Every finding on record at Hospice for All Seasons, LLC

Based on review of hospice policies/procedures, clinical records (CRs), and interview with the hospice Executive Director (EMP# 1), it was determined the hospice failed to ensure an initial bereavement risk assessment was completed for five (5) of nineteen (19) CRs reviewed. (CR# 1, CR# 8, CR# 9, CR# 17 and CR# 18) and failed to ensure a bereavement risk assessment at the time of death for three (3) of nineteen (19) CRs reviewed. (CR# 17, CR# 18 and CR# 19) --- Findings include:Review of policy, 'Bereavement Assessments Policy No. H: 2-053' on November 13, 2025 at approximately 10:30 a.m., section, 'Assessment Procedures' reads, " Pre-Bereavement Assessment is a paper form completed by the Bereavement Counselor upon request for bereavement services by a patient or family/caregiver....Post-Death Bereavement Assessment is a paper form completed by the Bereavement Counselor upon visitation with bereaved..."Review of CRs conducted on November 13. 2025 at approximately 9:30 a.m. and on November 14, 2025 at approximately 10:30 a.m. revealed the following:CR# 1, Start of Care (SOC): 9/30/2024:  Clinical record did not contain documentation that an initial bereavement risk assessment was performed.CR# 8, SOC: 2/25/2025:  Clinical record did not contain documentation that an initial bereavement risk assessment was performed.CR# 9, SOC: 10/3/2025:  Clinical record did not contain documentation that an initial bereavement risk assessment was performed.CR# 17, SOC: 9/5/2024:  Clinical record did not contain documentation that an initial and time of death bereavement risk assessments was performed.CR# 18, SOC: 9/13/2024:  Clinical record did not contain documentation that an initial and time of death bereavement risk assessments was performed.CR# 19, SOC: 1/3/2025:  Clinical record did not contain documentation that a time of death bereavement risk assessments was performed.An interview with EMP #1 conducted on November 14, 2025 at approximately 3:00 p.m. confirmed the above findings.

Based on review of hospice policies/procedures, clinical records (CRs), and interview with the hospice Executive Director (EMP# 1), it was determined that the agency failed to provide bereavement services, per policy, for three (3) of three (3) CR bereavement files reviewed (CR# 17, CR# 18 and CR# 19). --- Findings include:Review of policy, 'Bereavement Services Policy No. H: 2-008.1' on November 13, 2025 at approximately 11:30 a.m., section, 'Post-Death Procedures' reads, "...2. Sympathy Card will be sent within one week of death occurring to family/caregivers noted on Bereavement Care Plan...3. Mailings sharing regarding Bereavement Services will be sent unless Bereaved explicitly declines, these include: a. 1-Month Letter with grief brochure; b. 3-Month Letter and Brochure; c. 6-Month Letter and Brochure; d. 13-Month Letter and Brochure; e. Christmas Card; f. Memorial Invitation..."Review of CRs conducted on November 13. 2025 at approximately 9:30 a.m. and on November 14, 2025 at approximately 10:30 a.m. revealed the following:CR# 17, Start of Care (SOC): 9/5/2024:  Patient deceased 10/10/2024. No documentation provided of a 1-month Letter with grief brochure, 3-month Letter and Brochure and 6-month letter and brochure being sent to the bereaved per policy.CR# 18, SOC: 9/13/2024:  Patient deceased 12/10/2024. No documentation provided of a 1-month Letter with grief brochure, 3-month Letter and Brochure and 6-month letter and brochure being sent to the bereaved per policy.CR# 19, SOC: 1/3/2025:  Patient deceased 1/5/2025. No documentation provided of a 1-month Letter with grief brochure, 3-month Letter and Brochure and 6-month letter and brochure being sent to the bereaved per policy.An interview with EMP #1 conducted on November 14, 2025 at approximately 3:00 p.m. confirmed the above findings.