Heart to Heart Hospice of Detroit, LLC

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review. In 1 of 10 (10%) clinical records reviewed of patients with oxygen ordered, the agency did not ensure that the comprehensive assessment included a review of the patient’s current medications. Clinical Record 7: The patient elected hospice care on 05/24/2023 with a diagnosis of senile degeneration. The nursing assessment dated 11/01/2023 documented that the patient was short of breath and starting on oxygen per nasal via cannula. On 11/01/2023, the physician ordered 2 liters/minute per nasal cannula for shortness of breath and a low oxygen saturation of peripheral oxygen (SPO2). The medication profile did not document oxygen.”

“It is required that the hospice designates a registered nurse member of the IDG to: provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; [and] ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 23 (9%) clinical records reviewed of community hospice patients, the agency did not ensure the IDG designated Registered Nurse (RN) coordinated care and implemented the plan of care. Clinical Record 7: The patient elected hospice care on 05/24/2023 with a diagnosis of senile degeneration. On 08/17/2023, the physician ordered the skilled nurse (SN) to obtain a low oxygen saturation of peripheral oxygen (SPO2) (pulse oximetry) with vital signs every visit. The nursing assessment dated 11/01/2023 documented that the patient was short of breath and starting on oxygen per nasal via cannula. On 11/01/2023, the physician ordered 2 liters/minute per nasal cannula for shortness of breath and a low oxygen saturation of peripheral oxygen (SPO2). The plan of care and updated plans, which were reviewed every two weeks, did not include interventions for oxygen, and oxygen was not added to the plan of care. The SN visit frequency was two (2) times a week. The nursing assessments visit notes dated 09/29/2023, 10/02/2023, 10/04/2023, and 10/12/2023 documented vital signs but no SPO2. Clinical Record 10: The patient elected hospice care on 11/22/2023 with a diagnosis of senile degeneration. The plan of care from 11/22/2024 through 12/20/2024 documented goals and interventions for a pet therapy evaluation to meet the patient’s needs and promote emotional support. The skilled nurse comprehensive assessment documented a need for the patient to be evaluated for pet therapy services to provide comfort and emotional support. The interdisciplinary group meetings (IDG) on 11/26/2024, 12/11/2024, and 12/24/2024 did not address the pet therapy evaluation that had not occurred. There was no documentation of notification of pet therapy or updates to the plan of care. During an interview on 03/18/2025, the Regional Quality Manager/Administrator stated that pet therapy had not been started and that the new staff member had documented this in error, as pet therapy was unavailable. They stated that regarding clinical record 7, the pulse oxygen level had not been documented every visit as ordered.”

“It is required that each patient’s individualized written plan of care: reflects patient and family goals; 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 and interview. In 2 of 23 (9%) clinical records reviewed of community hospice patients, the agency did not ensure that the plan of care documented all interventions for the patient’s care based on problems identified in the comprehensive assessments. Clinical Record 2: The patient elected the hospice benefit on 12/19/2022 with a primary diagnosis of senile degeneration of the brain and secondary anxiety disorder. The certificate of terminal illness (CTI) dated 12/19/2022 documented, “assisted with controlling and helping a patient with agitation and anxiety as clinically warranted.” The initial and updated plan of care dated 12/28/2022, 01/11/2023, 01/25/2023, 02/08/2023, and 02/22/2023 did not document interventions to address the patient’s identified problem with anxiety and agitation. Clinical Record 7: The patient elected the hospice benefit on 05/24/2023 with the diagnosis of senile degeneration. On 08/17/2023, the physician ordered to “obtain an oxygen saturation of peripheral oxygen (SPO2) (pulse oximetry) with vital signs every visit, then on 11/01/2023, the physician ordered oxygen at 2 liters per nasal cannula for shortness of breath and low SPO2. The patient’s plan of care did not include documentation of interventions to address the patient’s identified problems with shortness of breath and low SPO2 as of this review on 03/18/2025. During an interview and joint record review on 03/18/2025, the Regional Quality Manager/Administrator stated that the interventions were not updated and complete.”

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 23 (9%) clinical records reviewed of community hospice patients, the agency did not ensure that the plan of care included all medications and treatments. Clinical Record 7: The patient elected hospice care on 05/24/2023 with the diagnosis of senile degeneration. On 08/17/2023, the physician ordered to “obtain an oxygen saturation of peripheral oxygen (SPO2) (pulse oximetry) with vital signs every visit, then on 11/01/2023, a physician ordered oxygen at 2 liters per nasal cannula for shortness of breath and low SPO2. The oxygen was not documented in the patient’s plan of care as of the review on 03/18/2025. Clinical Record 22: The patient elected the hospice benefit on 08/23/2024 with a diagnosis of skin cancer and died on 10/13/2024. The patient had a Foley catheter in place at admission. The initial and updated plans of care documented the intervention, “Educate on maintenance of Foley.” The plans of care did not include documentation of the care and maintenance of the Foley catheter, including the size, the frequency for changing and flushing the Foley catheter. During an interview and a joint record review on 03/18/2025, the Regional Quality Manager/Administrator confirmed that the plans of care did not include all medications and treatments the patient received.”

“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 a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, interview, and observation. In 3 of 21 (14%) clinical records reviewed of community and Inpatient Unit (IPU) hospice patients who received Hospice Aide services, the agency did not ensure that the HA received written patient care instructions from the Registered Nurse (RN) to meet the patient’s care needs. Clinical Record 1: The patient elected the hospice benefit on 08/24/2022 with a diagnosis of coronary heart disease (CAD). The patient was admitted with COVID-19. The HA care plan dated 08/25/2022 assigned the HA the relevant task: “Shower every visit, but the patient may need to medicate prior to showering.” The HA care plan included the assigned task of assessing for infection. The HA care plan was updated on 01/13/2023, 11/16/2023, and 12/05/2024 (the last update). The updated care plans continued to document that the patient had COVID-19. The patient did not have COVID-19 during the subsequent benefit periods. Clinical Record 3/Home Visit 3: The patient elected the hospice benefit on 06/27/2024 with a diagnosis of degeneration of the brain. The plan of care ordered HA services two (2) times a week. The patient was admitted with a Foley catheter that was discontinued on 08/04/2024. The HA care plan dated 06/27/2024 and updated on 06/28/2024 assigned the HA the relevant tasks: shower and perineal care every visit. The HA care plan did not document instructions for the HA regarding the care of the Foley catheter during the shower and pericare. The skilled nursing (SN) assessment visit note dated 06/28/2024 documented that the patient was wearing a brace on the right lower leg and heel protectors. There were no instructions for the HA regarding the brace and heel protectors. The patient continued with heel protectors, which were observed during the home visit with the Social Worker (SN) [Personnel Record 3] on 03/19/2025. Additionally, the SN assessment visit note dated 08/12/2024 documented a right heel wound with a foam dressing. The wound was dressed with a foam dressing through 09/17/2024. The HA care plan was updated on 08/20/2024 and 09/14/2024, continuing the assigned task for a shower every visit but not documenting that there was a dressing or what to do during the shower if the dressing was saturated or fell off. The HA care plan was updated on 10/03/2024, changing the shower to a bed bath. Clinical Record 17: The patient elected the hospice benefit on 12/19/2024 with a primary diagnosis of Alzheimer’s Disease, a recent fall, and a fractured left arm. The skilled nursing comprehensive assessment dated 12/19/2024 documented the patient’s use of a left arm sling 24 hours a day, 7 days a week. The HA care plan documented on 12/19/2024 assigned the HA the tasks of bed bath and shampoo every visit with a visit frequency of 2 times a week. The HA care plan was updated on 01/14/2025 and assigned the task of showering and shampooing every visit. The HA care plan did not provide the HA with instructions regarding using the sling during showers. During an interview and a joint record review on 03/18/2025, the Regional Director of Compliance/Administrator confirmed that the detail was not documented in the care plans.”