Compassus-Northern Detroit

“Based on observation, record review and interview, the hospice agency failed to provide nursing services to meet the needs of the patient in 2 (P-1 and P-3) of 3 patients (L591); failed to make bereavement services available to all of the bereaved family members who would be affected by the patient’s death and, failed to complete a bereavement plan of care that reflected the specific needs of each bereaved family member, the kind of bereavement services to be offered and the frequency of service delivery for 1 (BRV #1) of 1 BRV record (L596). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR§418.64 Core Services.”

“Based on record review and interview, the agency failed to ensure all complaints received were documented, investigated and showed efforts to resolve the complaint for 1 (P-1) of 1 patient with unresolved complaints, resulting in a violation of the patient’s rights, unresolved concerns and unmet care needs. Findings include: During a phone interview with the complainant (COM-1) on 6/1/26 at 3:37 PM (prior to the arrival to the agency for the complaint investigation), it was noted COM-1 stated that she submitted a formal complaint to the agency in early May and had only received a generic e-mail in return that stated leadership would reach out to her regarding her concerns. On 6/3/26 at 11:19 AM, COM-1 was able to provide documented evidence that she sent her complaint to the agency’s compliance e-mail address on 5/5/26 at 11:33 AM. COM-1 was also able to provide evidence of the response from the compliance department on 5/7/26 at 3:45 PM that stated the report had “….been submitted to Clinical leadership who will contact you regarding this issue.”On 6/3/26 at 11:00 AM, the agency’s complaint log for 2026 was requested for review. Upon review of the binder, it was noted there was no record of the complaint logged by COM-1 in May. During an interview on 6/3/26 at 12:10 PM, the director of clinical services (DCS-1) was asked if all completed and in-progress complaints were in the binder. DCS-1 stated the binder contained all reports and they were only waiting for finalization of one report from April; however, that report was also located in the binder.During an interview on 6/4/26 at 8:15 AM, DCS-1 was asked how electronically submitted complaints were handled. DCS-1 stated the agency has a corporate compliance department that receives the complaints and then distributes them to the appropriate area. Once received, usually by her or the other director of clinical services (DCS-2), the complaint is written in the log book and the investigation begins with a call to the complainant. DCS-1 stated all information collected and the status of each complaint should be located in the binder.During another interview on 6/4/26 at 11:00 AM, DCS-1 was asked if the agency had any record of a complaint received by or on behalf of Patient #1 (P-1). DCS-1 stated there had been no complaints filed to her knowledge related to P-1, unless it was in the complaint log binder.The agency failed to investigate all received complaints received by the agency.”

“Based on record review and interview, the agency failed to ensure patients received effective pain and symptom management for 1 (P-1) of 3 patients reviewed, resulting in the potential for discomfort at death. Findings include: Patient #1 (P-1): During an interview with P-1’s niece (COM-1) on 6/1/26 at 3:37 PM, COM-1 indicted P-1 displayed “ongoing and significant distress, including persistent moaning and visible discomfort for more than 36 hours” during her admission. COM-1 stated pain management efforts were insufficient as medications were not delivered on time and were also ordered “as needed” instead of on a scheduled regimen.During record review on 6/4/26, it was determined the plan of care ordered morphine (a medication used to treat pain) to be administered as a scheduled dose every 6 hours as well as a PRN (as needed) dose every hour for breakthrough pain.During record review on 6/4/26, it was noted that a skilled nursing note dated 4/10/26 at 11:24 AM indicated P-1’s pain level was a “6” (moderate) on the Behavioral Pain Scale (BPS, a scale use by healthcare workers to assess the pain of patients who cannot verbalize). At this time, P-1 had not been given any pain medication because they had not been delivered yet. P-1 did not receive her first dose of pain medication until 4/10/26 at 3:09 PM during a skilled nursing visit – more than 24 hours after P-1 was admitted to hospice.On 4/11/26 at 9:30 AM, a skilled nursing note documented P-1’s pain as a “2” on the BPS, however, P-1 was also described to be “moaning” and had a “furrowed brow” (other indicators of patient discomfort).On 4/11/26 at 8:58 PM, it was documented that P-1’s niece (COM-2) requested a PRN visit to assess P-1’s pain. COM-2 also requested that the morphine orders be changed to a scheduled dose as she did not feel that the facility staff knew when P-1 was in pain. However, according to an earlier review of the plan of care orders, it was determined P-1 should have already been getting a scheduled dose of morphine every 6 hours in addition to every hour for breakthrough pain. However, this was not reviewed by or verified by the skilled nurse following the request of COM-2. On 4/11/26 at 9:38 PM, a PRN skilled nursing note documented P-1’s pain as a “3” (mild) on the BPS scale but indicated P-1 was “restless,” “moaning, “agitated,” and that her stomach was “firm” and hurting. Additionally, it was documented, “Facility staff unable to medicate for hours as there is no med tech on duty tonight....The order for scheduled morphine will not go through until Monday per DON.” [sic] On 4/12/26 at 12:44 PM, a skilled nursing note again documented P-1’s pain as a “3” (mild) on the BPS scale but indicated P-1 was “restless,” “moaning,” and “agitated.” It was determined P-1’s bladder was full and a catheter was placed to relieve some of the symptoms she was experiencing. On 4/13/26 at 12:06 PM, a skilled nursing note again documented P-1’s pain as a “3” (mild) on the BPS scale but indicated P-1 was “restless,” “moaning,” and “agitated.” The narrative section of the note indicated the writer stated COM-2 was concerned that the order for the scheduled morphine (that was placed on 4/11/26 after the PRN visit) still had not gone through and that P-1 had not received any scheduled doses of morphine. During the visit, it was determined the order was just processed and P-1 was finally given the scheduled morphine as ordered. Upon further review of the record, it was determined that although the skilled nursing note dated 4/10/26 at 3:05 PM stated the medication administration report (MAR) was reviewed with the facility site manager, the original order for scheduled morphine (every 6 hours) was never added to the MAR. As a result, P-1 had only been receiving the PRN doses of morphine at variable intervals starting 4/10/26 at 7:06 PM. P-1 had been given 11 PRN doses of PRN morphine during her admission, however, there was no documentation that she was given any scheduled doses to effectively manage her pain until 4/13/26 - just prior to her death. Additionally, although pain ratings were scored as low/mild in the documentation, word descriptions continued to indicate patient discomfort throughout her admission.The agency failed to administer pain control measures as ordered. As a result, P-1 suffered inefficient pain control at the end of her life.Additionally, during the interview on 6/1/26 at 3:37 PM, COM-1 also indicated the ordered wound care and oral care supplies (for patient comfort) were not delivered until just prior to P-1’s death on 4/13/26. Although skilled nursing notes indicated wound care and oral had been performed on 4/10/26, the documentation was unclear as to where the supplies came from or if the patient/family had access to more. A skilled nursing note dated 4/13/26 indicated wound care could not be completed that day due to lack of supplies.During an interview with the director of clinical services DCS-1 on 6/4/26 at 8:15 AM, DCS-1 stated the nurses often use supplies they kept in their cars, however, DCS-1 acknowledged the documentation does not reflect this or if additional supplies were left for P-1’s family to use until the ordered supplies arrived. According to a “Proof of Delivery” report from the supply company, the supplies were ordered on 4/9/26 upon admission, however, they were not delivered until 4/13/26 at 2:32 PM. P-1’s death was reported by the facility on 4/13/26 at 4:50 PM. The agency failed to ensure the availability of other symptom management supplies as ordered.A review of agency policy titled “Hospital Drugs, Biologicals, Medical Supplies and DME” (dated 10/17/25) revealed, “7. Drugs and biologicals are available 24-hours per day, 7-days per week through established relationships with pharmacy providers who can meet the emergency needs of patients around the clock.”DCS-1 again reviewed and acknowledged the findings during an interview on 6/4/26 at 11:00 AM.”

“Based on record review and interview, the Hospice failed to ensure the comprehensive assessment included an initial bereavement assessment that captured the identification of the potential bereaved individuals, and the social, spiritual and cultural factors that may impact their ability to cope with the patient’s death for 2 (P-1, P-3) of 3 patient’s families that required a bereavement assessment, resulting in the potential for ineffective grieving and lack of bereavement support for the family members and caregivers upon the patient’s death. Findings include: Patient #3 (P-3) was admitted to hospice services on 3/27/26 with diagnoses which included chronic obstructive pulmonary disease, senile degeneration of brain-unspecified, and adult failure to thrive. On 6/3/26, review of P-3’s medical record noted social work services performed an initial evaluation on 3/30/26 which documented “(P-3) is single and does not have any children. (P-3) has a court appointed guardian. Patient reports having no famiky (sic) and states that she has 2 best friends... who she lives (sic) dearly.” However, further review found no evidence of an initial bereavement risk (BRA) was performed as required (per Agency policy referenced below). The above findings were reviewed and acknowledged by the Director of Clinical Services (DCS-1) during an interview on 6/4/26 at 1:25 PM. DCS-1 further acknowledged this did not meet agency expectations nor its policy referenced below.Agency Policy: “Bereavement Risk Assessment and Acuity Scale” HOS-C_19A (Revised 6/29/25) stated, “The Social Worker completes the initial bereavement risk assessment during the Social Worker’s comprehensive assessment conducted within 5 days of the hospice election.” Policy: Procedure: HOS-C_19A, Bereavement Risk Assessment and Acuity Scale, 6/29/25 stated, “The Social Worker completes the initial bereavement risk assessment during the social worker’s comprehensive assessment conducted within 5 days of the hospice election. A Spiritual Counselor (chaplain) or RN Case Manager may be asked to complete the assessment if the Social worker is not able to complete the assessment timely.” Patient #1 (P-1) was admitted to hospice on 4/9/26 with a terminal diagnosis of Malignant Neoplasm Left Breast. The Plan of Care (POC) ordered Skilled Nursing (SN), Spiritual Care (SC) and Medical Social Work (MSW) services to be provided. During the clinical record review on 6/3/26 at 2:15 p.m., it was noted that a document titled “Consent to Share Health Information with Family and Friends”, dated 4/9/26, listed 2 of P-1’s family members (Nieces). The Bereavement Risk Assessment dated 4/10/26 only listed one of the aforementioned family members. The agency failed to complete a bereavement risk assessment for all who would be affected by P-1’s death. Further review of the clinical record revealed that P-1 passed away on 4/13/26. The Bereavement Careplan [sic] Report dated 4/9/26 and modified on 4/16/26 only identified the one family member and stated, “Attempt to contact P-1’s family member to offer condolences, assess bereavement risk factors and discuss bereavement support services to no avail. MSW assessed low risk factors during her initial assessment. Bereavement mailings will be sent to P-1’s family member’s home.” On 6/3/26 at 11:58 a.m. during an interview, the agency’s Bereavement Coordinator stated, “I contact the primary caregiver. I also go through the family for family members that may not have been included.” When asked specifically, what family members are captured in the Bereavement Assessment, The Bereavement Coordinator responded, “The Primary Caregiver. I ask the team to capture whoever is in the room to have assessments completed.” The agency failed to ensure the Initial Bereavement Assessment included and identified all parties who would be affected by the patient’s death. These findings were reviewed and discussed with the Director of Clinical Services (DCS-1), Director of Clinical Services (DCS-2) and the Director of Clinical and Operations Solutions (DCOS-1) during an interview on 6/4/26 at 2:53 p.m. When queried about all parties who would be affected by P-1’s death not being included in the initial bereavement assessment, the above administrative staff offered no response.”

“Based on observation, record review and interview, the hospice agency failed to provide nursing services to meet the needs of the patient in 2 (P-1 and P-3) of 3 patients, resulting in the potential for poor emotional and physical outcomes. Findings include: Patient #3 (P-3) was admitted to hospice services on 3/27/26 with diagnoses which included chronic obstructive pulmonary disease, senile degeneration of brain-unspecified, and adult failure to thrive. On 6/3/26 at 2:35 PM, during a joint home visit with RN-4 at a skilled nursing facility (SNF), it was observed that P-3 was anxious who also reported being anxious with increased upper extremity tremors. RN-4 and surveyor/writer went to the SNF nurse to inquire about administering an 0.5 milligram Ativan tablet (medication used to lesson anxiety). However, the SNF nurse stated the Ativan was discontinued on 5/12/26 when it had failed to be renewed by Hospice’s SN services. A request was then made to review on RN-4’s computer how many opportunities there were to review P-3’s medication list (required during each SN visit per Agency policy referenced below). The following documentation was noted by RN-4 and surveyor/writer concerning the active order for Ativan since 3/27/26: RN-1 on 5.13.26 failed to acknowledge the expired Ativan.LPN-1 on 5.18.26 failed to acknowledge the expired Ativan.RN-3 on 5.21.26 failed to acknowledge the expired Ativan.LPN-2 on 5.26.26 failed to acknowledge the expired Ativan.LPN-2 on 5.29.26 failed to acknowledge the expired Ativan.RN-3 on 6.2.26 failed to acknowledge the expired Ativan.RN-4 on 6.3.26 during a joint home visit acknowledged the expired Ativan since 5/12/26.The above findings were reviewed and acknowledged by the Director of Clinical Services (DCS-1) during an interview on 6/3/26 at 4:14 PM. DCS-1 stated it has been a problem the Agency is aware of and is working to correct further.Agency Policy: “Medication Reconciliation and Management” HOS-C_15C (Revised 10/28/2025) stated, “For patients in the nursing facility setting, it is the responsibility of the hospice nurse to perform the following steps at each scheduled nursing visit after admission: Review the current MAR (Medication Administration Record) at the medication cart for the hospice patient.”Further record review noted that SN services failed to assess and update P-3’s full-code status. P-3’s physical status at the start of hospice was 5 feet and 4 inches with a weight of only 78 pounds. Performing full-code resuscitative measures on P-3 would not promote a peaceful death. The Hospice IDG, which included SN, had at least 4 opportunities to clarify this situation as it is unusual for hospice patients to be a full-code status with a terminal illness. In addition, on 6/3/26 during a joint home visit with SN, staff at the SNF stated P-3 has not had a visitor in the last year and is lonely much of the time. During the visit, P-3 was observed to be very pleasant and appreciative while conversing with anyone. No evidence was found that indicated SN services had reached out to volunteer services to provide P-3 some companionship. The above findings were reviewed and acknowledged by the Director of Clinical Services (DCS-1) during an interview on 6/4/26 at 1:35 PM. Patient #1 (P-1): During record review on 6/4/26, it was noted the plan of care ordered morphine (a mediation used to treat pain) to be administered as a scheduled dose every 6 hours as well as every hour as needed for breakthrough pain. According to a skilled nursing note dated 4/10/26, P-1’s medication administration report (MAR) was reviewed with the site manager at the facility and medications would be administered as ordered.Upon comparing the MAR to the plan of care orders for morphine, it was determined that the order for the scheduled morphine administered every 6 hours (dated 4/9/26) was never added to the MAR, therefore, the order was never initiated.Additionally, skilled nursing notes dated 4/11/26 and 4/12/26 indicated, “Patient resides in a nursing facility and current facility medication list is accurate.” This information is incorrect as the scheduled morphine dose ordered 4/9/26 was never added to the MAR to be administered. As a result, the skilled nurse failed to ensure the plan of care was followed as ordered and that the needs of the patient were met.A review of agency policy titled “Nursing Services” (dated 3/19/26) revealed, “3. Nursing services include the following:…Implementation of the individualized plan of care andThe director of clinical services (DCS-1) reviewed and acknowledged the findings during an interview on 6/4/26 at 11:00 AM.”

“Based on record review and interview, the hospice failed to make bereavement services available to all of the bereaved family members who would be affected by the patient’s death and, failed to complete a bereavement plan of care that reflected the specific needs of each bereaved family member, the kind of bereavement services to be offered and the frequency of service delivery for 1 (BRV #1) of 1 BRV record, resulting in the potential for ineffective coping/grieving and unmet bereavement needs. Findings Include: Policy: HOS-C19 Bereavement Services, 11/1/17 stated, “(This Hospice) will: Make bereavement services available to the family and other individuals in the bereavement plan of care for at least a year following the death of a patient..., Develop a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery..., Bereavement services reflect the information gathered during the initial bereavement risk assessment conducted not later than 5 days after the patient’s election of hospice services...”Patient #1 (P-1) was admitted to hospice on 4/9/26 with a terminal diagnosis of Malignant Neoplasm Left Breast. The Plan of Care (POC) ordered Skilled Nursing (SN), Spiritual Care (SC) and Medical Social Work (MSW) services to be provided. During the clinical record review on 6/3/26 at 2:15 p.m., it was noted that a document titled “Consent to Share Health Information with Family and Friends”, dated 4/9/26, listed 2 of P-1’s family members. Further review of the clinical record revealed that P-1 passed away on 4/13/26. The Bereavement Careplan [sic] Report dated 4/9/26 and modified on 4/16/26 only identified one of the family members and stated, “Attempt to contact P-1’s family member to offer condolences, assess bereavement risk factors and discuss bereavement support services to no avail. MSW assessed low risk factors during her initial assessment. Bereavement mailings will be sent to P-1’s family member’s home.” Additionally, during a review of the Bereavement (BRV #1) portion of the record, no Bereavement Plan of Care had been initiated for the second family member identified during the assessment. At the time of this review, there was no documented evidence that any post death bereavement services had been provided to either of P-1’s family members. On 6/3/26 at 11:58 a.m. during an interview, the agency’s Bereavement Coordinator stated, “I provide 13 months of bereavement services to our families after death. I step in within a week of death. I contact the primary caregiver. I also go through the family for family members that may not have been included.” When asked specifically, what family members are captured in the bereavement assessment, The Bereavement Coordinator responded, “The Primary Caregiver. I ask the team to capture whoever is in the room to have assessments completed.” These findings were reviewed and discussed with the Director of Clinical Services (DCS-1), Director of Clinical Services (DCS-2) and the Director of Clinical and Operations Solutions (DCOS-1) during an interview on 6/4/26 at 2:53 p.m. When asked about post death bereavement services, DCS-1 responded, “An attempt was made on 4/16/26 for the one family member.” DCS-1 further acknowledged there was no documented evidence to support that any further post death bereavement services were attempted or provided. In conclusion, the agency failed to provide post bereavement services to all parties who would be affected by the patient’s death.”

“Based on record review and interview, the agency failed to ensure its clinical records were accurate, legible and contained correct clinical information for 1 (P-2) of 2 deceased hospice patients, resulting in lack of clarity of clinical information during the end of life. Findings include: Patient #2 (P-2) was admitted to hospice on 4/9/25 with a terminal diagnosis of Leukemia. During the clinical record review on 6/4/26 at 10:50 a.m., it was noted that P-2 subsequently passed away on either 4/9/25 or 4/10/26. The exact date and time of P-2’s death could not be ascertained, as the information was unclearly documented in the clinical record. P-2’s Initial Hospice Assessment was conducted by the nurse on 4/9/25 at 3:35 p.m., and ended on 4/9/26 at 5:35 p.m. A “Hospice Unattended Death at Facility” note dated 4/10/25 stated that P-2’s date of death was 4/9/25. The time of death was reported as 1443 (2:43 p.m.) This information would indicate that, based on the times listed, P-2 would have already been deceased during the Initial Assessment, which would be unlikely. These findings were reviewed and discussed with the Director of Clinical Services (DCS-1), Director of Clinical Services (DCS-2) and the Director of Clinical and Operations Solutions (DCOS-1) during an interview on 6/4/26 at 3:00 p.m. to which DCS-2 responded, “The only thing I can think of is that, that’s when the hospice was notified.” This information did not satisfy the explanation of how the initial would have been performed after P-2’s unfortunate death. The agency failed to ensure the clinical record was clear, sensible, accurate and contained correct clinical information, as per this requirement.”

“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 document review and interview. In 3 of 23 (13%) clinical records reviewed, the hospice did not ensure the patient’s plan of care identified interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected hospice care on 06/08/2023. During the nursing comprehensive assessment on 06/10/2023, the nurse documented that a 16 FR (French) Foley catheter was placed. No interventions or goals for the care of the Foley catheter that was to be changed monthly were documented on the plan of care as of the patient’s death on 06/20/2023 Clinical Record 6: The patient elected hospice care on 11/27/2023 and resided in an ECF (extended care facility). The patient was diagnosed with C. Diff on 1/12/2024 and started a vancomycin treatment to last 28 days. The IDG notes dated 01/18/2024 documented a change in the patient’s condition due to the C. Diff. The skilled nurse (SN) visit note dated 01/23/2024 documented that the son was with the patient and that the patient was in isolation. The plan of care was not updated to include interventions and goals specific to the C. Diff. The plan of care did not identify if isolation was required or implemented by the ECF. Clinical Record 22: The patient elected hospice care on 09/01/2022. The initial plan of care dated 09/01/2022 documented an intervention for Foley catheter care. The initial comprehensive assessment documented the patient’s 16 FR/10cc catheter was to be changed monthly. The assessment dated 11/17/2022 documented the patient’s 16 FR/30cc balloon was to be changed every six weeks; the assessment dated 11/21/2022 documented the patient’s 16 FR/ 20cc balloon was to be changed every six weeks; the assessment dated 11/25/2022 documented the patient’s 16 FR/10cc balloon was to be changed every six weeks; the assessment dated 10/30/2023 documented the patient’s 18 FR /10cc balloon was to be changed every six weeks; and the assessment dated 02/03/2023 documented the patient’s 14 FR /10cc balloon was to be changed every six weeks. A review of the clinical record revealed the POC interventions were not updated for these catheter size changes and the frequency of catheter changes. Catheter Irrigations were ordered on 12/16/2022, with 50-60 cc NS (normal saline) two times a week; increased to three times a week on 12/27/2022, four times a week on 01/25/2023, and daily on 02/03/2023. The CTI (Certificate of terminal illness) dated 04/03/2023 documented that acetic acid flushes were started related to sediment. On 06/07/2023, the physician ordered acetic acid flushes of 60 cc, which changed from daily to three times a week. The interventions on the plan of care were not updated for these changes in irrigations for the patient. The patient has had no further catheter problems since moving to an extended care facility, as the wife could no longer manage at home. During an interview on 02/02/2024, the Area Director of Clinical Services confirmed the findings and stated that the hospice had scheduled education with the staff to address interventions specific to Foley catheter management.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan: As frequently as the patient’s condition requires; but no less frequently than every 15 calendar days. A revised plan of care includes Information from the patient’s updated comprehensive assessment and record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 23 (4%) clinical records reviewed, the hospice did not ensure that the interdisciplinary Group (IDG) documented progress toward goals specific to the patient. Clinical Record 6: The patient elected hospice care on 11/27/2023 and resided in an ECF (extended care facility). The patient was diagnosed with Clostridioides difficile (C. Diff) on 1/12/2024 and started a vancomycin treatment to last 28 days. The IDG notes dated 01/18/2024 documented a change in the patient’s condition. A review of the clinical record revealed the plan of care documented no updates to the patient’s progress toward goals and condition regarding the C. Diff. It was not documented if and how the ECF maintained the patient in isolation. An addendum note was added by the Case Manager on 02/01/2024 after the problem was identified. During an interview, the Director of Clinical Services, who spoke with the Case Manager, agreed that an addendum note to update this patient’s status would now be documented.”

“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: 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. Agency policy #C-11G “Bag Technique and Standard of Precautions” stated in part; “Standard Bag Technique: When care delivery is completed, and reusable supplies are to be returned to the bag: (iii) Wipe down with alcohol pad to disinfect.” In 1 of 4 (25%) home visits observed in which the clinician carried equipment to facilitate the visit, the agency did not ensure that all equipment was cleaned per standard precaution. Home Visit 3: The patient elected hospice care on 09/21/2023 with a decubitus ulcer and tube feedings. During the home visit with the Registered Nurse (RN) [Personnel Record 4] on 01/30/2024, the RN performed a complete physical assessment and the mid-arm circumference (MAC) measurement of the right arm with a tape measure. After assessing the patient’s MAC, the tape measure was retracted, and the outside tape measure was cleaned. The inside of the tape measure, which touched the patient’s bare arm, was not cleaned. The RN removed a different tape measure from the bag (it was a tape measurer for measuring wounds). After assessing the patient’s coccyx wound measurement (not touching the wound), the tape measure was retracted, and the outside tape measure was cleaned. The inside of the reusable tape measure was not wiped with an alcohol pad to disinfect it before returning it to the bag, according to the policy. During an interview, the Director of Hospice and the Regional Director of Clinical Services stated that the risk of infection was present and agreed they would follow up with the staff.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 4 of 21 (19%) clinical records reviewed in which a Hospice Aide (HA) was accepted for care, the hospice did not ensure that the aide care plan provided clear and specific instructions for all assigned tasks. Clinical Record 1: The patient elected hospice care on 06/08/2023. The aide care plan was documented on 06/082023 with no documented updates. The aide care plan assigned the HA the task of perineal care. A Foley catheter was placed on 06/09/2023 to be changed monthly, but the aide care plan was not updated to include Foley catheter care as of the patient’s death on 06/20/2023. Additionally, the skilled nurse (SN) visit note dated 06/10/2023 documented the patient’s pulse oximeter reading of “64%, oral care was provided, and oxygen flow was increased to 3 liters continuously. The aide care plan had not been updated since 06/08/2023 and did not address oxygen safety or instructions to the HA to ensure that the patient was wearing oxygen. Clinical Record 5: The patient elected hospice care on 04/22/2023. The aide care plan was documented on 4/27/2023 with no documented updates as of death 06/08/2023. The patient had a catheter to large bag drainage during the care provided. The aide care plan did not include documentation of instructions for Foley catheter care or that the patient had a catheter. Clinical Record 7: The patient elected hospice care on 03/29/2023 and resided in a facility. The patient’s primary diagnosis was senile degeneration of the brain. The aide care plan was documented on 03/29/2023 and updated on 11/13/2023. Both aide care plans assigned the HA the bathing tasks of shower and bed bath every visit. There was no decision maker for which bath. The SN visit note dated 05/12/2023 documented that the facility had determined the patient required Hoyer lift transfers. The aide care plan was not updated for the Hoyer lift transfers as of 01/29/2024. Clinical Record 15: The patient elected hospice care on 08/29/2023. The aide care plan was documented on 08/29/2023 and updated on 09/14/2023 and 11/28/2023. The aide care plans assigned the HA the bathing task of shower every visit. Fall precautions were documented on each aide care plan, but no transfer directions were documented. The initial and updated comprehensive assessments documented that the patient was maximum assist with a pivot transfer and non-ambulatory. The aide care plan included no documentation of specific instructions for the HA to safely transfer the patient to provide a shower. During the interview on 01/31/2024, the Director of Clinical Services and Area Director of Clinical Services agreed the details were lacking in the aide care plans.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 6 (33%) clinical records reviewed of patients with a Foley catheter, the agency did not ensure the patient’s clinical record included physician orders for the care and maintenance of the catheter. Clinical Record 6: The patient elected hospice care on 11/27/2023. The initial plan of care dated 11/27/2023 documented an intervention for care for the patient’s 16 FR (French)/10cc Foley catheter. The catheter was removed on 11/30/2023, reinserted on 12/03/2023, and removed on 01/04/2024 at the ECF (extended care facility). The patient was unable to urinate and had many clots; the hospital placed a catheter, a 22 FR/10cc Foley catheter, on 01/10/2024. A clinical record review revealed no evidence of a documented physician order for the 22 FR/10cc catheter and how often it was to be changed and irrigated. Clinical Record 22: The patient elected hospice care on 09/01/2022. The initial plan of care dated 09/01/2022 documented an intervention for Foley catheter care. The initial comprehensive assessment documented the patient’s 16 FR/10cc catheter was to be changed monthly. The assessment dated 11/17/2022 documented the patient’s 16 FR/30cc balloon was to be changed every six weeks; the assessment dated 11/21/2022 documented the patient’s 16 FR/ 20cc balloon was to be changed every six weeks; the assessment dated 11/25/2022 documented the patient’s 16 FR/10cc balloon was to be changed every six weeks; the assessment dated 10/30/2023 documented the patient’s 18 FR /10cc balloon was to be changed every six weeks; and the assessment dated 02/03/2023 documented the patient’s 14 FR /10cc balloon was to be changed every six weeks. A review of the clinical record revealed no documented physician’s orders for the change in catheter size, balloon size, or the frequency of Foley changes as documented. During an interview on 02/02/2024, the Director of Clinical Services confirmed the orders for the changed size of the catheter, and the frequency of changes was not documented.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: A copy of the hospice discharge summary; The patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed in which the patient was a live discharge, the hospice did not ensure the primary care physician was sent the discharge summary. Clinical Record 3: The patient elected hospice care on 04/26/2023 with uterine cancer and schizophrenia. The patient moved out of the hospice agency’s service area on 06/13/2023. A discharge summary was documented. A clinical record review revealed no evidence that a copy of the discharge summary was sent to the patient’s attending physician. Clinical Record 4: The patient elected hospice care on 05/28/2023 and revoked the hospice care benefit on 06/02/2023. A discharge summary was documented. A clinical record review revealed no evidence that a copy of the discharge summary was sent to the patient’s attending physician. During the interview with the Director of Clinical Services and the Area Director of Clinical Services, they agreed that documentation of the summary being sent was not located.”