Heartland Hospice (Ann Arbor)

“Based on record review and interview, it was determined that the hospice failed to ensure that skilled nursing coordinated and implemented the plan of care to meet the patient’s continuous needs in 1 (P-1) of 3 records reviewed resulting in the potential for poor patient outcomes for all 36 active hospice patients.Findings include: Patient #1 (P-1), a 64-year-old was admitted to the hospice agency on 11/14/24 with a terminal diagnosis of malignant neoplasm of unspecified ovary with secondary diagnoses of malignant neoplasm of unspecified lung and malignant pleural effusion. During record review on 5/22/25, it was noted that the “Care Plan” dated 11/27/24 stated, “…P (Problem): Respiratory. G (Goal): Patient will remain comfortable with no s/s (signs/symptoms) of respiratory distress. I (Intervention): SN (Skilled Nurse) to assess for understanding and compliance with interventions to manage respiratory symptoms…”Registered Nurse #1 (RN-1) completed the Hospice Comprehensive Start of Care on 11/15/24 and documented a “Coordination” note stating, “Patient is able to walk without assistive devices. She can walk 100 feet until she has to sit down and rest due to dyspnea. If she is doing any physical work, such as running the vacuum, she fatigues quickly, less than five minutes.” Registered Nurse #2 (RN-2) completed a “Skilled Nursing” visit on 3/19/25 and stated, “…Respiratory: Indicate respiratory status assessment findings: Shallow, Shortness of breath. Indicate shortness of breath findings: Minimal exertion, after walking, at rest. Indicate how may feet: 5. Indicate breath sounds: Diminished throughout. Is patient on oxygen: yes. Indicate oxygen findings: As needed. Was pulse oximetry obtained (only if ordered): No…Narrative: …Movements are slower…Respirations shallow, labored at rest. Reviewed morphine concentrate, patient aware and declines at this time, states she needs paracentesis. Fluid built up and pressing on lungs…Abdominal girth/tumor skin taught. Fluid pockets on either side of tumor. Appearance as a size of a basketball. Using oxygen every night. During the day intermittently…Lung sounds CTA (Clear to Auscultation) with diminished throughout. Respirations 22 shallow. Conversational dyspnea noted…” RN-2 completed the following “Skilled Nursing” visit on 4/2/25 and stated, “…Respiratory: Indicate respiratory status assessment findings: Labored, Shallow, Irregular, Shortness of breath. Indicate shortness of breath findings: Minimal exertion, after walking, at rest. Indicate breath sounds: Diminished throughout. Is patient on oxygen: yes. Indicate oxygen findings: As needed. Was pulse oximetry obtained (only if ordered): No…Narrative: …Movements are slower…sitting in chair. Unable to greet at door today. Respirations shallow, labored at rest…states she needs paracentesis. Fluid built up and pressing on lungs. Will follow up with team. Evidence of decline: Conversational dyspnea. Rests between sentences. Having a difficult time completing sentences without stopping to catch breath. Rest periods between activities, was ambulatory greater than 10 ft. Now approx. 5 ft…Friction rub audible when patient turns from side to side…Lung sounds CTA with diminished throughout. Respirations 22 shallow. Conversational dyspnea noted…” The Alternate Administrator (A-ADM) and Area Director of Clinical Operations (ADCO) reviewed and acknowledged the need for pulse oximetry based on the evidence of shortness in breath and difficulty in breathing findings listed above in an interview on 5/22/25 at 1:40 pm.”

“Upon patient record review, 2 of 19 records (Patient #8, #13) 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 #8: Diclofenac 1% gel BID prn to affected area. No specific location. corrected on site. Patient 13: Upon home visit, there was Ativan in home not on med profile. Corrected on site.”

“Upon patient record review, 1 of 19 records (Patient #5) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #5: On 2/20/24 there were 9 PRN Social Worker visits ordered , there was no evidence the scope and frequency of services were meeting the specific needs of the patient and family.”

“Upon patient record review, 2 of 19 records (Patient #6, #8) 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 #6: The record indicated there were 12 wounds. The wound order written on 2/3/24 did not identify the wound and indicated the nurse to cleanse all wounds, pat dry. Paint wound area with betadine. Apply alginate to draining wounds. Apply Allevyn dressing to all wound areas. The order did not state what to use to cleanse wounds. In addition, the foley order on 2/1/24 written as change foley 18F showed no evidence of the balloon size and frequency of when to change the foley and did not include irrigation orders. Patient #8: Diclofenac 1% gel BID prn to affected area, there was no specific location listed to identify where to apply the gel. Corrected on site.”

“Upon patient record review, 2 of 19 (Patient #18, #19) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient #18: There was no evidence the plan of care was updated when the patient was declining, the records indicated the last visit on 8/18/23 recorded a blood pressure reading of 80/43 with no follow up prior to the death pronouncement on 8/21/23. Patient #19: There was no evidence the plan of care was updated when the patient was declining, the records indicated on 09/11/23 the patients toes were turning blue and there was no urine output reported by the caregiver to the nurse. There was no follow up visit prior to the death pronouncement on 9/13/23.”

“Upon client record review, 5 of 19 records (Patient #3, #4, #6, #7, #13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: The Social Worker phone visit on 01/15/24 was not listed in the plan of care. Patient #4: There was no evidence of a nurse visit between the time period 3/17/24 to 3/23/24. Patient #6: The visit frequency for the Spiritual Care was 2W1 and 3 prn. The record indicated the spiritual visits conducted included the initial evaluation on 1/12/24 with subsequent routine visit on 2/6/24 and 3/6/24. The record did not indicate the second visit that was ordered for spiritual care was made. The record did not indicate Spiritual Care frequency orders for monthly visits that followed. Patient #7: The visit frequency for the Social Worker was one time per month starting January 5, 2024. There was no evidence of a visit in February 2024. Patient #13: Nurse frequency 2/25/24 to 3/2/24 5 times per week, only 3 visits done.”

“Upon patient record review 2 of 19 records (Patient #2,#4) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient #2: There was no evidence of a registered nurse making an on site visit to assess the quality of care and services provided by the hospice aide between 02/20/24 to 3/11/24. Patient #4: There was no evidence of a registered nurse making an on site visit to assess the quality of care and services provided by the hospice aide between 2/8/24 to 3/7/24.”

“Upon patient record review, 1 of 19 records (Patient #1) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient’s life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient’s conditions unrelated to the terminal illness patient #1: The record indicated the CTI was signed by Nurse Practitioner there was no evidence the Medical Director provided written certification.”

“Upon patient client record review, 2 of 19 records (Patient #3, #6) 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. The medications on the medication profile are consistent with the medications on the plan of care and what the patient/caregiver states they are taking. Patient #3: There was evidence on 3/15/24 of a declined visit without the specific discipline being specified to include the scope and frequency to meet the specific patient needs. Patient #6: The Medicare Election had an incorrect date which was incorrectly corrected. Corrected on site.”