Pathways Hospice and Palliative Care

“Based on policy review, record review, and interview, the hospice provider failed to ensure that the spiritual assessment was completed within five days of admission for hospice services in one of six records reviewed (Record/Patient #11). This deficient practice has the potential to affect all the patients served by the provider. Findings included:Review of the providers policy titled, “Assessment-Comprehensive Assessment of the Patient,” reviewed 02/2026, showed in part, the comprehensive assessment of the patient was to be completed by designated members of the interdisciplinary group (IDG) in consultation with the patient’s attending physician no later than five (5) calendar days after the patient elected the hospice benefit. RECORD/PATIENT #11:Review of the clinical record showed the patient was admitted to hospice services on 09/06/2025 with a terminal diagnosis of degenerative disease of the nervous system (the progressive deterioration and death of nerve cells). The patient resided in a long-term care facility (LTCF). Review of the chaplain visit note, dated 09/15/2025 (six days after the start of care), showed the chaplain was unable to assess the patient for spiritual needs due to the patient’s inability to verbalize. During an interview on 6/17/2026 at 2:35 PM, the bereavement coordinator stated that the spiritual assessment was to be completed during the admission process within five days of election. During an interview on 06/18/2026 at 9:30 AM, the director of support services stated that the spiritual assessment was to be completed within five days of the patient’s admission.”

“Based on policy review, record review, home visit observation, and interview, the hospice provider failed to ensure that an accurate and updated medication profile was maintained in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all the patients served by the provider. Findings included:Review of the provider’s policy titled, “Medication – Management,” revised 02/2026, showed a medication profile was maintained for every patient and included a listing of the current medication orders for each patient and specified whether the medication was or was not related to the patient’s terminal illness.RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 04/18/2025 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (a condition where plaque builds up in the original, un-bypassed heart arteries). The patient resided in a skilled nursing facility (SNF).Observation on 06/16/2026 at 9:00 AM, a comparison of the provider’s medication profile (PMP) to the facility’s medication administration record (FMAR) showed following discrepancies:-The FMAR showed the patient was to take acetaminophen 325 milligrams (mg) two tablets by mouth one time a day for pain. The PMP showed the patient was to take acetaminophen 325 mg two tablets by mouth three times a day for pain;-The FMAR showed the patient was to take tramadol 50 mg one tablet by mouth one time a day for pain. The PMP showed the patient was to take tramadol 50 mg one tablet two times a day for pain; and-The PMP showed the patient was to take lorazepam 0.5 mg take one tablet every six hours as needed for anxiety/behaviors. The FMAR failed to contain this medication.During an interview on 06/18/2026 at 9:15 AM, the administrator stated that he/she would expect the medication profile to match what the patient was receiving in the facility.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure that the nursing needs of the patient were met in one of five full records reviewed (Record/Patient #5). This deficient practice has the potential to affect all the patients served by the provider. Findings included:Review of the provider’s policy titled, “Assessment – Comprehensive Assessment of the Patient,” revised 02/2026, showed discipline-specific assessment tools obtain accurate and timely information that guide decisions for the development of the patient’s plan of care.RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 03/18/2026 with a terminal diagnosis of relapsing-remitting multiple sclerosis (a chronic autoimmune disease of the central nervous system). The patient resided in a skilled nursing facility (SNF).Review of the skilled nursing (SN) visit notes showed:-A visit dated 05/06/2026 showed the licensed practical nurse (LPN) failed to obtain the patient’s blood pressure;-A visit dated 05/11/2026 showed the LPN failed to obtain the patient’s blood pressure; and-A visit dated 06/10/2026 showed the registered nurse (RN) failed to obtain the patient’s blood pressure.During an interview on 06/18/2026 at 9:15 AM, the administrator stated that he/she would expect the RN and LPN to take the patient’s temperature, pulse, blood pressure, and respirations every visit.”

“Based on policy review, record review, and interview, the hospice provider failed to have an organized program for bereavement services and failed to ensure bereavement services reflected the needs of the bereaved in one of six records reviewed for bereavement (Record/Patient #11). This deficient practice has the potential to affect all the patients served by the provider. Findings included:Review of the provider’s policy titled, “Bereavement- Documentation,” reviewed 02/2026, showed in part the following:- The bereavement contact/electronic medical record (EMR) was to be initiated by the bereavement coordinator and the record was to be maintained for the 13 months following the patient’s death; and- The bereavement EMR was to contain the level of service, plan of care, and documentation of the care provided. Review of the provider’s policy titled, “Bereavement Care Planning,” reviewed 02/2026, showed in part the following:- Care planning was to be initiated when a bereavement client was admitted to bereavement services;- An in-person visit was to be offered with each of the phone contacts prescribed by the policy: Level of Service;- A bereavement assessment may be performed during these phone contacts or during in-person visits;- The plan of care was to reflect the assessed needs of the bereaved and was to establish appropriate goals and interventions; and- The bereavement coordinator was to ensure that the bereavement plan of care was followed for 13 months from the date of admission, or until the client was discharged. The bereavement care planning policy failed to include a bereavement assessment within two months of the patient’s death. Review of the provider’s policy titled, “Bereavement- Level of Service,” reviewed 02/2026, showed in part the following:- During the initial comprehensive assessment of the patient, ongoing, and following the patient’s death, the interdisciplinary team (IDT) was to collaborate to assess, document, and address anticipated bereavement needs of the member of the unit of care. Bereavement risk assessment was the primary tool in this effort;- Following the review of the collaborative discussion and assessment, one of the following bereavement levels of service was assigned: low risk, moderate risk, high risk, and mail only;- Interventions associated with the four levels of service included, but were not limited to, the following: * Low risk, the personal contact received bereavement mailings as well as a condolence phone call within a week of the patient’s death. If a message was left, a follow up phone call was made after one month; * Moderate risk, the personal contact received bereavement mailings as well as a condolence phone call withing a week of the patient’s death. If a message was left, a follow up phone call was made after one month. Follow up phone calls were to be scheduled after collaboration with the personal contact; * High risk, the personal contact received bereavement mailings as well as a condolence phone call within a week of the patient’s death and follow up phone calls each month; and * Mail only, the personal contact had requested no phone call, but was open to receiving bereavement mailings, or the personal contact had not responded to a phone call in the first two months. Review of the provider’s undated bereavement assessment titled, “Modified Bereavement Risk Index,” showed the following risk level scores and interventions:- Low risk score (less than seven (7)), give a copy of the booklet, “Now What? Understanding Grief,”;- Moderate risk score (7 to 10), give a copy of the booklet, “Now What? Understanding Grief,” and suggest contacting one of the support agencies listed in the booklet; and- High risk score (10 or more), give a copy of the booklet, “Now What? Understanding Grief,” and encourage the person to contact a [mental] health professional. Review of the provider’s undated bereavement care plan interventions, showed in part the following:- Identical mailings for low risk level (risk scores between 12 and 20), moderate risk level (risk scores between 21 and 31), and high risk level (risk scores between 31 and 60) included: * Invitation mailed two months prior to annual remembrance ceremony; * Scheduled mailings after week two were to include introductory letter, bereavement services, and newsletter; * Sympathy care after month one; * Newsletters after months two, four, six, eight, and 10; * Remembrance card after month 11; * Closure letter, survey, and newsletter after month 12; * Birthday card prior to the patient’s birthday; * Holiday newsletter after October;- For moderate and high risk level a condolence phone call was to be made within two weeks of patient’s death (interventions failed to show condolence phone call for low risk);- Low risk level phone calls at months one, two, six, and 12, and offer in -person visit and grief support group;- Moderate risk level phone calls at months one, three, six, nine, and 12, and offer in -person visit and grief support group; and- High risk level phone calls at months one through 12, offer in -person visit and grief support group, and mail the booklet titled, “The Nature of Grief,” after month one. RECORD/PATIENT #11:Review of the clinical record showed the patient was admitted to hospice services on 09/06/2025 with a terminal diagnosis of degenerative disease of the nervous system (the progressive deterioration and death of nerve cells). The patient resided in a long-term care facility (LTCF). Review of the medical social worker (MSW) visit note, dated 09/09/2025, showed the patient’s adult child was at a low risk level for bereavement. Review of the MSW visit note, dated 10/20/2025, showed the patient’s adult child remained appropriate for low risk bereavement support. Review of the MSW visit notes, dated 10/31/2025 and 11/12/2025, showed MSW left a voicemail for the patient’s adult child and encouraged him/her to call with any questions or needs. The adult child remained appropriate for moderate risk bereavement support. The provider failed to document what indicators changed the adult child’s risk level from low to moderate and failed to document interventions in response to the adult child’s moderate risk level for bereavement. Review of the registered nurse (RN) communication note, dated 11/25/2025, showed the patient had expired on 11/25/2025 at 9:20 AM. Review of the bereavement communication note, dated 11/26/2025, showed the IDG team discussed the patient’s death was peaceful, but very suddenly. The adult child presented some difficulty coping with the “sudden” and “unexpected” end of life. The MSW reported that the adult child was open to bereavement services and continued to be at a moderate risk level of service. Review of the bereavement communication note, dated 11/28/2026, showed a condolence call. The chaplain left a voicemail message that informed the adult child that the chaplain would call again in two weeks. Review of the bereavement communication note, dated 12/10/2025, failed to show that the bereaved adult child was sent the holiday newsletter as indicated in the bereavement care plan interventions. Review of the bereavement communication note, dated 12/16/2025, showed the chaplain left a voicemail message for the adult child to call anytime and the chaplain would call again in three months. The chaplain failed to follow the bereavement policy to make a follow up phone call after one month when a voice message was left. The provider failed to contact the adult child during the months of January and February. Review of the bereavement communication note, dated 03/02/2026, showed the chaplain spoke with the adult child on the phone. The adult child had experienced many “little triggers” over the past three months. He/she accepted the offer for “ongoing” phone calls. The adult child was at a moderate risk level for bereavement. The chaplain failed to define and document the extent of “ongoing” phone calls. No phone contacts, with the adult child, had been documented, since the patient passed on 11/25/2025 (three months prior). Review of the bereavement communication note, dated 04/23/2026, showed the MSW reached the adult child by phone. The adult child said that he/she was doing better and was attending a grief support group at his/her church. He/she stated that he/she appreciated the phone calls and asked that the phone calls continue. He/she requested a call in one month. He/she remained at a moderate risk level for bereavement. Review of the record failed to show documentation for a phone call during May 2026. Review of the bereavement communication note, dated 06/02/2026, showed the adult child at a high risk level for bereavement. He/she requested a call in one month. Review of the counselor care plan, printed 06/16/2026, failed to show the following:- The adult child was identified as high risk level for bereavement starting on 06/02/2026; - Interventions individualized to meet the needs of the adult child; and- Scheduled interventions that followed the provider’s care plan interventions. During an interview on 06/16/2026 at 4:10 PM, the bereavement coordinator stated that the bereavement plan of care did not show specific scheduled activities and that he/she knew the schedule by doing a search for each day to know what he/she needed to do as far as mailings and making phone calls. The bereavement scores were multiplied by three to correlate with the software scores and to generate a plan of care. During an interview on 06/18/2026 at 9:30 AM, the director of support services stated that if a family member was considered moderate risk for bereavement the type of services would be on an individualized basis and depended on what factors contributed to the risk. He/she would expect increased visits due to the moderate risk level. He/she would have expected when Patient #11’s adult child was not reached by phone, that more follow-up would have occurred. When the adult child was not reached in December, then he/she would have expected someone reaching out to the adult child in January.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure the spiritual assessment was completed in one of six records reviewed (Record/Patient #11). This deficient practice has the potential to impact the spiritual counseling needs for all the patients served by the provider. Findings included: Review of the providers policy titled, “Assessment-Comprehensive Assessment of the Patient,” reviewed 02/2026, showed in part the following:- The comprehensive assessment of the patient was to be completed by designated members of the interdisciplinary group (IDG) in consultation with the patient’s attending physician no later than five (5) calendar days after the patient elected the hospice benefit;- The registered nurse (RN) case manager was to coordinate the comprehensive assessment process and ensure that the patient’s physical, emotional psychosocial, spiritual, and bereavement needs were assessed; and- Discipline-specific assessment tools obtained accurate and timely information that guided decisions for the development of the patient’s plan of care. RECORD/PATIENT #11:Review of the clinical record showed the patient was admitted to hospice services on 09/06/2025 with a terminal diagnosis of degenerative disease of the nervous system (the progressive deterioration and death of nerve cells). The patient resided in a long-term care facility (LTCF). Review of the chaplain visit note, dated 09/15/2025, showed the chaplain was unable to assess the patient for spiritual needs due to the patient’s inability to verbalize. Review of the chaplain visit note, dated 11/10/2025, showed the chaplain planned to contact the patient’s daughter regarding spiritual concerns. The chaplain failed to document a follow up conversation regarding spiritual concerns. During an interview on 6/17/2026 at 2:35 PM, the bereavement coordinator stated that if the patient was non-verbal then the chaplain would complete the spiritual assessment with the caregiver. If the patient resided in a LTCF, then the chaplain would reach out to the family member regarding spiritual needs. During an interview on 06/18/2026 at 9:30 AM, the director of support services stated that if the patient was non-verbal, the chaplain was to get input from the family to complete the spiritual assessment, whether the patient resided at home or in a LTCF.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure that clinical notes were signed in a timely manner in, but not limited to, one of five full records reviewed (Record/Patient #3) and that documentation was accurate in, but not limited to, one of five full records reviewed (Record/Patient #5). This deficient practice has the potential to affect all the patients served by the provider. Findings included:Review of the provider’s policy titled, “Documentation Requirements,” reviewed 02/2026, showed, in part, the following:- Documentation was completed by all hospice staff and volunteers whenever patient/caregiver visits occurred;- All documentation was completed in the electronic medical record;- Documentation must be legible, grammatically correct, accurate, and timely;- All documentation contained complete, factual, essential, and accurate information; and- Staff and volunteers clearly stated what was seen (assessment), what was done (intervention) and how the patient/caregiver reacted (outcome). RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 03/18/2026 with a terminal diagnosis of relapsing-remitting multiple sclerosis (a chronic autoimmune disease of the central nervous system). The patient resided in a skilled nursing facility (SNF).Review of the skilled nursing (SN) visit notes showed:-On 03/18/2026, the patient’s blood pressure was 115/58 mmHg (millimeters of mercury) and triggered an alert stating the vital sign was outside of the acceptable range for this patient;-On 05/04/2026, the patient’s blood pressure was 98/50 mmHg and triggered an alert stating the vital sign was outside of the acceptable range for this patient;-On 05/13/2026, the patient’s blood pressure was 100/50 mmHg and triggered an alert stating the vital sign was outside of the acceptable range for this patient;-On 05/18/2026, the patient’s blood pressure was 104/58 mmHg and triggered an alert stating the vital sign was outside of the acceptable range for this patient;-On 05/27/2026, the patient’s blood pressure was 100/52 mmHg and triggered an alert stating the vital sign was outside of the acceptable range for this patient;-On 06/04/2026, the patient’s blood pressure was 95/50 mmHg and triggered an alert stating the vital sign was outside of the acceptable range for this patient; and-On 06/08/2026, the patient’s blood pressure was 90/54 mmHg and triggered an alert stating the vital sign was outside of the acceptable range for this patient.During an interview on 06/18/2026 at 9:15 AM, the administrator stated that these blood pressures are normal for the patient. He/she stated that the clinicians should have removed the automatic parameters from the electronic medical record (EMR) because these blood pressure reading were expected for this hospice patient. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 10/25/2025 with a terminal diagnosis of dysphagia following a cerebral infarction (difficulty swallowing following a stroke). The patient lived at home with a spouse as his/her caregiver.Review of a comprehensive assessment, dated 05/18/2026, showed the visit was signed on 05/27/2026 (nine days after the visit was completed);Review of a comprehensive assessment, dated 05/26/2026, showed the visit was signed on 06/01/2026 (six days after the visit was completed);Review of a comprehensive assessment, dated 06/01/2026, showed the visit was signed on 06/03/2026 (two days after the visit was completed); andReview of a comprehensive assessment, dated 06/09/2026, showed the visit was signed on 06/16/2026 (seven days after the visit was completed). During an interview on 06/18/2025, beginning at 9:15 AM, the administrator stated that he/she would expect clinical notes to be completed and signed by midnight on the date of the visit.”