Beacon Hospice of Michigan LP

“Based on record review and interview, the hospice agency failed to produce a plan of care which met the needs of the patient in 1 (P-2) of 19 records reviewed, resulting in the potential for poor clinical outcomes. Findings include: Patient #2 (P‑2) was admitted on 07/12/2026 with diagnoses that included senile degeneration of the brain (unspecified) and heart failure. During the record review on 09/15/2026 at 1:12 PM, it was noted that skilled nursing (SN/Staff‑C) documented in the start of care (SOC) comprehensive assessment that P‑2 had a BiPAP (bilevel positive airway pressure) machine delivering oxygen at 16 liters per minute. However, additional record review showed the following communication notes:07/11/2026 at 4:32 PM by (DME company):”Call hosp to see what type of mask is needed I realized when I was in hospital they gave me the mask to take home I am going to call fam to see if they can getanurse to at least tell the type and size ad hosp agreed to that.” (sic)07/11/2026 at 4:38 PM by (DME company):”Called Fam at hospital the hospital is going to let them take the bi-pap mask home.” (sic)07/11/2026 at 4:52 PM by (DME company):”(Hospice Administrator/Staff‑A) will enter new order for a medium nasal pap mask.” (sic)An interview with Staff‑A was conducted on 09/15/2026 at 3:57 PM to determine whether the new order for the BiPAP mask had been completed before SN/Staff‑C performed the initial comprehensive assessment on 07/12/2026 at 9:15 PM or prior to the patient’s transfer to another hospice agency on 07/13/2026 at 9:54 AM. Staff‑A stated, “No, and we do not use that DME company anymore.” When further questioned, Staff‑A acknowledged that the findings above did not meet agency expectations or its policy referenced below.Agency Policy: “Durable Medical Equipment and Supplies,” Policy No. 2‑018.1 (Revised February 2025) states, “Supplies required for optimal comfort, care, and management of the hospice patient will be obtained from the hospice stock supplies or approved company…””

“Based on record review and interview, the hospice agency failed to verify the needs of the patient could be met prior to hospice admission in 1 (P-2) of 19 records reviewed, resulting in the potential for unmet patient care needs and poor clinical outcomes. Findings include: Patient #2 (P‑2) was admitted on 07/12/2026 with diagnoses that included senile degeneration of the brain (unspecified) and heart failure. During the record review on 09/15/2026 at 2:28 PM, it was noted that the skilled nurse (SN/Staff‑C) documented in the start of care (SOC) comprehensive assessment that P‑2 had a BiPAP (bilevel positive airway pressure) machine delivering oxygen at 16 liters per minute with blood oxygen saturation at 91%. No other oxygen level checks were performed during the assessment and the family of P-2 stated she dropped “down into the 40’s” per complaint intake narrative. No indication was found during record review that the hospice agency was aware of this. Additional record review showed the following communication notes: 07/11/2026 at 4:32 PM by (DME company):”Call hosp to see what type of mask is needed I realized when I was in hospital they gave me the mask to take home I am going to call fam to see if they can getanurse to at least tell the type and size ad hosp agreed to that.” (sic)07/11/2026 at 4:38 PM by (DME company):”Called Fam at hospital the hospital is going to let them take the bi-pap mask home.” (sic)07/11/2026 at 4:52 PM by (DME company):”(Hospice Administrator/Staff‑A) will enter new order for a medium nasal pap mask.” (sic)An interview with Staff‑A was conducted on 09/15/2026 at 3:57 PM to determine whether the new order for the BiPAP mask had been completed before SN/Staff‑C performed the initial comprehensive assessment on 07/12/2026 at 9:15 PM or prior to the patient’s transfer to another hospice agency on 07/13/2026 at 9:54 AM. Staff‑A stated, “No, and we do not use that DME company anymore.” When further questioned, Staff‑A acknowledged that the findings above did not meet agency expectations, and going forward they would not admit or accept a patient until all appropriate DME was verified to be ready for use upon patient return to their home.”

“Observed in Record Review. In 3 of 14 patient records reviewed, it was noted by the nurse surveyor that for RRHV#2, the RN did not visit the hospice patient no less than 15 days to conduct an assessment. The RN visits were 21 days between assessments. For RRNHV#1, the patient had a missed RN visit which resulted in 16 days between RN assessments. For RRNHV#2, RN visits were 18 days apart. An LPN had been seeing all three patients. Findings were verified by the Administrator/Director of Nurses. Observed in Record Review. In 14 of 14 patient records reviewed, for active patients, it was noted by the nurse surveyor that for all records reviewed, the interdisciplinary group meeting notes did not consistently document decline, revisions to plans of care and goals of care. The notes consisted of cutting and pasting from staff visit notes with no documented progress toward goals Findings were discussed with the Administrator/Director of Nursing.”

“Observed in Record Review. In 5 of 14 patient records reviewed, for active patients, it was noted by the nurse surveyor that hospice aide supervisory visits were not documented no less frequently than every fourteen days. For RRHV#1, hospice aide supervisory visits were completed one day late last month (fifteen days apart) and two days late (sixteen days apart) this month. For RRHV#2, hospice aide supervisory visits were completed seven days late (twenty one days apart). For RRHV#3, hospice aide supervisory visits were completed five days late last month (nineteen days apart). For RRNHV#1, hospice aide supervisory visits were three days late last month (seventeen days apart). For RRNHV#2, hospice aide supervisory visits were three days late (seventeen days between supervisory visits). Findings were verified with the Administrator/Director of Nursing.”

“Observed in Tracer Activities. It was noted by the nurse surveyor that volunteers did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff for 2024 and all but two months of 2025. For 2024, the percentage of Volunteer of hours was 0.54%. For 2025, the percentage of volunteer hours was under 3.00% until July and August which were strong months. For the month of September of 2025, it was 0.00%. Findings were verified by the part-time shared Volunteer Coordinator and the Administrator/DON.”

“Observed in Record Review. In 2 of 6 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of RRNHV#4 the medication profile included an order for sliding scale insulin yet the order was incomplete as it did not specify a frequency the sliding scale was to be used. There were no orders for blood glucose monitoring to be used along with the sliding scale insulin, nor was the patient’s diabetes reflected on the plan of care. In RRNHV#6 there were duplicate active orders for Morphine. One order was for Morphine 100mg/5ml (20mg/ml) Give 0.5 ml by mouth every 4 hours as needed for pain/SOB, and another read Morphine 20mg/ml take 5 mg every 3 hours as needed 0.25 ml PO/SL Q3 hrs prn pain. There was an Ativan order that was incomplete that read Ativan 1mg tab, take 1 tablet Q4 as needed for. The order had no indication, and did not specify a frequency beyond Q4 such as minutes, hours, or days. Further, there was documentation that the patient had a wound with treatment, yet there was no wound care order noted on record or included in the plan of care. These observations were reviewed with the Administrator and Regional Director.”

“Observed in Record Review. In 7 of 10 patient records reviewed, the organization failed to ensure the plan of care goals were specific, measurable, realistic, and time-bound. Throughout the patient records reviewed with care plan goals were noted to not be specific, measurable, realistic, and time-bound. For example: in RRHV#1 and example was . Patient maintains highest level of mobility possible. An example in RRHV#3 was continuity of care will be maintained as appropriate to patient/primary caregiver needs. In RRNHV#4 examples were Anxiety/agitation controlled through course of care and patient will be able to demonstrate improved safety awareness as evidenced by:(___). In RRNHV#5 a goal was Decreased s/s exacerbations with medication regimen through certification period. Start Date- 12/19/2023 Target Date - 06/21/2024. Throughout RRNHV#7 there were goals that were non-specific with target dates that were not realistic such as Patient/caregiver verbalize understanding and adhere to measures to maintain adequate nutrition/hydration. Start Date- 12/11/2023 Target Date - 06/22/2024 4. Patient will maintain optimum bowel functioning consistent with food intake and stage of disease process Start Date- 12/11/2023 Target Date - 06/22/2024 and Patient/caregiver verbalize/demonstrate proper wound care/dressing procedures Start Date- 12/11/2023 Target Date - 06/22/2024. Similar goals were noted in RRNHV#8 such as Patient/caregiver will demonstrate understanding of appropriate use of medications for pain and symptom management Start Date: 9/28/2023; Target Date: 6/7/2024. The goal target date to demonstrate use of pain medication was noted to span 9 months. In RRNHV#9 an example was patient nutritional needs will be met as patient condition comfort allows These observations were reviewed with the Administrator and Regional Director. 
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“Observed in Record Review. In 7 of 10 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of RRHV#1 the plan of care included interventions for risk for impaired nutrition and documentation of declining appetite with weight/MAC loss yet there was no goal established for nutrition. There was documentation of a yeast rash in skin folds with medications added for treatment yet there was no integumentary care plan to guide the care. On review of RRHV#2 there were interventions for fall safety and wound care but no goals. There was documentation of a peg tube with feedings but no care plan to reflect the issues. In RRHV#3 the care plan included interventions for pain, impaired mobility, swallowing, skin integrity and respiratory yet no goals established. There were orders for an ultrasound to the neck yet the care was not reflected on the care plan. In RRNHV#4 there were changes in the pain medication regimen but the changes were not reflected in the care plan. There was documentation of a skin tear but no care plan to guide the treatment. In RRNHV#5 there was documentation on a stage 1 wound to the buttocks, but the issue was not reflected in the care plan. In RRNHV#7 the patient had a colostomy yet the gastrointestinal care plan did not reflect its presence. In RRNHV#8 the documentation noted the patient to have nephrostomy tubes and a colostomy yet there were no care plans to guide their care. These observations were reviewed with the Administrator.”

“Observed in Record Review. In 5 of 10 patient records reviewed, the organization failed to assess potential medication-related problems, including duplicate drug therapy. In review of RRHV#2 there were 2 active orders for oxygen, one for 3 lts continuous and another for 5 lts continuous. On review of RRHV#3 the medication profile noted duplicate orders for Lorazepam as one order was started on admission in January for Lorazepam 0.5 mg oral tablet. Take one tablet PO every 4 hours PRN for anxiety. An additional order started day of survey of Ativan 0.5 mg Q4 as needed for anxiety/agitation. In RRNHV#7 there were duplicate orders for pain medications: an order for MS Contin 30 mg tab extended release - give 1 tab by mouth every 12 hours. There was another MS Contin order that noted the same dosage but instead of every 12 hours it specified a frequency of 2 times a day. There were 4 active Morphine orders, 2 active Hydrocodone orders, and 2 active orders for Lorazepam. In RRNHV#8 there were also duplicate medication orders. There were 3 active Lorazepam orders; one order was for 0.5 mg 1 and 1/2 tab 3 times a day at 10, 2, and 6. Another was for Lorazepam 0.5 mg at 10 pm. The 3rd Lorazepam order was for 1 mg 1 tab every 6 hours. Further, there were 2 active orders for Ativan. There were 2 Morphine orders one stated Morphine concentrate 100mg/5ml (20mg/ml) by mouth/under tongue every hour when needed for pain/SOB, another active Morphine order noted to give the same dosage every 3 hours as needed. Multiple active orders for Morphine, and Ativan/Lorazepam were also noted in RRNHV#10. These observations were reviewed with the Administrator. Observed in Record Review. In 5 of 10 patient records reviewed, the organization failed to ensure the plan of care include all medications and treatment necessary to meet the patient’s needs. For example: on review of RRHV#2 there was documentation of a heel wound yet no orders noted on the record for wound care. In RRNHV#4 there was documentation of skin tears yet no physicians orders to treat the skin tears. In RRNHV#5 there was documentation of a stage 1 wound to the buttocks yet no treatment orders. In RRNHV#6 there was an order for tube feeding that was noted to be incomplete reading tube feeding with Nephro supplement 10ml/hr start 4 pm - 8 am there were no further specifics such as flushes, check residual, or tube site care. Most meds were also ordered to be given PO but the patient was ordered pleasure feeds only. In RRNHV#8 the wound care order was incomplete as it stated cleanse with saline, pat dry, apply A&D ointment, ABD pad and tape There was no frequency the care was to be performed or who was to perform the care. These observations were reviewed with the Administrator.”

“Observed in Record Review. In 6 of 10 patient records reviewed, the organization failed to ensure care and services were provided in accordance with the plan of care. For example: on review of RRHV#3 the MSW was ordered a frequency of 1 time a month however documentation and conversation with the social worker noted the visit were being made 2 times a month. In RRHV#4 the social worker was also ordered 1 time a month yet documented visits 2 times a month in April and May. Further, review of RRNHV#4 the RN documented providing wound yet there were no wound care orders included on the plan of care. In RRNHV#5, and RRNHV#9 the Chaplain was ordered 1 time a month yet documented 2 time a month visits. Further, the aide was ordered a frequency of 5 times a week yet in May there was a gap of 8 missed visits. On discussion with the Administrator it was explained that the aide was out and the facility did not want a replacement aide for the time the aide was out yet this was not reflected in the plan of care. In RRNHV#7 the MSW was ordered 1 time a month but documented 2 visits in April, and the Chaplain was ordered 1 time a month and documented 3 visits in April. There were also examples of the Aide and Chaplain not meeting the established plan of care frequency noted in RRNHV#10. These observations were reviewed with the administrator.”

“Observed in Record Review. In 1 of 1 HR files reviewed, the organization failed to ensure that the required elements for the aide competency evaluation was evaluated by observing an aide’s performance of the task with a patient or a pseudo-patient for the required elements of Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other staff - Reading and recording temperature, pulse, and respirations - Appropriate and safe techniques in personal hygiene and grooming that include bed, sponge, tub, or shower bath; sink, tub, or bed shampoo; nail and skin care; oral hygiene; toileting and elimination - Safe transfer techniques and ambulation - Normal range of motion and positioning. On review of HR#4 for the Hospice Aide the initial competency was documented as being evaluated verbally and not per observation. This observation was reviewed with the Regional Director.”

“Observed in Record Review. In 4 of 9 patient records reviewed, with aide services elected, the organization failed to ensure the RN provide written patient care instructions for the hospice aide. On review of RRHV#2 the patient have a peg tube and a wound to the heel yet the aide plan of care did not include instructions on how to handle the tube of wound while providing care. On review of RRNHV#4 the aide plan of care specified a tub bath and a bed bath yet no specific instructions on when to give which bath. In RRNHV#7 the patient had a foley catheter and a colostomy yet no instructions for the aide to know how to handle while providing care. In RRNHV#8 the patient had nephrostomy tubes and a colostomy yet there was no reflection of their presence with instructions for handling during care on the Aide’s care plan. These observations were reviewed with the Administrator.”