Every finding on record at Best Care Hospice LLC

Upon patient record review, 11 of 14 (Patient #1,3,4,5,6,7,8,9,10,13,14) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #1,3,4,5,6,7,8,9,10,13,14 did not have evidence of a Bereavement Risk Assessment completed at the time of admission or within 5 days.

Upon patient record 9 of 14 (Patient #1,3,4,5,6,7,8,9,10) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #1,3,4,5,6,7,8,9,10: POC for bereavement has not been updated since patient admission.

Upon patient record review, 2 of 14 (Patient #13,14) did not have evidence the hospice offers bereavement counseling that includes: • Ensuring that bereavement services reflect the needs of the bereaved •Patient #13,14 No evidence of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery.

Upon patient record review, 4 of 14 (Patient #1,5,7,9) did not have evidence in the patient record that hospice aide assignments and duties are: • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patients #1,5,7,9 had "as needed" frequency on task of "apply briefs" on the aide assignments.

Based on observation, record review and interview the facility failed to ensure medications were stored according to manufacturer’s instructions (L-693) and failed to properly dispose of the patient’s in-home controlled drugs (L-694) --- The cumulative effect of these systemic problems resulted in the Hospice Agency's inability to ensure the proper disposal and storage of medications for the Condition of Participation: 42 CFR §418.106 Drugs and biologicals, medical supplies, and durable medical equipment.

Based on observation, interview, and record review, the facility failed to ensure medications were stored according to manufacturer’s instructions resulting in 1 (P-1) of 3 patients reviewed receiving a medication that was not stored properly and the potential for inappropriate dosing.  Findings include: --- The contents of the locked medication box were observed on a shelf in a spare office on 7/8/25 at 1:45 p.m. and contained a list titled “In Office Medications (Donations)." All unused medications were received from the family of Patient #4 (P-4) and entered into the medication box on 6/11/25 by the Director of Nursing (DON #1) and Past Office Manager (POM #1). Specifically, the medication box contained two boxes of Lorazepam Intensol Oral Concentrate USP (Ativan) 2 MG/2 ML 30ML bottle. The Ativan boxes contained manufacturer’s instructions which stated, “Store at cold temperature. Refrigerate at 2 degrees to 8 degrees C (Celsius) (36 degrees to 46 degrees F (Fahrenheit)”.On 7/6/25 (Sunday) at 6 p.m., 1 dose of Ativan was retrieved from the medication box for a PRN (as needed) visit for P-1 that was completed by DON #1 from 6:30 p.m. to 7:30 p.m. The Ativan was administered 25 days after sitting at room temperature against manufacturer’s instructions, which could potentially affect the drug's potency.On 7/9/25 at 2:30 p.m., an interview was conducted with the Administrator (Adm #1) and DON #1. During the interview, both were queried regarding the storage of a medication that contained manufactures instructions of storing at a cold temperature and DON #1 stated, “I did not notice that the medication noted that.” Adm #1 stated, “We will obtain a refrigerator to properly store those medications.”

Based on record review and interview, the facility failed to properly dispose of the patient's in-home controlled drugs in 1 (P-4) of 1 record reviewed that contained donated medications. Findings include: --- The contents of the locked medication box were observed on a shelf in a spare office on 7/8/25 at 1:45 p.m. and contained a list titled “In Office Medications (Donations)." All unused medications were received from the family of Patient #4 (P-4) and entered into the medication box on 6/11/25 by the Director of Nursing (DON #1) and Past Office Manager (POM #1). Specifically, the medication box contained two boxes of Lorazepam Intensol Oral Concentrate USP (Ativan) 2 MG/2 ML 30ML bottle.On 7/6/25 (Sunday) at 6 p.m., 1 dose of Ativan was retrieved from the medication box for a PRN (as needed) visit for P-1 that was completed by DON #1 from 6:30 p.m. to 7:30 p.m.A review of the agency policy occurred on 7/9/25 titled "Home Use and Disposal of Controlled Substances Policy" (Undated). The policy states, "Controlled substances… disposed of in home when the patient no longer needs such drugs… Disposal… disposed of in compliance with State and Federal regulations.”  Michigan Legislature MCL – Section 333.17775 states, “… (5) Pharmacies, health professionals, and charitable clinics that participate in the program shall use the following criteria in accepting unused or donated prescription drugs from eligible facilities or manufacturers for use in the program:    (a) Only prescription drugs in their original sealed, tamper-evident, and unopened unit dose packaging may be accepted for dispensing. However, prescription drugs packaged in single-unit dose packaging may be accepted for dispensing even if the outside packaging is open as long as the single-unit dose packaging is unopened.    (b) The following shall not be accepted for dispensing:    (i) Expired prescription drugs.    (ii) Controlled substances as defined in article 7 or article 8 or by federal law.”

Upon patient record review, 4 of 5 (Patient #1, #2, #3, #4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1: SN note for 8/30/2022 includes Ibuprofen 600mg effective for pain. There was no evidence of Ibuprofen on medication profile. SN note dated 9/12/2022 includes Patient has hydration infusion on Wednesday afternoon. There was no evidence of IV infusion on medication profile. Corrected on site. Patient 2: There is an order for Marijuana for Pain in the Care plan, there is no evidence of Marijuana on the medication profile. Corrected on site. Patient 3: SN note for 8/16/2022 includes Ibuprofen 600mg effective for pain. There was no evidence of Ibuprofen on medication profile. There is an order dated 8/26/2022 for O2 3LPM via NC 24hr per day. There was no evidence of O2 on the medication profile. Corrected on site. Patient 4: Order dated 9/12/2022 for O2 3LPM via NC 24 hrs a day. There was no evidence of O2 on the medication profile. Corrected on site.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 4 of 5 (Patient #1, #2, #3, #4) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 1: Front of Patient file states Full Code, Dr. orders dated 5/20/2022 and 8/19/2022 state No Under DNR. Nurses notes dated 5/20/2022 state full code. HHA care plan dated 5/20/2022 stats No Code. Patient has a signed DNR dated 5/20/2022. Corrected on site. Patient 2: Patient has history of CVA and Seizures. Has neuro POC for seizures, no evidence of a problem/interventions for CVA. Corrected on site. Patient 3: Patient has history of CVA and Seizures. Has neuro POC for seizures, no evidence of a problem/interventions for CVA. Corrected on site. Patient 4: Patient has history of CVA . There was no evidence of a problem/interventions for CVA. Corrected on site.

Upon patient record review, 2 of 5 (Patient #1, #3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1: SN note for 8/30/2022 includes Ibuprofen 600mg effective for pain. There was no evidence an order for Ibuprofen. SN note dated 9/12/2022 includes Patient has hydration infusion on Wednesday afternoon. There was no evidence of an order for IV infusion. Corrected on site. Patient 3: SN note for 8/16/2022 includes Ibuprofen 600mg effective for pain. There was no evidence of an order for Ibuprofen. Corrected on site.

Upon client record review, 2 of 5 (Patient #2 and 5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: There was an order dated 9/6/2022 for MSW evaluation of insect infestation in home. There is no evidence of this evaluation being completed. Patient 5: There is an order dated 9/9/2022 for PT evaluation. Visits have been made 9/16, 9/19, 9/21, 9/26/2022. There was no evidence of an order for visit frequency. Corrected on site.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 1: Per Bag technique policy, RN to place waterproof barrier under nursing bag, no barrier used- place on patients bedding, did not clean medical items completely, i.e.: Cleansed just head of stethoscope, just cuff of sphygmomanometer, just head of thermometer. Patient 2: Got into clean nursing bag while doing patient care without using hand sanitizer. Patient 3: Got into clean nursing bag while doing patient care without using hand sanitizer.

Upon patient record review, 1 of 3 applicable (Patient #3) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 3: Patient has history of seizures, there was no evidence of seizure precautions in the Aide POC. Corrected on site.