #2 contacted the agency’s contracted pharmacy to report concerns regarding his/her morphine prescription and stated that hospice had been contacted, but no one had responded to address the issue. Per the documentation, Staff A indicated that during a morning visit, she identified two separate morphine bottles with differing concentrations in the patient’s possession. One bottle contained morphine 10 mg/5 mL and was supplied by the contracted pharmacy, while the second bottle contained morphine 20 mg/1 mL and was unlabeled. Staff A further documented that she intended to discard the remaining prefilled syringes prepared on 4/6/2026; however, the patient requested to retain them at that time, stating s/he did not intend to use them. Staff A reported that the five syringes with the higher concentration of morphine, along with the associated bottle, were placed in a zip-top bag and stored separately from the newly prepared prefilled syringes of morphine.Review of a photograph provided by the hospice agency revealed a bottle of morphine concentrate 20mg/ml. The bottle did not contain a did not include appropriate directions for use or required cautionary warnings associated with the medicationDuring a surveyor interview on 4/23/2026 at 1:25 PM, Staff A stated that the bottle used on 4/6/2026 was not labeled with the patient’s name, dosage, indication for use, or cautionary instructions. Staff A further reported that she found the bottle on the resident’s table in his/her room.During a surveyor interview on 4/23/2026 at approximately 2:20PM, with the Senior Director of Quality and Compliance, she acknowledged that the morphine concentrate 20mg/ml bottle was utilized for the patient on 4/6/2026 and the bottle was not labeled in accordance with the facility policy and federal regulations.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: prescription and over-the-counter (OTC) drugs, supplements; herbal remedies; [and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The drug profile is updated , at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 5 of 31 (16%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included a medication profile listing the patient’s current medications. CLINICAL RECORD 2: The patient elected hospice care on 11/10/2023 with a diagnosis of frontotemporal dementia (FTD). The plan of care dated 03/06/2026 included orders for emergency symptom management: Compazine 10 mg PO or 25 mg suppository as needed (PRN), Imodium, one (1) cap PO after each loose stool PRN, Scopolamine patch, one (1) patch for terminal secretions PRN. The medication profile did not document Compazine, Scopolamine, or Imodium. There was no evidence that the comprehensive assessment included a review of the Compazine, Scopolamine, or Imodium as part of the patient’s medication regimen. CLINICAL RECORD 7: The patient elected hospice care on 03/25/2026 with a diagnosis of malignant neoplasm unspecified (liver and abdominal nodes). The plan of care dated 03/25/2025 ordered, “May initiate if needed: (TX) Treatment of Respiratory Distress: Oxygen 2L/min as needed for dyspnea with hypoxia per nasal cannula/face mask trach mask, May initiate as needed Atropine 1% Ophthalmic Solution, two (2) drops every 4 hours sublingual (SL) PRN, Imodium, one (1) cap PO after each loose stool, Scopolamine Patch, one (1) patch behind the ear, change every 72 hours, Compazine 10 mg PO q12 hours PRN and Compazine supp. 25 mg q 12 hours PRN. The medication profile did not document Atropine, Compazine, Scopolamine, or Imodium. There was no evidence that the comprehensive assessment included a review of Atropine, Compazine, Scopolamine, or Imodium as part of the patient’s medication regimen. CLINICAL RECORD 8: The patient elected hospice care on 03/06/2026 with a diagnosis of chronic obstructive pulmonary disease (COPD). The plan of care dated 03/06/2026 included orders for emergency symptom management: Compazine 10 mg PO or 25 mg suppository PRN, Imodium, one (1) cap PO after each loose stool PRN, Scopolamine patch, one (1) patch for terminal secretions PRN. The medication profile did not document Compazine, Scopolamine, or Imodium. There was no evidence that the comprehensive assessment included a review of Compazine, Scopolamine, or Imodium as part of the patient’s medication regimen. CLINICAL RECORD 9: The patient elected hospice care on 04/01/2026 with diagnoses of hypertensive heart disease and chronic kidney disease. The plan of care dated 04/01/2026.ordered, “May initiate if needed: Atropine 1% Ophthalmic Solution, two (2) drops every 4 hours SL PRN, Imodium, one (1) cap PO after each loose stool PRN, Scopolamine patch, one (1) patch behind the ear, change every 72 hours, Compazine 10 mg PO q12 hours PRN and Compazine supp. 25 mg q 12 hours PRN. The medication profile did not document Atropine, Compazine, Scopolamine, or Imodium. There was no evidence that the comprehensive assessment included a review of the Atropine, Compazine, Scopolamine, or Imodium as part of the patient’s medication regimen. CLINICAL RECORD 10: The patient elected hospice care on 02/09/2026 with a diagnosis of malignant neoplasm of the breast. The plan of care dated 02/09/2026 included orders for emergency symptom management: Compazine 10 mg PO or 25 mg suppository as needed (PRN), Imodium, one (1) cap PO after each loose stool PRN, Scopolamine patch, one (1) patch for terminal secretions PRN. The medication profile did not document Compazine, Scopolamine, or Imodium. There was no evidence that the comprehensive assessment included a review of Compazine, Scopolamine, or Imodium as part of the patient’s medication regimen. In an interview on 04/16/2026, the Clinical Manager stated, “We have a system that we order emergency symptom management items for all patients not in a skilled nursing facility (SNF) or inpatient unit (IPU), so we have orders just in case we need them.””

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of pediatric patients, the agency did not ensure that the patient’s plan of care was individualized to meet the drug and treatment needs of the patient. CLINICAL RECORD 6: The six (6) year old female pediatric patient elected hospice care on 02/26/2024 with diagnoses of Trisomy 18 and anoxic brain damage. The initial comprehensive assessment documented the patient’s: tracheostomy (trach), ventilator dependent, and gastrostomy (G-tube) tube. The plan of care included documentation of the following standing orders: “May initiate as needed: Tx of Nausea/Vomiting: Compazine 10 mg PO q 6 hours PRN (or if unable to take PO) Compazine Supp 25 mg PR q 12 hours PRN, May initiate as needed: TX of terminal secretions: Hyoscyamine oral solution 0.125-0.25mg PO q 4-6 hours PRN, May initiate as needed: TX of terminal secretions: Scopolamine Patch, 1 patch behind ear change Q 72 hours. May initiate as needed: for terminal secretions, Atropine 1% ophthalmic solution 2 drops Q 4 hrs. SL PRN, May initiate if needed. Bowel regime: Imodium 1 cap PO after each loose stool, not to exceed 6 doses in 24 hours.... May insert a Foley catheter with 50-100CC normal saline PRN, may insert a Foley to drain, change q month. May use condom catheter as needed; May initiate as needed: Bowel Regime Step 1 If on Opioids: Senokot S 1-3 tablets PO BID, Step 2 if no BM x 48 hours, administer 1 dose Dulcolax 10 mg PO or PR; add Milk of Magnesia 30-60 mL at bedtime or Sorbitol 30-60 ml PO at bedtime. Step 3 If no BM x 72: SN to perform rectal exam to r/o impaction, and if not impacted, administer Dulcolax supp 10 mg PR or FLEET enema. Step 4 If impacted SN to manually disimpact if the stool is soft enough. Follow up with Fleet enema and increase the intensity of the bowel program.” The plan of care standing orders including the drugs with dosages and routes of administration and an as needed (PRN) foley or condom catheter were not individualized to meet the drug and treatment needs of the pediatric female with a G-Tube, trach and vent. CLINICAL RECORD 13: The fourteen (14) year old female pediatric patient elected hospice care on 03/13/2026 with a diagnosis of malignant neoplasm of the connective tissue. The plan of care included documentation of the following standing orders: “May initiate as needed: Tx of Nausea/Vomiting: Compazine 10 mg PO q 6 hours PRN (or if unable to take PO) Compazine Supp 25 mg PR q 12 hours PRN, May initiate as needed: TX of terminal secretions: Hyoscyamine oral solution 0.125-0.25mg PO q 4-6 hours PRN, May initiate as needed: TX of terminal secretions: Scopolamine Patch, 1 patch behind ear change Q 72 hours. May initiate as needed: for terminal secretions, Atropine 1% ophthalmic solution 2 drops Q 4 hrs. SL PRN, May initiate if needed. Bowel regime: Imodium 1 cap PO after each loose stool, not to exceed 6 doses in 24 hours.... May insert a Foley catheter with 50-100CC normal saline PRN, may insert a Foley to drain, change q month. May use condom catheter as needed; May initiate as needed: Bowel Regime Step 1 If on Opioids: Senokot S 1-3 tablets PO BID, Step 2 if no BM x 48 hours, administer 1 dose Dulcolax 10 mg PO or PR; add Milk of Magnesia 30-60 mL at bedtime or Sorbitol 30-60 ml PO at bedtime. Step 3 If no BM x 72: SN to perform rectal exam to r/o impaction, and if not impacted, administer Dulcolax supp 10 mg PR or FLEET enema. Step 4 If impacted SN to manually disimpact if the stool is soft enough. Follow up with Fleet enema and increase the intensity of the bowel program.” The plan of care standing orders including the drugs with dosages and routes of administration and an as needed (PRN) foley or condom catheter were not individualized to meet the drug and treatment needs of the pediatric female. During a review of clinical records and findings on 04/16/2026, the leadership team confirmed that the plans of care were not individualized. The Patient Care Manager Team B stated “We use those standing orders on all patients who do not live in a skilled nursing facility (SNF) or an inpatient unit.”

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 31 (6%) clinical records reviewed, the agency did not ensure that the plan of care included the medical supplies and appliances necessary to meet the needs of the patient. Clinical Record 18: The patient elected hospice care on 03/20/2026. The plan of care activities permitted documented transfer assistance using walker and wheelchair, effective 03/20/2026. The durable medical equipment section of the plan of care was blank and did not document a walker or wheelchair. Clinical Record 20: The patient elected hospice care on 03/25/2026. The plan of care safety measures dated 03/26/2026 documented fall precautions and the use of an assistive device. The durable medical equipment section of the plan of care was blank and did not document an assistive device. The Patient Care Manager stated in an interview on 04/16/2026, “You are right, we need to start checking that closer.””

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) clinical records reviewed with Hospice Aide services, the agency did not ensure that the Hospice Aide (HA) received written patient care instructions to meet the patient’s needs. CLINICAL RECORD 2: The patient elected hospice care on 11/10/2023 with a diagnosis of frontotemporal dementia (FTD). For the benefit period dated 02/27/2026 through 04/27/2026, the plan of care included orders to cleanse the left shin with wound wash, apply xeroform, cover with an adhesive foam dressing, and change weekly, effective 02/28/2026; and right forearm skin tears: cleanse with wound cleanser, apply an adhesive foam dressing, and change weekly starting 01/29/2026. The HA care plan dated 02/24/2026 was not updated to include instructions for the HA regarding wounds and dressings should they become wet, soiled, or dislodged during personal care. The Senior Director of Quality and Compliance confirmed that the aide care plan did not include complete instructions for the aide.”

“It is required that a registered nurse makes an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. This standard was not met as evidenced by document review, interview and personnel record review. Agency policy #WE.H40 “Hospice Aide Supervision” (last revised in 02/2026) stated in part, “At the completion of the probationary period and an annual basis, a Registered Nurse (RN) makes an on-site visit to the location where a patient is receiving care in order to observe and assess each Hospice Aide while he or she is performing care.” In 1 of 1 (100%) personnel record reviewed of a hospice Aide (HA), the agency did not ensure that an annual on-site visit was made to observe and assess the HA while performing care. PERSONNEL RECORD 18: The Hospice Aide was hired on 03/04/2019. A review of the personnel record revealed a competency and supervisory Hospice Aide visit completed by a RN on 03/21/2024 and an annual skills competency visit completed by a RN on 03/05/2026. There was no documented evidence of an annual on-site competency visit for 2025. During an interview on 04/17/2026, the Senior Director of Human Resources, who was present for the review of the personnel record, confirmed that there was no additional documented evidence of on-site competency visits between 03/21/2024 and 03/05/2026 in the personnel record. During an interview on 04/17/2026, the Patient Care Manager who supervises the HA, confirmed that no additional documentation for an on-site competency visit between 03/21/2024 to 03/05/2026 was available.”

“It is required that the hospice inpatient facility has documented and dated written reports of Life Safety Code (LSC) fire drills at varied times on all shifts. The hospice inpatient facility has evacuation diagrams posted and visible to all staff, patients, and family members or visitors. This standard was not met as evidenced by document review and interview. The agency did not ensure that quarterly fire drills were conducted and documented for each shift in the inpatient unit (IPU). Agency policy “Fire Policy” #CES.S15 (last revised 01/2026) states, in part, “Fire Drills are conducted on a regular basis at both locations and all information documented and maintained by the Facilities Department.” Additionally, this references K712 “Fire Drills: Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift....” IPU TOUR: A review on 04/16/2026 of the fire drill logs for the IPU revealed fire drills held on the following days: 02/04/2023 during the day shift, 08/27/2024 during the day shift, 08/26/2025 during the day shift, and 04/2026 during the night shift. No additional documented evidence of additional fire drills was present. During an interview on 04/16/2026, the Director of Support Services, who accompanied the IPU tour, confirmed that no fire drills were conducted beyond those listed in the fire drill logs. During an interview on 04/16/2026, the Senior Director of Quality and Compliance, who accompanied the IPU tour, confirmed that the “both locations” listed in the Safety - Fire policy referred to the main office and the alternate delivery site and that the IPU was considered part of the main office. A tour of the agency’s inpatient unit (IPU) revealed that the agency did not ensure that fire drills were held quarterly on each shift in the IPU.”

“Based on record review and staff interview, it has been determined that the facility failed to document measurable outcomes anticipated from implementing and coordinating the plan of care for 1 of 2 patient’s reviewed related to pressure sores, Patient ID #2. Findings are as follows:Record review of a community reported complaint sent to the Rhode Island Department of Health on 6/9/2025 alleges in part that Patient ID #2 had become bedbound, couldn’t walk anymore, and has now developed bedsores. Record review of an agency provided document titled, “Wound Care Management Hospice” revealed in part, “Determine the organization-approved assessment tool and required frequency of wound assessments…Reassess the wound regularly for healing or deterioration and response to interventions…”Record review of the “Hospice Plan of Care” from various certification periods revealed the following interventions:-Assess skin integrity with start dates of 7/16/2024, 1/8/2025 and 3/19/2025-Deep tissue injury (DTI) - pressure induced damage to underlying tissue) to R (right) hip, R knee, L (left) hip, L knee, R ischium (one of three bones forming the lower back portion of the pelvis) will not open in…next 2 weeks with a start date of 11/20/2024-Open area to R shoulder will not worsen in the next 2 weeks with a start date of 11/20/2024-Will not develop any new DTIs in two weeks with start dates of 1/22/2025 and 4/2/2025.Record review of a “Nursing Comprehensive Reassessment” completed by Registered Nurse, Staff A, revealed in part, “Open area to R shoulder [measuring] 2x1…DTI to bilateral hips, bilateral inner knees, R ischium, bilateral elbows, bilateral knees…” Further review of the document revealed that a measurement and an assessment was present for the right shoulder open area, however, no assessments were present for any of the above-mentioned DTIs.During a surveyor interview on 6/24/2025 at 10:09 AM with Registered Nurse, Staff A, she acknowledged that she had only completed assessment documentation for the right shoulder because it was an open wound. She further indicated that she did not measure or document an assessment of the DTIs because they were closed.Further review of the “Nursing Comprehensive Reassessment” revealed the following regarding wounds:-12/13/2024, revealed no documentation related to wound measurements/assessments-12/16/2024, revealed all open areas had resolved. There was no assessment or documentation related to the multiple DTIs noted on the assessment from 11/20/2024-12/30/2024, 1/10/2025, and 1/24/2025 revealed no documentation related to wound measurements/assessments-2/7/2025, revealed that they were offloading pressure and separating the patient’s knees. There was no documentation related to wound measurements/assessments-2/21/2025, revealed no documentation related to wound measurements/assessments-2/28/2025, revealed the patient had a stage 1 pressure injury (intact skin with non-blanchable erythema (redness) of a localized area, usually over a bony prominence) to his/her coccyx. There were no measurements or assessments documented.-3/14/2025, revealed that the patient had a stage 2 pressure ulcer (partial-thickness loss of skin involving the epidermis and/or dermis) on the coccyx). There were no measurements or assessments documented.-3/21/2025, revealed the patient had a stage 2 pressure ulcer on the coccyx and a DTI to the coccyx. There were no measurements or assessments documented.-3/28/2025, revealed the patient had a stage 2 pressure ulcer on the coccyx. There was no measurements or assessments of the wound. Additionally, there was no mention of the DTI which was noted on 3/21/2025.-4/7/2025, revealed no documentation related to wound measurements/assessmentsDuring a surveyor interview on 6/24/2025 at approximately 11:15 AM with the Patient Care Manager, she acknowledged that the above wounds should be measured and assessed. Additionally, she acknowledged that the failure to assess the wounds makes it difficult for the nurses to assess for improvement or worsening of the wounds.”

“Based on record review and staff interview, it has been determined that the agency failed to ensure that Hospice Aides report changes in the patient’s medical needs to a registered nurse and complete appropriate records in compliance with the hospice policy and procedures related to 1 of 2 patients reviewed, Patient ID #2. Findings are as follows:Record review of a facility policy titled, “Hospice Aide Assignments and duties” with a revision date of December 2024, revealed in part, “…Hospice Aides…follow the Hospice Aide plan of care in providing care to assigned patients…Hospice Aides must complete accurate and legible documentation of services provided for the patient at the time of the visit…”Record review of a community reported complaint sent to the Rhode Island Department of Health on 6/9/2025 alleges in part that Patient ID #2 was given medications that caused him/her to become constipated or have diarrhea daily. Record review of the patient’s “Hospice Aide Visit Notes” from 6/7/2024 through 1/10/2025 revealed that the hospice Aide must report if the patient has No BM in 4 days to the supervisor or case manager. The notes further failed to reveal any documentation related to bowel movements (BM) for 73 of 73 “Hospice Aide Visit Notes” reviewed. The areas of the forms which state date of last BM were left blank.Record review of a “Hospice Face to Face Encounter” dated 11/8/2024, revealed that the patient’s physician had documented, “…constipation…requiring aggressive bowel regimen and [as needed] suppository…”During a surveyor interview on 6/23/2025 at 2:36 PM with Registered Nurse, Staff A, she revealed that the patient had issues with constipation. Further, she revealed that she was not aware of the form that the hospice aides fill out, but she would expect the aide to inform her if it had been 4 days since the patient moved their bowels.During a surveyor interview on 6/24/2025 at approximately 11:15 AM with the Patient Care Manager, she acknowledged the above concern related to documentation of BMs and indicated that more education was needed.During a surveyor interview with the Senior Director of Quality and Compliance on 6/23/2025 at approximately 3:00 PM, she acknowledged that the Hospice Aides had failed to document the date of the patient’s last BM on the visit notes. She further acknowledged that the aides are in the patient’s home more often than the nurse is, and without this documentation it would be difficult for the aides to determine and report to the nurse if the patient has gone 4 days without a BM.”

“Based on record review and staff interview, it has been determined that the agency failed to immediately investigate all alleged violations of abuse involving anyone furnishing services on behalf of the agency and immediately take action to prevent further potential violations while the alleged violation is being verified, Patient ID #1. Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health (RIDOH) on 5/15/2025, alleges that Patient ID #1 was verbally abused and mocked by Registered Nurse (RN), Staff A, and Nursing Assistant (NA), Staff B, on the night of 5/3/2025, while they were providing care to him/her. Further review of the complaint revealed video footage of the complainant confronting both staff members as they were exiting the patient’s room. Additionally, on the video footage Staff A apologized stating that she was “frustrated” and her behavior towards Patient ID #1 “was not appropriate at all.” Record review of the agency reported incident submitted to the RIDOH on 5/18/2025, revealed that Staff A, out of frustration, told Patient ID #1 if s/he falls out of bed she will not pick him/her up.Record review revealed Patient ID #1 was admitted to hospice services while in the community in November of 2024 with a diagnosis including but is not limited to, chronic obstructive pulmonary disease (COPD; a lung disease that causes persistent and progressive airflow obstruction and breathing problems). Further record review revealed the patient was transferred to the hospice’s inpatient facility in April of 2025, due to his/her worsened condition. Record review of the agency’s staffing schedule revealed that Staff A worked on the following dates, 5/5, 5/6 and 5/7/2025, after the date of the allegation on 5/3/2025. Additionally, the staffing schedule revealed that Staff B worked on 5/4, 5/8, 5/9 and 5/11/2025 indicating that the agency did not take immediate action to prevent further potential violations, while the alleged violation was being verified:During a surveyor interview on 5/19/2025 at 12:42 PM with the Chief Clinical Officer, she revealed that both Staff A and B were moved to another unit to work after the allegation of abuse was reported to the night supervisor. Additionally, she indicated that on 5/5/2025, the Chief of Human Resources was made aware of the allegation and advised that both staff be transferred to the 3rd floor unit to avoid any confrontation with the patient’s family, indicating they were allowed to care for other patients while the potential violation was being verified. During a survey interview on 5/19/2025 at 12:45 PM with the Unit Manager, she revealed that Staff A and B continued to work and provide care to the other patients, even though there was an allegation of verbal abuse made on 5/3/2025. Additionally, the Unit Manager stated that she did not speak to Staff A until 5/8/2025 at 7:30 AM, which was 5 days after the incident. During that conversation Staff A acknowledged that she was verbally abusive to Patient ID #1 on the night of 5/3/2025, while she was providing care for him/her. Further, the Unit Manager indicated that Staff A continued to provide care to the agency’s other patients, until she was terminated on 5/15/2025. The Unit Manager revealed that Staff B continued to work until 5/17/2025 and is currently on an administrative leave.During a surveyor interview on 5/19/2025 at 2:07 PM with the Chief of Human Resources, she indicated that she was not made aware of the incident involving Staff A and B that occurred on 5/3/2025, until 5/5/2025. She revealed that Staff A and B continued to work after the allegation of abuse was made. Further, she indicated that she would not have expected either staff member to be allowed to work after such an allegation had been made.During a surveyor interview on 5/21/2025 at 11:02 AM with Staff B, she revealed that she had worked with Staff A on the night of 5/3/2025 when this incident occurred. Additionally, she revealed that Staff A, had a difficult time placing an intravenous line into the patient’s vein as s/he was groaning in pain. She revealed that Staff A said to the patient “you have all these tattoos, if you fall out of bed and break your neck, I will not pick you up because I am not coming back to this room.” Furthermore, Staff B revealed that she had worked her usual schedule when the agency told her that she would be placed on administrative leave on 5/17/2025 because the allegation of abuse is on now the local news.A surveyor interview was attempted to be conducted with Staff A, however a return call was not received. Cross reference L-511, L-517 and L-795”

“Based on record review and staff interview, it has been determined that the agency failed to report an allegation of abuse within 5 working days of the agency becoming aware of an alleged staff-to-patient abuse incident, for 1 of 1 patient reviewed, Patient ID #1. Findings are as follows:Review of a facility policy titled “Abuse, Neglect, Mistreatment and Exploitation” last revised in December of 2024 states in part “…Report mechanism… - Any member with knowledge of a reasonable cause to suspect that a disabled person, or a patient in a facility, has been abused…shall make an immediate report to their [agency] Manager…who will follow-up in consultation with the Director of Quality and compliance or designee in conjunction with the Department of Health…”Record review of a community reported complaint submitted to the Rhode Island Department of Health on 5/15/2025, alleges that Patient ID #1 was verbally abused and mocked by Registered Nurse (RN), Staff A, and Nursing Assistant (NA), Staff B, on the night of 5/3/2025, while they were providing care to him/her. Further review of the complaint revealed video footage of the complainant confronting both staff members as they were exiting the patient’s room. Record review revealed the patient was admitted to Hospice services in the community in November of 2024 with diagnosis including but is not limited to, chronic obstructive pulmonary disease (COPD, lung disease that cause persistent and progressive airflow obstruction and breathing problems). Further record review revealed the resident was transferred to the hospice inpatient facility in April of 2025 due to his/her worsened condition.During a surveyor interview on 5/21/2025 at 11:25 AM with Staff B, she revealed that while she was assisting Staff A on the night of 5/3/2025, she witnessed her mimicking the patient as s/he groaned in pain. Additionally, Staff B indicated that Staff A told him/her that if s/he falls and break his/her neck, she will not pick him up because she will not come back to the room. During a surveyor interview of 5/19/2025 at 12:42 PM with the Chief Clinical Officer, she acknowledged that the incident was not reported to the Rhode Island Department of Health within 5 working days as required. Cross reference L-509, L-517 and L-795”

“Based on record review, complainant and staff interview, it has been determined that the agency failed to ensure patients are free from mistreatment, neglect, verbal or mental abuse, relative to 1 of 1 patient reviewed for abuse, Patient ID #1. Findings are as follows:Review of a facility policy titled “…Abuse, Neglect, Mistreatment and Exploitation” last revised in December of 2024 states in part “…[the agency] follow all federal and state requirements regarding alleged violations involving mistreatment, neglect, or verbal, mental…and/or physical abuse...by anyone providing services on behalf of the hospice…abuse means causing intentional pain or harm. This includes physical, mental, verbal…”Record review of a community reported complaint submitted to the Rhode Island Department of Health (RIDOH) on 5/15/2025, alleges that Patient ID #1 was verbally abused and mocked by Registered Nurse (RN), Staff A, and Nursing Assistant (NA), Staff B, on the night of 5/3/2025, while they were providing care to him/her. Further review of the complaint revealed video footage of the complainant confronting both staff members as they were exiting the patient’s room. Record review of the agency reported incident submitted to the RIDOH on 5/18/2025 revealed that Staff A, out of frustration, told Patient ID #1 if s/he falls out of bed she will not pick him/her up.Surveyor observation of the video footage that was submitted with the complaint revealed Staff A was mocking Patient ID #1 as s/he was moaning, by mimicking his/her moans. Additionally, Staff A was heard telling the patient that she was not going to pick him/her up if s/he fell. Further review of the footage revealed Staff A acknowledged the above observations to the patient’s family member and apologized to him/her.Record review revealed the patient was admitted to Hospice services while living in the community in November of 2024 with a diagnosis including but is not limited to, chronic obstructive pulmonary disease (COPD; a lung disease that causes persistent and progressive airflow obstruction and breathing difficulties). Further record review revealed the patient was transferred to the hospice’s inpatient facility in April of 2025 due to his/her worsened condition.Review of a nursing progress note dated 5/2/2025 revealed that the patient was transferred from the community to the inpatient unit due to worsening dyspnea (difficulty or labored breathing), agitation and pain. Additionally, the note indicated that the prognosis (the likely outcome or course of a disease) was hours to days. Therefore the goal of care was for comfort measures only. During a surveyor interview on 5/19/2025 at 12:45 PM with the Unit Manager, she revealed that when she spoke to Staff A on 5/8/2025 at 7:30 AM, Staff A acknowledged that she had verbally abused the patient during the overnight shift on 5/3/2025.During a surveyor interview on 5/21/2025 at 11:25 AM with Staff B, she revealed that while she was assisting Staff A with the care of Patient ID #1, on the night of 5/3/2025, she witnessed her mimicking the patient as s/he groaned in pain. Staff B further acknowledged that Staff A told the patient that if s/he falls and breaks his/her neck, she will not pick him/her up because she will not come back to the room. During a surveyor interview on 5/21/2025 at approximately 10:00 AM, with the complainant, s/he revealed that on the night of 5/3/2025, when s/he went to visit the patient, s/he overheard the nurse making inappropriate comments while providing care to the patient, as s/he waited outside of the room. S/he indicated that Staff A was telling the patient if s/he fell out of bed, she would not pick him/her up as she would not return to the room. The complainant revealed that when s/he met the unit Manager on 5/4/2025 following the incident, she indicated that Staff A would be retrained, as she would continue to work on another unit after this incident of abuse had occurred.During a surveyor interview on 5/19/2025 at 3:20 PM, with the Director of Quality and Compliance, she was unable to provide evidence that the agency kept Patient ID #1 free from abuse by Staff A.Record review revealed that Staff A was terminated from the hospice agency on 5/15/2025, 12 days after this incident of abuse occurred. Cross reference L-509, L-511, and L-795”

“Based on record review and staff interview, it has been determined that the agency failed to obtain a criminal background check (BCI) on all agency employees who have direct patient contact or access to patient records before employment, relative to 1 of 2 employees involved in an incident of abuse, Staff B. Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health (RIDOH) on 5/15/2025, revealed Registered Nurse (RN), Staff A, and Nursing Assistant (NA), Staff B, on the night of 5/3/2025, were involved in an incident of staff to resident abuse. Record review of Staff B’s employee personnel file on 5/19/2025 revealed she was hired on 1/12/2004. Further review of the file failed to reveal evidence that a BCI check was obtained.During a surveyor interview on 5/19/2025 at approximately 2:30 PM with the Chief of Human Resources, she acknowledged that Staff B was hired on 1/12/2004 and had been working for the agency since that date. Additionally, she was unable to provide evidence that a BCI check was obtained for Staff B.Cross reference L-509, L-511 and L-517”