Every finding on record at Mothers Love Hospice, LLC

Based on clinical record review, staff and family interviews, it was determined that the Hospice failed to manage pain and control symptoms for one patient (P) P#3 of three patients reviewed. --- Review of the clinical record for P#3 revealed the Comfort kit (a small amount of medications for pain and comfort related to the terminal illness) was ordered on 9/3/25 and delivered on 9/5/25. P#3 was pronounced by Registered Nurse (RN) AA on 9/5/25.Review of record of P#3 revealed the agency failed to provide the Comfort kit until time of pronouncement.During a telephone interview with family member of P#3 on 9/16/25 at 12:06 p.m., family member stated the Comfort Kit arrived after the pronouncement and she gave it to RN AA as she (RN AA) was leaving.During a telephone interview on 9/16/25 at 1:52 p.m. with Licensed Practical Nurse (LPN) AA confirmed that she received a call around 10:21 p.m. to do an on-call visit for P#3. The family member of P#3 called and requested pain medications and a nursing visit as P#3 was wailing and thrashing about in pain. LPN AA stated that it took her more than two hours to arrive for the visit. LPN AA picked up pain medications as P#3 was still without Comfort Kit.  LPN AA stated that she did not stay after administering the Morphine (opioid pain reliever) tablet, Phenergan (medicine used for allergy symptoms, nausea, vomiting, sedation, and pain relief) , and Ativan (used to treat anxiety) as the daughter was a nurse and would monitor P#3.

Based on policy titled “Complaint Resolution,” record reviews, and family and staff interviews it was determined the agency failed to investigate the complaint reported by patient's family member and take appropriate corrective action for one patient (P) (P#3) of three patients reviewed. Specifically, the agency failed to investigate the complaint from a family member that P#3 had not received a Comfort Kit (pain and comfort medications) until after P#3 was pronounced on 9/5/25. --- Findings include:Review of policy titled “Complaint Resolution,” revised June 2019 revealed the hospice will document both the existence and the resolution (or attempts at resolution) of the complaint. This documentation will be kept confidential in a file titled "Complaints." Complaints are to be logged and incorporated into Quality Assurance.Review of records failed to reveal an agency complaint log.During an interview with the Administrator on 9/16/25 at 10:00 a.m. the Administrator confirms that he is aware of the complaint. The Administrator states that the agency has not kept a complaint log since the year 2023. During an interview with Registered Nurse (RN) RN BB on 9/16/25 at 10:54 a.m., RN BB states that she keeps a complaint log but was unable to provide it for review. During an interview with the Executive Director (ED), on 9/16/25 at 12:51 p.m., ED stated that she spoke to the complainant last 9/11/25. She stated that the complainant was tearful and wanted this incident to be a teachable moment for the staff. The ED was unable to produce documentation of the complaint or conversation with the complainant

Based on policy titled “After Hours Accessibility,” clinical record review, and staff interviews, it was determined that the agency failed to provide effective pain management and symptom control for one patient (P) (P#3) of three patients reviewed. Specifically, the agency failed to ensure that pain and comfort medications were made available 24 hours a day/7 days per week for P#3. --- Findings include:Review of policy titled “After hours Accessibility” revised June 2019, revealed that nursing services, physician services and drug and biologicals are routinely available on a 24 hour basis 7 days a week.Review of a document with a heading of “FedEx” revealed the Comfort Kit (a set of medicines and supplies for fast relief of symptoms in end-of-life situations) had a ship date of  Sep 4, 2025 and a delivery date of Sept 5, 2025, 16:44.Review of ordered prescriptions for P#3 revealed that the Comfort Kit was ordered on 9/3/25 at 5:33p.m.During an interview on 9/16/25 at 12:51p.m. with the Executive Director (ED) who stated that because the Comfort Kit had not arrived an order for Morphine (opioid pain-reliving medication) tablets was placed by the Administrator to a local pharmacy and Licensed Practical Nurse (LPN) AA, the on-call nurse picked it up and delivered to P#3. The ED stated that if the Comfort Kit is ordered on the day of admission and is expected to arrive on the same day if ordered before 3:00 p.m. If the Comfort Kit is ordered after 3:00 p.m. it is expected to arrive the following day. She confirms that Comfort Kit did not arrive to home of P#3 until after patient expired.

Based on policy titled “Medication Dispensing,” record review and family and staff interviews, it was determined that the agency failed to follow the written plan of care for one patient (P) P#3 of three patients reviewed. Specifically, pain and comfort medications ordered on the plan of care for P#3 failed to be administered to manage pain and control symptoms related to the terminal illness. --- Findings include:Review of policy titled “Medication Dispensing, ” revised June 2019 revealed the following:Procedure1. The hospice will provide drugs and biologicals related to the palliation and management of the terminal illness and related conditions as identified in the Hospice plan of care.4. The Hospice staff will order medications from contracted pharmacy in advance of patient's need to ensure timely delivery of medications.6. Hospice provides medications 24 hours/day, 7 days/week through contracted pharmacy providers.Review of document titled "HOSPICE CERTIFICATION AND PLAN OF CARE" dated 9/3/25 for P#3 revealed that the comfort kit medications had been ordered on 9/3/25.During an interview on 9/16/25 at 12:51p.m. with the Executive Director (ED) who stated that the Comfort Kit had not arrived, an order for Morphine tablets was placed by the Administrator to a local pharmacy. Licensed Practical Nurse (LPN) AA, the on-call nurse picked it up and delivered them to P#3. The ED stated if the Comfort Kit is ordered on the day of admission and is expected to arrive on the same day if ordered before 3:00p.m. If the Comfort Kit is ordered after 3:00 p.m. it is expected to arrive the following day. She confirms that Comfort Kit did not arrive to home of P#3 until patient was pronounced.

Based on policy titled “Medication Reconciliation,” record review, and staff and family interviews, it was determined that the agency failed to include all services for palliation and management of the terminal illness for one patient (P) (P#3) of three patients reviewed. Specifically, the care plan failed to include MS tablets (morphine sulfate, a medication for pain) that were administered during an after-hours on-call visit. --- Findings included:Review of  policy titled "Medication Reconciliation, " revised June 2019 revealed the following:The medication list/profile will be updated with each new or changed medication.Review of HOSPICE CERTIFICATION AND PLAN OF CARE dated 9/3/25 for P#3 failed to reveal an order for MS 15 mg tablets.During an interview with Registered Nurse (RN) on 9/16/25 at 1:18 p.m., RN AA stated that when she assessed P#3 on 9/4/25 she was not in pain. On 9/5/25 she administered a “cocktail” of MS tablets, Ativan and Phenergan. She stated that she reassessed P#3 and she was comfortable. RN AA acknowledge that the MS 15mg tablets were not on the plan of care for P#3.

Based on policies titled “Complaint Resolution,” and “Quality Assurance and Performance Improvement (QAPI) Plan,” and staff interviews, it was determined that the hospice failed to analyze and track complaints as part of the QAPI program. --- Findings include:Review of the policy titled “Complaint Resolution,” revised May 2022 revealed the following:3. The designated individual to respond to and takes action to resolve complaints is the Administrator.• Complaints are logged, tracked and trended.• Complaint management is incorporated into QAPI activities.Review of the policy titled “Quality Assurance and Performance Improvement (QAPI) Plan,” revised May 2023 revealed the following:3. Data collection will include process of care, hospice services and operations and includes developing indicators, criteria or performance levels for each process determined to be improved. Data collection will be ongoing and frequency will be determined by the process improvement activity and approved by the Governing Body. Data collected will be used to monitor the effectiveness and safety of services and the quality of care.7. Hospice will also collect data about:•  Priorities identified by leaders.•  Incident reporting.•  Internal and external complaints, including patient complaints/grievances.•  Effectiveness of pain management.•  Nursing services.•  Patient rights.•  Contract services.Review of an email received by the Administrator on 9/7/2025 from the family of P#3 revealed the following:“Hospice care is meant to provide comfort and dignity at the end of life. In this most basic expectation, Trinity Hospice failed my mother.” No documentation of the agency’s response was provided.A complaint log was requested but not provided. On 9/16/2025 at 10:00 a.m., an interview was conducted with the Administrator, who verbalized that the agency no longer keeps a complaint log because the electronic medical record (EMR) can record and track occurrences. However, the administrator was unable to provide any documentation of any complaints, investigations, or resolutions, and stated there were no complaints in September 2025.  On 9/16/2025 at 10:54 a.m., an interview was conducted with the Compliance Officer, who revealed that complaints are reviewed every other week at Interdisciplinary Group (IDG) meetings. The Compliance Officer acknowledged that the reviews are not documented or compiled for the QAPI committee to track.

Based on policy titled “Governing Body,” record review, and family and staff interviews, it was determined the hospice failed to organize, manage, and administer resources by failing to provide care to optimize comfort/dignity for one patient (P) (P#3) of three sampled patients. Specifically, the agency failed to deliver a comfort kit prior to patient death, failed to investigate complaints regarding P#3, and failed to arrive within an hour to respond to a request for a home visit to manage pain for P#3. --- Findings include: Review of the policy titled “Governing Body,” revised June 2019 revealed the following:POLICYThe Governing Body assumes full legal authority and responsibility for the management of Hospice, the provision of all Hospice services, its fiscal operations and assumes responsibility for the safety and quality of care provided, including QAPI.Review of clinical record revealed P#3 was admitted on 9/3/2025 and expired on 9/5/2025. Review of Hospice Certification and Plan of Care dated 9/3/2025 reveals an order for a comfort kit to include Morphine (an opioid pain reliever). Pharmacy records review revealed a comfort kit was ordered on 9/3/25 at 5:33 p.m. but was not delivered until 9/5/2025 at 4:44 p.m., after Registered Nurse (RN) AA pronounced P#3 at 4:25 p.m. Review of agency on-call logs revealed a visit was requested by the family of P#3 for unmanaged pain at 10:21 p.m. on 9/4/2025. A visit note dated 9/5/2025 revealed an on-call visit was made to P#3 for pain unrelieved by oxycodone (opioid analgesic used to treat moderate to severe pain). The nurse arrived at 12:45 a.m. Review of an email received by the Administrator on 9/7/2025 from P#3’s family revealed the following:“Hospice care is meant to provide comfort and dignity at the end of life. In this most basic expectation, Trinity Hospice failed my mother.” No documentation of the agency’s response was provided.Review of records failed to reveal an agency complaint log.During an interview with the Administrator on 9/16/25 at 10:00 a.m. the Administrator confirms that he is aware of the complaint. The Administrator states that the agency has not kept a complaint log since the year 2023. On 9/16/2025 at 10:00 a.m., an office interview was conducted with the Administrator, who explained the hospice no longer keeps a complaint log as the electronic medical record (EMR) can be used to document occurrences. The Administrator verbalized that the agency has not done a good job of documenting complaints and stated that no complaints have been logged for “over a year.” He additionally verbalized that there were no complaints in September 2025. On 9/16/2025 at 10:42 a.m., an interview was conducted at the agency with the Executive Director (ED), who explained that the comfort kit was delivered after P#3 expired because of pharmacy shipping issues. The ED revealed that she spoke to P#3’s family member, who “upset and crying,” last week, but confirmed there was no documentation of the phone conversation or complaint. The ED verbalized that there was no complaint documentation because problems with third-party vendors are not considered complaints. On 9/16/2025 at 12:06 p.m., a telephone interview was conducted with the family of P#3, who verbalized that P#3 suffered uncontrolled pain and symptoms due to not having the comfort kit as ordered. The family member additionally verbalized communicating with several hospice employees about P#3 needing medications. The family of P#3 confirmed waiting for more than two hours for a nurse when the patient was in pain and the medications weren’t working.Cross reference to L0650 relating to care that optimizes comfort and dignityCross reference to L0651 relating to governing bodyCross reference to L0653 relating to 24-hour availability of nursing and drugs

Based on policy titled “Governing Body,” record review, and staff and family interviews, it was determined that the hospice failed to provide care that optimizes comfort and dignity consistent with patient and family needs for one patient (P) (P#3) of three sampled patients. The agency failed to deliver a comfort kit (a small supply of medications that is kept in a patient's home to treat symptoms that may occur) until after the patient’s death, and an on-call nursing visit was made more than one hour from the call requesting a visit for unmanaged pain. --- Findings include:Review of the policy titled, “Governing Body,” revised June 2019 revealed the following:13. Additional activities to the Governing Body include:• Overall management and operations.• Provision of care and services that optimizes comfort and dignity and that is consistent with patient and family needs and goals as priority.Review of agency on-call logs revealed a visit was requested by the family of P#3 for unmanaged pain at 10:21 p.m. on 9/4/2025. A visit note dated 9/5/2025 revealed an on-call visit was made to P#3 for pain unrelieved by oxycodone. The nurse arrived at 12:45 a.m. Pharmacy records review revealed a comfort kit was ordered when P#3 was admitted on 9/3/25 but was not delivered until 9/5/2025 at 4:44 p.m., after RN AA pronounced P#3 at 4:25 p.m. On 9/16/2025 at 12:06 p.m., a telephone interview was conducted with the family of P#3, who verbalized that P#3 suffered uncontrolled pain and symptoms due to not having the comfort kit as ordered. The family member additionally verbalized waiting for more than two hours for a nurse to come when the patient was in pain.  On 9/16/2025 at 12:51 p.m., an office interview was conducted with the Executive Director (ED), who acknowledged that P#3’s comfort kit was delivered after the patient expired. On 9/16/2025 at 1:18 p.m., a telephone interview was conducted with Registered Nurse (RN) AA, who confirmed that the comfort kit was not delivered to P#3 until after the patient was pronounced on 9/5/2025.   On 9/16/2025 at 1:52 p.m., a telephone interview was conducted with Licensed Practical Nurse (LPN) AA, who confirmed that she received a call on 9/4/2025 around 10:21 p.m. to do an on-call visit for P#3, who was having uncontrolled pain. LPN AA confirmed that it took her more than one hour to arrive for the visit.

Based on policies and procedures, record reviews and staff and family interviews, of it was determined the governing body failed to assume responsibility for all hospice services and continuous quality assessment and performance improvement (QAPI). Specifically, the agency failed to provide comfort medications (a small supply of medications that is kept in a patient's home to treat symptoms that may occur) as ordered and failed to follow up on complaints for one patient (P) (P#3) of three sampled patients. The agency also failed to log complaints in order to track as part of the agency’s QAPI program. --- Findings include:Review of the policy titled “Governing Body,” revised June 2019 revealed the following: 13. Additional activities to the Governing Body include:• Overall management and operations. Review of the policy titled “Complaint Resolution,” revised June 2019 revealed the following:PROCEDURE1. A patient complaint may be formal or informal and in writing or verbal. The complaint may be made to any Hospice employee, volunteer or individual furnishing services under arrangement. The complaint may be made by the patient or patient representative.2. Patients are encouraged to make suggestions for improving care and/or register complaints to Hospice without fear of coercion, discrimination or reprisal for doing so or unreasonable interruption of care.• Hospice will investigate complaints made by a patient, patient's family or guardian regarding treatment or care that is (or fails to be) furnished.• Hospice will document both the existence and the resolution (or attempts at resolution) of the complaint. This documentation will be kept confidential, in a file titled "Complaints."3. The designated individual to respond to and takes action to resolve complaints is the Administrator.• Complaints are logged, tracked and trended.• Complaint management is incorporated into QAPI activities.Record review revealed a comfort kit was ordered for P#3 on 9/3/25 and delivered on 9/5/25 after P#3 was pronounced by Registered Nurse RN AA. The patient experienced unmanaged symptoms before her death and waited more than one hour for a nursing visit. Review of agency on-call logs revealed a visit for unmanaged pain was requested by the family of P#3 on 9/4/2025 at 10:21 p.m. The nurse documented the time of arrival at P#3’s home as 12:45 a.m. on 9/5/2025.Review of an email received by the Administrator on 9/7/2025 from P#3’s family revealed the following:“Hospice care is meant to provide comfort and dignity at the end of life. In this most basic expectation, Trinity Hospice failed my mother.” No documentation of the agency’s response was provided.On 9/16/2025 at 10:42 a.m., an interview was conducted at the agency with the Executive Director, who confirmed that the comfort kit was delivered after P#3 expired. The ED explained that comfort kits are usually sent through a mail-order pharmacy and that the delay in delivering P#3’s comfort kit was due to the pharmacy’s shipping issues. The ED revealed there was no complaint documentation because problems with third-party vendors are not considered complaints. She further revealed that she did speak to P#3’s family member last week, who was “upset and crying,” but confirmed there was no documentation of the complaint, phone conversation or follow-up. On 9/16/2025 at 12:06 p.m., a telephone interview was conducted with the family of P#3, who revealed speaking to several hospice employees about needing medications and that P#3 suffered uncontrolled pain and symptoms due to not having medications as ordered. On 9/16/2025 at 10:00 a.m., an office interview was conducted with the Administrator, who explained the hospice no longer keeps a complaint log as the electronic medical record (EMR) can be used to document occurrences. The Administrator verbalized that the agency has not done a good job of documenting complaints and stated that no complaints have been logged for “over a year.” He additionally verbalized that there were no complaints in September 2025.

Based on review of policies and procedures, record review, and staff and family interviews, it was determined the hospice failed to ensure nursing services and drugs are available on a 24-hour basis for one patient (P) (P#3) of three sampled patients. --- Findings include:Review of the policy titled “Medication Dispensing,” revised June 2019 revealed the following:4. Hospice staff will order medications from contracted pharmacy in advance of patient's need to assure timely delivery of medications.6. Hospice provides medications 24 hours/day, 7 days/week through contracted pharmacy providers. Review of the policy titled “After Hours Accessibility,” revised June 2019 revealed the following:PROCEDUREI. Nursing services, physician services and drug and biologicals are routinely available on a 24 hour basis 7 days a week. Other covered services must be available on a 24 hour basis when reasonable and necessary to meet the needs of the patient and family.Record review revealed a comfort kit was ordered on admission (9/3/25) for P#3 and was not delivered until 9/5/2025 at 4:44 p.m., after P#3 was pronounced at 4:25 p.m. Review of pharmacy records confirms a comfort kit was ordered on 9/3/2025 at 5:33 p.m. The kit included:1. Tylenol suppositories (medication that can be given rectally for pain or fever) 5 suppositories2. Hycosamine (can be used to treat excessive secretions at the end of life) 10 tablets3. Lorazepam (a medication used to treat anxiety) 10 tablets4. Promethazine (a sedative, anti-nausea, and antiallergy medication, used to treat various conditions) 10 tablets5. Bisacodyl suppositories (an over-the-counter stimulant laxative given rectally for the short-term treatment of occasional constipation) 5 suppositories6. Ondansetron (a prescription antiemetic medication used to treat and prevent nausea and vomiting) 10 tablets7. Haldol (antipsychotic medication used to treat a variety of mental and behavioral health conditions) 10 tablets8. Morphine concentrate (a powerful opioid medication used to treat severe pain) 30 ml Record review revealed P#3’s family called the agency on 9/4/2025 at 10:21 p.m. to report P#3 was in pain and thrashing in the bed. Review of the on-call nursing note reveals the nurse arrived at 12:45 a.m. on 9/5/2025.  On 9/16/2025 at 10:42 a.m., an interview was conducted at the agency with the Executive Director, who confirmed the delay in P#3 receiving comfort kit. The ED explained that comfort kits are usually sent through a mail-order pharmacy and that the delay in delivering P#3’s comfort kit was due to pharmacy shipping issues.On 9/16/2025 at 12:06 p.m., a telephone interview was conducted with family of P#3, who confirmed waiting for over two hours for a nursing visit and that comfort medications were delivered only after the patient had died. On 9/16/2025 at 1:18 p.m., a telephone interview was conducted with Registered Nurse (RN) AA, who confirmed that the comfort kit was not delivered to P#3 until after the patient was pronounced on 9/5/2025.  On 9/16/2025 at 1:52 p.m., a telephone interview was conducted with Licensed Practical Nurse (LPN) AA, who confirmed that she received a call on 9/4/2025 around 10:21 p.m. to do an on-call visit for P#3, who was having uncontrolled pain. LPN AA confirmed that it took her more than an hour to arrive for the visit.

Based on policy titled “Medication Disposal,” record review, and staff interview, it was determined the agency failed to provide a copy of the agency’s policy and procedures on management and disposal of controlled drugs to patients when admitted to hospice. --- Findings include:Review of the policy titled “Medication Disposal,” revised June 2022 revealed the following:I. At the time when controlled drugs are first ordered, Hospice will:• Provide a copy of the Hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family.• Discuss the Hospice policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and the family in a language and manner that they understand to ensure that these parties are educated regarding the safe use and disposal of controlled drugs.• Document in the patient's clinical record that the written policies and procedures for managing controlled drugs was provided and discussed.Review of the agency’s admission packet revealed patient consents and patient handouts. The admission packet failed to reveal a copy of the agency’s policy and procedures on the management and disposal of controlled drugs On 9/17/2025 at approximately 12:30 p.m., an office interview was conducted with the Administrator, who confirmed the admission packet was complete and contained all information given to patients during admission. The Administrator acknowledged the packet did not include information for drug disposal.