Mid Michigan Home Health & Hospice, LLC

“It is required that all hospice aide provides services are ordered by the Interdisciplinary Group, Included in the plan of care, permitted to be performed under state law and regulation and consistent with the hospice aide training. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by a review of clinical records and interviews which revealed the hospice: Failed to ensure that the Registered Nurse prepared the written home health aide care plan with clear and patient-specific directions (75%), {HCDT.15. I/L625}; Failed to ensure that ensure that aide supervision was documented every 14 days (100%) {HSRM.25.I/L629}. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.76, Hospice Aide and Homemaker Services. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“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; 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; 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 and interview. In 3 of 6 (50%) clinical records reviewed the agency did not ensure that the medication profile was accurate for all medications that the patient was taking and could not correctly review all medications for potential interactions. CLINICAL RECORD 1:The hospice election of benefit form was dated 12/31/2025 with a primary diagnosis of chronic obstructive pulmonary disease. T he nursing assessment documented 01/16/2026 documented that the patient started Gabapentin three times a day. The medication was not on the medication profile where it would have been reviewed for potential interactions. The patient also had oxygen at 5 Liters per nasal cannula that was not documented on the medication profile. CLINICAL RECORD 3: The hospice election of benefit form was dated 12/26/2025 with a primary diagnosis of chronic obstructive pulmonary disease and secondary of Alzheimer’s Disease. The initial comprehensive assessment documented on 12/26/2025 that the patient was using oxygen 4 liter per nasal cannula but this was not on the medications profile. CLINICAL RECORD 5: The hospice election of benefit form was dated 05/23/2026 with a primary diagnosis of Lung Cancer. The nursing assessment documented 06/05/2026 documented that the patient was doing well taking the stool softener and Norco and Motrin .for pain The following medications were not on the medication profile as of review 06/09/2026: Motrin and the stool softener that was not identified. The patient also had oxygen and 3 liter per nasal cannula that was not documented on the medication profile. During interview with the director of nursing and the administrator it was stated that several staff are new and there was a current process improvement plan in place for this.”

“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 clinical record review, interview and observation. In 4 of 6 (67%) clinical records reviewed, it was revealed that the agency did not ensure that all interventions for problems identified in the initial and updated comprehensive assessments were included in the plan of care. CLINICAL RECORD 1: The hospice election of benefit form was dated 12/31/2025 with a primary diagnosis of chronic obstructive pulmonary disease. The initial comprehensive assessment documented on 12/31/2026 documented a fall risk of 8/10 and patient was a fall risk. The plan of care documented 12/31/2026 and updated every 2 week did not document any interventions for fall prevention. CLINICAL RECORD 3: The hospice election of benefit form was dated 12/26/2025 with a primary diagnosis of chronic obstructive pulmonary disease and secondary of Alzheimer’s Disease. The initial comprehensive assessment documented a fall risk of 7/10 and that the patient was a fall risk. The initial plan of care documented 12/26/2025 and updated every two weeks did not include documentation of fall prevention interventions. CLINICAL RECORD 4: The hospice election of benefit form was dated 12/18/2025 with a primary diagnosis of coronary artery disease and dementia. The initial comprehensive assessment documented 12/18/2025 documented a fall risk of 7/10 and that the patient was at risk but no fall risk interventions were documented on the initial plan of care or updated plans of care every two weeks. CLINICAL RECORD 6: The hospice election of benefit form was dated 11/11/2025 with a diagnosis of senile degeneration of the brain. The initial nursing comprehensive assessment completed on 11/11/2025 documented a fall risk of 7/10 with a risk of falls. The initial plan of care dated 11/11/2025 and the plans of care updated every two weeks did not document any interventions for fall precautions. During the home visit on 06/09/2026 with the Registered Nurse (Personnel Record 4), it was observed that the patient had a fall mat and a Broda chair to decrease fall injury. The nurse stated that when the patient was up in the Broda chair she was always monitored for falls. During interview with the director of nursing and the administrator on 06/09/2026 who reviewed the record, stated that instruction had been provided for fall safety but agreed that there were no documented interventions.”

“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: Medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 3 of 6 (50%) clinical records reviewed, the agency did not ensure that the supplies for patient care were included on the plan of care. CLINICAL RECORD 1: The hospice election of benefit form was dated 12/31/2025 with a primary diagnosis of chronic obstructive pulmonary disease. The initial plan of care dated 12/31/2025 and updated every two weeks documented supplies as “None”. The patients initial comprehensive assessment documented that the patient was using oxygen and the plan of care documented that the patient was using oxygen at a 5 liter flow rate per nasal cannula. The plan of care did not include oxygen supplies. CLINICAL RECORD 3: The hospice election of benefit form was dated 12/26/2025 with a primary diagnosis of chronic obstructive pulmonary disease and secondary of Alzheimer’s Disease. The initial plan of care documented 12/26/2025 and the plans of care updated every two weeks, documented that supplies were none. The initial comprehensive nursing assessment documented 12/26/2025 documented that the patient had oxygen at 4 liters per nasal cannula and the updated assessments documented continued use of oxygen. The plan of care did not include oxygen supplies. CLINICAL RECORD 5: The hospice election of benefit form was dated 05/23/2026 with a primary diagnosis of lung cancer. The initial plan of care documented 05/23/2026 and updated every 2 weeks documented supplies as none. The initial comprehensive assessment documented on 05/23/2026 documented oxygen used at 3 liters per minute per nasal cannula and that the patient had a hospital bed. The plan of care did not include oxygen supplies or the hospital bed. During interview the administrator stated that some of the facilities used vendors that they did not have a contract with and preferred to provide the oxygen but agreed that that did not include all the records.”

“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 and interview. In 3 of 4 (75%) clinical records reviewed of patients accepting Hospice Aide Services the agency did not ensure that the registered nurse prepared a hospice aide plan of care that contained clear and specific instruction for patient required care. CLINICAL RECORD 1: The hospice election of benefit form was dated 12/31/2025 with a primary diagnosis of chronic obstructive pulmonary disease. The initial nursing comprehensive assessment dated 12/31/2025 documented that the patient had a PEG (percutaneous endoscopic gastrostomy) tube and tube feeding. The hospice aide plan of care documented 12/31/2025 and not updated, did not document the feeding tube. The aide had an assigned task of shower but the plan did not identify care for the feeding tube during care. CLINICAL RECORD 2: The hospice election of benefit was dated 12/13/2025 with a primary diagnosis of Alzheimer’s Disease. The hospice aide plan of care documented on 12/13/2025 and not updated, documented for the following bathing tasks. Bed bath as needed (no identified decision maker) and a shower every visit. This left the decision to the hospice aide. CLINICAL RECORD 3: The hospice election of benefit was dated 12/26/2025 with a primary diagnosis of chronic obstructive pulmonary disease and secondary diagnosis of Alzheimer’s Disease. The hospice aide plan of care documented on 12/26/2025 documented partial sponge bath as needed and shower every visit. There was no documented decision maker. During interview with the Director of Nursing and Administrator on 06/09/2026 stated that as needed and no identified decision makers was not allowed.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed in which a hospice aide was accepted, the agency did not ensure that aide supervision was documented every 14 days. CLINICAL RECORD 1: The first hospice aide visit was dated 01/07/2026 with a visit frequency of 2 x a week. There was no documented supervision as of discharge 01/30/2026. This was a total of 23 days and missed the 14 day supervision. CLINICAL RECORD 2: The first hospice aide visit was dated 12/17/2025 with a visit frequency of 2 times a week. There was no documented aide supervision until 01/29/2026. This was day 43 and was 29 days late. This missed 3 fourteen day supervisions. CLINICAL RECORD 3: The first hospice aide visit was dated 12/31/2025 with no supervision documented until 02/23/2026. This was 54 days and was 40 days late. The next supervision was documented 03/12/2026 which was day 17 and was 4 days late. CLINICAL RECORD 6: The first hospice aide visit was dated 11/14/2025 with no supervision documented until 12/15/2025. This was day 45 which was 31 days late. There was no additional supervision documented until 01/06/2026 which was day 22 and was 8 days late. The next supervision documented was dated 01/22/2026 which was day 16 and was 2 days late. There was no additional documentation of supervision documented until 03/18/2026 which was day 26 and was 12 days late. During interview with the nurses on 06/09/2026, it was stated that they thought when they answered “no” to the question of aide supervision that they were documenting that the aide was not present during the visit not that supervision was not done. The attachment for aide supervision was attached every 14 days but they did not understand the question. During interview with the director of nursing and the administrator who reviewed the record, they stated that they would re-education staff and monitor this.”

“It is required that the comprehensive assessment includes consideration of the following factors: Symptoms and symptom severity, including skin integrity. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 19 (5%) records reviewed it was revealed that the hospice agency did not ensure the comprehensive assessment included skin integrity. Document 10: Policy #1-014, titled Comprehensive Assessment (revised November 2021) sub-section one (1) stated in part, “During the comprehensive assessment, all baseline data and other relevant information will be documented in the patient’s clinical record, including at least the following information: (B) An assessment of the severity of secondary symptoms, such as (4) skin integrity. (I) A physical assessment including skin and other relevant data related to the pertinent physical findings and the patient’s terminal illness.” Clinical Record 3: The hospice benefit election date was 4/25/2023. The patient resided in an Assisted Living Facility (ALF). The initial RN assessment dated 4/25/2023 identified a wound. The sub-section integumentary stated in part, “One (1) wound was a stage four (4), and the patient had two (2) wounds of pressure all stages”. Sub-section narrative stated in part, “Wound on the left heel and coccyx. Patient is questioning of RN presence and agitation, and anxiety is present, wound assessment not completed due to this. Staff report coccyx wound is stage four (4)”. The wound was first assessed on 6/12/2023 with a wound assessment tool. A joint record review and interview with the Alternate Administrator (staff 1) on 1/2/2024 confirmed the hospice did not ensure a complete comprehensive initial assessment was performed. The Alternate Administrator stated, “We did not assess the wound for over a month”.”

“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 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, document review, interview and observation. In 1 of 4 (25%) home visit observations where medication reconciliation was completed, by comparing the hospice agency medication profile to the patient’s current regimen, it was revealed that the hospice agency did not ensure the medication profiles were updated accurately and included the patient’s current medication regimen. Document 7: Policy #2-004, titled Medication Profile (revised November 2021) sub-section seven (7) stated in part, “A drug regimen review will be performed at the time of the initial and the comprehensive assessment when updates to the comprehensive assessment are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication.” Home Visit 4: The home visit was conducted on 1/4/2024 in the presence of the Administrator (staff). The hospice benefit election date was 2/6/2023 and the patient (record 11), resided in a Skilled Nursing Facility. The Skilled Nursing Facility (SNF) medication administration record/medication list dated 1/4/2023 stated in part, “Lexapro twenty (20) milligrams (mg). Give one (1) tablet by mouth one time a day. The active order date was 7/28/2023”. The hospice agency medication list did not contain the medication Lexapro. The same medication administration record/medication list stated in part, “Morphine Sulfate twenty (20) milligrams (mg) per milliliter (ml) (20mg/ml). Give zero (0) point (.) two (2) five (5) (0.25) millimeters (ml) every two (2) hours. The active order date was 12/27/2023.” The hospice agency medication profile stated in part, “Morphine Sulfate twenty (20) milligrams (mg) per milliliter (ml) (20mg/ml). Give zero (0) point (.) two (2) five (5) (0.25) millimeters (ml) every three (3) hours. The active order date was 11/13/2023.” The agency medication list dated 1/4/2023 stated in part, “Morphine Sulfate twenty (20) milligrams (mg) per milliliter (ml) (20mg/ml). Give zero (0) point (.) two (2) five (5) (0.25) millimeters (ml) every three (3) hours.” A joint record review and interview with the Alternate Administrator (staff 1) on 1/4/2024 confirmed the hospice agency medication profile was not updated to include the patient’s current medication regimen.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals, and 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, document review and interview. In 3 of 19 (16%) records reviewed it was revealed that the written plan of care did not contain all goals and interventions based on the problems that were identified in the initial assessment. Document 6: Policy #9-017, titled The Plan of Care (revised November 2021) sub-section twelve (12) stated in part, “The written plan of care will contain, but not be limited to the following: (B) Identification of patient/family/caregiver needs including physical, psychosocial, cultural, Spiritual, nutritional, educational and counseling. (G) Nutritional requirements. (L) Individual interventions to assist with end-of-life care. (N) Statement of treatment goals”. Clinical Record 7: The hospice benefit election date was 9/11/2023 and the Certificate of Terminal Illness (CTI) stated in part, “Patient has a suprapubic catheter.” The plan of care dated 9/11/2023-12/9/2023 that did not contain any problems, goals, or interventions related to the suprapubic catheter. Clinical Record 10: The hospice benefit election date was 11/28/2023. The (CTI) stated in part, “Patient has an ileostomy.” The plan of care dated 11/28/2023-2/25/2024 did not contain any problems, goals, or interventions related to the ileostomy. Clinical Record 17: The hospice benefit election date was 6/15/2023. The initial RN assessment dated 6/15/2023 documented in part, “Patient is a new colostomy status times (Xs) one (1) month. Discharged yesterday from a rehab center.” The plan of care dated 6/15/2023-9/12/2023 that did not contain any problems, goals, or interventions related to the colostomy. A joint record review and interview with the Alternate Administrator on 1/4/2024 (staff 1) confirmed the hospice did not ensure the written care plans contained all goals and interventions based on the problems identified in the initial assessments.”

“It is required that a hospice aide provide services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 19 (16%) records reviewed where hospice aide services were accepted it was revealed that the hospice agency did not ensure the hospice aide provided all of the services and tasks that were included in the plan of care. Document 6: Policy #9-017 titled, The Plan of Care (revised November 2021), sub-section stated in part, “The care provided to the patient must be in accordance with the plan of care”. Clinical Record 4: The hospice benefit election date was 2/6/2023. The hospice aide care plan dated 11/3/2023-1/1/2024, stated in part, “Offer fluids.” The hospice aide documented fluids were not offered on 12/21/2023, 12/18/2023, 12/14/2023, 12/11/2023, and 12/7/2023. The record did not contain evidence the hospice aide informed the RN that the intervention not performed. Clinical Record 5: The hospice benefit election date was 9/27/2023. The hospice aide care plan dated 9/27/2023-12/25/2023 and had a hospice aide intervention that stated in part, “Shower every visit.”. The hospice aide documented on 10/21/2023 that they did not complete the shower because the facility had already completed’. The record did not contain evidence the hospice aide notified the RN that the task was not completed. Clinical Record 6: The hospice benefit election date was 11/30/2023. The hospice aide care plan dated 11/30/2023-2/27/2023, stated in part, “Routine ostomy care change gauze around PEG tube on 12/19/2023. The hospice aide documented the intervention was not completed. The record did not contain any evidence that the RN was notified that the intervention was not performed. Interview: A joint record review and interview with the Alternate Administrator on 1/2/2024 (staff 1) confirmed that the hospice aide did not perform all interventions ordered by the Interdisciplinary Group (IDG).”

“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 3 of 19 (16%) records reviewed it was revealed that the hospice agency did not ensure that the patient’s clinical record contained all physician’s orders. Clinical Record 7: The hospice benefit election date was 9/11/2023. The certificate of terminal illness (CTI) stated in part, “Patient has a suprapubic catheter.” The Initial RN assessment dated 9/11/2023 sub-section genitourinary stated in part, “Suprapubic catheter 22 French changed one month ago as stated by the wife.” The RN assessment dated 9/11/2023 indicated a “yes” by the sub-section if there was an order for irrigation and stated, “Normal Saline Flush, twenty (20) ml as needed.” The RN visit note dated 10/6/2023 documented the RN changed the Foley catheter, but the record did not contain a physician’s order changing or flushing a suprapubic catheter. Clinical Record 10: The hospice benefit election date was 11/28/2023. The (CTI) stated in part, “Patient has an ileostomy.” There were no physician orders in the clinical record for ileostomy care. Clinical Record 17: The hospice benefit election date was 6/15/2023. The initial RN assessment dated 6/15/2023 documented under the sub-section genitourinary in part, “Abnormal GI findings, ostomy.” The sub-section titled narrative stated in part, “Patient is a new colostomy status times (Xs) one (1) month. Discharged yesterday from the rehab center.” The CTI dated 6/21/2023 stated in part, “Patient has an ostomy.” The record did not contain any physician orders for ostomy care. In a joint record review and interview with the Alternate Administrator on 1/4/2024, the Alternate Administrator confirmed the records did not contain physician’s orders for care.”