Trinity Health at Home Southeast Michigan

“Observed in Record Review. In 1 of 18 patient records reviewed the organization did not ensure that updated assessments include all required information. For example, a review of the medical record for HosRRNHV#10, revealed that during week 3 of services, a clinician documented the following information: Stage 2 slow to heal with friction and shearing, ordered gel cushion to off load pressure, continue to use island foam dressing to area. Wound approximately 0.5cm, no drainage or signs and symptoms of infection. The wound assessment did not include the location of the wound, complete wound measurements, and the condition of the surrounding skin. This observation was reviewed with the Regional Director of Hospice Operations.”

“Observed in Record Review. In 3 of 18 patient records reviewed, it was noted that the organization did not ensure the plan of care goals included outcome measures for specific care activities. For example, a review of the medical record for HosRRHV#5, revealed that the patient’s terminal illness diagnosis was Dysphagia following Cerebral Infarction. The plan of care did not include a goal statement to evaluate the response to care, treatment, and services related to Dysphagia following Cerebral Infarction.Example #2: During a review of the medical record for HosRRNHV#5, an updated assessment documented that the patient was experiencing pain at his foot and receiving wound care for a stage two (2) pressure ulcer at the coccyx area. The plan of care did not include goal statements to evaluate the response to care, treatment and services related to pain management and wound care interventions. Example #2: A review of the medical record for HosRRNHV#10, revealed that during week 3 of services, a clinician documented the following information: Stage 2 slow to heal with friction and shearing, ordered gel cushion to off load pressure, continue to use island foam dressing to area. Wound approximately 0.5cm, no drainage or signs and symptoms of infection. The plan of care was not updated with a goal statement related to the care, treatment, and services of the patient’s non-intact skin. This observation was reviewed with the Regional Director of Hospice Operations.”

“Observed in Record Review. In 1 of 18 patient records reviewed, it was noted that the organization did not ensure the plan of care was revised when the patient’s condition changed. For example, during the assessment update completed during week 3 of the 1st benefit period, the clinician documented that the patient had experienced a fall with injury. The plan of care was not updated with interventions to maintain safety and strategies to prevent injury. Example #2: A review of the medical record for HosRRNHV#10, revealed that during week 3 of services, a clinician documented the following information: Stage 2 slow to heal with friction and shearing, ordered gel cushion to off load pressure, continue to use island foam dressing to area. Wound approximately 0.5cm, no drainage or signs and symptoms of infection. The plan of care was not updated with interventions to address the care, treatment, and services of the patient’s non-intact skin. Example #3: In 2 of 18 patient records reviewed, it was noted that the organization did not ensure the plan of care goals included outcome measures for specific care activities. For example, a review of the medical record for HosRRHV#5, revealed that the patient’s terminal illness diagnosis was Dysphagia following Cerebral Infarction. The plan of care did not include a goal statement to evaluate the response to care, treatment, and services related to Dysphagia following Cerebral Infarction. Example #4: During a review of the medical record for HosRRNHV#5, an updated assessment documented that the patient was experiencing pain at his foot and receiving wound care for a stage two (2) pressure ulcer at the coccyx area. The plan of care did not include care, treatment, and service interventions related to pain management and wound care. This observation was reviewed with the Regional Director of Hospice Operations.”

“Observed in Individual Tracer. In 1 of 6 individual tracers, it was noted that the organization did not ensure the medication list included accurate information. For example, individual tracer activities for HosRRHV#6, revealed that the medication list provided to the Hospice Surveyor, and the medication list in the patient’s home folder, did not include an accurate description of the medication’s the patient was currently taking. The following medication was not listed: Men’s Multivitamin & Omega – 3 gummies daily. Example #2: In 1 of 18 patient records reviewed, the organization did not ensure the medication list was updated when medication changes were noted. For example, a review of the medical record for HosRRNHV#5, revealed that during week 3 of the 1st benefit period the patient started taking Tylenol for foot pain. The medication list was not updated to include the addition of the this pain management medication. This observation was reviewed with the Regional Director of Hospice Operations.”

“Observed in Record Review. During review of a bereavement record, the Hospice pharmacy surveyor noted that an entry in this record by the bereavement coordinator was originally dated 12/16/2024. However there was also an entry listed as 1/6/2025 for this same information. Upon interview the bereavement coordinator indicated that she had entered a couple of misspelled words and when this change was made, it changed the note entry date to the new date in this case 1/6/25 which made the date now observed as inaccurate, This change in date made the current date of the original order in the patient’s EMR to include a date which reflected an original inaccurate original note entry. date as well. This issue was validated wit the bereavement coordinator and the Hospice management team at the time of the survey.”

“Observed in Individual Tracer. In 1 of 2 Individual tracers, for patient’s receiving home oxygen therapy, it was noted that the organization did not ensure the comprehension of education related to general oxygen safety risks was assessed. For example, during the home visit activity for HosRRHV#6, it was noted that two oxygen tanks were stored in the patient’s closet. There was no documentation of the assessment of patient’s, family’s and/or caregiver’s level of comprehension of this identified risk and compliance with suggested interventions. This finding was observed during survey activity but corrected onsite prior to the surveyor’s departure. The corrective action taken needs to be included in the organization’s Evidence of Standards Compliance submission. Example #2: In 1 of 18 patient records reviewed, it was noted that the organization did not ensure the comprehension of education related to wound care was assessed. For example, during the record review activity for HosRRNHV#1, it was noted that the clinician documented the patient’s caregiver was performing the wound care. There was no documentation of the assessment of patient’s, family’s and/or caregiver’s level of comprehension of the wound care regimen and skin integrity interventions. This observation was reviewed with the Regional Director of Hospice Operations.”