Every finding on record at Constellation Home Care, LLC

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

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

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

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

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

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

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

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

Based on clinical record review, staff interviews and review of agency documentation for one of three patients (Patient #1) who received hospice services, the hospice agency failed to provide timely and effective pain management and symptom control for conditions related to the terminal illness and failed to follow the physician certified care plan. The finding includes: --- Patient #1 had a hospice election date of 11/13/2022 with diagnoses that included chronic obstructive pulmonary disease, small b-cell lymphoma Covid-19 and pneumonia. The physicians orders for the certification periods of 11/13/2022 to 1/11/2023 included skilled nursing services 1 to 2 times a week for 9 weeks, and 6 visits, as needed to assess the current pain management regimen, medication side effects, assess for changes in treatment plan as related to a change in condition, assess severity of symptoms, assess the ability of the patient and/or family to safely administer drugs and biologicals to the patient in the home. Interview and review of patient #1s clinical notes with the Hospice Director on 2/6/2023 at 11:00 AM, identified at the hospice agency patients start of care initial assessment visit, a "Comfort Pak" - a medication pack for (medications to be used to treat symptoms of pain and anxiety as it relates to the end of life process), would be entered by the Registered Nurse (RN) into the patients electronic medication administration record (EMR), and sent to the physician authorizing/ordering Hospice services, for a signature and authorization to release the medication profile for pharmacy filling and delivery to the patient.. The agency Hospice Director identified a Comfort Pak request would be entered by the Hospice start of care nurse into the medication profile, at the time of the initial assessment, but identified that specific medications, including Morphine Sulfate, were placed "on hold" until needed by the patient for symptoms and pain management. The medication request would then be sent to the physician for authorization and pharmacy delivery to the patient. It was further identified that when a change in patient condition was identified, the RN would request the Morphine be added to the Comfort Pak. A review of the physicians orders for Patient #1 identified the Comfort Pak included #4 Acetaminophen 650 milligrams (mg) suppositories (medication to treat pain/fever), 15 milliliters (ml) of Haloperidol suspension (medication to treat agitation) 2mg/ml, (12 ml) suspension Hyoscyamine (medication to treat secretions) 0.123mg sublingual tablets, (10) Lorazepam (medication to treat anxiety) 05.mg tablets, (15ml) Morphine Sulfate 20mg/ml solution (medication to treat pain/shortness of breath), # 6 Prochlorperazine (medication to treat nausea/vomiting) 10mg tablets, and (2) Bisacodyl (medication to treat constipation) suppositories 10mg. Interview and review of the Patient #1s clinical notes on 2/6/2023 at 11:50 AM with RN #1, patient #1s clinical manager, identified the Morphine Sulfate was not ordered for pain during the initial start of care assessment, as patient had no symptoms of shortness of breathing or complaint of pain or discomfort. On 12/27/2023 during a home visit patient's family/caregiver reported that the patient needed pain medication over night and utilized medication, Oxycodone 2 tablets, that was given to her by a friend, as there was no pain medications in the home. Interview and review of the hospice call log and communication notes with the Supervisor of Clinical Services #1 (SCS) on 2/6/23 at 2:00 PM, identified on 12/25/22 at 3:33 PM, Patient #1s caregiver called to report Patient #1 had pain and discomfort. The on-call triage nurse (RN #2) indicated to Patients caregiver that the Morphine Sulfate would be ordered on 12/25/2022, and delivered to the patient's residence. Additionally, the hospice call log identified Patient #1s caregiver called the hospice again on 12/26/2022 at 8:26 PM to report the patient still remained uncomfortable and in pain, and that the Morphine Sulfate had not been delivered as expected, and requested Morphine medication for patient. A review of patient #1s clinical notes identified no nursing visits were made or Morphine ordered until 12/27/2022. On 12/27/2022, RN #1 completed a home visit, and determined patient #1 had been taking oxycodone a friend had provided, to manage their pain, and subsequently the morphine sulfate was ordered on that date. Patient #1s morphine arrived on 12/27/2022 after the morning nursing visit was completed. An evening nursing visit was arranged to prefill syringes with morphine 10mg per ml administer 0.5ml once a day at bedtime. SCS #1 and the Hospice Director identified a visit should have been made after the caregivers initial call on 12/25/2022 to assess the patients pain and medication regimen. Request was made to the Hospice Director for a copy of the agency policy for the ordering of Comfort Paks, the Hospice Administrator identified the agency did not have one.

Based on clinical record review, staff interviews and review of agency documentation for one of three patients (Patient #1) who received hospice care, the hospice agency failed to provide timely and effective pain management and symptom control for conditions related to the terminal illness and failed to follow the physician ordered plan. The finding includes: --- Patient #1 had a hospice election date of 11/13/2022 with diagnoses that included chronic obstructive pulmonary disease, small b-cell lymphoma Covid-19 and pneumonia. The physicians orders for the certification periods of 11/13/2022 to 1/11/2023 included skilled nursing services 1 to 2 times a week for 9 weeks, and 6 visits, as needed, to assess the current pain management regimen, medication side effects, assess for changes in treatment plan as related to a change in condition, assess severity of symptoms, assess the ability of the patient and/or family to safely administer drugs and biologicals to the patient in the home. Interview and review of patient #1s clinical notes with the Hospice Director on 2/6/2023 at 11:00 AM, identified at the hospice agency patients start of care initial assessment visit, a "Comfort Pak" - a medication pack for (medications to be used to treat symptoms of pain and anxiety as it relates to the end of life process), would be entered by the Registered Nurse (RN) into the patients electronic medication administration record (EMR), and sent to the physician authorizing/ordering Hospice services, for a signature and authorization to release the medication profile for pharmacy filling and delivery to the patient. The agency Hospice Director further identified a Comfort Pak request would be entered by the Hospice start of care nurse into the medication profile, at the time of the initial assessment, but identified that specific medications, including Morphine Sulfate, were placed "on hold" until needed by the patient for symptoms and pain management. The medication request would then be sent to the physician for authorization and pharmacy delivery to the patient. It was further identified that when a change in patient condition was identified, the RN would request the Morphine be added to the Comfort Pak. A review of the physicians orders for Patient #1 identified the Comfort Pak included #4 Acetaminophen 650 milligrams (mg) suppositories (medication to treat pain/fever), 15 milliliters (ml) of Haloperidol suspension (medication to treat agitation) 2mg/ml, (12 ml) suspension Hyoscyamine (medication to treat secretions) 0.123mg sublingual tablets, (10) Lorazepam (medication to treat anxiety) 05.mg tablets, (15ml) Morphine Sulfate 20mg/ml solution (medication to treat pain/shortness of breath), # 6 Prochlorperazine (medication to treat nausea/vomiting) 10mg tablets, and (2) Bisacodyl (medication to treat constipation) suppositories 10mg. Interview and review of the Patient #1s clinical notes on 2/6/2023 at 11:50 AM with RN #1, patient #1s clinical manager, identified the Morphine Sulfate was not ordered for pain during the initial start of care assessment, as patient had no symptoms of shortness of breathing or complaint of pain or discomfort. On 12/27/2023 during a home visit patient's family/caregiver reported that the patient needed pain medication over night and utilized medication, Oxycodone 2 tablets, that was given to her by a friend, as there was no pain medications in the home. Interview and review of the hospice call log and communication notes with the Supervisor of Clinical Services #1 (SCS) on 2/6/23 at 2:00 PM, identified on 12/25/22 at 3:33 PM, Patient #1s caregiver called to report Patient #1 had pain and discomfort. The on-call triage nurse (RN #2) indicated to Patients caregiver that the Morphine Sulfate would be ordered on 12/25/2022, and delivered to the patient's residence. Additionally, the hospice call log identified Patient #1s caregiver called the hospice again on 12/26/2022 at 8:26 PM to report the patient still remained uncomfortable and in pain, and that the Morphine Sulfate had not been delivered as expected, and requested Morphine medication for patient. A review of patient #1s clinical notes identified no nursing visits were made or Morphine ordered until 12/27/2022. On 12/27/2022, RN #1 completed a home visit, and determined patient #1 had been taking oxycodone a friend had provided, to manage their pain, and subsequently the morphine sulfate was ordered on that date. Patient #1s morphine arrived on 12/27/2022 after the morning nursing visit was completed. An evening nursing visit was arranged to prefill syringes with morphine 10mg per ml administer 0.5ml once a day at bedtime. SCS #1 and the Hospice Director identified a visit should have been made after the caregivers initial call on 12/25/2022 to assess the patients pain and medication regimen. Request was made to the Hospice Director for a copy of the agency policy for the ordering of Comfort Paks, the Hospice Administrator identified the agency did not have one.

Based on clinical record review, agency documentation, interview with the agency personnel, and review of the facility policy, for one of twenty patients (Patient# 12) in the survey sample, the hospice nurses failed to follow the physician-certified plan of care. The findings include: Patient#12 elected the Hospice benefit on 1/26/2022. Patient#12's diagnoses included malignant neoplasm of frontal lobe, hypertension, and emphysema. The physician's orders dated 2/9/2022 included nursing services for assessments and teaching the patient/family on the medication regiment and signs and symptoms to report to the nurse. Patient #12's medications included Morphine Sulfate 20 mg/ml (milligrams/milliliter), administer 5 mg/0.25 ml by mouth every three hours as needed for moderate to severe pain or shortness of breath, Lorazepam 0.5 mg 1 tab by mouth every six (6) hours as needed for anxiety, and haloperidol 2 mg/ml, 1 mg/0.5 ml by mouth for agitation. Interview and review of the nursing note dated 2/2/2022 with the Director of Hospice on 5/5/2022 at 1:00 pm indicated that Registered Nurse/RN #1 prefilled five (5) Morphine, (5) Lorazepam, (5) Haldol syringes but failed to identify a physician's order that authorized the nurse to prefill the patient's medications and failed to identify nursing adherence to the plan of care. Review of the physician's orders dated 2/5/2022 directed to discontinue Lorazepam 0.5 mg 1 tablet by mouth every six (6) hours as needed for anxiety, and haloperidol 2 mg/ml, give 1 mg/0.5 ml by mouth for agitation, and initiate Haloperidol 2 mg/ml, give 05 ml/1 mg every four hours for agitation and Lorazepam 2 mg/ml, give 0.25 ml by mouth every four hours as needed for anxiety. Interview and review of the nursing note dated 2/5/2022 with the Director of Hospice on 5/5/2022 at 1:00 pm indicated that RN #1 prefilled eight (8) Morphine, (8) Lorazepam and (8) Haldol syringes but failed to identify a physician's order that authorized the nurse to prefill the patient's medications and failed to identify nursing adherence to the plan of care. Review of the physician's orders dated 2/7/2022 directed to discontinue Lorazepam 2mg/ml, give 0.25 ml every four hours as need for anxiety and Haloperidol 2mg/mL, give 0.5 ml/1 mg by mouth every four hours as needed and imitate Haloperidol 2 mg/mL, give 1 ml every four hours as needed and Lorazepam 2 mg/mL, give 0.5 ml by mouth every four hours as needed. a. Interview and review of the nursing note dated 2/9/2022 with the Director of Hospice on 5/5/2022 at 1:00 pm indicated that RN #1 prefilled ten (10) Haldol and (10) Lorazepam syringes but failed to identify a physician's order that authorized the nurse to prefill the patient's medications and failed to identify nursing adherence to the plan of care. b. Interview and review of the nursing note dated 2/10/2022 with the Director of Hospice on 5/5/2022 at 1:15 pm indicated that RN #2 prefilled (undocumented/unknown) amount of Morphine, Lorazepam and Haldol syringes but failed to identify a physician's order that authorized the nurse to prefill the patient's medications and failed to identify nursing adherence to the plan of care. Review of physician's orders dated 2/11/2022 directed to discontinue Morphine 20 mg/ml, give 0.5ml/5 mg every three hours as needed and Lorazepam 2 mg/mL, give 0.5 ml every four hours as needed and initiate Lorazepam 2 mg/ml, give 1 ml every four hours as needed for anxiety and Morphine 20 mg/ml, give 0.5 ml every four hours for pain and shortness of breath, and Morphine 20 mg/ml, give 1 ml every two hours as need for pain and shortness of breath. a. .Interview and review of the nursing note dated 2/11/2022 with the Director of Hospice on 5/5/2022 at 1:15 pm indicated that RN#1 prefilled fifteen (15) Morphine syringes but failed to identify a physician's order that authorized the nurse to prefill the patient's medications and failed to identify nursing adherence to the plan of care. b. Interview and review of the nursing note dated 2/14/2022 with the Director of Hospice on 5/5/2022 at 1:15 pm indicated that RN#1 prefilled twelve (12) Morphine syringes, ten (10) Haldol and ten (10) Lorazepam syringes but failed to identify a physician's order that authorized the nurse to prefill the patient's medications and failed to identify nursing adherence to the plan of care. c. .Interview and review of the nursing note dated 2/15/2022 with the Director of Hospice on 5/5/2022 at 1:15 pm indicated that RN#2 prepoured medications (not identified ) but failed to identify a physician's order that authorized the nurse to prepour the patient's medications and failed to identify nursing adherence to the plan of care. The agency policy on medication pre-pour directed to use physician's order, current medication profile and Medication Administration Record (MAR)

Based on review of clinical record and interview with hospice personnel, for one of twenty patients (Patient # 12) in the survey sample, the hospice nurses failed to document the pre-pouring process in accordance with the hospice policies. The findings include:The findings include: Patient#12 elected the Hospice benefit on 1/26/2022. Patient#12's diagnoses included malignant neoplasm of frontal lobe, hypertension, and emphysema. The physician's orders dated 2/9/2022 included nursing services for assessments and teaching the patient/family on the medication regiment and signs and symptoms to report to the nurse. Patient #12's medications included Morphine Sulfate 20 mg/ml (milligrams/milliliter), 5 mg/0.25 ml by mouth every three hours as needed for moderate to severe pain or shortness of breath and Lorazepam 0.5 mg 1 tab by mouth every six (6) hours as needed for anxiety, and haloperidol 2 mg/ml, 1 mg/0.5 ml by mouth. Interview and review of the nursing note dated 2/2/2022 with the Director of Hospice on 5/5/2022 at 1:00 pm indicated that Registered Nurse/RN #1 prefilled five (5) Morphine, (5) Lorazepam syringes, but failed to identify an accurate documentation of Controlled Substances pre-pour in accordance with the agency policy. Review of the physician's orders dated 2/5/2022 directed to discontinue Lorazepam 0.5 mg 1 tablet by mouth every six (6) hours as needed for anxiety, and Haloperidol 2 mg/ml, give 1 mg/0.5 ml by mouth for agitation, and initiate Haloperidol 2 mg/ml, give 05 ml/1 mg every four hours for agitation and Lorazepam 2 mg/ml, give 0.25 ml by mouth every four hours as needed for anxiety. a. Interview and review of the nursing note dated 2/5/2022 with the Director of Hospice on 5/5/2022 at 1:00 pm indicated that RN #1 prefilled eight (8) Morphine, (8) Lorazepam syringes, but failed to identify an accurate documentation of Controlled Substance pre-pour in accordance with the agency policy. Review of the physician's orders dated 2/7/2022 directed to discontinue Lorazepam 2mg/ml, give 0.25 ml every four hours as need for anxiety and Haloperidol 2mg/mL, give 0.5 ml/1 mg by mouth every four hours as needed and imitate Haloperidol 2 mg/mL, give 1 ml every four hours as needed and Lorazepam 2 mg/mL, give 0.5 ml by mouth every four hours as needed. a. Interview and review of the nursing note dated 2/9/2022 with the Director of Hospice on 5/5/2022 at 1:00 pm indicated that RN #1 prefilled ten (10) Lorazepam syringes but failed to identify an accurate documentation of Controlled Substance pre-pour in accordance with the agency policy. b. Interview and review of the nursing note dated 2/10/2022 with the Director of Hospice on 5/5/2022 at 1:15 pm indicated that RN #2 prefilled (undocumented amount) of Morphine and Lorazepam syringes, but failed to identify an accurate documentation of Controlled Substance pre-pour in accordance with the agency policy. Review of the physician's orders dated 2/11/2022 directed nursing staff to discontinue order Morphine 20 mg/ml, give 0.5ml/5 mg every three hours as needed and Lorazepam 2 mg/mL, give 0.5 ml every four hours as needed, and to initiate Lorazepam 2 mg/ml, give 1 ml every four hours as needed for anxiety and Morphine 20 mg/ml, give 0.5 ml every four hours for pain and shortness of breath, and Morphine 20 mg/ml, give 1 ml every two hours as need for pain and shortness of breath. a. Interview and review of the nursing note dated 2/11/2022 with the Director of Hospice on 5/5/2022 at 1:15 pm indicated that RN#1 prefilled fifteen (15) Morphine syringes but failed to identify an accurate documentation of Controlled Substance pre-pour in accordance with the agency policy. b. Interview and review of the nursing note dated 2/14/2022 with the Director of Hospice on 5/5/2022 at 1:15 pm indicated that RN#1 prefilled twelve (12) Morphine syringes and ten (10) Lorazepam syringes, but failed to identify an accurate documentation of Controlled Substance pre-pour in accordance with the agency policy. The agency policy on Controlled Substances directed for Controlled Drugs to be accounted for on a narcotic count record, which will be maintained as part of the clinical record.

Based on review of the clinical record and interview with agency personnel, for one of twenty patients (Patient # 18) in the survey sample, the agency failed to ensure timely filing of the clinical notes in accordance with Connecticut State regulations. The findings include: Patient #18 elected the Hospice benefit on 3/31/2022. Patient#18's diagnoses included end-stage heart disease, hypertension, and mitral valve prolapse. The physician's orders for the certification period from 3/31/2022 through 5/29/2022 included nursing services for assessments and teaching. a. Interview and review of the nursing note dated 4/1/2022 with the Hospice Director on 5/5/2022 at 1:30 pm identified that Registered Nurse/RN#1 completed a home visit on 4/1/2022, but failed to complete a visit note until 4/20/2022 (19 days later) and failed to identify conformance with the Connecticut regulation 19-13-D75 (b)(6) which required the incorporation of clinical notes no later than seven days after the patient encounter. b. Interview and review of the nursing note dated 4/4/2022 with the Hospice Director on 5/5/2022 at 1:30 pm identified that Registered Nurse/RN#1 completed a home visit on 4/4/2022, but failed to complete a visit note until 4/29/2022 (25 days later), and failed to identify conformance with the Connecticut regulation 19-13-D75 (b)(6) which required the incorporation of clinical notes no later than seven days after the patient encounter. c. Interview and review of the nursing note dated 4/6/2022 with the Hospice Director on 5/5/2022 at 1:30 pm identified that Registered Nurse/RN#1 completed a home visit on 4/6/2022 but failed to complete a visit note until 5/17/2022 (41 days later ) and failed to identify conformance with the Connecticut regulation 19-13-D75 (b)(6) which required the incorporation of clinical notes no later than seven days after the patient encounter. d. Interview and review of the nursing note dated 4/11/2022 with the Hospice Director on 5/5/2022 at 1:30 pm identified that Registered Nurse/RN#1 completed a home visit on 4/11/2022, but failed to complete a visit note until 5/2/2022 (21 days later), and failed to identify conformance with the Connecticut regulation 19-13-D75 (b)(6) which required the incorporation of clinical notes no later than seven days after the patient encounter. e. Interview and review of the nursing note dated 4/13/2022 with the Hospice Director on 5/5/2022 at 1:30 pm identified that Registered Nurse/RN#1 completed a home visit on 4/13/2022, but failed to complete a visit note until 5/3/2022 (20 days later), and failed to identify conformance with the Connecticut regulation 19-13-D75 (b)(6) which required the incorporation of clinical notes no later than seven days after the patient encounter. f. Interview and review of the nursing note dated 4/22/2022 with the Hospice Director on 5/5/2022 at 1:30 pm identified that Registered Nurse/RN#1 completed a home visit on 4/22/2022, but failed to complete a visit note until 5/3/2022 (11 days later), and failed to identify conformance with the Connecticut regulation 19-13-D75 (b)(6) which required the incorporation of clinical notes no later than seven days after the patient encounter. g. Interview and review of the nursing note dated 4/23/2022 with the Hospice Director on 5/5/2022 at 1:30 pm identifed that Registered Nurse/RN#1 completed a home visit on 4/23/2022 but failed to complete a visit note until 5/3/2022 (19 days late), and failed to identify conformance with the Connecticut regulation 19-13-D75 (b)(6) which required the incorporation of clinical notes no later than seven days after the patient encounter. Interview with the Hospice Director on 5/5/22 at 1:30 pm identified that the agency personnel were expected to completed a visit note 24 to 48 hours after the visit, and failed to identify that the nurses followed the agency practice in regard to a timeliness of the note completion. In addition, the Hospice Director indicated that the agency did not have a policy regarding a timeliness of a skilled visit note completion.