Pathlight Hospice

“Based on policy titled “Hospice Plan of Care,” record reviews, home observations, patient family/caregiver interviews and staff interview, it was determined that the agency failed to update patients’ drug profile for three patients (P) (P4, P7, P9) of three sampled patient home visits. Findings included: Review of policy titled “Hospice Plan of Care,” dated 2022, reveals the following:12. The Hospice written interdisciplinary plan of care is developed and individualized for each patient and family, reflects patient/family goals based upon problems identified in the initial/updated assessments, and includes all services necessary for palliation and management of the terminal illness and related conditions, including the following:h. Treatments, drugs, biologicals and interventions to manage pain and symptoms of the terminal illness: including dosage/frequency/route when applicable; 1. Review of medical record for P4, with a start of care (SOC) on 10/23/2025, clinical document titled “Patient Medications List,” dated 06/16/2026, reveals ordered Albuterol Sulfate inhalation Solution (bronchodilator for treating breathing difficulties). On 06/16/2026 at 9:30 AM, during a home visit, revealed P4 was currently taking the following medications:• Metformin (treatment for high blood sugar levels)• Amlodipine (treatment for high blood pressure)• Atorvastatin (treatment of high cholesterol• Ursodiol (treatment for gallstone prevention in the liver)• Metoprolol (treatment of high blood pressure)• Aspirin (mild blood thinner) On 06/16/2026 at 9:45 AM, during a home visit, P4 caregiver confirmed P4 has been taking the previous medication since hospice admission. 2. Review of medical record for P7, with a SOC on 03/07/2026, clinical record titled “Patient Medications List,” dated 06/15/2026 reveals P7 was ordered the following medications:• Atorvastatin Calcium Tablet (treatment of high cholesterol)• Cephalexin (treatment for infection)• Fluconazole (treatment for yeast infection)• Hydrocodone-Acetaminophen (treatment for pain)• Miralax Powder (treatment of constipation)• Tramadol (treatment of pain) On 06/16/2026 at 9:30 AM, during a home visit, observed patient was currently taking the following medications:• Hydrocodone-Acetaminophen (treatment for pain)• Miralax Powder (treatment of constipation)• Tramadol (treatment of pain)• Mag Oxide (treatment for magnesium deficiencies)• Midodrine (treatment for low blood pressure)• Mycophenolate (immunosuppressant)• Tacrolimus (immunosuppressant)• Prednisone (anti-inflammatory) On 06/16/2026 at 9:45 AM, during a home visit, P7 confirmed taking the previous observed medication. 3. Review of medical record for P9, with a SOC on 04/08/2026, clinical document titled “Patient Plan of Care,” dated 06/15/2026 reveals P9 was ordered the following medications on 03/07/2026:• Aspirin (low dose blood thinner)• Sitagliptin (treatment for high blood sugar)• Isosorbide (treatment for high blood pressure• Amlodipine (treatment for high blood pressure)• Atorvastatin (treatment for high cholesterol)• Lisinopril (treatment for high blood pressure)• Donepezil (treatment for dementia)• Clopidogrel (blood thinner)• Trazadone (antidepressant)• Myrbetriq (treatment for overactive bladder)• Vitamin D (supplement)• Morphine Sulfate (treatment for pain/shortness of breath)• Acetaminophen (treatment of pain/fever)• Bisacodyl (treatment for constipation)• Haloperidol (treatment of agitation)• Hyoscyamine (treatment of excessive secretions)• Lorazepam (treatment for anxiety)• Ondansetron (treatment for nausea/vomiting) Review of P9’s clinical documentation titled “Medication Administration Report” dated May 28, 2026 to June 26, 2026, received from P9’s place of residence, revealed P9 was only taking the following medications:• Atorvastatin (treatment for high cholesterol)• Clopidogrel (blood thinner)• Donepezil (treatment for dementia)• Januvia (treatment of high blood sugar)• Lisinopril (treatment for high blood pressure)• Metformin (treatment of high blood sugar)• Trazadone (antidepressant)• 24-hour isosorbide mononitrate (treatment of high blood pressure)• Amlodipine (treatment for high blood pressure)• Aspirin (low dose blood thinner) On 06/16/2026 at 9:30 AM, during a home visit, P9’s caregiver confirmed P9’s current medication orders received from P9’s place of residence. On 6/17/2026 at 11:00 AM, during an office interview, the Administrator confirmed P4, P7, and P9’s clinical chart did not contain an updated medication list.”

“Based on review of policy titled “Coordination of Services,” observations, record review and staff interview, it was determined the agency failed to coordinate care and services for one patient (P) (P7) of ten sampled active patients. Findings included: Review of policy titled “Coordination of Services,” dated 2022, revealed the following:“Policy:The IDG ensures that there is a coordinated and effective ongoing sharing of information amongst and between all disciplines, with all contracted service providers and in all settings.Procedure:1. The hospice will maintain a system of communication and integration, in accordance with the hospice’s own policies and procedures, to:e. Provide for an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions.3. An assigned hospice RN Case Manager coordinates the patient’s plan of care and facilitates the ongoing sharing of information with the attending physician, contracted facilities, vendors, other members of the IDG and non-hospice healthcare providers furnishing services unrelated to the terminal illness.” On 06/16/2026 at 9:30 AM, a home observation was conducted with P7. The Hospice Director of Nursing (DON) was in attendance and was observed speaking with P7 about an upcoming visit with the urologist ((doctor who specializes in diagnosing and treating disorders of the urinary system) to assess possible removal of indwelling Foley catheter (a semi-flexible plastic tube inserted into the bladder and attached to a bag that collects urine, used when someone cannot urinate normally). Review of the clinical record revealed P7 was admitted to hospice on 03/07/2026 with a Coude Foley catheter (a specialized urinary catheter with a slight bend at the insertion tip that allows catheter to get past urethral obstructions or narrowed passages and inserted in the bladder). Review of a physician order, dated 03/07/2026, revealed:“Order: Catheter OrderSupply type: Foley CatheterSize (Fr): 16Balloon (ml): 10Other Notes: Coude catheterQty to Dispense: 1Change Every: 30 days and prn” Review of documents titled “IDG Meeting,” revealed the following:Interdisciplinary Group (IDG) meeting, dated 03/18/2026, failed to reveal who was managing the catheter.Further review of the clinical chart failed to reveal plan of care specifying who was responsible for catheter, communication with P7’s urologist, or clinical notes regarding urology visits and previous catheter changes. On 06/16/2026 at 11:00 AM, an office interview was conducted with the Director of Nursing (DON), who revealed P7’s urinary catheter is managed by a urologist, who changes it every 30 days. The DON acknowledged P7’s plan of care does not include the urologist and confirmed that all documentation for P7 had been provided.”

“Based on policy titled “Hospice Plan of Care,” record reviews, and staff interview, it was determined that the agency failed to ensure that hospice aide services were provided according to the patients plan of care for three patients (P) (P3, P6, P10) of 10 active sampled patients. Findings included: Review of policy titled “Hospice Plan of Care,” dated 2022 reveals the following:Based on the results of the assessment of the patient, the hospice care team must:• Provide and supervise hospice care and services in accordance with accepted standards of care and the plan of care. 1. Review of clinical document titled “Patient Plan of Care,” dated 06/17/2026 for certification period starting 05/13/2026, reveals P3 is ordered hospice aide (HA) services two times a week for certification period 05/13/2026 through 06/15/2026.Review of records reveals P3 received one HA visit on 05/30/2026 for the week of 05/24/2025 through 05/30/2026. 2. Review of document titled “Order Document,” dated 03/02/2026 reveals P6 has HA services ordered for five times a week since 03/01/2026 for certification period starting on 03/02/2026.Review of records reveals P6 failed to receive HA visits on 03/27/2026 and 04/10/2026. 3. Review of document titled “Patient Plan of Care,” dated 06/16/2026 for certification period 03/30/2026 reveals P10 is ordered HA services for seven times a week beginning on 04/29/2026.Review of records revealed P10 received HA visits on 05/05/2026, 05/06/2026, 05/07/2026 and 05/08/2026 for week of 05/02/2026 through 05/08/2026. On 06/15/2026 at 2:35 PM, during an office interview, the Administrator confirmed P3 had undocumented missed HA visits for the week of 05/24/2025 through 05/30/2026. On 06/15/2026 at 2:50 PM, during an office interview, the Administrator confirmed P6 had undocumented missed HA visits for certification period starting on 03/02/2026. On 06/15/2026 at 3:00 PM, during an office interview, the Administrator confirmed P10 had undocumented missed HA visits for week of 05/02/2026 through 05/08/2026.”

“Based on the review of policies and procedures, records review, and staff interviews, it was determined the facility failed to ensure that a governing body (or designated persons so functioning) assumes full legal authority and responsibility for the management of the hospice, and the provision of all hospice services to include the following:1. failure to update patients’ drug profile for three patients (P) (P4, P7, P9) of three sampled patients home visits.2. failure to coordinate care and services for one patient (P) (P7) of ten sampled active patients.3. failure to ensure that hospice aide services were provided according to the patients plan of care (POC) for three patients (P) (P3, P6, P10) of ten active sampled patients. Findings included: Review of undated policy titled “AD. G10 GOVERNING BODY,” revealed the following:“POLICYThe Governing Body operates in accordance with its bylaws and assumes full legal and financial authority and responsibility for determining, implementing and monitoring policies governing the hospice’s total operation, including its quality assessment and performance improvement (QAPI) program.The hospice agency must organize, manage, and provide resources to provide the hospice agency care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness and related conditions.Hospice Service:These services include but are not limited to:Medical direction and careNursingSocial work/counselingSpiritual AdvisementPersonal Care AideHome makingPhysical Therapy/ Occupational Therapy/ Speech TherapyVolunteerGeneral Inpatient CareRespitePharmacyDurable Medical Equipment and SuppliesAll these services are provided in relation to the patient’s terminal disease. Duties of the Governing Body include the following:8. Assumes full legal authority and responsibility for:a. Determining, implementing and monitoring policies governing the hospice’s total operations;b. The management of hospice;c. The quality and care of all hospice services;d. Hospice fiscal operations; ande. Performance improvement15. Ensure that the hospice agency provides coordinated care that includes at a minimum medical, nursing, social, spiritual, volunteer, and bereavement services that meet the needs of the patients.32. Ensures that information is shared with non-hospice healthcare providers furnishing unrelated services. Cross refer to L0530 for findings related to Content of Comprehensive Assessment.Cross refer to L0554 for findings related to Coordination of Services.Cross refer to L0555 for findings related to Coordination of Services.”