A&d Hospice

“Based on document review the agency’s governing body failed to ensure CMS, the state agency (SA) and the Medicare Approved Contractor (MAC) were kept apprised of the current location from which the Hospice was providing services, resulting in a lack of clarity as to the hospice’s actual location. Findings include: A complaint survey of the Hospice was conducted on 7/18/24 at 3375 Carver Drive, Saginaw, MI 48603-2310, the site of the Hospice’s clinical operations. It was noted that the address in the Federal database (iQies) and the State of Michigan’s Hospice licensing system, was 3150 Enterprise Dr, Saginaw, MI 48603. There is no evidence that the agency has made the effort to correct the address of the location from which Hospice clinical operations are being provided to patients.”

“Based on record review and interview, the agency failed to ensure initial training in emergency preparedness policies and procedures was provided to 5 (Staff B, F, G, H, I) of 9 personnel files reviewed of new and existing staff and 3 (Staff J, K, L) of 3 personnel files reviewed of volunteers, resulting in the potential for unprepared responses to emergencies and an interruption in the provision of needed patient care services. Findings include: **Policy No. 4-001 titled “Emergency Management Plan” (revised April 2021) stated on page 369 under “Training”, “1. The training includes initial training in emergency preparedness policies and procedures and their assigned emergency response roles to all new and existing staff, individuals providing service under arrangement, and volunteers if applicable.” Personnel files were reviewed on 4/4/24. During review, it was determined there was no evidence of initial Emergency Preparedness (EP) training in the files for Staff B, F, G, H and I. During an interview on 4/4/24 at 1:00 PM, the Human Resources Coordinator (Staff D) was asked if there was a record of this kept in the file. Staff D presented a form titled “;A&D Healthcare Professionals Core Orientation Plan” which showed a check box next to a line titled “;Emergency Preparedness” on the second page. Upon further review of the above records, it was noted they contained a form with the same name; however, “;Emergency Preparedness” was not included. Staff D reported those must be old forms and there was no other evidence that initial EP training had been provided. During review of personnel files for volunteers, it was determined the files for Staff J, K and L had a similar form titled “;Core Volunteer Orientation Plan,” however, this form also did not list EP as one of the topics. Staff D was asked to provide evidence the volunteers had received initial training on EP. Upon seeing the orientation form, Staff D reported it did appear that volunteers were given initial EP training and acknowledged the findings. Findings were again reviewed with and acknowledged by the Administrator (Staff A) and Clinical Hospice Supervisor (Staff C) during the exit interview on 4/4/24 at 2:45 PM.”

“Based on record review and interview, it was determined the hospice failed to develop an Emergency Preparedness Plan using a facility-based and community-based risk assessment, resulting in the potential to negatively affect all patients seen by the hospice. Findings include: During review of the hospice Emergency Preparedness (EP) program on 4/4/24, it was discovered that the hospice utilized regional based exercises for their EP program. The region for their exercises was region 3, which covered a large geographical area of rural and denser populations including various cities, towns and counties. The exercises were not facility based with regard to the actual location of the agency. During an interview on 4/4/24 at 2:10 p.m., the Clinical Hospice Supervisor (Staff-C) acknowledged the above findings.”

“Based on record review and interview, the hospice failed to ensure the comprehensive assessment included an initial bereavement assessment of the patient’s family to determine factors that may impact the family’s ability to cope with the patient’s impending death for 7 of 14 (P-1, 3, 6, 7, 9, 10, 14) records reviewed. This deficient practice has the potential to negatively affect the loss/grief issues for these 7 patients and their family members. Findings include: P-9: This 87-year-old patient was admitted to this hospice agency on 1/23/24 with the terminal diagnosis of secondary malignant neoplasm of liver and intrahepatic bile duct (liver cancer). During record review on 4/2/24, it was determined the initial bereavement assessment for the patients husband was not completed (blank). The Bereavement Coordinator (Staff B) was asked why it was not done during an interview on 4/3/24 at 11:15 AM. Staff B found a note in her records that stated, “;called back and left message, no one answered and no return call.” There was no date or time on this note to determine when the call was made. Staff B acknowledged she needed to follow-up with the husband, as the patients start of care was several months ago. Upon further review of the initial bereavement for this patient, it was noted the patient had a daughter who was involved in her care. She was also listed in the patient profile/bereavement risk list in the record; however, no bereavement assessment was completed for her. P-10: this 78-year-old patient was admitted to this hospice agency on 8/3/23 with the terminal diagnosis of senile degeneration of the brain. During record review on 4/2/24, it was determined the initial bereavement assessment had been performed on one of the patients sisters. However, a social work note dated 10/17/23 reported the patients sisters both visit weekly – indicating a close relationship and potential for bereavement risk in the record. The other sister was also listed in the patient profile/bereavement risk list. Staff B was unable to provide documentation of a refusal or the other sister being present for the initial assessment. P-14: This 82-year-old patient was admitted to this hospice agency on 10/20/23 with the terminal diagnosis of senile degeneration of the brain. During record review on 4/1/24, it was determined an initial bereavement assessment was completed with the patients son – who was listed as the primary caregiver. Upon further review of the record, it was noted in the start of care notes dated 10/20/23 that the patient is married and the patients husband visits daily, therefore is very involved in her care. He is also listed on the patient profile/bereavement risk list in the record. Staff B was asked why an initial bereavement assessment had not been completed with the patients husband. Staff B stated she remembered the husband was elderly and hard of hearing and was likely present during the initial assessment with the son. Staff B was unable to provide documentation of this. During the record review, it was noted that every record reviewed only had an initial bereavement assessment completed on one individual, despite other individuals being identified in the record. During the interview on 4/3/24 at 11:15 AM, Staff B was queried regarding how individuals are identified for the initial bereavement assessment. Staff B stated the patient profile/bereavement risk list is filled out by the nurse or social worker at the start of care, and she uses that list to contact the primary person listed. Staff B was asked why other family members were not included in the initial bereavement assessment. Staff B stated she only evaluates the primary contact listed, as that is what she had been told to do. Staff B also stated other individuals often “;dont want it” or are present during the assessment of the primary person. Staff B was asked how she keeps track of who does not want or need an assessment. Staff B reported she typically puts notes in her planner with details, however, was unable to find documentation for the examples above and acknowledged the findings. Findings were again reviewed with the Administrator (Staff A) during an interview on 4/3/24 at 3:00 PM. Staff A stated she was unaware only the primary contact was being assessed for initial bereavement. Staff A believed the others listed refused assessment, however, was unable to provide evidence of this and acknowledged the findings. P-1: The start of care (SOC) date was 2/6/23, with diagnoses of senile degeneration of brain, congestive heart failure (CHF), and oxygen use. During review of the record on 4/2/24, it was discovered that the patient profile/bereavement risk indicated a primary and two other family members. The primary was the only family member documented as needing bereavement services. P-3: The start of care (SOC) date was 7/28/23, with diagnoses of Alzheimer’s. During review of the record on 4/3/24, it was discovered that the patient profile/bereavement risk indicated a primary and three other family members. The primary was the only family member documented as needing bereavement services. P-6: The start of care (SOC) date was 3/8/24, with diagnoses of Parkinson’s, hypertension (HTN), and chronic kidney failure (CKD). During review of the record on 4/4/24, it was discovered that the patient profile/bereavement risk indicated a primary and secondary family member. The primary was the only family member documented as needing bereavement services. P-7: The start of care (SOC) date was 2/15/24, with diagnoses of Parkinson’s Disease, hypertension (HTN), and chronic kidney failure (CKD). During review of the record on 4/4/24, it was discovered that the patient profile/bereavement risk indicated a primary and two additional family members. The primary was the only family member documented as needing bereavement services. During an interview on 4/3/24 at 2:10 p.m., the bereavement/volunteer coordinator (Staff-B), when asked about the bereavement of all listed family members, stated, “I only assess the primary person for bereavement risk.” During an interview on 4/4/24 at 2:10 p.m., the Clinical Hospice Supervisor (Staff-C) acknowledged the above findings.”

“Based on record review, and interview, it was determined that the hospice failed to ensure the plan of care (POC) included patient specific measurable goals in 14 of 14 records reviewed out of a total sample of 14 records (records 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14), which resulted in the potential for unmet patient goals. Findings include: P-1: The Start of Care (SOC) was dated 8/20/23. The Plan of Care (POC) identified diagnoses of senile degeneration of brain, congestive heart failure, and oxygen use. During review of the record on 4/1/24, it was noted that the goals on the POC were not objectively measurable. For example, one goal stated, “Patient/caregiver will verbalize understanding of alternative pain relief measures.” Another stated, “Patient’s pain will remain at comfortable level during care/within certification period of time.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-2: The Start of Care (SOC) was dated 7/28/23. The POC identified diagnoses of cerebrovascular disease, difficulty walking, and hemiplegia. During review of the record on 4/2/24, it was noted that the goals on the POC were not objectively measurable. For example, one goal stated, “Patient/caregiver will verbalize understanding signs/symptoms of constipation.” Another stated, “Patient will express/exhibit relief from emotional pain.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-3: The Start of Care (SOC) was dated 4/16/23. The POC identified diagnoses senile degeneration of brain, congestive heart failure and oxygen use. During review of the record on 4/2/24, it was noted that the goals on the POC were not objectively measurable. For example, one goal stated, “Bowels will function with disease process.” Another stated, “Patient/caregiver will demonstrate proper and safe use of oxygen set up.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-4: The Start of Care (SOC) was dated 2/2/23. The POC identified diagnoses of heart disease, and angina. During review of the record on 4/3/24, it was noted that the goals on the POC were not objectively measurable. For example, one goal stated, “Patient/caregiver will be compliant with the use of pain meds.” Another stated, “Caregiver understands signs and symptoms of imminent dying process.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-5: The Start of Care (SOC) was dated 2/16/24. The POC identified diagnoses of chronic obstructive pulmonary disease, heart failure, and hypertension. During review of the record on 4/3/24, it was noted that the goals on the POC were not objectively measurable. For example, one goal stated, “Caregiver/family will understand and deliver care needed to maintain patient safety and comfortably [sic] at home.” Another stated, “Fall prevention will be maintained during care.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-6: The Start of Care (SOC) was dated 3/8/24. The POC identified diagnoses of Parkinson’s disease, chronic kidney disease, and hypertension. During review of the record on 4/4/24, it was noted that the goals on the POC were not objectively measurable. For example, one goal stated, “Patient will achieve maintain optimal physical comfort.” Another stated, “Patient will achieve optimal breathing patterns, airway patency, and comfort.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-7: The Start of Care (SOC) was dated 2/15/24. The POC identified diagnoses of hepatic failure. During review of the record on 4/4/24, it was noted that the goals on the POC were not objectively measurable. For example, one goal stated, “Patient will maintain optimal mobility during care.” Another stated, “Patient/caregiver will demonstrate ability to manage bowel routine within certification period.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. During an interview on 4/4/24 at 2:10 p.m., the Clinical Hospice Supervisor (Staff-C) acknowledged the above findings. P-8: This 83-year-old patient was admitted to this hospice agency on 12/7/23 with the terminal diagnosis of late onset Alzheimers Disease. During record review on 4/3/24, it was noted the goals on the Plan of Care (POC) dated 12/7/23 were not objectively measurable to allow patients progress to be tracked or the need for revisions in treatment to be identified. For example, one goal stated, “;Patients pain will remain at comfortable level during care/within certification period of time.” Another goal stated, “;Patient will maintain optimal primary elimination patterns and comfort throughout certification period.” P-9: This 87-year-old patient was admitted to this hospice agency on 1/23/24 with the terminal diagnosis of secondary malignant neoplasm of liver and intrahepatic bile duct (liver cancer). During record review on 4/2/24, it was noted the goals on the POC dated 1/23/24 were not objectively measurable to allow patients progress to be tracked or the need for revisions in treatment to be identified. For example, one goal stated, “;Patient/caregiver will receive optimal teaching and support as cardia and pulmonary functions change during care throughout certification period.” Another goal stated, “;Patients nausea/vomiting will be controlled within certification period of time.” P-10: This 78-year-old patient was admitted to this hospice agency on 8/3/23 with the terminal diagnosis of senile degeneration of the brain. During record review on 4/2/24, it was noted the goals on the POC dated 8/3/24 were not objectively measurable to allow patients progress to be tracked or the need for revisions in treatment to be identified. For example, one goal stated, “;Bowels will function with disease process.” Another goal stated, “;Promote optimal nutrition/hydration during care/withing certification period of time.” P-11: This 79-year-old patient was admitted to this hospice agency on 2/5/25 with the terminal diagnosis of unspecified severe protein-calorie malnutrition. During record review on 4/2/24, it was noted the goals on the POC dated 2/5/24 were not objectively measurable to allow patients progress to be tracked or the need for revisions in treatment to be identified. For example, one goal stated, “;Patient will maintain adequate cardiac/circulatory function and fluid volume as long as possible.” Another goal stated, “;Patient will maintain optimal swallowing this certification period.” P-12: This 98-year-old patient was admitted to this hospice agency on 2/21/23 with the terminal diagnosis of heart failure. During record review on 4/2/24, it was noted the goals on the POC dated 2/21/23 were not objectively measurable to allow patients progress to be tracked or the need for revisions in treatment identified. For example, one goal stated, “;Optimal hygiene will be maintained during care.” Another goal stated, “;Patient will achieve optimal breathing patterns, airway patency, and comfort.” P-13: This 72-year-old patient was admitted to this hospice agency on 6/16/23 with the terminal diagnoses of heart failure. During record review on 4/1/24, it was noted the goals on the POC dated 6/16/23 were not objectively measurable to allow patients progress to be tracked or the need for revisions in treatment identified. For example, one goal stated, “;Patient does not exhibit diabetic complications.” Another goal stated, “;Patients pain will remain at comfort level during care/within certification period of time.” P-14: This 82-year-old patient was admitted to this hospice agency on 10/20/23 with the terminal diagnosis of senile degeneration of the brain. During record review on 4/1/24, it was noted the goals on the POC dated 10/20/23 were not objectively measurable to allow patients progress to be tracked or the need for revisions in treatment identified. For example, one goal stated, “;Patient will express/exhibit relief from spiritual pain.” Another goal stated, “;Patient will express/exhibit relief from spiritual pain.” Findings were reviewed with the Clinical Hospice Supervisor (Staff C) during an interview on 4/4/24 at 10:30 AM. He agreed the above goals were not measurable and acknowledged the findings.”

“Based on record review and interview, the hospice failed to ensure the aide provided services as ordered in the plan of care for 7 of 11 (P-1, 2, 3, 11, 12, 13, 14) records reviewed with aide services ordered, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: P-1: The Start of Care (SOC) was dated 8/20/23. The Plan of Care (POC) identified diagnoses of senile degeneration of brain, congestive heart failure, and oxygen use. During review of the record on 4/1/24, it was noted that the home health aide (HHA) care plan ordered the HHA to document “Last bowel movement (BM) and size.” During review of the HHA visit notes, it was discovered that the HHA failed to document BM information for the 3/7/24 patient visit. P-2: The Start of Care (SOC) was dated 7/28/23. The POC identified diagnoses of cerebrovascular disease, difficulty walking, and hemiplegia. During review of the record on 4/2/24, it was noted that the home health aide (HHA) care plan ordered the HHA to document “Last bowel movement (BM) and size.” During review of the HHA visit notes, it was discovered that the HHA failed to document BM information for the 3/25/24 patient visit. P-3: The Start of Care (SOC) was dated 4/16/23. The POC identified diagnoses senile degeneration of brain, congestive heart failure and oxygen use. During review of the record on 4/2/24, it was noted that the home health aide (HHA) care plan ordered the HHA to document “Last bowel movement (BM) and size.” During review of the HHA visit notes, it was discovered that the HHA failed to document BM information for the 4/17, 4/19, 4/24, 5/1, and 5/3 patient visits. During an interview on 4/4/24 at 2:10 p.m., the Clinical Hospice Supervisor (Staff-C) acknowledged the above findings. P-11: This 79-year-old patient was admitted to this hospice agency on 2/5/24 with the terminal diagnosis of unspecified severe protein-calorie malnutrition. During record review on 4/2/24, it was noted the aide care plan dated 2/5/24 ordered the date of the patients last bowel movement to be documented every visit and to notify the registered nurse if there hadnt been a bowel movement in 3 days. Upon further review of the record, it was noted the date of the last bowel movement was not documented on 2/12/24, 2/14/24, and 4/1/24. P-12: This 98-year-old patient was admitted to this hospice agency on 2/21/23 with the terminal diagnosis of heart failure. During record review on 4/2/24, it was noted the aide care plan dated 7/22/23 ordered the date of the patients last bowel movement to be documented every visit and to notify the registered nurse if there hadnt been a bowel movement in 3 days. Upon further review of the record, it was noted the date of the last bowel movement was not documented on 12/19/23 and 12/21/23. P-13: This 72-year-old patient was admitted to this hospice agency on 6/16/23 with the terminal diagnoses of heart failure. During record review on 4/1/24, it was noted the aide care plan dated 9/21/23 ordered the date of the patients last bowel movement to be documented every visit and to notify the registered nurse if there hadnt been a bowel movement in 3 days. Upon further review of the record, it was noted the date of the last bowel movement had not been documented on 12/19/23, 12/21/23, and 1/18/24. P-14: This 82-year-old patient was admitted to this hospice agency on 10/20/23 with the terminal diagnosis of senile degeneration of the brain. During record review on 4/1/24, it was noted the aide care plan dated 1/10/24 ordered the date of the patients last bowel movement to be documented every visit and to notify the registered nurse if there hadnt been a bowel movement in 3 days. Upon further review of the record, it was noted the date of the last bowel movement had not been documented on 1/19/24, 1/22/24, 1/29/24, 2/2/24, 2/16/24, and 3/20/24. The Clinical Hospice Supervisor (Staff C) acknowledged the findings during an interview on 4/4/24 at 10:30 AM. He stated the nursed had reported this as an issue and they have been working to improve that.”

“Based on record review and interview, the agency failed to ensure volunteers provided day-to-day administrative and/or direct patient care services in an amount that totaled at least 5 percent of the total paid patient care hours, resulting in a lack of cost savings for the agency. Findings include: The Volunteer Coordinator (Staff B) was interviewed regarding the agencys volunteer program on 4/3/24 at 10:45 AM. During the interview, Staff B reported she had 4 volunteers currently, however, she was unsure what percentage of hours the volunteers provided. Staff B stated she would try to find the information. On 4/3/24 at 12:30 PM, the Administrator (Staff A) presented information for 3 quarters of 2021 and each quarter of 2022 and 2023. According to the records, volunteers provided a total of 7.51% in 2021, 16.26% in 2022 and 12.75% in 2023. Upon further review of the records, it was determined the totals above were a summation of the percentages from each quarter and not a total average for the year (see below). 2021: Quarter 2 (Q2) 2.86% + Quarter 3 (Q3) 2.35% + Quarter 4 (Q4) 2.35% = 7.51% 2022: Quarter 1 (Q1) 3.4% + Q2 3.78% + Q3 2.47% + Q4 6.61% = 16.26% 2023: Q1 4.74% + Q2 3.45% + Q3 1.81% + Q4 2.75% = 12.75% The findings were reviewed with Staff A during an interview on 4/3/24 at 1:00 PM. Staff A acknowledged the findings and reported she has been “;doing it wrong” and was not aware.”

“Based on observation, record review, and interview, it was determined the governing body and administrator failed to ensure that Federal and State agencies were notified of the hospice’s change of address (COA), resulting in the potential for the agency to be operating out of compliance with Federal requirements. Findings include: Upon arrival to the agencys address listed in the State of Michigan (SOM) database (3150 Enterprise Drive, Saginaw, MI 48603-2310) on 4/1/24 at 8:50 AM, it was determined the hospice portion of the corporation does not operate from this location and the surveyors were directed to a location around the corner (3375 Carver Street, Saginaw, MI 48603-2310). After arriving at the second location, the Administrator (Staff A) was queried regarding the change in location. Staff A stated she was unsure how long hospice had been operating at that location, however it had been there since before she was hired 3 years ago. Staff A stated the other location is where administration for the corporation operated. Staff A was asked to provide a letter from the Centers for Medicare and Medicaid Services (CMS) that showed the address change was approved. Staff A was unable to locate a letter of approval, however, did provide an 855 application dated 2/24/22. Review of the application regarding the relocation of the hospice agency noted the following: Section 2 titled “;Identifying Information” on page 12 listed the current SOM listing as the “;Correspondence Address” (3150 Enterprise Drive, Saginaw, MI 48603-2310). Section 4 titled “;Practice Location Information (continued)” on page 20 noted the current address (3375 Carver Street, Saginaw, MI 48603-2310), however no box was checked next to “;Change”, “;Add”, or “;Delete” to determined the action needed. There was also no dated listed to indicate a date effective. When asked if anyone else would be able to locate a letter of approval, Staff A stated the owner was out of town, but she would see who else could help. During an interview on 4/4/24 at 12:00 PM, the Director of Clinical Services (Staff E) was asked if there was any update regarding the letter of approval. Staff E stated nobody was able to find a letter of approval, but a call had been made to CMS who stated one could be sent in 10 to 15 days. No further evidence was provided that the National Government Services (NGS) or CMS had acknowledged the receipt of the 855 application. Findings were again reviewed with and acknowledged by Staff A during the exit interview on 4/4/24 at 2:45 PM.”