Olympia Hospice and Palliative Care

“Upon patient record review, 2 of 14 (Patient #8, 9) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient’s progress toward desired outcomes • Reassessment of the patient’s response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #8 - Comprehensive assessment completed on 03/26/25 then not again until 04/11/25. Patient #9 - Comprehensive assessment completed on 04/03/25 then not again until 04/23/25.”

“Upon patient record review, 2 of 14 (Patient #6, 11) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient #6 - There was no evidence that the plan of care noted the patient’s progress toward outcomes and goals specified in the plan of care by SC. SC documented on 02/15/25, 03/09/25 and 04/19/25 “will remain available to meet spiritual needs” Patient #11 - There was no evidence that the plan of care noted the patient’s progress toward outcomes and goals specified in the plan of care by the MSW or SC. MSW and SC documented on 03/17/25, 03/31/25 and 04/14/25 “will remain available to meet spiritual and psychosocial needs”.”

“Upon patient record review, 4 of 14 (Patient #5, 12, 13, 14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #5 -SN documented on 03/14/25 “performed urine dip stick” with no order noted for test. Patient #12 -MSW visit frequency 1x month. No visit made month of April. Patient #13 -MSW visit frequency 1x month. No visit made month of April. LVN visit frequency 1x week and RN to visit 1 every 2 weeks. LVN made 2 visits week of 03/16/25 - No PRN visits ordered. Patient #14 -MSW visit frequency 1x month. No visit made month of April.”

“Upon patient record review 4 of 14 (Patient #7, 8, 9, 11) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient #7 - SN made aide supervisory visit 03/12/25 then not again until 04/09/25. Patient #8 - SN made aide supervisory visit 03/26/25 then not again until 04/11/25. Patient #9 - SN made aide supervisory visit 04/03/25 then not again until 04/23/25. Patient #11 - SN made aide supervisory visit 03/26/25 then not again until 04/23/25.”

“Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure proper medication reconciliation (the process of comparing a patient’s medication orders to all of the medications that the patient has been taking) was done for two of 14 sampled patients (Patients 2 and Patient 10).This deficient practice had the potential to result in medication errors and adverse drug reactions (an unintended, harmful or unpleasant response to a drug, occurring under normal conditions of use and related to the drug) which can be life threatening for Patient 2 and Patient 10. b. A Review of Patient 10’s Patient Information Sheet (face sheet) indicated a start of care (SOC) date of 2/23/2024. Patient 10 had a primary diagnosis of Alzheimer’s disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 10’s medication profile indicated a order for Zofran (a medication to treat nausea) 4 milligrams (mg-a unit of measurement) tablet, take one tablet every 4 hours as needed for nausea/vomiting. The order was placed on 2/23/2024. On 4/23/2025, at 9am a home visit was conducted for Patient 10 at their place of residence with Licensed vocational nurse (LVN1). During that visit, a medication reconciliation was conducted with the Facility’s nurse supervisor (NS 1), and Patient 10’s Zofran could not be found. During an interview on 4/23/2024, at 9:30am, SN! Stated that she did not know where the medication was. SN1 stated that that medication is usually part of the patient’s comfort pack ( a collection of medications kept in a kit to provide quick relief for urgent, distressing symptoms that may arise in hospice patients), but they do not have a comfort pack for the patient. During an interview on 4/23/2025, at 9:34am, LVN 1 stated that she will need to follow up on the Zoran. LVN 1 stated that the medication may have expired, and it was thrown away. LVN 1 stated that she performs medication reconciliation once a month. During an interview on 4/24/2025, 2:15pm, the Nurse Practitioner/Case Manager (NP/CM) stated that the visiting nurses are supposed to check the medications at every visit. The NP/CM stated that the nurse needs to look at the medications to make sure that the medications match the orders to ensure patients are getting the correct medication and dose. A review of the Agency’s policy titled “Medication Reconciliation”, (undated), indicated that patients will have a current, accurate medication profile in the clinical record. A medication reconciliation should be completed at every skilled visit and any changes should be documented both in the home medication profile and in the MD order. a.During a review of Patient 2’s Patient Information Sheet (face sheet), the Patient Information Sheet indicated a start of care (SOC) date of 12/27/2024 with a terminal diagnosis of Alzheimer’s disease (a progressive disease that destroys memory and other important mental functions).During a review of Patient 2’s medication profile, the medication profile indicated an order for the following:Carvedilol 25 milligram (mg, unit of measurement), one tablet, oral, once daily for hypertension, date ordered 4/11/2025Norco 5 mg-325 mg tablet, one tablet, oral, three times daily for pain, date ordered 3/22/2025Bisacodyl 10 mg Rectal Suppository, 10mg, one suppository, rectal, once daily as needed if no bowel movement for three days for constipation, date ordered 1/4/2025Imodium A-D 2 mg caplet, 2 mg, oral, take two capsules initially, then one capsule as needed after each loose stool for diarrhea, date ordered 12/31/2024On 4/23/2025 at 10 a.m., a home visit was conducted with Patient 2’s place of residence with Licensed Vocational Nurse (LVN2). The LVN performed vital signs, a head to toe assessment, wound care and medication reconciliation. Patient 2 was laying in bed with eyes closed and able to be aroused and answer her name and if she was in pain.During an observation and interview on 4/23/2025 at 11:20 a.m., the Carvedilol medication container label was observed. LVN2 stated that the label read by mouth two times a day.During an observation and interview on 4/23/2025 at 11:26 a.m., a bottle of Cardizem mediation was observed. LVN2 stated that this medication was discontinued, should not be with the patient’s current medications and should be discarded.During an observation and interview on 4/23/2025 at 11: 32 a.m., the Imodium AD medication could not be located. LVN2 stated that the medication was not here.During an observation and interview on 4/23/2025 at 11:36 a.m., the Bisacodyl Rectal Suppository could not be located. LVN 2 stated that the medication was not here.During an interview on 4/23/2025 at 11:37 a.m., LVN 2 stated that the patient’s medications should be checked every visit by the LVN or RN.During an interview on 4/24/2025 at 3:04 p.m., the Nurse Practitioner/Case Manager (NP/CM) stated that the visiting nurses should check the patient’s medications at every visit. The NP/CM stated that the nurse needs to look at the medications to make sure that the medications match the orders, send out for new medications and discard discontinued medications if the orders have changed. The NP/CM stated it was important to ensure patients are getting the correct medication and dose to prevent medical errors and harm to patients.”

“Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to perform a bereavement (the family member or caregiver’s state of sadness, grief, and mourning after the loss of a loved one to death) assessment for one of 14 sampled patients (Patient 7).This deficient practice had the potential to result in the family and caregiver of Patient 7 to experience pain and sadness, and being unable to cope with the loss of a loved one. Findings:During a record review of Patient 7’s Face Sheet, the Face Sheet indicated Patient 7 was admitted to the HA on 8/25/2023 with a terminal diagnosis of hypertensive heart disease with heart failure (prolonged, uncontrolled high blood pressure leading to heart changes and ineffective pumping of blood). During a record review of Patient 7’s Bereavement Assessment, dated 8/28/2023, the Bereavement Assessment was not completed and the names of the primary bereaved was left blank.During an interview on 4/24/2025 at 3:43 p.m., the Nurse Practitioner/Case Manager (NP/CM) stated that a bereavement assessment should be performed and completed for every admission. The NP/CM stated that it was important to assess the family and caregiver for risks and stressors for bereavement, and if there is a risk, to ensure a plan of care and interventions are implemented.During a review of the HA’s policy and procedure titled, “Bereavement Services,” dated 1995, the policy indicated that a bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice.”

“Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure to developed an individualized plan of care (a written document that outlines the specific care and support needed for an individual based on their assessed needs) for five of 14 sampled patients (Patient 1, Patient 2, Patient 10, Patient 11 and Patient 12) by failing to ensure to: 1. Developed and implemented a bereavement (the sorrow the person feel when a relative or close friend dies) care plan to provide emotional, psychosocial, and spiritual support for Patient 1’s Family Member (FM 1), when Patient 1 was diagnosed with a terminal diagnosis (any condition expected to end in death) of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities). This failure resulted in FM 1 not receiving emotional, psychosocial, spiritual support, did not have anyone to talk with, and had a hard time accepting Patient 1’s decline of health and did not know what to do if Patient 1 passed away. 2. Developed and implemented a care plan (a written plan that specifies scope, frequency, duration of services and a program of treatment or care) for Patient 2, who was using Xanax (medication that produces a calming effect on the brain, which helps to reduce anxiety and promote relaxation) and Risperidone (medication used to improve mood, thoughts, and behaviors). This failure had the potential to result in Patient 2 experiencing adverse effects (an unintended, harmful or unpleasant response to a drug, occurring under normal conditions of use and related to the drug) related to the use of psychotropic (drugs that affect brain activity, particularly those associated with mental processes and behaviors) medications including, but not limited to drowsiness, dizziness, dry mouth, constipation, increased risk of fall, tardive dyskinesia (a medical condition causing involuntary movements), or death. 3. Developed and implemented a plan of care for Patient 10, who was taking Clopidogrel (medication to prevent blood clots and reduces the risk of heart attacks and strokes). This failure had the potential to result in Patient 10 not receiving adequate monitoring and assessment of side effects (an effect of a drug or other type of treatment that is in addition to or beyond its desired effect) of medications like bruising or bleeding. 4. Developed and implemented a care plan for Patient 11, who was taking Mirtazapine (a medication used to treat depression and insomnia). This failure had the potential to result in Patient 10 not receiving adequate monitoring and assessment of side effects (an effect of a drug or other type of treatment that is in addition to or beyond its desired effect) of medications like having agitation, drowsiness, confusion, difficulty breathing. 5. Developed and implemented a plan of care for Patient 12, who had a stage 2 pressure ulcer (a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough) and taking pain medication routinely. This failure has the potential to result in delayed wound healing and unmonitored pain for Patient 12. c.A Review of Patient 10’s Patient Information Sheet (face sheet) indicated a start of care (SOC) date of 2/23/2024. Patient 10 had a primary diagnosis of Alzheimer’s disease (a progressive disease that destroys memory and other important mental functions). Patient 10 also had secondary diagnoses that included essential hemorrhagic thrombocytopenia (a rare chronic blood cancer that causes the bone marrow to produce too many platelets. As a result, there is an increased risk of blood clots to form), cerebral infarction (stroke: brain tissue des due to a lack of blood flow) and polycythemia (a blood disorder that occurs when the body produces too many red blood cells, which could lead to serious problems like blood clots). A review of Patient 10’s medication profile, indicated that they were prescribed Clopidogrel (Plavix-blood thinner) 75mg tablet, once daily. Medication was ordered on 2/23/2024. A review of Patient 10’s Plan of Care indicated that they did not have a care plan for the medication Plavix. During an interview on During an interview on 4/24/2025, at 2:15pm, the Nurse Practitioner/Case Manager (NP/CM) stated that Patient 10 should have had a care plan for Plavix because it is a blood thinner, and the patient has a risk for bleeding. d.A review of Patient 11’s face sheet indicated a start of care date of 2/12/2025,with a primary diagnosis of Alzheimer’s disease, with secondary diagnoses which included insomnia (a sleeping disorder characterized by difficulty falling asleep, staying asleep, or experiencing non-restorative sleep) and depression (a mental disorder characterized by a loss of interest in activities, causing significant impairment in daily life). A review of Patient 11’s medication profile indicated an order for Mirtazapine (a medication to treat depression and insomnia), which was ordered on 2/12/2025. A review of Patient 11’s Plan of Care indicated that they did not have a care plan for the medication Mirtazapine, for depression or insomnia. During an interview on During an interview on 4/24/2025, at 2:15pm, the NP/CM stated that Patient 11 should have had a care plan for the medication and depression to monitor the effectiveness of the medication.e. A review of Patient 12’s face sheet indicated a SOC date of 1/9/2023, with a primary diagnosis of Alzheimer’s disease. Patient 12 also had secondary diagnoses with included contractures of muscles (condition where muscles and surrounding tissues shorten and stiffen, leading to a limited range of motion and potential deformities), quadriplegia (loss of motor function and sensation in all four limbs) and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). A review of Patient 12’s medication profile indicated that they were taking acetaminophen (Tylenol-a pain medication) 500 mg, 2 tabs twice a day routine. The medication was ordered on 2/23/25. A review of Patient 12’s Re-Cert nursing assessment, dated 4/9/2025, indicated that Patient 12 had a new stage 2 pressure ulcer (a partial-thickness skin loss, extending into the dermis, but not into the subcutaneous tissue. It presents as a shallow, open ulcer with a red or pink wound bed). A review of Patient 12’s Plan of Care indicated that they did not have a care plan for pain or pressure ulcers. During an interview on During an interview on 4/24/2025, at 2:15pm, the NP/CM stated that Patient 12 should have had a care plan for pain, since patient is on a scheduled pain medication they need to be able to monitor its effectiveness. NP/CM also stated that Patient 12 should also have a care plan for their pressure ulcer make sure the treatment is working, if not they need to change the interventions. A review of the HA’s policy titled “ Interdisciplinary Group Plan of Care”, (undated), indicated that the type and scope of services provided by the interdisciplinary group will develop a comprehensive plan of care that defines patient and family/caregiver problems, goals and interventions. The interdisciplinary group will conduct assessments, develop and update the plan of care, and review the effectiveness of care a minimum of every 15 calendar days. a.During a review of Patient 2’s Patient Information Sheet (face sheet), the Patient Information Sheet indicated a start of care (SOC) date of 12/27/2024 with a terminal diagnosis of Alzheimer’s disease (a progressive disease that destroys memory and other important mental functions).During a review of Patient 2’s medication profile, the medication profile indicated an order for the following:Xanax (a medication that treats anxiety and panic disorder) 0.5 milligram (mg, a unit of measurement) tablet, 0.5 mg, one tab, oral, once daily in the morning for panic attacks, date ordered 4/21/2025Risperidone (a medication used to treat schizophrenia, bipolar disorder, or irritability associated with autistic disorder) 1 mg tablet, one mg, one tab, oral twice daily for agitation and anxiety.During an interview and record review on 4/23/2025 at 3:30 p.m., with the Nurse Practitioner/Case Manager (NP/CM), Patient 2’s Plan of Care, dated 4/24/2025, was reviewed. The NP/CM stated that Patient 2 did not have a care plan for Xanax and Risperidone and the patient should have a care plan to monitor the effectiveness of the medication or to see if the dose needs to be adjusted, or if the patient is having any adverse events. The NP/CM stated it was important to have a care plan for these medications to ensure that the patient’s symptom was managed and that the patient is in a safe environment.”

“Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to include wound treatment orders in the Plan of Care (POC) and provide wound care per physician orders for two of 14 sampled patients (Patient 2 and Patient 12).This deficient practice had the potential to result in a delay in wound healing. b.A review of Patient 12’s face sheet indicated a SOC date of 1/9/2023, with a primary diagnosis of Alzheimer’s disease. Patient 12 also had secondary diagnoses with included contractures of muscles (condition where muscles and surrounding tissues shorten and stiffen, leading to a limited range of motion and potential deformities), quadriplegia (loss of motor function and sensation in all four limbs) and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). A review of Patient 12’s Re-Cert nursing assessment, dated 4/9/2025, indicated that Patient 12 had a new stage 2 pressure ulcer (a partial-thickness skin loss, extending into the dermis, but not into the subcutaneous tissue. It presents as a shallow, open ulcer with a red or pink wound bed). The document did not include a wound assessment. A review of Patient 12’s wound care treatment order, dated 4/4/2025, indicated “stage II (2) pressure ulcer over sacrum. Cleanse with NS (normal saline-solution), pat dry, apply hydrogen (an ointment that keeps wound bed moist and promotes healing) and cover with dressing. Change every 2 days or when soiled. SN (skilled nurse) to assess skin integrity every visit. A review of Patient 12’s Nurse Visit Note, dated 4/9/2025, did not indicate that the wound care treatment was done. During an interview on During an interview on 4/24/2025, at 2:15pm, NP/CM confirmed that there was no documentation that wound care was done and there was no wound assessment, such as wound measurements and appearance. NP/CM stated that nurses should be documenting wound assessments weekly to monitor if the wound is getting better or worse. Need to know if they need to charge interventions and the plan of care. A review of the agency’s policy titled “ Wound Care Policy and Procedure”, (undated), indicated that wound assessments should include documenting wound location, size (length x width x depth), drainage, order, tissue type, surrounding skin and pain level and staff should complete detailed wound assessments in the EMR (electronic medical record). Findings:During a review of Patient 2’s Patient Information Sheet (face sheet), the Patient Information Sheet indicated a start of care (SOC) date of 12/27/2024 with a terminal diagnosis of Alzheimer’s disease (a progressive disease that destroys memory and other important mental functions).During a review of Patient 2’s Physician Orders, dated 12/27/2024, the Physician Orders indicated a Treatment to Patient 2’s right heel deep tissue (pressure) injury (DTPI, a persistent, non-blanchable deep red, maroon, or purple discoloration of the skin, either intact or non-intact, or a blood-filled blister, indicating damage to the underlying soft tissues caused by pressure and/or shear forces) and to cleanse with betadine, dry, apply hydrogel, cover with dressing. Change every two to three days or when soiled.During a review of Patient 2’s Plan of Care (POC), the POC indicated the following:-Integumentary/Skin care plan, dated 12/27/2024, issue: Stage 2 sacral pressure injury with intervention to assess alteration in skin integrity every visit.-Integumentary/Skin care plan, dated 12/27/2024, issue: Right heel deep tissue injury with intervention to assess alteration in skin integrity every visit.During a review of Patient 2’s LVN visit notes dated 4/5/2025, 4/8/2025, and 4/12/2025, the visit notes indicated that wound care was provided as ordered to sacrum and heels.On 4/23/2025 at 10 a.m., a home visit was conducted with Patient 2’s place of residence with Licensed Vocational Nurse (LVN2). The LVN performed vital signs, a head-to-toe assessment, wound care and medication reconciliation. Patient 2 was lying in bed with eyes closed and able to be aroused and answer her name and if she was in pain.During an interview on 4/23/2025 at 11:31 a.m. with Licensed Vocational Nurse (LVN2), LVN2 stated she cleansed Patient 2’s wound with wound cleanser, applied betadine and covered with dry dressing. LVN2 stated she did not use hydrogel during the wound treatment to Patient 2’s right heel.During an interview on 4/24/2024 at 3:33 p.m., with the Nurse Practitioner/ Case Manager (NM/CM), the NM/CM stated that it was important to document the wound treatment and the wound measurements weekly to monitor the effectiveness of the wound treatment and if it was not effective, to change the plan of care.During a review of the HA’s policy and procedure titled, Wound Care Policy and Procedure, dated 1/5/2025, the policy indicated to review wound care effectiveness during interdisciplinary team (IDT) meetings and to adjust care plans based on patient goals and clinical presentation.During a review of the HA’s (undated) policy and procedure titled, Interdisciplinary Group Plan of Care, the policy indicated that the type and scope of services provided by the interdisciplinary group will be based on comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and the comprehensive plan of care that defines the family/caregiver problems, goals, and interventions. The policy indicated that written evidence of care coordination will be found in the plan of care and/or interdisciplinary team meeting forms in the patient’s clinical record , and will involve the hospice patient’s attending physician.”

“Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to perform a bereavement (the state of sadness, grief, and mourning after the loss of a loved one to death) reassessment and plan of care for one of 14 sampled patients (Patient 1).This deficient practice had the potential to result in the family and caregiver of the hospice patient to experience pain and sadness and unable to cope with the loss of a loved one. Findings:During a review of Patient 1’s Patient Information Sheet (face sheet), the Patient Information Sheet indicated a start of care (SOC) date of 2/8/2025 with a terminal diagnosis of Alzheimer’s disease (a progressive disease that destroys memory and other important mental functions).During a review of Patient 1’s Plan of Care (POC)/Interdisciplinary Group (IDG, a group of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families), dated 2/12/2025, the POC/IDG indicated an order on 2/8/2025 for Bereavement Care Coordinator to assess and evaluated the bereavement and grieving risk score within five days of admission. The POC/IDG indicated an order on 2/8/2025 for the Spiritual Counselor to perform Initial Assessment within five days, recertification and monthly visits to provide spiritual support and bereavement assessment/counseling.During a review of Patient 1’s Communication Log, dated 2/10/2025, the communication log indicated that FM1 requested intravenous (IV, via vein) hydration because she was worried about Patient 1’s hypotension and lethargy due to dehydration. The communication note indicated that FM1 was concerned about Patient 1’s chronic kidney disease (CKD, condition where the kidneys are damaged and lose their ability to filter waste and fluid out of blood) and need for more hydration. The communication log indicated that the NP/CM provided FM1 an option to discharge Patient 1 from hospice services and seek more aggressive treatment including treatment of chronic kidney disease and offered to transfer patient to FM1’s choice of hospice that would provide Patient 1 with IV hydration.During a review of Patient 1’s Communication Log, dated 2/11/2025, the communication log indicated that “FM1 mentioned that Patient 1 might die soon.” The communication log indicated that FM1 asked when Patient 1 would pass, and the Nurse Practitioner/Case Manager told her that it was difficult to know that exact date when Patient 1 would pass away.During a review of Patient 1’s Bereavement Assessment, dated 2/12/2025, indicated the primary bereaved (Family Member, FM1) had extreme dependency, inadequate coping skills, and was a low risk for bereavement risk and stressor. The bereavement assessment indicated in the narrative that “FM1 talked about not having anyone to stalk with” and “she (FM1 doesn’t know how she will move on once he (Patient 1) is gone.” The narrative indicated that the (bereavement) risk was low at this time, and if that should change in the future, it would be updated accordingly. The bereavement assessment was performed by the HA’s Spiritual Counselor.During a review of Patient 1’s Communication Log, dated 2/17/2025, the communication log indicated that FM1 was having a hard time accepting the patient’s decline and kept repeating, “patient was able to speak and recognize her in the hospital prior to hospice admission.”During a review of Patient 1’s POC/IDG, dated 3/3/2025, the POC/IDG indicated a new order for the Spiritual Counselor to visit twice a month to provide spiritual and bereavement care and support. There was no care plan to address the bereavement or grief support for FM1.During a review of Patient 1’s History of Bereavement POC, the history was blank.During a review of Patient 1’s History of Bereavement Letters, the history was blank.During an interview on 4/24/2025 at 2:13 p.m., the Spiritual Counselor (SC) stated that there was no bereavement care plan for Patient 1. The SC stated it was important to have a bereavement POC to help support FM1 accept Patient 1’s decline and the process he (Patient 1) was going through. The SC stated that when she (SC) saw FM1 on 3/3/2025, I did not believe she was coping well and that she had unrealistic expectations to get her husband up to have breakfast. The SC stated Patient 1 was not waking up and FM1 was talking about treatment options for Patient 1 to help him get better. The SC stated that Patient 1’s Bereavement Assessment should have been updated and changed to moderate risk when I (SC) spoke with FM1 on 3/3/2025.During a concurrent interview and record review on 4/24/2025 at 4:58 p.m., with the NP/CM, Patient 1’s POC/IDG, dated 3/3/2025, was reviewed. The NP/CM stated that there was no bereavement plan of care and that it should have been created to support FM1. The NP/CM stated that it was important to have a bereavement POC to provide emotional, psychosocial and spiritual support for family and caregivers because they are grieving the loss of their loved ones. During a record review of the HA’s policy and procedure titled, Bereavement Services, dated 1995, the policy indicated the program will provide bereavement services to the family/caregivers of hospice patients, before and after the patient’s death, in accordance with the plan of care. The policy indicated that the purpose of these services will be to facilitate a normal grieving process and to identify and appropriately refer those persons who may be experiencing pathological grief reactions that may interfere with the eventual resolution and integration of their losses. The policy indicated that after the bereavement risk assessment is completed, a plan will be developed to address bereavement/grief issues and will be implemented and updated a needed.”