Corewell Health Children’s Patch Program

“It is required that the comprehensive assessment includes consideration of symptoms and symptom severity, including skin integrity. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 14 (7%) records reviewed it was revealed that the hospice agency did not ensure the comprehensive assessment included skin integrity. Clinical Record 2: The hospice benefit election date was 06/14/2022. The initial RN comprehensive assessment dated 06/14/2022 included in the subsection integumentary stated in part, “Wounds.” The narrative sub-section indicated in part “Receives all medications and nutrition via G-tube.” The patient received RN assessments on 06/24/2022, 06/30/2022, 07/8/2022, and 07/22/2022. The sub-section integumentary stated in part, “no problems identified” on each of the assessments. The RN assessment completed on 07/29/2022, in the sub-section narrative stated in part, “He continues to have healing pressure sores on his heels and had a new stage one (1) pressure sore on his buttocks. Mom was instructed to keep the patient positioned off the back and leave it open to air as much as possible.” During the home visit conducted with the RN (staff 3) in the presence of the Charge Lead RN (staff 1) an interview was conducted with the mother, who is also the caregiver. The mother confirmed the patient did have wounds to his heels on admission that both she and the hospice RN managed. The wounds to the heels were currently resolved. A joint record review and interview with the Charge Lead Nurse (staff 1) on 02/21/2024 confirmed the clinical record did not contain documentation of a skin assessment from admission on 06/14/2022 for forty-six (46) days until 07/29/2022.”

“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 document review and observation. In 1 of 3 (33%) home visit observations conducted where medication reconciliation was completed it was revealed that the hospice agency did not ensure the medication profiles were updated accurately to reflect the patient’s current medication regimen. Clinical Record 2: The hospice benefit election date was 6/14/2022. The home visit was conducted on 02/21/2024 in the presence of the Charge Lead RN. The medication profile dated 02/21/2024, stated in part, “Baclofen twenty thousand 20,000 micrograms (mcg) per twenty (20) milliliters (ml). Administer twenty-six (26) points (.) six (6) (26.6) micrograms (mcg) every hour. The order date was 6/22/2022. The current regimen for the patient per the caregiver, as well as a paper copy of a physician’s order provided by the infusion provider, stated “Baclofen twenty thousand 20,000 micrograms (mcg) per twenty (20) millimeters (ml). Administer twenty-eight (28) point (.) six (6) (28.6) micrograms (mc) every hour. The order date was 1/17/2024. A joint record review, interview, and observation with the charge lead nurse (staff 1) on 02/21/24 confirmed the hospice agency’s medication profile did not reflect the current medication regimen.”

“It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) records reviewed it was revealed that the hospice agency did not ensure the coordination of care was provided by the registered nurse as part of the hospice interdisciplinary group (IDG). Clinical Record 1: The hospice benefit election date was 01/5/2024. The initial plan of care dated 01/5/2024-04/3/2024 stated in part, “Physical therapy (PT) effective 01/7/2024 one (1) week times (X’s) one (1)”. The record contained no evidence that the patient received a physical therapy visit. In addition, the record did not contain any evidence that the Interdisciplinary Group (IDG) was notified that the intervention of physical therapy was not being provided. Clinical Record 6: The hospice benefit election date was 12/12/2023. The patient had a nasogastric (NG) tube on admission. The physician order dated 12/12/2023 stated, “Caregiver and hospice RN to change NG tube every twenty-one (21) days and as needed (PRN). The record contained no evidence that the NG tube had been changed as of 02/20/2024. A joint record review and interview with the Charge Lead Nurse (staff 1) on 02/20/24 confirmed the hospice agency did not ensure coordination of patient care. The Charge Lead RN stated, “I can see the coordination is not reflected in our documentation, but I know we are providing the coordination.””

“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 2 of 14 (14%) records reviewed revealed the hospice agency did not ensure the plan of care contained all problems, goals, and interventions necessary for the palliation of the patient. Document 1: Policy# 7161, titled Hospice-Plan of Care (revised 02/9/2021) sub-section seven (7), stated in part, “The plan of care may include the following: (d) reflects patient and family goals. (e) Identified planned interventions based on problems identified on the initial and updated comprehensive assessments.” Clinical Record 1: The hospice benefit election date was 01/5/2024. The Certificate of Terminal Illness (CTI) stated in part, “Patient may die at any time of aspiration.” The initial RN assessment narrative note completed on 01/5/2024 stated in part, “Struggles with secretions. (Patient name) is orally fed, but can only tolerate soft foods. Patient is at high risk for aspiration”. The Plan of Care dated 01/5/2024-04/3/2024 contained no aspirations-related goals or interventions. Clinical Record 2: The hospice benefit election date 06/14/2022. The initial RN assessment narrative dated 6/14/2022 stated in part, “Receives all medications and nutrition via G-tube.” The plan of care dated 6/14/2022- 09/11/2022 did not contain any problems/goals or interventions related to the G-Tube site care. A joint record review and interview with the Charge Lead RN (staff 1) on 02/20/2024 confirmed the plans of care did not contain the relate goals or interventions.”

“It is required that each patient’s individualized written plan of care includes all medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 14 (7%) records reviewed it was revealed that the hospice agency did not include all appliances necessary to meet the patient’s needs in the care plan. Document 1: Policy# 7161 titled, Hospice-Plan of care (revised 02/9/2021), sub-section seven (7) stated in part, “The plan of care may include the following: (f) Includes all services necessary for the palliation and management of the terminal illness, including the following: medical supplies and appliances”. Clinical Record 7: The hospice benefit election date was 10/10/2023. The initial RN comprehensive assessment dated 10/10/2023 sub-section equipment and supplies stated in part, “Ventilator.” Sub-section eligibility criteria stated in part, “Vent dependent with no respiratory drive.” Sub-section narrative stated in part, “Ventilator DME provider (name) were present, and assessed parents in setting up vent with the connection.”. “ The plan of care dated 10/10/2023- did not contain the ventilator or contain ventilator settings. The sub-section DME stated in part, “Pediatric supplies”. The medication section stated in part, “Oxygen one (1) liter ventilator”.”

“It is required that the hospice is primarily engaged in providing the following care and services in a manner consistent with accepted standards of practice that include occupational therapy and speech-language pathology services. This standard was not met as evidenced by document review, interview and personnel record review. A review of personnel records and contracted vendors revealed the hospice agency did not ensure occupational therapy and speech therapy services were made available either under an arrangement or provided directly by staff, to patients under the hospice agency’s care. Document 3: Policy# 7663556, titled Scope of Services (last review 02/27/2023), sub-section (F) stated in part, “An interdisciplinary Group of professionals will develop a plan of care, which will include the following services as appropriate: six (6) therapists (physical, occupational, and speech)”. A joint personnel record review and document review with the Administrator/Director of Nursing (staff 10) on 02/21/2024 confirmed the hospice agency did not have an occupational therapist or speech therapist on staff or under a contractual arrangement. A document review of personnel records and contracted vendors revealed the hospice agency did not ensure occupational therapy services and speech therapy services were made available either under an arrangement or provided by staff to patients under the hospice agency’s care.”

“It is required that a patient’s clinical record includes, at a minimum physician orders. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 14 (29%) records reviewed it was revealed that the hospice agency did not ensure the patient’s clinical record contained all physician orders. Document 2: Policy# 9897, titled Content of Record (no revision date), stated in part, “The patient’s clinical record includes four (4) point (.) eleven (11) (4.11) appropriate, current, and signed medical orders by the physician, in compliance with regulatory and accrediting bodies.” Clinical Record 2: The hospice benefit election date was 6/14/2022. The initial RN assessment was dated 6/14/2022. The subsection integumentary stated in part, “wounds.” The narrative sub-section stated in part, “Receives all medications and nutrition via G-tube.” The record did not contain any physician orders for wound care or G-tube site care as of 2/22/2024, the date of review. Clinical Record 3: The hospice benefit election date was 05/25/2022, and the patient was admitted to the hospice agency on a ventilator. The initial RN assessment sub-section stated, “Switched to a home vent on 04/21/2022”. The record did not contain any physician orders for the ventilator settings or coordination documentation between the hospice agency and the DME provider as to what the ventilator settings were.” The RN visit on 01/11/2024 stated in part, “Discussed with pulmonology the family’s desire to never use the ventilator again. DME company contacted. The ventilator was removed from the home”. The record did not contain a physician order to discontinue the ventilator. Clinical Record 6: The hospice benefit election date of was 12/12/2023. The patient had a nasogastric (NG) tube on admission where the RN stated in comprehensive assessment sub-section gastrointestinal the patient received seventy-three (73) milliliters (ml) of breast milk every three hours (did not specify route). There was no physician order for the amount of breast milk to be administered and the route. Clinical Record 13: The hospice benefit election date was 10/17/2023. The RN assessment completed on 11/16/2023 stated in part, “Parents continue to straight cath (name).” The record did not contain a physician’s order for straight catheterization. A joint record review and interview with the Charge Lead RN (staff 1) on 02/22/2024 confirmed the clinical records did not contain all of the physician’s orders.”

“It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require all contracted employees with direct patient contact or access to patient records to obtain criminal background checks. This standard was not met as evidenced by document review and interview. A review of the agency’s contracts revealed multiple contracts were missing the criminal background clause of contracted employees with direct patient contact or access to the patient records to obtain criminal background checks. Contract 1: The agency contract for general inpatient and respite levels of care was titled, Service Agreement Between Hospice and Hospital, and had an effective date “blank.” Neither party signed the contract. The agreement did not contain the criminal background check clause. Contract 3: The agency contract for the Durable Medical Equipment Supplier agreement effective 2021 did not contain the criminal background check clause. A joint document review and interview with the Director of Nursing/Administrator (staff 10) on 02/22/2024 confirmed the contracts did not contain the criminal background check clause. A review of the agency’s contracts revealed multiple contracts were missing the criminal background clause of contracted employees with direct patient contact or access to the patient records to obtain criminal background checks. Specifically, the agreement between the Hospice agency and the GIP/Respite provider did not contain the criminal background check clause. In addition, the DME contract did not contain the criminal background check clause.”