Hospice of the Calumet Area Inc.

“Based on record review and interview, the hospice failed to evidence a process for cooperation and collaboration with local, state and federal emergency preparedness officials that included documented attempts to contact officials in an effort for collaboration and cooperative planning in 1 of 1 agency. Findings include: A review of the hospice’s Emergency Preparedness Plan on 06/02/2025, failed to evidence documentation of collaboration with local, state and federal emergency preparedness officials. During an interview, on 06/02/2025, beginning at 9:50 AM, the Quality Improvement Coordinator, Administrative Staff 3, indicated the hospice did not have documentation of attempts to collaborate with local, state and federal emergency preparedness officials.”

“Based on record review and interview, the hospice failed to ensure the patient’s drug profile was reviewed in 1 of 1 clinical record reviewed who resided in an assisted living facility and a home visit observation was conducted (Patient #1) and 1 of 1 clinical record review who resided in a SNF and a home visit was conducted (Patient #2). Findings include: 1. A revised policy dated 12/16/2015 titled, “Assessment Updates to the Comprehensive Assessment,” indicated the comprehensive assessment of the patient included but not limited to a review of all the patient’s prescription and over the counter drugs that could affect drug therapy. 2. A revised policy, dated 11/10/2020, titled, “Medication Management,” indicated a medication profile would be maintained for every patient. 3. A revised policy, dated 04/21/2020, titled, “Medication Administration,” indicated at the time of the initial and comprehensive assessment the registered nurse [RN] would verify medications with the patient/caregiver/representative to include over the counter medications, and prescription medications. 4. A RN Hospice Initial Assessment, dated 03/31/2025, for Patient #1, indicated a medication profile review was completed of prescription /non-prescription medications for new or changed medications and for issues including effectiveness of therapy, side effects, actual/potential interactions and duplicate drug therapy. Entity E, an assisted living facility, documents indicated Patient moved into the facility on 03/25/2025. Documentation indicated Patient was taking medications to include but not limited to dexamethasone (corticosteroid used to reduce inflammation) 4 milligrams [mg] one tablet twice a day for inflammation. The Report indicated dexamethasone had a start date of 03/29/2025 and was last administered on 05/30/2025. A Hospice Medication Profile, print date of 05/29/2025, failed to evidence the dexamethasone. A Plan of Care for the benefit period 03/31/2025 to 06/28/2025, indicated hospice began on 03/31/2025; the POC failed to evidence the dexamethasone. During an interview, on 06/02/2025, beginning at 1:30 PM, RN 1 indicated the admitting RN should have completed a medication review upon Patient admission and the RN should review medications with the facility staff. RN 1 indicated she would need to follow up with the facility staff about the use of Patient’s dexamethasone and she was unaware Patient was taking dexamethasone. 5. A Skilled Nursing Visit Note, identified as a comprehensive assessment, dated 05/22/2025, indicated a medication profile review was completed for Patient #2’s prescription/non-prescription medications for new or changed medications and for issues including effectiveness of therapy, side effects, actual/potential interactions, and duplicate drug therapy. An Entity A, a skilled nursing facility, Physician Order Report, dated 05/02/2025 to 06/02/2025, indicated Patient medications to include but not limited to Tylenol, generic name acetaminophen (pain reliever) extended release 650 mg every 8 hours as needed for pain and Hydrocodone/acetaminophen (narcotic pain reliever) 7.5/325 mg one tablet twice a day. The Report indicated not to exceed 4 grams of acetaminophen in 24 hours. A Hospice Plan of Care, for benefit period 04/14/2025 to 06/12/2025, indicated hydrocodone/acetaminophen 7.5/325 mg one tablet twice a day and failed to evidence Tylenol. A Hospice Medication Profile, printed on 05/29/2025, failed to evidence the Tylenol. During an interview on 06/03/2025, beginning at 2:00 PM, RN 2 indicated Patient was not using the Tylenol and was taking scheduled Hydrocodone/Acetaminophen. During an interview, on 06/02/2025, beginning at 1:30 PM, RN 1 indicated the admitting RN should have completed a medication review upon Patient admission and the RN should review medications with the facility staff.”

“Based on record review and interview, the hospice failed to ensure the interdisciplinary group maintained responsibility for directing, coordinating and supervising the care and services provided in 1 of 1 active clinical record reviewed of a patient who resided in a skilled nursing facility and a home visit observation was completed (Patient #2). Findings include: A revised policy, dated 04/21/2020, titled, “Coordination of Services,” indicated the registered nurse [RN] case manager would coordinate the patient’s plan of care and facilitate the ongoing sharing of information with the contracted facility and non-hospice healthcare providers furnishing services unrelated to the terminal illness. A Patient Care Order, dated 05/19/2025, indicated Patient #2’s right forearm skin tear orders included clean with normal saline, and apply foam dressing 2 days per week and as needed and indicated the wound care orders were provided by the wound care team Person C, from Entity A, a skilled nursing facility. An entity A, wound care order, dated 05/16/2025, indicated cleanse right elbow skin tear with normal saline, pat dry, apply polymem (wound covering), then cover with foam dressing every Tuesday, Friday and as needed. An entity A, wound care order, dated 05/22/2025, indicated cleanse right elbow skin tear with normal saline, pat dry, apply polymem, then cover with foam dressing every Tuesday, Friday and as needed. Hospice Skilled Nursing Visit Notes, dated 05/22/2025 and 05/27/2025, indicated the right upper arm forearm skin tear was cleansed with normal saline and covered with a foam dressing. The hospice order failed to evidence the skilled nursing facility wound care team’s order for polymem wound covering to be applied prior to the foam dressing. During an interview, on 06/03/2025, beginning at 2:00 PM, RN 2 indicated she should have obtained the skilled nursing facility’s wound care updated orders for Patient’s right arm skin tear and did not. RN 2 indicated the skilled nursing facility’s wound care team would often do wound care prior to hospice nurse visits. During an interview, on 06/05/ 2025, beginning at 10:00 AM, Person C, from Entity 1 indicated Patient’s wound care orders for the right arm skin tear always included the use of a polymem wound covering prior to the foam dressing due to polymem would prevent the foam dressing from sticking to the skin tear.”

“Based on record review and interview, the hospice failed to ensure care and services are provided in accordance with the plan of care in 1 of 1 active clinical records reviewed with a gastrostomy tube (Patient #8). Findings include: A revised policy, dated 08/31/2021 and titled “Plan of Care,” indicated the plan of care would be developed by the interdisciplinary group [IDG] in accordance with the physician orders and comprehensive assessment of the patient to identify the care and services necessary to meet the needs of the patient/caregiver. The policy indicated the patient’s plan of care would include but not limited to treatments necessary to meet the needs of the patient. A POC for the benefit period 04/04/2025 to 06/02/2025, indicated Patient #8’s gastrostomy (surgical opening into the stomach from the abdomen for nutrition) site and function would be monitored and the area around the site would be cleansed daily. A Skilled Nursing Visit Note, dated 05/29/2025, identified as a comprehensive assessment, indicated Patient had a g-tube (gastrostomy tube); the comprehensive assessment failed to include documentation of the assessment of the site or function of the g-tube. During an interview, on 06/04/2025, beginning at 4:30 PM, the Family Clinical Coordinator, Administrative Staff 2, indicated the comprehensive assessment from 05/29/2025 did not have assessment of the g-tube site and the nurse should have documented the assessment of the site.”

“Based on record review and interview, the hospice failed to evidence they provided for ongoing sharing of information with non-hospice healthcare providers furnishing services in 3 of 3 active clinical records reviewed of patients residing in a skilled nursing facility with advanced directives (Patient #2, Patient #10, and Patient #12). Findings include: 1. A revised policy, dated 12/15/2018, titled “Nursing Facility Residents Coordination of Care,” indicated the following information was to be provided to the facility to include but not limited to advanced directives specific to each patient. 2. A revised policy, dated 08/31/2021, titled “Nursing Facility Residents Hospice Plan of Care,” indicated the registered nurse [RN] case manager assigned to the patient was responsible for coordinating and implementing the patient’s plan of care in collaboration with the hospice’s interdisciplinary team and with representatives from the facility. The policy indicated all care provided to the facility patient would be in accordance with the written plan of care that included the patient’s medical, physical, social, emotional and spiritual needs. 3. A revised policy, dated 02/20/2025, titled “Advanced Directives,” indicated valid advanced directives would be followed to the extent that they are consistent with the hospice’s policies, and in the event a patient chose a life prolonging advanced directive, the hospice would assist the patient and family in locating an appropriate health care provider. The policy indicated the advanced directives recognized would include but not limited to out of hospital do not resuscitate declaration and allowed a patient to say they did not want cardiopulmonary resuscitation [CPR] if the heart or lungs stopped working in a location that was not a hospital or health facility, and a physician orders for scope of treatment [POST] was a direct physician order that reflected a patient’s wishes related to CPR, medical interventions, antibiotics, and artificially administered nutrition. 4. A revised policy, dated 04/21/2020, titled “Coordination of Services,” indicated the interdisciplinary group [IDG] would ensure that there was coordinated and effective sharing of information between all disciplines, with all contracted service providers and in all settings. The policy indicated the RN case manager would coordinate the patient’s plan of care and facilitate the ongoing sharing of information with the attending physician, contracted facilities, other members of the IDG, and non-hospice healthcare providers furnishing services unrelated to the terminal illness. 5. A Hospice Plan of Care for the benefit period 04/14/2025 to 06/12/2025, indicated Patient #2’s hospice care began on 04/19/2024 and that Patient was a Full Code (CPR would be used if a patient’s heart or breathing stopped). The POC indicated under Patient had a healthcare proxy and resided in Entity A, a skilled nursing facility [SNF]. A Physician Order Report from Entity A and dated 05/02/2025 to 06/02/2025, indicated Patient was a DNR. During an interview, on 06/02/2025 beginning at 10:30 AM, RN 2 indicated Patient was not a DNR and the facility would do CPR on Patient if required, indicated hospice patients were able to receive CPR.During an interview, on 06/02/2025 beginning at 10:30 AM, Licensed Practical Nurse D, of Entity A indicated Patient was a DNR and presented documentation of a Physician Orders for Scope of Treatment [POST] for Patient. The POST Document, received from Entity A on 06/02/2025, indicated Patient was a DNR and was signed on 03/29/2022. During an interview, on 06/02/2025 beginning at 1:00 PM, masters of social worker [MSW] 1 indicated she would need to follow up with the Social Worker [SW] responsible to have advanced directives documents in Patient’s clinical record.During a follow up interview, on 06/02/2025 beginning at 1:45 PM, MSW 1 indicated the SW did not follow up on the advanced directive document or with the SNF. MSW 1 indicated the SW was to enter Patient’s DNR status on the POC after documentation was received or completed. 6. The POC for the initial benefit period 05/23/2025 to 08/20/2025, indicated Patient #10 was not a DNR and indicated no advanced directives. The POC indicated Patient resided in Entity A. A MSW visit note, dated 05/28/2025, indicated Patient had advanced directives to include a DNR, living will, and health care proxy. During a follow up interview, on 06/02/2025, beginning at 1:45 PM, MSW 1 indicated the hospice SW was to enter Patient’s DNR status on the POC after documentation was received; the MSW relayed the SW was responsible for obtaining advanced directive documentation and adding the code status and or DNR to the POC.During an interview, on 06/03/2025 beginning at 4:20 PM, MSW 1 indicated she does not know the status of Patient’s DNR, and the hospice does not have the DNR document. 7. The POC for the 2nd benefit period dated 05/26/2025 to 08/23/2025 indicated Patient #12 was not a DNR and indicated Patient had a surrogate decision maker and a healthcare proxy. A MSW visit note, dated 02/26/2025, indicated Patient’s advanced directives included documents of DNR, living will, and healthcare proxy.A POST dated 04/29/2025, was received on 06/03/2025, from Entity B, a SNF; the POST indicated Patient was a DNR. During an interview, on 06/03/2025, beginning at 4:00 PM, MSW 1 indicated she received the DNR document from Entity B via fax on 06/03/2025, and the SW was responsible for documenting Patient’s advanced directives on the POC and did not. MSW 1 indicated hospice did not have Patient’s DNR document in the electronic clinical record.8. During an interview, on 06/02/2025 beginning at 1:00 PM, the Administrator indicated their patients POC should have included their advanced directives.”

“Based on record review and interview, the hospice failed to evidence the performance improvement activities focused on high risk, high volume or problem prone area in 12% of the 12 month unduplicated census of patients with documented falls from 05/02/2024 to 05/18/2025. Findings include: A revised policy, dated 08/15/2017 and titled, “QAPI [quality assurance performance improvement] Program Data,” indicated priorities for data collection and measurement activities are based on the identification of negative trends and areas that require a more focused review and analysis. A revised policy, dated 12/02/2008 and titled, “QAPI Performance Improvement Activities and Projects,” indicated performance improvement activities are selected that are focused on high risk, high volume or problem prone areas and would consider incidence, prevalence of severity of problems in high risk, high volume or problem prone areas and affect palliative outcomes, patient safety and quality of care. A Quality Assurance Performance Improvement Plan, dated 2025, indicated the performance improvement team would consider the following factors when prioritizing problem and solution selections for performance improvement projects to include but not limited to high risk, high volume, problem prone areas, and the frequency of the problem and severity of potential harm.A Hospice Fall Log for 2024 indicated 57 patients had falls. Hospice Fall Log for 2025 indicated 22 patients had falls from 01/04/2025 to 05/18/2025. A Quality Assurance Performance Plan failed to evidence the hospice performance improvement activities focused on patients’ falls and failed to evidence analysis of patients’ to an action plan. During an interview, on 06/03/2025, beginning at 10:30 AM, the Performance Improvement Coordinator, Administrative Staff 3, indicated the QAPI program did not analyze or have an action plan in place for patients’ falls.”

“Based on record review and interview, the hospice failed to track adverse events for performance improvement activities in 1 of 2 active clinical records reviewed with a documented fall (Patient #12). Findings include: A Quality Assurance Performance Improvement Plan, dated 2025, indicated the objectives of the plan would be to measure, analyze and track quality indicators, including adverse events, to enable the assessment of processes of care and hospice services. A Skilled Nursing Visit Note, dated 05/06/2025, indicated the hospice social worker contacted the nurse to report that Patient #12’s family member had reported Patient was found on the floor, beside the bed and Patient was unable to tell the staff what had happened. A Hospice Fall Log, dated 2025, failed to evidence documentation of Patient’s fall.During an interview on 06/03/2025, beginning at 1:00 PM, the Performance Improvement Coordinator, Administrative Staff 3 indicated an adverse event for Patient’s fall was not on the fall log and an adverse event report should have been completed by the nurse and was not.”

“Based on record review and interview, the Quality Assessment and Performance Improvement [QAPI] Program failed to evidence a method of identifying urinary tract infections and implementing an action plan that would result in improvement and disease prevention in 12% of the 12 month unduplicated census of urinary tract infections from Quarter 3 to Quarter 4 in 2024, and January 2025 to May 2025. Findings include: A revised policy, dated 08/15/2017 and titled, “QAPI Program Data,” indicated the performance improvement team would be responsible for reviewing and analyzing routine data that would be collected by the hospice program that would include but not limited to infection surveillance data. The policy indicated the performance improvement team would utilize the results of the data analyzed to monitor the effectiveness and safety of services and the quality of care to identify performance improvement opportunities.A revised policy, dated 12/02/2008 and titled, “QAPI Performance Improvement Activities and Projects,” indicated the performance improvement team would make recommendations for potential performance improvement activities and projects that reflects areas of weakness as identified through data analysis. The policy indicated the performance improvement activities would be selected that included focus on high risk, high volume or problem prone areas, consider incidence, prevalence and severity of problems in highs risk areas and activities that would affect palliative outcomes, patient safety and quality of care. A 2024 Summary of Logs for Patients’ Urinary Tract Infections [UTI] indicated 12 UTI for Quarter 1 of 2024, 15 for Quarter 2 of 2024, 13 for Quarter 3 of 2024 and 14 for Quarter 4 of 2024. A 2025 Infection Log indicated 32 patients with urinary tract infections from 01/07/2025 to 05/18/2025. During an interview, on 06/03/2025, beginning at 10:30 AM, the Performance Improvement Coordinator, Administrative Staff 3, indicated the hospice’s QAPI program did not include an action plan related to patients’ urinary tract infections.”

“Based on record review and interview, the hospice failed to evidence they collected and maintained documentation of advanced directives in 2 of 2 clinical records reviewed where the patients resided in a skilled nursing facility and whose hospice care began before 05/23/2025 (Patient #2 and Patient #12). Findings include: 1. A revised policy, dated 02/20/2025, titled, “Advance Directives,” indicated at the time of admission to the hospice program the existence of an advance directive would be documented, and a copy would be requested for the patient’s medical record. 2. A Hospice POC for the benefit period 04/14/2025 to 06/12/2025, indicated Patient #2 who began hospice services on 04/19/2024, was not a do not resuscitate [DNR] (CPR would not be used if a patient’s heart or breathing stopped). The POC indicated Patient had a healthcare proxy.A Physician Order Report dated 05/02/2025 to 06/02/2025, from Entity A a SNF, indicated Patient was a DNR and provided a Physician Orders for Scope of Treatment [POST] Document, on 06/02/2025 which indicated Patient was a DNR; the document was signed on 03/29/2022.During an interview, on 06/02/2025 beginning at 1:45 PM, MSW 1 indicated the SW did not follow up on the advanced directive document or with the SNF. MSW 1 indicated the SW was to enter Patient’s DNR status once received or completed and to add to the clinical record. 3. Plan of Care, for the 2nd benefit period 05/26/2025 to 08/23/2025, indicated Patient #12 was not a DNR and indicated Patient had a surrogate decision maker and healthcare proxy. The record included a MSW Visit Note, dated 02/26/2025, which indicated Patient’s advanced directives included documentation of a DNR, living will and healthcare proxy. The clinical record failed to evidence documents to evidence Patients’ code status to be a fill code, a DNR, or other choice.4. During an interview, on 06/03/2025, beginning at 4:00 PM, MSW 1 indicated she received the DNR document from entity B via fax on 06/03/2025. MSW 1 indicated that the hospice did not have Patient’s DNR document in the electronic clinical record.”

“Based on record review, and interview, the hospice failed to ensure patients’ plans of care identified the care and services that were needed and identify which provider was responsible for performing those functions for 3 of 3 active clinical records reviewed of patients residing in a skilled nursing facility (Patient #2, Patient #10, Patient #12). Findings include: 1. A revised policy, dated 08/31/2021, titled, “Nursing Facility Residents Hospice Plan of Care,” indicated the plan of care for the facility patient would identify the care and services that were needed and specifically identify which provider was responsible for performing the functions. 2. A Plan of Care, for benefit period 04/14/2025 to 06/12/2025, indicated Patient #2 was disoriented, incontinent of bowel and bladder, required 24 hour supervision, was on complete bedrest, had wound care to the left knee daily, and left calf wound care 2 times per week.A Skilled Nursing Visit Note, dated 05/22/2025, indicated Patient had a Karnofsky Performance Status Score (an assessment tool for functional impairment) of 30% that indicated Patient was unable to care for self and was severely disabled. A Hospice/Nursing Facility Coordinated Services Plan of Care from Entity A, a SNF, indicated hospice nurse visits were Monday and Thursday, 04/14/2025 to 06/12/2025, and hospice aide visits were Monday, Wednesday and Friday. The Hospice /Nursing Facility coordinated Services Plan of Care indicated a wound care schedule for hospice wound care, beginning of 04/14/2025, was Monday, Wednesday, and Friday for knee wound care 2 times per week and daily calf wound care. The POC failed to evidence the care to be provided, the wound care to be provided and the activities of daily living to be provided by the skilled nursing facility in the absence of the hospice staff. 3. A POC for the benefit period 05/23/2025 to 08/20/2025, indicated Patient #10 required wound care to left foot, right foot, and right thigh 2 times per week and as needed if the dressing became loose, soiled, or dislodged and was short of breath with minimal exertion. An Aide Care Plan, dated 06/03/2025, indicated Patient’s activity was to be up to wheelchair with maximum assistance with facility staff assistance, and incontinent care, and bed bath were to be completed by the hospice aide. A Hospice /Nursing Facility Coordinated Services Plan of Care indicated hospice nurse visits and hospice wound care was Mondays and Thursdays and hospice aide visits were Monday, Wednesday and Friday. The POC failed to evidence the care to be provided by the skilled nursing facility in the absence of the hospice staff. 4. A POC for the benefit period 05/26/2025 to 08/23/2025, indicated Patient #12 was incontinent of bowel and bladder, was lethargic, required 24 hour supervision, had a foley catheter (a tube that drains urine), diet was pleasure feeds as tolerated, and required wound care to a buttocks wound 3 times per week on Monday, Wednesday, Friday and as needed for soilage. The record included an Order, dated 05/31/2025, which indicated buttocks deep tissue injury wound care daily. A Hospice / Nursing Facility Coordinated Services Plan of Care, indicated hospice nurse visits and wound care on Tuesday and Friday, hospice aide visits Tuesday, Thursday and Friday, and foley catheter change. The Coordinated Services Plan of Care indicated foley catheter change 04/23/2025 and under party responsible and frequency hospice or long term care the area was blank. The POC failed to evidence the care to be provided by the skilled nursing facility in the absence of the hospice staff. During an interview, on 06/02/2025, beginning at 1:00 PM, the Patient Care Coordinator, indicated the hospice was responsible for the management of their patients and the delineation of care did not include the skilled nursing facility’s responsibilities.”