Every finding on record at Pathway Hospice and Palliative Care, Inc.

Upon patient record review, 4 of 14 (Patient #1,2,3,5) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: Patient 1: Upon home visit, patient reports she no longer takes CoQ-10 or Bisacodyl 5mg both on the medication list and she is taking Prese vision soft gels twice daily, Potassium 90mg daily, calcium gummies, multivitamin gummies and Acetaminophen 500 mg PRN. She also has a bottle that is non-labeled which she reports is tums which are not present on agency medication list. Corrected on site with medication reconciliation and orders obtained. Patient 2: Upon home visit, wife reports patient is no longer taking tamsulosin 0.4 mg and probiotic blend which remains on agency medication list and caregiver reports Fentanyl patch is now as needed. Agency medication list contains an order for Fentanyl. Staff confirm that Fentanyl patch should have been discontinued with recent medication orders. Corrected on site with medication reconciliation and orders obtained. Patient 3: Upon home visit, son reports patient is taking Eliquis 5mg tablet twice daily and Eliquis is listed once daily on agency medication list and POC. Son administers medications including Miralax PRN, Vit D3 &Vit K2 twice daily which are not included on the agency medication list. Corrected on site with medication orders discontinuing Vit D3 & Vit K2 and obtaining order for Miralax and corrected frequency of Eliquis. Patient 5: Acetaminophen orders for 500mg scheduled 2 tabs twice daily and acetaminophen 650 mg every 6 hours rectally prn with no warning to limit to no more than 4 grams in 24 hour period. Corrected on site with medication orders updated.

Upon patient record review, 4 of 14 (Patient #1, 3, 9 and 10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 1: The POC 4/14/25 contains an order for Eliquis and there is no evidence of bleeding precautions on the POC. Corrected on site with update made to POC. Patient 3: The POC 8/6/25 contains an order for Eliquis 5mg tablet and there is no evidence of bleeding precautions on the POC. Corrected on site with update made to POC. Patient 9: The POC 7/1/25 contains an order for Eliquis 2.5 mg twice daily on medication profile and there is no evidence of risk for bleeding on the POC. Corrected on site with update made to POC. Patient 10: Initial POC 7/2/25 does not include individualized goals, interventions reflective of patient complaints of dyspnea rating “7” on 1-10 scale and timeframes for completion are not time specific.

Upon patient record review, 4 of 14 (Patient # 1, 2, 3, 5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1: Upon home visit, patient reports she no longer takes CoQ-10 or Bisacodyl 5mg both on the medication list and she is taking Prese vision soft gels twice daily, Potassium 90mg daily, calcium gummies, multivitamin gummies and Acetaminophen 500 mg PRN. She also has a bottle that is non-labeled which she reports is tums which are not present on agency POC. Corrected on site with medication reconciliation and updates to POC. Patient 2: Upon home visit, wife reports patient is no longer taking tamsulosin 0.4 mg and probiotic blend which remain on agency medication list and caregiver reports Fentanyl patch is now as needed. Agency medication list contains an order for Fentanyl. Staff confirm that Fentanyl patch should have been discontinued with recent medication orders. Corrected on site with medication reconciliation and updates to POC. Patient 3: Upon home visit, son reports patient is taking Eliquis 5mg tablet twice daily and Eliquis is listed on agency medication list and POC once daily. Son administers medications including Miralax PRN, Vit D3 &Vit K2 twice daily which are not included on agency medication list. Corrected on site with medication reconciliation and updates to POC. Patient 5: Acetaminophen orders for 500mg scheduled 2 tabs twice daily and acetaminophen 650 mg every 6 hrs rectally prn with no warning to limit to no more than 4 grams in 24 hour period. Corrected on site with updates to POC.

Upon patient record review, 1 of 14 (Patient #2) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient 2: Patient has a central access PICC line inserted for chemotherapy prior to admission that was not removed prior to SOC on 11/13/24 SN documents "Discharge planner stated patient will only live a few weeks so they decided against taking out line.” There is no evidence of any further discussion by the IDG members at the meetings. The POC only stated on admission for PICC line plans "Cover with tegadem every two weeks and monitor for infection".

Upon patient record review, 6 of 14 (Patient # 1,2,3,4,6, and 7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1,2,3,4,6,7: There is evidence of patient receiving massage therapy with no physician order for services.

Upon personnel record review, 3 of 14 (Personnel # 1,2,13) did not have evidence that all bereavement services are provided by a qualified counselor in accordance with applicable laws and regulations, professional practice standards, the hospice's policies and procedures and/or job descriptions which includes experience or education in grief or loss counseling. Personnel 1,2,13: Bereavement Coordinator role is in transition and is currently filled by certified aide who is transitioning out of role to attend nursing school and in the interim, role is being supported by Administrator and Alt Administrator.

Upon personnel record review, 2 of 14 (Personnel # 7 and 13) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed Personnel 7,13: There is not evidence the aide had direct observation or pseudo-patient evaluation of all types of bathing and hair care by RN. All tasks are on same line of competency evaluation and when evaluating RN is asked about observation, states "I did not know I had to observe each task separately."

Upon patient record review, 4 of 14 (Patient # 2,5,7 and 9) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 2: The aide POC on 2/13/25 allows patient choice for bed bath and shower “Give patient choice” Patient has recently only been taking bed baths and is unable to get out of bed. There is no evidence of updated aide POC since admission SOC 11/13/24. Aide POC should include patient's cognitive ability to make choice of selecting tasks. Patient 5: The aide POC on 2/13/25 allows patient choice for bed bath and shower “Give patient choice” Patient has recently only been taking bed baths and is unable to get out of bed. There is no evidence of updated aide POC since admission SOC 5/12/25. Aide POC should include patient's cognitive ability to make choice of selecting tasks. Patient 7: The aide POC 6/17/25 allows options for shower or bed bath per patient choice. Updated Aide POC 7/2/25 continues to offer bathing options including shower, bed, or sponge bath. Aide POC should include patient's cognitive ability to make choice of selecting tasks. Patient 9: The aide POC initiated on 7/2/25 for aide visits 3x weekly at SOC includes bathing. Patient has refused bathing every visit with no updates to POC to not include bathing.

Upon patient record review, 1 of 14 (Patient # 2) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 2: The Comprehensive nursing assessment on 6/27/25 and 7/1/25 the SN documents “Foley Cath 18 Fr last change date 3/25/25. Pt complaining of pressure and pain in groin. He was distended." Cath was changed at hospital on 6/25 and SN continues to document last change 3/25/25.

Upon patient record review 2 of 12 (Patients #11, #12) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #11 admitted on 12/23/21 and the psychosocial assessment was completed on 12/30/21. Patient #12 admitted on 5/11/22 and the psychosocial assessment was completed on 5/19/22.

Upon patient record review 2 of 12 (Patient #1, #10) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patients #1 and 10: no evidence of a psychosocial assessment as part of the initial comprehensive assessment.

Upon patient record review, 2 of 12 (Patient #1, #4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: The medical record did not not specify the location of the areas to apply nystatin cream on the medication profile. Corrected on site. Patient #4: The medical record contained nursing documentation of IV infusion of TPN, Vitamin C, and magic mouthwash there was no evidence of TPN, Vitamin C, or magic mouthwash on the medication profile. Corrected on site.

Upon patient record review, 6 of 12 (Patient #1, #8, #9, #10, #11, #12) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #1, 8, 9, 10, 11, 12: The medical record did not contain evidence of a completed bereavement risk assessment within 5 days.

Upon patient record review, 5 of 12 (Patient #2, #3, #4, #5, #6) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #2: On 5-4-22 the medical record contained documentation of orders for gentamycin eye drops however there were no problems, interventions, or goals related to infection of the eye on the plan of care. Corrected on site. Patient #3: On 5-13-22 the medical record contained documentation of a decrease in cognition and functionality however there were no problems, goals, and interventions on the plan of care related to the cognition or functionality of the patient on the plan of care. Corrected on site. Patient #4: The nursing documentation dated 6-23-22 contained evidence of pain and a "bloody vaginal discharge" and pain as a problem however no pain interventions initiated on the plan of care and no problems, goals, or interventions related to genitourinary addressed on the plan of care. Corrected on site. Patient #5: The medical record contained documentation that the caregiver was concerned about finances and placement however no problems, goals, or interventions related to financial needs on the plan of care. Corrected on site. The nursing documentation on 5-17-22 contained evidence the patient lost 37 pounds there are no problems, goals, or interventions related to nutrition on the plan of care. Corrected on site. Patient #6: The medical record contained a high bereavement risk assessment and the plan of care did not address any problems, interventions, or goals related to the pre-bereavement need. Corrected on site.

Upon patient record review, 3 of 12 (Patient #1, #4, #6) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: The medical record did not not specify the location of the areas to apply nystatin cream in the plan of care. Corrected on site. Patient #4: No evidence of an order for management of iv access to specify frequency of dressing changes or flushing of the device on the plan of care. Corrected on site. Patient #6: No evidence of orders for Bactrim DS and lotromin ultra. The medical record did not contain evidence of orders to manage purewick system included on the plan of care.

Upon patient record review, 1 of 12 (Patient #2) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #2: The medical record did not contain evidence of an order for a shower chair that was included on the aide visit notes and nursing documentation. Corrected on site.

Upon client record review, 4 of 12 (Patient #2, 4, 5, 6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: POC dated 5-4-22 includes a social worker frequency of 1 visit every 6 weeks and there have been no visits from the social worker since 5-5-22 and no evidence of patient refusing visits. Patient #4: The initial plan of care dated 6-23-22 does not include a frequency for the social worker, the social worker completed a visit to do the initial assessment. Patient #5: POC dated 5-17-22 includes a social worker frequency of 1 visit every 4 weeks and there have been no visits from the social worker since 5-20-22 and no evidence of refused patient visits. Patient #6: social worker frequency of 1 visit every 4 weeks was ordered and there have been no visits from the social worker since May and no evidence of refused visits.

Upon personnel record review, 1 of 1 applicable (Personnel #2) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient. Personnel #2: The personnel file did not contain evidence of a satisfactory competency of placement of a purewick collection system; task documented as completed by the aide on 6-29-22.

Upon patient client record review, 4 of 12 (Patient #3, #4, #6, #7) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #3: On the comprehensive nursing assessment dated 6-23-22 the documentation contained a discrepancy of the date of the patient's last bowel movement dated 9/30/22. Corrected on site. Patient #4: On the comprehensive nursing assessment dated 4-1-22 the documentation contained a discrepancy that the patient needed thickened liquids and the patient was on a regular diet. Corrected on site. Patient #6: On the comprehensive nursing assessment dated 5-13-22 the documentation contained a discrepancy that the patient had a diagnosis of dysphagia. Corrected on site Patient #7: On the comprehensive nursing assessment dated 6-25-22 there was documentation that contained a discrepancy that the patient had a diagnosis of dementia. Corrected on site