Heart to Heart Hospice of Mid-Michigan, LLC

“It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient’s attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by clinical record review, document review, and interviews with the Clinical Manager and Regional Manager, which revealed the hospice: Failed to ensure that each patient’s written plan of care included planned interventions based on problems identified in the initial and updated comprehensive assessments in 6 of 14 (43%) clinical records reviewed [HCPC.21.I/L545]. 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 418.56: Interdisciplinary group, care planning, and coordination of service. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the hospice agency.”

“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, document review, and interview. Agency policy #TX.06 stated in part, “The plan of care must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments.” In 6 of 14 (43%) clinical records reviewed, the agency did not ensure that the plan of care documented all individualized interventions for problems identified in the initial and updated comprehensive assessments. Clinical Record 2: The patient elected the hospice benefit on 04/30/2024 with a diagnosis of congestive heart failure (CHF). The patient was admitted with oxygen of 2-4 liters continuously. The initial plan of care, dated 04/30/2024, ordered oxygen as needed and documented the patient’s goal was to verbalize oxygen safety. The initial and updated plans of care did not include documentation of interventions specific to oxygen safety instruction. Additionally, the nursing assessment visit note dated 05/01/2024 identified that the patient had a history of suicide risk, and the daughter and patient were fearful of having morphine in the house related to this. The plan of care did not document interventions related to the patient’s history of suicide risk as of the patient’s revocation for aggressive treatment on 05/06/2024. Clinical Record 3: The patient elected hospice care on 05/12/2024. The initial comprehensive assessment documented that the patient was not always compliant using their oxygen, the patient had a fall while going out to smoke, and on the CTI (certificate of terminal illness), the physician documented the patient was non-compliant with oxygen. The initial POC documented the patient intervention: “The SN will educate the patient and wife on oxygen safety.” The intervention was not individualized to what the patient may need for oxygen safety related to the non-compliance. Clinical Record 7: The patient elected hospice care on 08/18/2023 with a diagnosis of CHF. On 01/02/2024, the patient’s diagnosis was updated to include COVID-19 positive. The patient was started on oxygen at 2-4 liters on 01/02/2024. The updated plans of care dated 01/11/2024 and 01/25/2024 did not include documentation of interventions or goals for oxygen safety. Clinical Record 8: The patient elected hospice care on 07/26/2024 with a diagnosis of CHF. The patient resided in a skilled nursing facility (SNF). The initial comprehensive assessment identified diabetes as a risk for infections. The follow-up comprehensive assessments dated 08/06/2024 and 09/24/2024 documented blood sugars being checked by the facility, with the highest of 270 but usually 120 -150. As of the review on 10/23/2024, there were no documented interventions for blood sugar monitoring or diabetes on the plan of care. Clinical Record 10: The patient elected hospice care on 02/29/2024 with diagnoses: end-stage renal disease and urinary tract infections (UTI). The updated nursing comprehensive assessment dated 10/10/2024 documented that the patient started oxygen 10/10/2024 for increased shortness of breath. The plan of care was not updated to include documentation of interventions and goals for oxygen safety as of the review on 10/23/2024. Clinical Record 14: The patient elected hospice care on 06/21/2024 with a diagnosis of Alzheimer’s disease. The updated nursing comprehensive assessments dated 07/22/2024 documented a blood sugar range of 179-293; 08/22/2024 documented a blood sugar range of 80-122; 09/09/2024 documented a blood sugar range of 164 - 334, and 10/08/2024 documented a blood sugar of 201. The updated plans of care did not include documentation of interventions or goals for blood sugar monitoring or management. During an interview and a joint record review, the Clinical Manager and Regional Manager stated that the interventions for oxygen were not documented or for diabetes but that the patient handbook did have oxygen information that likely was used.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the nterdisciplinary Group. The 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, personnel record review, and interview. In 1 of 14 (7%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that the HA received written instructions to meet the patient’s needs. Clinical Record 8: The patient elected hospice care on 07/26/2024 with a diagnosis of congestive heart failure (CHF). The patient resided in a skilled nursing (SNF). The HA care plan dated 07/26/2024 and updated 09/03/2024 and 09/16/2024 assigned the HA the relevant task of using the Hoyer Lift every visit. The skilled nursing (SN) assessment dated 08/06/2024 documented that the patient was a “3-person assist for a Hoyer transfer related to patient anxiety.” The nursing assessments completed through 10/23/2024 documented that the patient was a “3-person assist for a Hoyer transfer.” The HA documented the transfer per Hoyer lift but did not document if others assisted. There was evidence that the HA was competent to use the Hoyer lift. The HA care plan did not reflect the 3-person assist for the Hoyer lift transfer. During the interview, the Clinical Manager stated that the HA care plan would be updated to include the “3-person assist for a Hoyer transfer.””

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of: the hospice discharge summary described in HCDT 40. I; and the patient’s record, if requested. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #PE.3 stated in part, “If the care of a patient is transferred to another Medicare/Medicaid-certified facility, the Agency will forward copies of the following to the receiving facility: The discharge summary which includes but is not limited to: a summary of the patient care, the patient current plan of care, including the current medications profile, the latest physician orders; and any other documentation requested.” In 1 of 1 (100%) clinical records reviewed of patients discharged to a facility, the agency did not ensure that the discharge summary was sent to the facility, Clinical Record 3: The patient elected hospice care on 05/21/2024 with a diagnosis of congestive heart failure (CHF). The patient fell on 06/15/2024 and was sent via ambulance to a hospital that did not contract with the hospice. The patient was discharged from the hospice on 06/16/2024. There was no documentation of the discharge summary being sent to the facility as of review 10/22/2024. During an interview and a joint record review, the Clinical Manager stated that the triage nurse spoke to the hospital several times about the patient but did not send the discharge summary.”

“It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IID representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed of patients who resided in a skilled nursing facility (SNF), the agency did not ensure that the plan of care identified the care and services that were needed and specified which provider was responsible for performing the functions that were agreed upon and included in the plan of care. Clinical Record 8: The patient elected hospice care on 07/26/2024 with the diagnosis of Congestive heart failure (CHF). The patient resided in a SNF. The initial comprehensive assessment identified diabetes as a risk for infections. The follow-up comprehensive assessments dated 08/06/2024 and 09/24/2024 documented that blood sugars were checked by the facility with the highest of 270 but usually 120 -150. The plan of care did not document interventions for blood sugar monitoring or who would perform the blood sugar monitoring and reporting as of the review on 10/23/2024. During an interview and a joint record review, the Clinical Manager confirmed that the interventions for blood sugar monitoring were not documented in the plan of care.”