Optimal Hospice of Michigan, Inc.

“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 and interview. In 1 of 9 (11%) clinical records reviewed, it was revealed that the agency did not ensure that the plan of care included interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 1: This patient elected the hospice benefit on 03/25/2025 with a terminal diagnosis of COPD. The Registered Nurse (RN) comprehensive assessment dated 03/25/2025 documented a patient request for physical therapy to address upper arm pain and stiffness. One physical therapy visit was documented for comfort and patient/staff education. The hospice plan of care was reviewed for the dates of 03/25/2025-06/17/2025. There were no planned interventions for physical therapy present in the hospice plan of care as requested by the patient. During an interview and joint review of findings with the Director of Nursing (DON) on 06/17/2025, the DON stated the hospice plan of care did not include interventions for physical therapy. She stated the electronic medical record (EMR) the agency was using was a newer program and that she could not find care plans in the EMR for physical therapy. She stated she would seek assistance from the EMR company to be able to include physical therapy interventions in the hospice plan of care.”

“It is required that medical social services are provided by a qualified social worker according to the patient’s and family’s needs and acceptance of these services and per the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed in which patients requested medical social worker visits, the agency did not ensure that medical social services were provided according to the patient’s and family’s needs and acceptance of these services. CLINICAL RECORD 1: This patient elected the hospice benefit on 03/25/2025 with a terminal diagnosis of COPD. The Registered Nurse (RN) initial comprehensive assessment documented the patient made the request to see the Medical Social Worker (MSW) weekly. In review of the MSW visits for the dates of 03/25/2025-06/18/2025, one MSW visit was documented for 03/26/2025. This did not meet the request of the patient of one MSW visit weekly. During an interview and review of findings with the Director of Nursing (DON) on 06/17/2025, the DON stated only one visit had been completed by the MSW for this patient. This did not meet the request of the patient of MSW visits weekly. The DON stated that the agency recognized a concern with the MSW completing visits and changed this staff member.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the patient’s current plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (50%) clinical records reviewed in which the patient revoked or was discharged, it was revealed that the agency did not ensure that the hospice discharge summary provided to the facility receiving the hospice patient for care—or to the patient’s community attending physician upon hospice discharge—included at least the patient’s current plan of care. CLINICAL RECORD 5: This patient elected the hospice benefit on 04/28/2025 with a terminal diagnosis of cerebral infarction and was admitted to the hospital on 05/30/2025. A hospice discharge summary was faxed to the attending physician and the hospital on 06/03/2025. The documentation of the fax did not include the patient’s current plan of care. CLINICAL RECORD 9: This patient elected the hospice benefit on 11/09/2024 for a terminal diagnosis of heart failure and revoked the benefit on 02/17/2025. A hospice discharge summary was faxed to the attending physician and the hospital on 02/17/2025. The documentation of the fax did not include the patient’s current plan of care. During an interview and review of findings with the Chief Executive Officer (CEO) on 06/18/2025, there was an extensive search for documentation that the discharge summaries included a hospice plan of care. The CEO explained the agency’s policy was to include a hospice plan of care with the discharge summary to the attending physician and the receiving facility, but there was no evidence present in the clinical record or the faxed reports that the hospice plan of care was included. The CEO stated that the agency was new to the electronic medical record (EMR) software, and it was noted at this time that the new EMR did not include the hospice plan of care with the discharge summary process.”