West Michigan Hospice, LLC

“Based on record review and interview, the Hospice agency failed to develop and maintain a complete Emergency Preparedness communication plan, resulting in the agency’s inability to ensure the coordination of patient care during an emergency/disaster and the potential to negatively affect the health and safety of all patients receiving services. Findings include: On 2/18/26, review of the agency’s emergency preparedness documentation concerning its Communication Plan (CP) noted a failure to document how the agency would coordinate patient care within the facility and across other healthcare providers. The CP also failed to have documented evidence of how the agency would interact and coordinate with emergency management agencies and systems to protect patient health and safety in the event of a disaster. Further, the CP contained no language or process of how any staff member would communicate and coordinate the support of patient care needs within the agency and other healthcare providers during an emergency/disaster. The findings above were reviewed and acknowledged by the Administrator (Staff-A) and Clinical (Staff-B) during an interview on 2/18/26 at 3:20 PM.”

“Based on record review and interview, the agency failed to ensure emergency preparedness training was provided to staff every 2 years for 5 (Staff A, Staff B, Staff C, Staff F, and Staff G) of 5 employees hired in 2023 or after, resulting in the potential for an unprepared staff response in the event of an emergency. Findings include: During review of personnel files on 2/18/26 at 1:30 PM, the director of clinical services (Staff B) was asked to provide evidence of ongoing emergency preparedness (EP) training (every 2 years) for 5 staff hired since 2023 (Staff A, Staff B, Staff C, Staff F, Staff G). Upon further review of the personnel files, it was determined there was no evidence of ongoing EP training for any employees.During an interview with the administrator (Staff A) on 2/18/26 at 1:39 PM, Staff A was asked about ongoing EP training. Staff A stated he did not think EP was included in their annual in-service list and acknowledged the findings at the time of interview.”

“Based on record review and interview, the Hospice agency failed to provide documentation that it had participated in the community-based, full-scale exercise required every two years, resulting in the potential for patients and staff not to be properly prepared in the event of an actual emergency. Findings include: On 2/18/26, review of the agency’s emergency preparedness binder found no evidence that the Hospice agency had conducted the required full-scale community-based exercise every two years. No communication or effort was noted by the Agency in reaching out to the local incident command center to participate in the community-based exercise for the last 3 years. The above findings were reviewed with and acknowledged by the Administrator (Staff-A) and Clinical Director (Staff-B) during an interview on 2/18/26 at 3:22 PM.”

“Based on record review and interview, the agency failed to ensure the drug profile included all patient medications for 3 (P-2, P-3, P-10) of 16 records reviewed and review of all medications for significant drug interactions for 2 (P-15 and P-16) of 16 records reviewed, resulting in the potential for harmful drug interactions. Findings include: Patient #15’s (P-15) Start of Care (SOC) was dated 1/30/25. The Plan of Care (POC) identified a terminal diagnosis of Nonalcoholic Steatohepatitis. During record review on 2/17/26, it was noted that the “Medication Interaction” report within the EMR (Electronic Medical Record) noted 1 Drug-Drug interactions with “Severity: Major” interaction between Paroxetine and Tramadol. There was no documented evidence that a drug review was completed per the policy. Patient #16’s (P-16) Start of Care (SOC) was dated 10/24/25. The Plan of Care (POC) identified a terminal diagnosis of Nasal Cancer. During record review on 2/18/26, it was noted that the “Medication Interaction” report within the EMR (Electronic Medical Record) noted 1 Drug-Drug interactions with “Severity: Major” interaction between Tramadol and Trazodone. There was no documented evidence that a drug review was completed per the policy. A review of the agency policy occurred on 2/19/26 titled “Medication Monitoring” (Revised June 2019). The policy states, “Procedure: 2. A Registered nurse reviews all of the patient’s prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy on an ongoing basis. This review is done in collaboration with other IDG members which may include a physician, and/or pharmacist during the IDG meeting and whenever needed. This review includes, but is not limited to: Actual or potential drug interactions.”The Administrator (Staff-A) and Director of Clinical Services (Staff-B) reviewed and acknowledged the findings listed above in an interview on 2/19/26 at 2:00 pm. Patient #10 (P-10) was admitted to this hospice agency on 2/1/24 with the terminal diagnosis of senile degeneration of the brain. During a joint home visit on 2/17/26 at 1:00 PM, a medication list was requested from the medication passer at the assisted living facility where P-1 resided. Upon comparison of the medications listed on the plan of care and the medications listed from the facility, it was determined there were 2 medications (“anti-diarrheal 2 mg caplet” and “atropine 1% eye drops”) that were on the list from the assisted living facility but were not on the most recent plan of care. Additionally, the plan of care dated 1/21/26 indicated “*Added O2 at 2L” on 1/6/26. Upon further review of the medication profile, it was determined oxygen was not listed.A review of agency policy titled “Medication Reconciliation” (revised June 2019) revealed, “Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication.”The administrator (Staff A) and the director of clinical services (Staff B) reviewed and acknowledged the findings during an interview on 2/19/26 at 11:00 AM. Patient #2 (P-2) was admitted to this hospice facility 1/15/26 with the terminal diagnosis of malnutrition. Review of records on 2/18/26 concluded that the patient required oxygen therapy. Documentation to support the findings includes: Hospice Plan of Care and Certificate of Terminal Illness (CTI) for episode 1/14/26-4/13/26, included the narrative, “recent hospitalization and sub-acute rehab stay due to aspiration pneumonia in December…. required oxygen and been unable to wean…”HOPE (Hospice Outcomes and Patient Evaluation) Assessments dated 1/15/26 and 1/22/26 26 included documentations under the “O2” assessment O2: “Yes” Liters/Min: “2” … Via-NC/other: “NC”.Skilled Nursing (SN) visits (1/16/26, 1/29/26, 2/5/26, and 2/12/26) include documentation of “Oxygen 2 LPM” (liters per minute) and checked boxes for “continuous” and “Nasal Cannula” in the Respiratory/Pulmonary Status assessment. Review of the Hospice Plan of Care was void of an order for oxygen. Upon further review of the medication profile dated 1/15/26 it was determined that oxygen was not listed. Patient #3 (P-3) was admitted to this hospice facility 12/29/26 with the terminal diagnosis of malnutrition. The review of records on 2/18/26 revealed documentation of “Oxygen marked “PRN” (as needed) and Oxygen Via: “Nasal Cannula”, in 5 of 5 SN visit notes reviewed (1/6/26,1/27/26, 2/3/26, 2/10/26, 2/17/26). Review of the plan of care was void of an order for oxygen. Upon further review of the medication profile dated 12/30/26 it was determined that oxygen was not listed. The Agency Administrator (Staff-A) and Clinical Director (Staff-B) reviewed and acknowledged the findings during an interview on 2/19/26 at 13:00 PM.”

“Based on record review and interview, the hospice failed to ensure the Initial Bereavement Assessment (IBA) included the identification of the potential bereaved individuals, and the social, spiritual and cultural factors that may impact their ability to cope with the patient’s death in 13 (P-1, P-2, P-3, P-4, P-5, P-7, P-9, P-11, P-12, P-13, P-14, P-15, and P-16) of 16 patients, resulting in the potential for ineffective grieving and lack of bereavement support for the family members, caregivers and others that may be affected upon the patient’s death. Findings include: Patient #9’s (P-9) Start of Care (SOC) was dated 1/9/26. The Plan of Care (POC) identified a terminal diagnosis of Prostate Cancer. During record review on 2/18/26, it was noted that a bereavement risk assessment was not completed. The agency failed to assess potential bereaved per policy. Patient #15’s (P-15) Start of Care (SOC) was dated 1/30/25. The Plan of Care (POC) identified a terminal diagnosis of Nonalcoholic Steatohepatitis. During record review on 2/17/26, it was noted that the bereavement risk assessment was completed by the Chaplain on 2/3/25 for the patient’s daughter. The MSW completed an assessment on 1/31/25 stating, “…P-15 currently lives in the ALF (Assisted Living Facility) portion of ALF with her husband…Daughter confirmed that P-15 has a medical DPOA (Durable Power of Attorney) and that is her and her 2 siblings…” The bereavement risk assessment failed to include the patient’s husband and other 2 siblings. Patient #16’s (P-16) Start of Care (SOC) was dated 10/24/25. The Plan of Care (POC) identified a terminal diagnosis of Nasal Cancer. During record review on 2/18/26, it was noted that the bereavement risk assessment was completed by the Chaplain on 11/3/25. The bereavement assessment contained no documentation on who was assessed and was blank under the background information for relationship and emergency contact. The referral documented, “Emergency Contacts: Spouse, Daughter, Daughter.” The bereavement risk assessment failed to include the patient’s spouse and other 2 daughters. The Administrator (Staff-A) and Director of Clinical Services (Staff-B) reviewed and acknowledged the findings listed above in an interview on 2/19/26 at 2:00 pm. Patient #11 (P-11) was admitted to this hospice facility on 1/30/26 with the terminal diagnosis of Parkinson’s disease. During record review on 2/18/26, it was noted the initial bereavement assessment only listed P-11’s spouse. Upon further review of the record, it was determined P-11 had a son and a daughter listed on the consent paperwork dated 1/30/26 as other individuals involved in his care.Patient #12 (P-12) was admitted to this hospice agency on 11/22/25 with the terminal diagnosis of pancreatic cancer. During record review on 2/18/26, it was noted the initial bereavement assessment only listed “Richard” (relationship to P-12 was not documented). Upon further review of the record, it was determined the social worker documented on the plan of care dated 11/22/25 that P-12 lived with one of his daughters and had another daughter who was active in his care.Patient #13 (P-13) was admitted to this hospice agency on 1/6/26 with the terminal diagnosis of senile dementia of the brain. During record review on 2/18/26, it was noted the initial bereavement assessment only listed P-13’s daughter. Upon further review of the record, it was determined another person was listed as her durable power of attorney (DPOA) and a son was listed as a back-up. Additionally, the social work evaluation dated 1/12/26 indicated P-13 had a niece who was present and involved in her care.Patient #14 (P-14) was admitted to this hospice agency on 10/22/25 with the terminal diagnosis of colon cancer. During record review on 2/18/26, it was noted the initial bereavement assessment only listed P-14’s daughter. Upon further review of the record, it was determined the social work evaluation dated 10/22/25 indicated P-14 lived with his son and his niece was his DPOA.The initial bereavement assessment failed to assess all individuals potentially affected by the death of the patient.The administrator (Staff A) and director of clinical services (Staff B) reviewed and acknowledged the findings during an interview on 2/19/26 at 11:00 AM. Patient #5 (P-5): The patient’s hospice start of care (SOC) was on 11/25/25, with a terminal diagnosis of lung cancer with metastasis (spreading) to the brain. Record review on 2/17/26 noted the IBA was void of any names of family members or close friends qualifying for bereavement services and 14 of 17 assessment areas were left blank. Examples include: “Are there any conflicts between family members; Has there been previous experience dealing with loss; Is the bereaved individual being treated for anxiety, depression, or other mental illness?” In addition, during a joint home visit with skilled nursing services on 2/17/26, it was revealed during an interview at 12:23 PM that P-5’s husband, son and daughter-in-law are very important to her as care givers and emotional support on a frequent basis. Patient #7 (P-7): This patient’s hospice SOC date was 1/13/26, with a terminal diagnosis of protein calorie malnutrition, dementia, chronic kidney disease stage 4, and heart disease. Record review on 2/18/26 noted the IBA mentioned P-7’s husband but was void of other family members or close friends qualifying for bereavement services and 14 of 17 assessment areas were left blank. Examples include: “Are there any health concerns affecting the family; Has there been previous experience dealing with loss; Is the bereaved individual being treated for anxiety, depression, or other mental illness?” Further record review noted the following documentation from Social Work services: “Their younger daughter visits approximately twice per week, often stopping by after work and on Saturdays and Sundays. Their older daughter is currently undergoing cancer treatment and medication. Social Work provided empathy and emotional support as (P-7’s husband) shared about his daughter’s illness.” The IBA failed to comprehensively assess all individuals that would be significantly impacted by the death of the patient. The above findings were reviewed with and acknowledged by the Administrator (Staff-A) and Clinical Director (Staff-B) during an interview on 2/19/26 at 1:47 PM. Both further noted this did not meet agency expectations or its policy referenced below.Agency Policy: “Bereavement Services” 4.26.1 (Revised June 2019) stated, “An initial Bereavement Risk Assessment will be performed as a part of the Comprehensive Assessment. The services are available to assist the patient and family in minimizing stress and problems that arise from the terminal illness, related conditions and the dying process.” Patient #1 (P-1) was admitted to this hospice facility 1/29/26 with the terminal diagnosis of corticobasal degeneration (progressive brain cell death). During record review on 2/17/26, the initial bereavement assessment (IBA) only listed P-1’s spouse and was void of other family members or close friends qualifying for bereavement services. Additionally, 18 out of 31 assessment areas were left blank. For example, “List other family members requiring care; Time since diagnosis; Has there been previous experience dealing with loss; Is the bereaved individual being treated for anxiety, depression, or other mental illness?” Further review of the medical social worker evaluation dated 1/28/26 indicated that P-1 had six children (5 daughters and 1 son), a caregiver and a “lady who comes to read to her every Thursday.” Patient #2 (P-2) was admitted to this hospice facility 1/15/26 with the terminal diagnosis of malnutrition. During the record review on 2/18/26, the IBA dated 1/20/26 was not completed and included the comment: “I had a brief text correspondence (only one brief reply from daughter) without additional follow up despite daughter’s message indicating that she would follow up again by this week. Unable to perform bereavement assessment.” At the time of the review, the record was void of documentation of further attempts to complete the bereavement assessment.Patient #3 (P-3) was admitted to this hospice facility 12/29/25 with the terminal diagnosis of malnutrition. During record review on 2/18/26, the IBA only included P-3’s daughter-in-law and was void of other family members or close friends qualifying for bereavement services. Additionally, 18 out of 31 assessment areas were left blank. For example, “List other family members requiring care; Time since diagnosis; Has there been previous experience dealing with loss; Is the bereaved individual being treated for anxiety, depression, or other mental illness; Is the bereaved individual involved in the care of the patient?” Further review of the medical social worker evaluation dated 12/31/25 indicated that P-3 resides with her son, daughter-in-law, and spouse.Patient #4 (P-4) was admitted to this hospice facility 11/15/24 with the terminal diagnosis of Alzheimer’s. Review of the initial bereavement assessment dated 11/15/24 only included P-4’s daughter and commented that P-4’s “… son’s may have more complicated grief d/t (due to) their closer relationship and more chaotic social circumstances.” During the home visit 2/18/26 it was observed that P-4 resides with her spouse.The IBA failed to comprehensively assess all individuals that would be significantly impacted by the death of the patients.The above findings were reviewed with and acknowledged by the Administrator (Staff-A) and Clinical Director (Staff-B) during an interview on 2/19/26 at 12:47 PM.”

“Based on record review and interview, the agency failed to ensure a registered nurse was a member of the interdisciplinary group in 1 (P-9) of 16 records reviewed, resulting in uncoordinated care and the potential for unmet care needs. Findings include: Patient #9’s (P-9) Start of Care (SOC) was dated 1/9/26. The Plan of Care (POC) identified a terminal diagnosis of Prostate Cancer. During record review on 2/18/26, it was noted that Registered Nurse failed to document within the “Hospice IDT Meeting Report” for the meeting dated 1/14/26. The registered nurse documented two completed visits: 1/9/26 and 1/13/26. The agency failed to incorporate a registered nurse as a member of the IDT. The Administrator (Staff-A) and Director of Clinical Services (Staff-B) reviewed and acknowledged the findings listed above in an interview on 2/19/26 at 2:00 pm.”

“Based on record review and interview, the agency failed to ensure the patient/caregiver(s) received education and training as ordered in the plan of care (POC) in 1 (P-6) of 16 records reviewed, resulting in the potential for unrecognized hazards and patient suffering. Findings include: Patient #6 (P-6): was admitted to this hospice agency on 5/15/25, with a terminal diagnosis of lung cancer with metastasis (spreading) to the brain. Record review on 2/18/26 noted the following POC order: “Skilled nurse to teach and instruct: Signs and symptoms of UTI (urinary tract infection), ... Signs and symptoms to observe and report to nurse or MD, ... Fall Precautions/Transfer safety, ... Emergency Information.” Further record review of the 7 skilled nursing (SN) visits dated 1/5/26 through 2/16/26, noted all 7 visits documented the following on: “Education Provided: Patient Education: none. Caregiver Education: none.” No evidence was found within any of the 7 SN visit notes that any education or training had been provided as ordered.The above findings were reviewed with and acknowledged by the Administrator (Staff-A) and Clinical Director (Staff-B) during an interview on 2/19/26 at 1:37 PM.”

“Based on record review and interview, the agency failed to ensure the plan of care (POC) included all services to be provided to the patient in 1 (P-10) of 16 patients reviewed; and failed to include pertinent safety measures to protect all individuals against injury in 1 (P-5) of 16 patients reviewed, resulting in the potential for unapproved services being rendered and an unsafe patient environment. Findings include: Patient #10 (P-10) was admitted to this hospice agency on 2/1/24 with the terminal diagnosis of senile degeneration of the brain. During record review on 2/17/26, it was noted the patient received visits from a volunteer on 9/5/24, 10/4/24, 11/1/24, and 11/27/24. Upon review of the plans of care dated 7/30/24 and 9/28/24 (surrounding the volunteer visits), it was determined volunteer services were not listed on either.During an interview with the administrator (Staff A) and the director of clinical services (Staff B) on 2/19/26 at 11:00 AM, Staff A stated the volunteer services “should be on the plan of care.” Staff A and Staff B acknowledged the findings at the time of interview. Patient #5 (P-5): was admitted to this hospice agency on 11/25/25, with a terminal diagnosis of lung cancer with metastasis (spreading) to the brain. Record review on 2/17/26 found that the POC included an “oxygen concentrator with backup, oxygen tubing, and portable oxygen.” However, under “Safety Measures” the only risk factor listed pertained to patient falls. No oxygen precautions were found under P-5’s “Safety Measures”.The above findings were reviewed with and acknowledged by the Administrator (Staff-A) and Clinical Director (Staff-B) during an interview on 2/19/26 at 1:27 PM.”

“Based on record review and interview, the Hospice agency failed to ensure that the Plan of Care (POC) included patient specific measurable goals as required in 4 (P-5, P-6, P-7 and P-8) of 16 records reviewed. Findings include: Patients #5 - #8 (P-5 through P-8): During record review from 2/17/26 through 2/19/26, it was noted that the POC’s were generic and not measurable as required. Subsequently, progress made (or lack of) could not be tracked and trended to enable Hospice staff to accurately perform an objective evaluation of the patient’s progress concerning the specified goal. The scope of non-measurable goals corresponded as follow: P-5 (21 of 21 goals); P-6 (19 of 19 goals); P-7 (19 of 19); and P-8 (27 of 27). These non-measurable goals concerned patient care related items such as spiritual needs, coping skills, pain control, skin integrity, medication safety, among others.The above findings were reviewed with and acknowledged by the Administrator (Staff-A) and Clinical Director (Staff-B) during an interview on 2/19/26 at 1:53 PM.”

“Based on observation, interview, and record review the Hospice agency failed to share information and coordinate patient needs between disciplines and the physician in 3 (P-2, P-4, P-6) of 16 records reviewed, resulting in the potential for unmet urgent care needs and poor clinical outcomes. Findings include: Patient #6 (P-6): was admitted to this hospice agency on 5/15/25, with a terminal diagnosis of lung cancer with metastasis (spreading) to the brain. Record review on 2/19/26 found a visit note dated 2/18/26 by home health aide (HHa) services. The HHa (Staff J) documented under “Comments” the following: “Patient stated she was very shaky and chest palpitations- called staff and had them evaluate her. She hadn’t had breakfast yet that morning.”This finding was reviewed with and acknowledged by the Administrator (Staff-A) and Clinical Director (Staff-B) during an interview on 2/19/26 at 1:35 PM. Both further acknowledged that the Hospice agency had no documented follow-up evaluation or physician notification concerning the above finding. Staff B was noted when asked that this did not meet agency expectations for coordinating care services. Patient #2 (P-2) was admitted to this hospice facility 1/15/26 with the terminal diagnosis of malnutrition. During the record review on 2/18/26 of the Hospice Plan of Care and Certificate of Terminal Illness (CTI) for episode 1/14/26-4/13/26, included the narrative, “…recent hospitalization and sub-acute rehab stay due to aspiration pneumonia… dietary requirements have changed, now only able to tolerate thickened liquids”. Further review concluded a lack of coordination of care of P-2’s safety needs of aspiration precautions, evidenced by:The HOPE (Hospice Outcomes and Patient Evaluation) Assessment dated 1/15/26 marked aspiration precautions. However, the Plan of Care (POC) was void of documented safety measures of aspiration precautions.The aide care plan did not include the communication of P-2’s risk for aspiration or safety measures of aspiration precautions.POC ordered “1.) RN to monitor appetite, oral intake and signs of dysphagia or aspiration…” and ordered diet “general diet-as tolerated”.Skilled Nursing (SN) visits (1/16/26, 1/29/26, 2/5/26, and 2/12/26) assessment of appetite documented “poor”, and void of the assessments of oral intake and signs of dysphagia or aspiration.Further review of SN visits found no documentation that SN provided education to P-2/caregiver the signs of dysphagia or aspiration, with 5 of 5 documented caregiver education to include: “Medication application, Hospice goals, Patient goals, Comfort pack”.Patient #4 (P-4) was admitted to this hospice facility 1/9/26 with the terminal diagnosis of Alzheimer’s. Review of records on 2/18/26 noted a Patient Communication Log dated 2/1/26 that documented the agency received a text from the staff where P-4 resides, an assisted living facility (ALF). Communication noted that P-4 fell and stated “…texted RN that pt had a fall. No signs or symptoms of pain reported…”. Further review the aide POC dated 1/9/26 did not include safety measures of fall precautions. Whereas the Hospice Plan of Care included fall precautions. No documented updated aide POC or communication notifying the aide of the fall was found during the record review. The 2/11/26 interdisciplinary meeting had no documented mention of the reported fall 2/1/26. Additional evidence supporting the lack of care coordination was observed during the home visit observation 2/18/26. It was observed that while the agency aide (Staff-D) transferred P-4 from the wheelchair to the shower chair, no gait belt or non-slip socks/shoes were utilized. During the transfer Staff-D lifted P-4 by the waist and underarms. P-4 required full assistance related to stiff/rigid upper and lower extremities Staff-D was queried if a gait belt is typically used for transfer. Response “Oh she does not have one in her room”.The Agency failed to ensure communication and care was coordinated among team members concerning significant safety needs of the patients. The Agency Administrator (Staff-A) and Clinical Director (Staff-B) acknowledged the findings during an interview on 2/19/26 at 13:00 PM, which did not meet agency expectations or their policy referenced below.A review of agency policy titled Title “IDG Care Planning Process” (Revised June 2019), revealed, “4. A registered nurse that is a member of the IDG is designated to provide coordination of care and to ensure continuous assessment of each patient’s and family’s needs and implementation of the IDG plan of care”.”

“Based on record review and interview, it was determined that the Hospice agency failed to ensure its Governing Body approved the frequency and detail of the data collection used for the Quality Assurance Performance Improvement (QAPI) program which is needed to monitor trends for measurable improvement in patient care quality indicators. Findings include: On 2/18/26, review of the Governing Body meeting minutes for 2025 noted that there was no evidence that the data collection plan for the QAPI program had been presented to and approved by the Governing Board as required. The above findings were reviewed with and acknowledged by the Administrator (Staff-A) and Clinical Director (Staff-B) during an interview on 2/19/26 at 1:13 PM.”

“Based on record review and interview, the agency failed to ensure skilled nursing provided follow-up in 1 (P-10) of 16 patients reviewed, resulting in the potential for poor patient outcomes. Findings include: Patient #10 (P-10) was admitted to this hospice agency on 2/1/24 with the terminal diagnosis of senile degeneration of the brain. During record review on 2/17/26, it was noted a hospice aide visit note dated 2/13/26 stated, “Skin concerns on bottom, hip, and leg reported to RN.” Upon review of the next skilled nursing note dated 2/16/26, it was determined the nurse failed to document assessment of the skin problems reported by the aide.The administrator (Staff A) and director of clinical services (Staff B) reviewed and acknowledged the findings during an interview on 2/19/26 at 11:00 AM.”

“Based on record review and interview, the agency failed to maintain documentation to demonstrate hospice aide training requirements were met for 1 (Staff H) of 3 hospice aides reviewed, resulting in the potential for delivery of untrained services. Findings include: During review of personnel files on 2/18/26 at 1:30 PM, the director of clinical services (Staff B) was asked to provide evidence of hospice aide training for Staff H. During review of the personnel file for Staff H, it was determined Staff H was not registered as an aide with the Michigan Department of Licensing and Regulatory Affairs (LARA). At 1:40 PM, the administrator (Staff A) was asked for evidence of the required aide training for Staff H. Staff A stated “she has done her competencies” with the agency upon hire, however, he did not have evidence of her initial 75 hours of training, including 16 hours of classroom time. At 3:45 PM, Staff B sent a text to Staff H to see if she was able to provide evidence of her completed aide training program.On 2/19/26 at 9:35 AM, Staff A and Staff B were asked if they had received anything from Staff H. Staff A stated that Staff H sent pictures of some completion certificates for review. Upon review of the certificates, it was determined they did not provide evidence of her initial aide training program per the requirements of the regulation. At 10:05 AM, Staff A stated he talked to one of Staff H’s previous employers to see if she could provide the evidence, however, that person was out sick and would be gone for a while. At 11:30 AM, Staff A and B were asked again for an update. Staff A and Staff B stated they had no additional information at that time and that they would let surveyors know if they received anything else from Staff H.A review of agency policy titled “Hospice Aide Services and Training Program” (revised June 2019) revealed, The Hospice Aide training program must address each of the following subject areas through classroom and supervised practical training totaling at least 75 hours, with at least 16 hours devoted to supervise practical training. The individual being trained must complete at least 16 hours of classroom training before beginning the supervised practical training.” The policy also stated, “Documentation is maintained to demonstrate that the training requirements are met and includes: A description of the training/competency evaluation program, including the qualifications of the instructions; A record that distinguishes between skills taught at a patient’s bedside with supervision, and those taught in a laboratory using a real person (not a mannequin) and indicators of which skills each aide was judged to be competent; How additional skills (beyond the basic skills listed in the regulation) are taught and tested...”No additional documentation was provided by Staff A or Staff B by the time of exit on 2/19/26 at 3:00 PM and Staff A and Staff B acknowledged the findings.”

“Based on record review and interview, the agency failed to ensure the hospice aide only provided services as ordered in the plan of care in 1 (P-10) of 16 patients reviewed, resulting in the potential for delivery of unapproved services. Findings include: Patient #10 (P-10) was admitted to this hospice agency on 2/1/24 with the terminal diagnosis of senile degeneration of the brain. During record review on 2/17/26, it was determined the aide care plan included the tasks of shampoo, skin care, mouth/denture care, foot care, range of motion (ROM) exercise (per PT/OT), and reposition in bed. Upon review of 7 hospice aide visit notes dated from 1/23/26 through 2/13/26, it was determined the notes included additional tasks that were completed in the narrative section including dressing, brief change, and cream to bottom. These tasks were not listed on the aide care plan.A review of agency policy titled “Hospice Aide Services and Training Program” (revised June 2019) revealed, “The duties of the Hospice Aide are to provide services that are ordered by the IDG, included in the plan of care and are permitted to be performed by applicable state(s) laws and are consistent with Hospice Aide training.”During an interview with the administrator (Staff A) and the director of clinical services (Staff B) on 2/19/26 at 11:00 AM, Staff A stated he wasn’t sure why the aide did that as it was not typical of her. Additionally, during the interview, Staff B was asked for evidence of physical or occupational therapy (PT/OT) instruction in the ROM exercises as noted on the aide care plan. Staff B stated there was no involvement of a PT or OT. Staff A and Staff B acknowledged the findings at the time of interview.”

“Based on interview and record review, the agency failed to provide a completed volunteer plan of care in 2 of 4 (P-21 and P-22) records reviewed in which the agency documented volunteer services were provided. Patient # 21 (P-21): A review of the clinical record revealed a Hospice Volunteer Note completed 7/1/24 by Staff-C the Volunteer Coordinator. The “Volunteer Hours Log” documented that P-21 received volunteer services on 7/1/24 by someone other than Staff-C. No defined plan of care for volunteer services was found in the clinical record. Patient # 22 (P-22) was listed on the “Volunteer Hours Log” as receiving volunteer services on 7/22/24. A review of clinical record revealed a Hospice Volunteer Assessment dated 7/22/24 was performed. The assessment was found to be missing documentation under the General Patient Assessment Information section. Under this section of the assessment the following patient clinical information was not obtained: the patient’s activity status, safety precautions, communication needs, and the patient’s preferences.The documented service requested was “Companionship”, no frequency for this service was documented. No documentation of a defined plan of care for the volunteer services was found in the clinical record. During the interview with Staff-A on 2/19/26 at 12:05 PM, the findings above were reviewed. Staff-A reviewed P-21 and P-22’s records and reported he could not locate volunteer services in the plan of care or a separate plan of care specifically for volunteer services. Staff-A acknowledged findings above, which did not meet agency expectations or its policy referenced below. A review of agency policy titled Title “Volunteer Services” (Revised June 2019), revealed, “9. Volunteer duties may include, but are not limited to: Patient care activities, e.g., emotional support, companionship… Such duties must be evident in the patient’s pan of care. Each volunteer will document time spent and services provided.” [sic]”

“Based on interview and record review, it was determined the hospice failed to maintain documentation of ongoing efforts to recruit and retain volunteers, resulting in the potential for unfulfilled patient volunteer requests. On 2/18/26 at 12:48 PM the Volunteer Coordinator (Staff-C) was queried about the agency’s volunteer recruitment efforts. He explained that the agency receives inquiries from the community via phone or email. He provides follow-up for each inquiry to offer detailed information about the expectations for hospice volunteers and to evaluate whether the individual could be a suitable candidate for volunteering. Additionally, the agency website advertises volunteer services. Staff-C voiced he did not have documentation of recruitment efforts.A follow-up interview with the administrator (Staff-A) on 2/19/26 was conducted to ascertain the documentation of volunteer recruitment efforts. Staff-A could vocalize recruitment efforts, for example, during community events, the volunteer opportunities would be discussed, and an agency pamphlet would be handed out. Staff-A unable to provide documentation of recruitment efforts. Staff-A acknowledged on 2/19/26 at 12:15 PM the findings above, which did not meet agency expectations or their policy referenced below.A review of agency policy titled Title “Volunteer Services” (Revised June 2019), revealed, “1. Hospice will document active and ongoing efforts to recruit and retain volunteers.””

“Based on interview and record review, the agency failed to ensure volunteers provided administrative and/or direct patient care services in an amount that equals at least 5% of the total patient care hours of all paid hospice employees and contract staff for 2 of 2 records reviewed (P-20, P-23), resulting in a lack of cost savings for the agency. An interview was conducted 2/18/26 at 12:48 PM with the Volunteer Coordinator (Staff-C). When asked to provide documentation of the volunteer hours for 2024 and 2025, Staff-C provided a document titled, “Volunteer Hours Log”. The review of the document noted it did not provide the direct patient care hours needed to determine the annual volunteer level of activity. Staff-C explained that direct patient care hours are tracked by the agency’s administrator (Staff-A).At 1:45 PM Staff-A was requested to provide documentation for the last 2 years of direct patient care hours, and the cost savings generated by the volunteer program. Staff-A provided printed documents, “2024 Volunteer Summary” and “2025 Volunteer Summary”. The review of these documents noted they did not include the annual direct patient care hours. Staff-A was queried about the missing hours. He then provided verbally, 2024 direct patient care hours- 19,981.61 and 2025 direct patient care hours- 26,773.50.On 2/19/26 two patient records (P-20 and P-23) were randomly selected from the “Volunteer Hours Log” for review of volunteer service documentation. The volunteer listed for P-20 and P-23 is employed by the agency (Staff-I) as a Nurse Practitioner.Patient #20 (P-20) was listed to have received volunteer services on 5/9/24. The review of records revealed no documentation that the patient received volunteer services on 5/9/24 by Staff-I. Further review of the record found that Staff-I documented a “Patient Communication Log” dated 6/13/24 with a visit “Type: Provider Note and Subject: NP Palliative Visit”. The record was void of documented volunteer services performed by Staff-I or an assigned alternate volunteer.Patient #23 (P-23) was listed to have received volunteer services on 9/20/24 and 9/25/24. The record review revealed that Staff-I documented a “Patient Communication Log” dated 9/25/24 with a visit “Type: Provider Note and Subject: NP Palliative Visit”. The record was void of documented volunteer services performed by Staff-I or an assigned alternate volunteer.On 2/19/26 at 12:15 PM the above findings were reviewed and acknowledged by Staff-A who explained that the patients listed as seen by Staff-I, on the “Volunteer Hours Log”, (10.5 total hours), were in palliative care at that time, and volunteer services were not provided. The adjusted 2024 volunteer hours total is 338. The final review of all the documents concluded that the volunteer level of activity to be less than 5% for 2024 and 2025. See calculation below. 2024 2025Volunteer hours 338 150Direct care hours 19,981 26,774Volunteer level of activity 1.69% 0.56% Staff-A acknowledged the findings above, which did not meet agency expectations or their policy referenced below.A review of agency policy titled “Volunteer Services” (Revised June 2019), revealed, “Hospice will document the cost savings achieved through the use of volunteers and will include:… Hospice will document and maintain a volunteer staff sufficient to provide administrative and/or direct patient care in an amount that, at a minimum, equals 5% of the total patient care hours of all paid hospice employees and contract staff… “”

“Based on record review and interview, the Hospice agency failed to provide MSW (Master of Social Work) services as required in 1 (P-8) of 16 records reviewed, resulting in the potential for poor patient outcomes due to a lack of MSW evaluations, assessments and interventions. Findings include: Patient #8 (P-8): was admitted to this hospice agency on 1/2/26, with a terminal diagnosis of sarcopenia (progressive loss of muscle, strength and function) and heart disease. Record review on 2/19/26 found no evidence that the Hospice agency had provided MSW services since admission (over 6 weeks). Further the plan of care for P-8 was void of any evidence of acknowledgement of MSW services. Subsequently no evaluations or interventions by MSW services were found in the medical record.This finding was reviewed with and acknowledged by the Administrator (Staff-A) and Clinical Director (Staff-B) during an interview on 2/19/26 at 1:35 PM. Both further acknowledged this did not meet agency expectations and was unacceptable.”

“Based on record review and interview, the hospice failed to ensure that each patient’s record included appropriate clinical assessment notes to document the care provided in 1 (P-16) of 16 records reviewed, resulting in a lack of documented care. Findings include: Patient #16’s (P-16) Start of Care (SOC) was dated 10/24/25. The Plan of Care (POC) identified a terminal diagnosis of Nasal Cancer. During record review on 2/18/26, it was noted that the POC ordered Skilled Nursing (SN) at a frequency of weekly visits and 5 PRN (as needed). The SN visit completed on 12/30/25 stated, “Pain intensity: 5. Pain Duration: Blank. Patient’s acceptable pain level: 3. Medication last taken: Blank. Pain description: Blank.” The SN visit completed on 2/17/26, “Pain intensity: 5. Pain Duration: Blank. Patient’s acceptable pain level: Blank. Medication last taken: Blank. Pain description: Blank.” The agency failed to assess and document the pain assessment notes per policy.A review of the agency policy occurred on 2/19/26 titled “Patient Record Content” (Revised June 2019). The policy states, “Procedure: 1. Hospice will initiate and maintain an individual and accurate patient record containing past and current findings for each patient receiving care in compliance with all federal/state laws and regulations. The record must contain correct clinical information that is available to the patient’s attending physician and Hospice staff… 3. Each patient record will contain the following as applicable: Conclusions of patient medication monitoring.”The Administrator (Staff-A) and Director of Clinical Services (Staff-B) reviewed and acknowledged the findings listed above in an interview on 2/19/26 at 2:00 pm.”

“Based on record review and interview, the agency failed to ensure all clinical record entries were completed and properly authenticated in 1 (P-14) of 16 patients reviewed, resulting in an incomplete clinical record. Findings include: Patient #14 (P-14) was admitted to this hospice agency on 10/22/25 with the terminal diagnosis of colon cancer. During record review on 2/18/26, it was determined a social work noted dated 10/29/25 was void of most information and failed to include a signature of the clinician. It was also noted the note was listed as “In Use” and “Not Signed” instead of “Completed.”A review of agency policy titled “Patient Record Content” (revised June 2019) revealed “All entries must be legible, clear, complete and appropriately authenticated.”During an interview with the director of clinical services (Staff B) on 2/19/26 at 11:00 AM, Staff B was asked about the status of this note. Staff B stated it appeared that the social worker did not complete this note, however, he was unsure of why and acknowledged the findings. The administrator (Staff A) was also present during the interview and acknowledged the findings.”

“Based on record review and interview, the hospice failed to send a copy of the patient’s discharge summary to the receiving hospice agency for 1 (P-15) of 1 record reviewed in which the patient transferred to another hospice agency, resulting in the potential lack of continuity of care for this patient. Findings include: Patient #15’s (P-15) Start of Care (SOC) was dated 1/30/25. The Plan of Care (POC) identified a terminal diagnosis of Nonalcoholic Steatohepatitis. During record review on 2/17/26, it was noted that the patient was transferred to another hospice agency on 2/18/25. There was no documented evidence that a discharge summary was sent to the receiving hospice agency. The agency failed to verify that the discharge summary was sent to the accepting hospice agency. A review of the agency policy occurred on 2/19/26 titled “Discharge Summary” (Revised June 2019 2017). The policy states, “Procedure: 1. If the care of a patient is transferred to another Medicare/Medicaid-certified facility, Hospice will forward, to the receiving facility; a copy of: The Hospice discharge summary...”The Administrator (Staff-A) and Director of Clinical Services (Staff-B) reviewed and acknowledged the findings listed above in an interview on 2/19/26 at 2:00 pm.”

“Based on record review and interview, the agency failed to ensure a discharge summary was forwarded to the patient’s attending physician following a revocation of services for 1 (P-14) of 2 patients with live discharges reviewed, resulting in the potential for poor continuity of care. Findings include: Patient #14 (P-14) was admitted to this hospice agency on 10/22/25 with the terminal diagnosis of colon cancer. During record review on 2/18/26, it was determined P-14 revoked his hospice benefit on 11/18/25 due to being admitted to the hospital for treatment. Upon further review of the record, it was determined there was no discharge summary written for this patient.During an interview with the director of clinical services (Staff B) on 2/19/16 at 11:00 AM, Staff B was asked about the discharge summary for P-14. Staff B stated this was a was a strange case and that P-14 ended up being re-admitted a couple of days later. However, Staff B agreed there should have been a discharge summary written and sent to the physician following the revocation.A review of agency policy titled “Discharge Summary” (revised June 2019) revealed, “If a patient revokes the election of Hospice care, or is discharged from Hospice, Hospice will forward to the patient’s attending physician, a copy of: The Hospice discharge summary; The patient’s record, if requested.”Staff B and the administrator (Staff A) acknowledged the findings at the time of interview.”

“Based on record review and interview, the hospice failed to document a discharge summary that included a summary of the patient’s course of care in 1 (P-15) of 2 discharge records, resulting in a lack of information provided to the receiving hospice agency. Findings include: Patient #15’s (P-15) Start of Care (SOC) was dated 1/30/25. The Plan of Care (POC) identified a terminal diagnosis of Nonalcoholic Steatohepatitis. During record review on 2/17/26, it was noted that the patient was transferred to another hospice agency on 2/18/25. The Skilled Nurse (SN) completed a Hospice Discharge on 2/18/25. There was no documented discharge summary. The hospice agency failed to ensure the discharge summary compiled the patient’s course of care, including treatments, symptoms, and pain management.A review of the agency policy occurred on 2/19/26 titled “Discharge Summary” (Revised June 2019 2017). The policy states, “Procedure: 3. The Hospice discharge summary will include: A summary of the patient’s stay including treatments, symptoms and pain management...” The Administrator (Staff-A) and Director of Clinical Services (Staff-B) reviewed and acknowledged the findings listed above in an interview on 2/19/26 at 2:00 pm.”

“Based on record review and interview, the agency failed to ensure hospice aide met the required qualifications in 1 (Staff H) of 3 hospice aide reviewed, resulting in the potential for unqualified delivery of services. Findings include: During review of personnel files on 2/18/26 at 1:30 PM, the director of clinical services (Staff B) was asked to provide evidence of hospice aide training for Staff H. Upon review of the files, it was determined Staff H did not have a registration number through the Michigan Department of Licensing and Regulatory Affairs (LARA). At 1:40 PM, the administrator (Staff A) was asked for evidence of Staff H’s initial aide training and Staff A stated “she has done her competencies” with the agency upon hire, however, he did not have evidence of her initial 75 hours of training, including 16 hours of classroom time. During an interview on 2/19/26 at 10:05 AM, Staff A was asked how he verified she was qualified as an aide when Staff H applied to this agency. Staff A stated it was based on her previous work history and that she completed her competencies upon hire. Staff A was unable to provide evidence Staff H met the required personnel qualifications for a hospice aide. Staff A acknowledged the findings at the time of interview.”

“Based on record review and interview, the agency failed to ensure nursing services included physical assessments to monitor the patient and ensure the nursing needs were met in 2 (P-1 and P-3) of 3 records reviewed, resulting in the potential for unmet care needs. Findings include: Patient #3 (P-3) was admitted to this hospice agency on 6/23/25 with the terminal diagnosis of a malignant neoplasm of the ascending colon (colon cancer). P-3 had additional diagnoses of type II diabetes mellitus, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF).During record review on 9/12/25, it was determined the following sections of the comprehensive assessment were left blank by skilled nursing on 6/23/25: pain location, heart sounds, edema (swelling), weight, blood pressure, pulse, temperature, respirations, oxygen saturation, and lung sounds.A review of agency policy titled “Initial Assessment/Comprehensive Assessment” (revised June 2019) revealed, “The initial assessment includes the patient’s immediate physical, psychosocial, emotional and spiritual status related to the terminal illness and related conditions. The initial assessment gathers essential information necessary to begin the plan of care and provide the immediate necessary care and services.” Additionally, the policy indicated, “6. The comprehensive assessment will include data elements that allow for measurement of outcomes. Hospice will measure and document data in the same way for all patients. The data elements will take into consideration aspects of care related to Hospice and palliation.”The skilled nursing assessment failed to establish baseline measurements for multiple systems to effectively monitor changes in the patient’s status. During an interview with the Director of Clinical Services (DCS #1) on 9/12/25 at 12:01 PM, DCS #1 was asked about the agency expectation regarding these sections of the comprehensive assessment. DSC #1 stated these sections should be filled out by the skilled nurse to establish a baseline to monitor changes in the patient’s status. DCS #1 acknowledged the findings at the time of interview. (Patient #1) P-1’s start of care was 6/19/25 with a terminal diagnosis of Stage 4 Lung Cancer. The Plan of Care ordered Skilled Nursing (SN), Hospice Aide and Medical Social Work (MSW) services to be provided. On 9/11/25 at 12:15 p.m., the clinical record review revealed the following: The section of the Initial Assessment, completed by the Registered Nurse, dated 6/19/25, titled Principal Diagnosis Criteria/Cancer diagnosis was left blank. The questions, “When does usually pain starts? [sic] and how long does it last? were left blank. The Medication Status-Medication Regiment review was left blank. The SN visit note dated 6/24/25 was void of an assessment of P-1’s vital signs (blood pressure, temperature).The SN visit note dated 7/1/25 was void of an assessment of P-1’s blood pressure and temperature.The SN visit note dated 7/8/25 was void of an assessment of P-1’s blood pressure and temperature. On 9/12/25 at 9:23 a.m., during an interview, the Registered Nurse (RN #1) was queried regarding her process of assessment of patients during home visits and reported, “I assess their pain and if it’s at an acceptable level. If they are due for their pain medications, I administer it. I assess lungs bowels, edema, anxiety, sleep and eating habits and I ask if they have any questions or concerns before I leave. I also check on their supplies.” When asked if she assesses the patient’s vital signs, RN #1 responded, “We don’t always do blood pressure. I do pulse check, O2 and listen to the lungs.” When asked if the agency’s policy was to only check the areas mentioned, RN #1 responded, “I don’t know if there is a specific policy, but we check heart rate. I only check their blood pressure if they complain of pounding.” RN #1 made no mention of the patient’s temperature. On 9/12/25 at 10:14 a.m., the Director of Clinical Services (DCS #1) was queried about the expectation to assess the patient’s vital signs and reported, “I do the initial assessments. I ask families if they want a set of vitals. Most times I do. Most times they don’t want that. Lung sounds, heart sounds, pain, head to toe assessment. We only check the vitals if the patient wants them.” When asked if it is the expectation that the patient’s vital signs are assessed in accordance with professional standards of practice, DCS #1 responded, “It is my expectation that all vital signs be assessed, unless the patient declines.” The agency failed to ensure the Registered Nurse thoroughly assessed the patient’s health status to determine the presence of a decline and to provide subsequent relief of the presented symptoms.”