Seasons Hospice & Palliative Care of Michigan

“Based on record review and interview, the agency failed to ensure services were provided in accordance with an established plan of care in 3 (P-1, P-2, and P-3) of 3 records reviewed, resulting in patients not receiving care and services in accordance with their identified needs and the potential for poor patient outcomes. Findings include: Patient #2 (P-2) was admitted to this hospice agency on 6/16/25 with the terminal diagnoses of functional quadriplegia, osteoarthritis, and adult failure to thrive. During record review on 10/9/25, it was noted the plan of care (dated 6/16/25) indicated, “NURSE WILL OBTAIN WOUND CARE ORDERS AND FOLLOW WOUND CARE PROTOCOL FOR ASSESSMENT AND DOCUMENTATION.” Upon further review of the record, it was determined the order for wound care dated 6/18/25 indicated, “FACILITY NURSE TO CLEANSE WOUND TO COCCYX WITH SOAP AND WATER, PAT DRY, APPLY TRIAD AND COMFORT FOAM DAILY AND PRN IF SOILED. HOSPICE NURSE TO ASSESS WEEKLY.” [sic]Upon further review of the skilled nursing notes, it was determined P-2 received hospice care from this agency for 6 weeks prior to passing away. During this time, 15 of 16 skilled nursing notes documented that somebody other than the hospice nurse provided wound care for P-2 or that it wasn’t ordered for that visit. Although the assessment section of the wound care note was filled out weekly and weeks 3 and 4 included updated measurements, there was no evidence the hospice nurse saw and assessed the wound herself because the wound care was being performed by somebody else. The only note that provided documented evidence the hospice nurse removed the wound dressing and performed the wound care was dated 7/14/25. Patient #3 (P-3) was admitted to this hospice agency on 5/29/25 with the terminal diagnoses of a malignant neoplasm of the left lung (lung cancer), anemia, and chronic obstructive pulmonary disease (COPD). During record review on 10/10/25, it was noted the plan of care (dated 5/29/25) indicated, “NURSE WILL CHANGE DRESSING DURING WEEKLY VISIT IF SOILED OR DISLODGED MEDILODGE STERLING STAFF ARE ORDERED TO CHANGE DRESSING Q2 DAYS AND IF SOILED OR DISLODGED.” [sic]A follow-up order added to the plan on 5/30/25 indicated, “R ISHIUM: CLEANSE WITH WOUND CLEANSER. PACK WITH IODOFORM GAUZE. APPLY FOAM BORDER DRESSING. FACILITY STAFF AT MTB TO CHANGE DAILY AND PRN IF LOOSE OR SOILED. HOSPICE NURSE TO ASSESS WEEKLY.” [sic]During review of skilled nursing notes between 5/29/25 and 8/5/25, it was noted the weeks of 6/1/25 and 7/13/25 failed to include updated measurements or assessments of the wound. Although the skilled nursing notes during the weeks of 6/8/25, 6/22/25, 6/29/25, 7/6/25,7/20/25 and 7/27/25 included wound measurements, it was documented the hospice did not perform the wound care, therefore, there was no evidence the hospice nurse saw the wound to assess it. It was documented the measurements on 7/10/25 (during the week of 7/6/25) were obtained from the wound care nurse at the facility.During an interview with Director of Clinical Operations (DCO #1) on 10/10/25 at 1:18 PM, DCO #1 was asked how new measurements for the weekly assessment could be documented during a visit if wound care was not provided by the hospice nurse. DCO #1 stated some facilities have a wound care nurse who also assesses and measures the wound, and sometimes staff records the measurements from them. However, DCO #1 stated it should be documented who made the measurements if it is somebody other than the hospice nurse. Additionally, DCO #1 was asked about the agency expectation regarding weekly wound assessment by the hospice nurse, even if another nurse was also assessing the wound. DCO #1 stated the hospice nurse should be doing their own assessment weekly per the plan of care.The agency failed to ensure the hospice nurse assessed the wounds weekly per the plan of care. DCO #1 acknowledged the findings during the interview. Patient #1 (P-1) was admitted to Hospice on 10/31/24 with terminal diagnoses that included Alzheimer’s Disease, Dementia and Heart Failure. The Plan of Care (POC) ordered Skilled Nursing, Medical Social Work, Spiritual Care and Hospice Aide services to be provided. During the clinical record review on 10/9/25, it was noted that the patient resided in a skilled nursing facility (SNF). A Physician’s order dated 2/4/25 stated, “Order signed in facility EMR (Electronic Medical Record) – Wound care – Facility staff to complete wound care as ordered below, hospice nurse to complete wound care at weekly visits – coccyx, cleanse with wound cleanser pat dry apply Medihoney (wound gel) and cover with foam dressing change daily; Right heel cleanse with wound cleanser pat dry apply Medihoney and wrap with kerlix. Change daily.” A Physician’s order dated 2/25/25 stated, “Hospice nurse to provide instruction related to prevention/management of skin breakdown. Goals: Facility staff will verbalize/demonstrate measures to prevent/manage skin breakdown AEB (As Evidence By) no further progression if impaired skin integrity x 14 days.” [sic] A Physician’s ordered dated 3/11/25 stated, “Need prn (as needed) visits.” A Physician’s order dated 4/4/25 stated, “Order signed in facility EMR. L calf skin tear – Optalis staff to cleanse with wound cleanser, pat dry, apply foam dressing and change QOD (every other day), hospice nurse to change at weekly visits.” On 10/10/25 at 1:55 p.m., during an interview with the Executive Director (ED #1) and the Director of Clinical Operations (DCO #1), a request was made to review P-1’s Plan of Care (POC) in order to determine if the ordered tasks to be carried out was clearly defined between the SNF and the Hospice. On 10/10/25 at 1:57 p.m., upon receipt and review of P-1’s POC titled “Hospice POC Report”, it was noted that there was no clear delineation of tasks to be completed by the SNF vs Hospice Staff. The POC read, “NDP (unknown): altered skin integrity-Hospice; NDP: Need for wound care-Hospice; NDP: Need for facility staff care coordination; I (intervention): Reviewed Hospice plan of care with facility staff – added-no...” The Executive Director (ED #1) and the Director of Clinical Operations (DCO #1) were queried as to the meaning of NDP; and stated that it stands for Nursing Diagnosis Pathway. However, both parties acknowledged the POC did not reflect delineation of duties for the Hospice and the SNF. Additionally, there was no documented evidence that the above Physician’s orders had been incorporated into the POC to allow for coordinated care between the two entities. The facility failed to provide care and services in accordance with an established plan of care that clearly established the roles and tasks to be carried out by the Hospice and Skilled Nursing Facility. The Executive Director and Director of Clinical Operations reviewed and acknowledged the above findings during an interview on 10/10/25 at 1:55 p.m.”

“Based on record review and interview, the agency failed to ensure nursing needs of the patient were assessed for patients with wounds in 3 (P-1, P-2, and P-3) of 3 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: A review of agency policy titled “Wound Care” (revised 12/14/22) revealed, “The Hospice nurse will assess wounds at least once per Medicare week.” Patient #2 (P-2) was admitted to this hospice agency on 6/16/25 with the terminal diagnoses of functional quadriplegia, osteoarthritis, and adult failure to thrive. During record review on 10/9/25, it was noted P-2 also received wound care for a stage III pressure ulcer on her coccyx.During review of the record, it was determined P-2 received hospice services from this agency for 6 weeks prior to passing away. Upon further review of the skilled nursing notes, it was noted the weeks of 6/22/25 and 7/20/25 failed to include updated measurements or assessments of the wound. Although the skilled nursing notes during the weeks of 6/29/25 and 7/6/25 included wound measurements, it was documented the hospice nurse did not perform the wound care, therefore, there was no evidence the hospice nurse saw the wound to assess it. Patient #3 (P-3) was admitted to this hospice agency on 5/29/25 with the terminal diagnoses of a malignant neoplasm of the left lung (lung cancer), anemia, and chronic obstructive pulmonary disease (COPD). During record review on 10/10/25, it was noted P-3 was also receiving wound care for a pressure ulcer on her right ischium (buttock).During review of skilled nursing notes between 5/29/25 and 8/5/25, it was noted the weeks of 6/1/25 and 7/13/25 failed to include updated measurements or assessments of the wound. Although the skilled nursing notes during the weeks of 6/8/25, 6/22/25, 6/29/25, 7/6/25,7/20/25 and 7/27/25 included wound measurements, it was documented the hospice nurse did not perform the wound care, therefore, there was no evidence the hospice nurse saw the wound to assess it. It was documented the measurements on 7/10/25 (during the week of 7/6/25) were obtained from the wound care nurse at the facility.During an interview with Director of Clinical Operations (DCO #1) on 10/10/25 at 1:18 PM, DCO #1 was asked how new measurements could be documented during a visit if wound care was not provided by the hospice nurse. DCO #1 stated some facilities have a wound care nurse who also assesses and measures the wound, and sometimes staff records the measurements from them. However, DCO #1 stated it should be documented if somebody other than the hospice nurse made the measurements. Additionally, DCO #1 was asked about the agency expectation regarding weekly wound assessments, even if another nurse was also assessing the wound. DCO #1 stated the hospice nurse should be doing their own assessment weekly per the plan of care and per agency policy. The agency failed to provide the necessary nursing assessment of wounds per agency policy. DCO #1 acknowledged the findings at the time of interview. Patient #1 (P-1) was admitted to Hospice on 10/31/24 with a terminal diagnosis of Alzheimer’s Disease. The Plan of Care (POC) ordered Skilled Nursing, Medical Social Work, Spiritual Care and Aide services to be provided. During the clinical record review on 10/9/25, it was noted that P-1 initially began care with this agency on 10/31/24 and was recertified for continuing care on 11/6/24 and again on 2/4/25. During the review, it was noted that a Physician’s order dated 1/20/25 ordered, “Hospice nurse to education wound care and complete care at weekly visits-Optalis SNF (Skilled Nursing Facility) staff to complete wound care as follows: L (left) hip: cleanse with wound cleanser, pat dry, apply nickel thick layer of Medihoney (wound gel) and cover with border foam nightly and prn (as needed) when loose or soiled; L heel: cleanse with wound cleanser, pat dry and apply skin prep allow to dry and leave open to air/float heels while in bed; Sacrum: cleanse with wound cleanser, pat dry and apply nickel thick layer of Medihoney to wound bed and cover with boarder form dressing.” A Physician’s order dated 2/19/25 stated, “Order signed in facility EMR (Electronic Medical Record). Cleanse with wound cleanser, pat dry, apply Medihoney, cover with foam dressing. Facility staff to change daily and hospice nurse to change at weekly visits.” There was no indication of which wound this order was in reference to. A Physician’s order dated 2/25/25 stated, “Hospice nurse to provide instruction related to prevention/management of skin breakdown. Goals: Facility staff will verbalize/demonstrate measures to prevent/manage skin breakdown AEB no further progression if impaired skin integrity x 14 days.” [sic] A Physician’s order dated 3/19/25 stated, “Right heel wound, cleanse with wound cleanser, pat dry, paint with betadine and cover with border dressing. Facility staff to complete care to right heel wound daily, Hospice RN to complete care during weekly visits.” A Physician’s order dated 4/4/25 stated, “Order signed in facility EMR. L calf skin tear – Optalis staff to cleanse with wound cleanser, pat dry, apply foam dressing and change QOD (every other day), hospice nurse to change at weekly visits.” A review of the Hospice Nursing visit notes revealed that no wound care or wound care assessments had been conducted by the Hospice Nurse during visits to the SNF on the following dates: 2/4/25 Mid Sacral, Rt Heel “caregiver completed care.”2/11/25 Mid Sacral, Right Heel “caregiver completed care.”2/25/25 Mid Sacral, Iliac Crest, Lt, healed, Right Heel “caregiver completed care.”3/13/25 Mid Sacral, Right Heel “caregiver completed care.” 3/19/25 Mid Sacral (says healed, but wound care done) “caregiver completed care.” Per note, wound care was performed on right heel only.3/24/25 Right Heel “caregiver completed care.”4/4/25 Proximal Calf Lt, Skin Tear, Right Heel “Refused care to right heel..., new wound to left calf.”4/8/25 Proximal Calf, Lt, Skin Tear, Right Heel “Refused care.”4/14/25 “Refused care” 4/14/25 “SIX wounds identified during this visit: LEFT POSTERIOR POPLITEAL, RIGHT CALF X2, LEFT HEEL, RIGHT HIP, RIGHT ISCHIUM.”The Hospice Visit Note dated 4/14/25 documented, “FACILITY NURSE ABLE TO PROVIDE WOUND CARE, PATIENT REFUSING MEASUREMENTS AT THIS TIME. PATIENT HAS 6 TOTAL WOUNDS, 2 DOCUMENTED IN HCHB (Electronic Medical Record system/Home Care Home Base), WILL ADD 4 ADDITIONAL AFTER MEASUREMENTS AND STAGING ARE OBTAINED BY WOUND CARE AT FACILITY.” During the review, it was noted that it could not be determined who the “Caregiver” was reported to have completed the wound care. On 10/10/25 at 4:26 p.m., an interview was conducted with P-1’s Primary Caregiver (PCG #1). When asked if PCG #1 performed wound care for P-1, PCG #1 reported, “There were care conferences at the SNF. We were kept up to date with P-1’s progress; however, we were never trained to perform wound care.” Upon further review, there was no documented evidence that the Hospice nurse performed consistent, direct wound care and assessments of P-1’s wounds during the Hospice Nurse’s scheduled visits in accordance with the Physician’s orders. It could not be ascertained how many wounds had actually been identified. Further, there was no Physician’s order in place for the Hospice Nurse to forego wound care in the instances where the “caregiver” provided wound care, and no documented evidence that the Physician had been notified of the above instances where the Hospice nurse did not provide direct wound care. The Executive Director and Director of Clinical Operations reviewed and acknowledged the above findings during an interview on 10/10/25 at 1:55 p.m.”

“Observed in Record Review. In 3 of 20 patient records reviewed, The organization failed to ensure documentation of patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services. On review of RRHV#5 there was documentation of an after hours call to report 3 unstageable wounds to the patient’s bottom. On the next documented visit there was no documentation of a comprehensive wound assessment. The nurse noted an abrasion to the buttocks yet no specifics such as size, color, odor, and drainage as required. In RRNHV#10 the patient had dry gangrene wounds to the foot yet the wounds were not assessed weekly as per policy as the documentation noted the wound was not assessed on week 2 or week 4 of hospice care. In review of RRNHV#13 the patient was admitted with Thyroid cancer with a mass to the neck that affected swallowing also a mass to the ribs per the documentation yet there was no documentation of a comprehensive assessment of the masses such as size, shape, color, and surrounding area. These observations were reviewed with the Director of Clinical Operations.”

“Observed in Record Review. In 1 of 20 patient records reviewed, it was noted that plan of care goals were not individualized. For example, in record RRHV#3 no goals included any time frames. Goal example: Patient will receive assistance with personal care and hygiene and other activities of daily living as needed. Patient name will have safety needs met. This was discussed with the Director of Clinical Operations. Observed in Record Review. In 3 of 20 patient records reviewed, the organization failed to ensure the plan of care was based on the patient’s goals that were individualized, specific, measurable and time-bound. On review of RRHV#6 the goal for the patient’s infection was noted to not be specific and time-bound such as patient/caregiver will verbalize/demonstrate understanding of management of UTI. In RRNHV#8 there were also goals that were not specific, measurable and time bound such as medication will be managed appropriately as evidenced by steady symptom control. In RRNHV#10 an example of a non-specific, not measurable goal was staff verbalize adequate knowledge of required care to manage suprapubic catheter at every visit. These observations were reviewed with the Director of Clinical Operations.”

“Observed in Record Review. In 5 of 20 patient records reviewed, the organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. On review of RRHV#4 the documentation noted issues with respiratory where Oxygen was started yet there was no respiratory care plan initiated to guide the care. There were infections with antibiotics of a UTI in November and URI in December yet the issues were not reflected in the plan of care. In RRHV#5 the documentation noted the patient with hearing issue related to ear wax build up with medication added to treat, yet the issue was not reflected on the plan of care. Further, the patient had a primary terminal diagnosis of Parkinson’s disease, yet there was no neuro care plan to guide the care. In RRNHV#8 there was documentation of the patient’s alcohol use and risk for seizures yet the issue was not reflected in the plan of care. Further the patient was noted to have issues with respiratory status with shortness of breath. Oxygen safety and use was noted on the plan of care but there was no care plan for the patient’s shortness of breath and respiratory to guide the care. In RRNHV#11 there was documentation of the patient with a cough that was treated with Benzonatate yet the issue was not reflected in the patient’s plan of care. In RRNHV#13 there was documentation of a Shingles infection with antiviral medication yet the issues was not reflected on the plan of care. The patient had a tumor to the neck area affecting swallowing, and a tumor to the rib area yet no care plan to guide the care. These observations were reviewed with the Director of Clinical Operations.”

“Observed in Record Review. In 2 of 20 patient records reviewed, the plan of care did not included all services needed for the palliation and management of care including a statement of the scope and frequency of the services necessary to meet the patient’s needs. For example, in record RRHV#3 it was noted in the initial assessment that the patient stated that Yes she would like to have volunteer visits. However, volunteers were not included on the POC with no frequency, goals or interventions. In record RRNHV#2 the goal Staff at (facility name) will verbalize measure to manage patient’s post surgical site on left breast as evidence by no s/s infection to area within 14 days. However, there was no documentation on the POC for the wound care intervention to be provided. This was discussed with the Director of Clinical Operations.”

“Observed in Record Review. In 2 of 20 patient records reviewed, the organization failed to ensure the plan of care include all services need for the palliation of the terminal illness and related conditions. On review of RRNHV#8 the documentation noted the patient was using home oxygen, yet there was no physicians order for the oxygen noted on the plan of care. In RRNHV#10 the wound care order noted on the plan of care was incomplete as it stated cleanse with wound cleanser, pat dry, apply triad. The order lacked a frequency and if the wound was open to air or to be covered. This observation was reviewed with the Director of Clinical Operations.”

“Observed in Record Review. In 2 of 20 patient records reviewed, The organization failed to provide the patient with care, treatment, and services in accordance with the patient’s individualized plan of care. On review of RRHV#4 the hospice aide was ordered a frequency of 2 times a week per the plan of care yet the last two weeks of December there was only one visit documented. In RRNHV#12 the hospice aide was ordered per the plan of care a frequency of 2 times a week yet review of the record noted multiple weeks in the 1st benefit where only one aide visit was documented. This can be seen in the 5th week of November, the 2nd, 3rd, 4th and 5th week of December. These observations were reviewed with the Director of Clinical Operations. Observed in Patient Home. In 1 of 6 home visits conducted, it was noted that care was not provided according to hospice plan of care. For example, during RRHV#2 the nurse performed wound care. The plan of care stated the wound was to be cleansed with NS then apply Betadine. However the nurse cleansed with Betadine. This was discussed with the Team Director present.”

“Observed in Patient Home. In 2 of 6 home visits conducted, the organization failed to ensure it implemented activities for the prevention and control of infections and communicable diseases. On home observation for RRHV#1 the hospice aide during home observation was noted to miss opportunities for hand hygiene. The Aide provided the patient with a shower and upon completion of the shower to include perineal care, the aide failed to remove gloves and sanitize hands prior to completing the tasks assigned such as dressing and skin care. Further, upon removing gloves the Aide failed to sanitize hands and proceeded to provide care for the patient. In RRHV#6 the RN was observed to provide perineal care to the patient with a diaper change, yet failed to remove gloves and sanitize hands per policy prior to continuing care with clean tasks. These observations were reviewed with the RN and the Director of Clinical Operations.”

“Observed in Patient Home. In 1 of 6 home visits conducted, the organization failed to ensure the patient record contain all information to reflecte the patient’s care, treatment, or services. On home observation for RRHV#6 during the medication reconciliation it was noted the medications being administered in the home were not reflected on the patient’s medical record. For example: the patient was taking Cipro for UTI but the med was not on the medication profile. The caregiver noted the supplements magnesium, mecobalamin, and vitamin d3 had been stopped in November, yet were still noted as active on the medication profile. This observation was reviewed with the RN and the Director of Clinical Operations.”

“Observed in Patient Home. In 2 of 6 home visits conducted, the organization failed to ensure it implemented activities for the prevention and control of infections and communicable diseases. On home observation for RRHV#2 the hospice nurse during home observation was noted to miss opportunities for hand hygiene. The nurse performed wound care and multiple times upon removing gloves the nurse failed to sanitize hands and proceeded to provide care for the patient. The organization’s Hand Hygiene 4003 Protocol policy stated that upon removing gloves hands were to be sanitized. On home visit RRHV#1 the bedbound patient’s call button was on the floor throughout the visit and the MSW step on it. At the end of the visit the MSW pick the call button up off the floor and attached it to the patient’s bedding with no cleaning or disinfection. This observation was reviewed with the Director of Clinical Operations.”