Corewell Health Hospice & Palliative Care Southwest Michigan

“It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 23 (17%) clinical records reviewed, it was revealed that, the agency did not ensure that the plans of care documented all updated interventions for the care of the patients. POLICY AND PROCEDURES: Agency policy titled, Hospice - Interdisciplinary Team/Interdisciplinary Group, reviewed 02/08/2024, stated in part, “The interdisciplinary Group reviews and updates the plan of care at least every 15 days which includes, but not limited to: Reviewing admission and initial comprehensive assessments, ensuring compliance with Hospice policies and procedures”. CLINICAL RECORD 1: The hospice election of benefit form was dated 03/09/2025 with a general inpatient (GIP) level of care. The patient was admitted with a peripheral catheter in the right antecubital space. The line was assessed following hospital protocol every 4 hours and orders were documented. The hospice plan of care did not document any interventions or goals for the assessment of the peripheral line and dressing changes that would be required. CLINICAL RECORD 6: The hospice election of benefit form was dated 11/26/2024 and the initial plan of care documented an intervention for foley catheter change monthly and prn. The comprehensive nursing assessment documented on 12/18/2024 documented that the Foley catheter would not be routinely changed related to a mass and comfort only change with symptoms but updated plans on 12/24/2024 and, 01/08/2025 and 01/22/2025 were not updated for the Foley catheter care and continued to document a monthly change as the intervention. CLINICAL RECORD 9: The hospice election of benefit form was dated 11/06/2024. The updated nursing comprehensive assessment was documented on 12/09/2024, which reported a skin tear on the left arm with wound care of cleaning with a Mepilex dressing. The interdisciplinary plan of care dated 12/18/2024 and 01/04/2025 did not document any interventions for skin integrity, and no Interventions for wound care and assessment were updated. The nursing clinical notes documented the wound each visit and wound measurements with improvement noted. CLINICAL RECORD 16: The hospice election of benefit form was dated 09/21/2024. The updated nursing comprehensive assessment dated 09/23/2024 documented that a Foley catheter was initiated. The updated plan of care dated 09/25/2024, did not document any interventions for Foley catheter care. The patient died on 10/05/2024. Interview with the Clinical Director and Quality Director stated that plan of care interventions was part of the process improvement as the software change in April 2024 had been a lot of teaching and the agency noted continued work in this area.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions, such as hand hygiene, and safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids. This standard was not met as evidenced by document review, interview and observation. In 1 of 6 (17%) home visit observations with clinicians who carried a bag with equipment, it was revealed that the agency did not ensure that staff followed the agency policy for cleaning equipment. POLICY AND PROCEDURES: Agency policy titled, Equipment, Supplies and Bag Technique, with an effective date of 02/08/2024, stated, “Non-critical items should be cleaned and disinfected with an environmental protection Agency (EPA) - registered disinfectant wipes, as appropriate and approved by the health system and using the manufacturer’s instructions for use. Only dry supplies that are cleaned and disinfected can be placed back into a supply bag.” Product Label: Sani-Wipe Label Read, “Allow the surface to remain wet for two minutes. Let air dry.” HOME VISIT 6: During the home visit with the registered nurse, (personnel record 15), on 03/12/2025, the nurse performed a comprehensive visit and provided wound care to the patient. After care had been provided and the visit was concluding the nurse cleaned the equipment of pulse ox, stethoscope, blood pressure cuff, and scissors. All equipment was wiped once with a Sani cloth and immediately placed in the nursing bag. No wet or dry time was completed. During interview with the visit nurse she stated that her equipment had not dried before it was placed in the bag.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed of patients with a request for volunteer services, it was revealed that the agency did not ensure that the requested volunteer service was provided. CLINICAL RECORD 13: The interdisciplinary meeting signed on 01/16/20/2025 documented that the patient would benefit from a volunteer providing pet therapy. This update from the social worker stated that a referral was made for pet therapy from the volunteer program. As of the record review on 03/12/2025, no volunteer visits had been documented. No volunteer visit frequency was documented and no documentation of contact with the patient or family. During an interview with the social worker and volunteer coordinator, they stated that the referral had been made but had not been provided and the pet volunteer was contacted as well as the patient that day and volunteer services were to be started.”

“It is required that the hospice and its staff operate and provide care and services in compliance with local, state, and federal law and regulation related to the health and safety of patients. This standard was not met as evidenced by document review, interview and observation. A tour of the agency’s main office revealed that the fire extinguishers were not being inspected monthly per OSHA regulations and the agency’s policy. OSHA REGULATION: Occupational Health and Safety Administration (OSHA) regulation 1910.157 (e)(2) states, “Portable extinguishers or hose used in lieu thereof under paragraph (d)(3) of this section shall be visually inspected monthly.” POLICY AND PROCEDURES: The agency systemwide policy titled, Fire Extinguisher Policy” (reference # 29118, version # 2, effective date 12/16/2024) stated, in part, “Inspection, testing and maintenance requirements” include “12 monthly inspections”. OFFICE TOUR 1: During a tour of the administrative office on 03/11/2025, the inspection tags on the portable fire extinguishers located throughout the office did not include evidence of monthly inspections. The agency had no logs of monthly fire extinguisher checks. During an interview with the Nurse Manager, Post-Acute (PR# 7) on 03/11/2025, she stated that monthly inspections of the portable fire extinguishers were not being conducted. She also stated that no other logs of monthly inspections were being kept outside of the inspection tags on the extinguishers. A tour of the agency’s main office revealed that the fire extinguishers were not being inspected monthly per OSHA regulations and the agency’s policy.”

“It is required that a hospice-operated inpatient care facility complies with all applicable federal, state and local health and safety codes, including the applicable provisions of the Life Safety Code (LSC) of the National Fire Protection Association NFPA 101, Life Safety Code 2012 edition; and, Tentative Interim Amendments (TIA) 12-1, TIA 12–2, TIA 12–3, and TIA 12–4; and the Health Care Facilities Code NFPA 99, 2012 edition and Tentative Interim Amendments TIA 12–2, TIA 12–3, TIA 12–4, TIA 12–5, TIA 12–6 – except Chapters 7, 8, 12, and 13 that do not apply to hospice. This standard was not met as evidenced by interview and observation. A tour of the agency’s inpatient unit (IPU) revealed that the agency did not ensure that ground fault circuit interceptor (GCFI) receptacles were used for the appropriate appliances. IPU TOUR: During a tour of the IPU on 03/12/2025, a vending machine in the breakroom that was accessible to the patients’ families was not plugged into a GCFI outlet. (K912) During an interview on 03/12/2025 with the agency’s Project Specialist for Facility Staffing, who participated in the IPU tour, she stated that the vending machine was not plugged into the GCFI receptacle. She said that other vending machines in other facilities overseen by the same healthcare system as the agency were recently switched over to GCFI receptacles, but the vending machine in the IPU was overlooked. A tour of the agency’s inpatient unit (IPU) revealed that the agency did not ensure that ground fault circuit interceptor (GCFI) receptacles were used for the appropriate appliances.”

“It is required that the hospice inpatient facility provides meals to each patient that are palatable, attractive, and served at the proper temperature. This standard was not met as evidenced by document review, interview and observation. A tour of the agency’s inpatient unit (IPU) revealed that the agency was not ensuring that the food served to patients was served at the proper temperature. POLICY AND PROCEDURES: The agency policy titled, Food Handling - Production and Service, (reference# 8226, version #7, effective date 01/30/2024), stated in part, “Cook/designee will take and record temperatures of all foods hot and cold prior to putting them into service to assure that they meet the acceptable food temperature per FDA food code”. IPU TOUR: During a tour of the IPU on 03/12/2025, the agency was not able to produce documentation of food temperature checks. During an interview on 03/12/2025 with the nursing supervisor, for the IPU, who participated in the IPU tour, she stated that the IPU staff were checking the temperature of the food that was delivered to the IPU from an outside vendor for patient use. She said that the IPU staff were trained and equipped to make these temperature checks. No logs were kept documenting temperature checks, and no process was in place for monitoring food temperature checks or logs. A tour of the agency’s inpatient unit (IPU) revealed that the agency was not ensuring that food was being served to patients at the proper temperatures.”

“Based on record review and interview, the Hospice failed to ensure that 1 (P-1) of 6 patients received supplemental oxygen to relieve shortness of breath, in accordance with the plan of care, from a total of 10 sampled patients reviewed, resulting in unrelieved episodes of hypoxia and unmet care needs. Findings include: P-1: This 85-year-old patient was admitted to hospice care on 4/18/23 with terminal diagnosis of cerebrovascular disease, nontraumatic chronic subdural hemorrhage, and vascular dementia. P-1 was then admitted to Merlin and Carolyn Hansen Hospice Center (hospice multi-site) from 10/3/23 until his passing on 10/8/23. During record review on 2/26/24, it was noted the Plan of Care ordered oxygen 2 Liters per Nasal Cannula PRN (as needed) effective 10/3/23. P-1’s baseline blood oxygen level on 10/3/23 was 96% on room air (supplemental oxygen is commonly utilized when blood oxygen levels fall below 90%). Further review revealed the following clinical assessments concerning P-1 by skilled nursing (SN) on 10/7/23. SN documented at 8:20 AM., “Occasional labored breathing. Short period of hyperventilation.” At 8:25 AM., “Patient given nebulizer treatment for increased respirations and wheezing. Patient repositioned in bed.” SN documented 2 entries at 9:49 AM. and 12:26 PM. that P-1 was in no distress and sleeping. However, at 2:09 PM., SN documented, “ Patient is now diaphoretic (excessive sweating), lethargic, HR (heart rate) in the 120’s, T (temperature) 99.2F, spO2 (blood oxygen level) 86%, increased mucous production... X ray ordered stat. At 3:40PM., SN documented, “Patient lying in bed with eyes open. Patient has productive cough. HOB (head of bed) at 45 degrees.” No documentation was found in the medical record that P-1 had received any oxygen as ordered on 10/7/23. These findings were reviewed with and acknowledged by the hospice Director (Staff-A) during an interview on 2/26/24 at 1:30 PM. Staff-A stated SN should have utilized the ordered supplemental oxygen in the 2:09 PM. entry to determine its effectiveness in meeting P-1’s increased respiratory needs at the time to aid in the provision of comfort measures.”