Every finding on record at Chs of Michigan LLC

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 medication review process includes the identification of the following: The effectiveness of drug therapy, Drug side effects, Actual or potential drug interactions, Duplicate drug therapy, and Drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. 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, clinical record review, and interview. In 3 of 10 (30%) clinical records with medication changes documented, the agency did not ensure the medication profile was updated and a medication review was completed when medication changes were documented. Agency policy PC.M55 Medication Profile, required in part, "The medication profile must include: all current medications, date discontinued. The patient medication profile review includes but is not limited to ensuring appropriateness of the medications, the dose, route of administration, and dosage schedule, determining if there are medications that have been or may be discontinued, monitoring medication effectiveness, actual or potential medication-related effects, and untoward interactions." CLINICAL RECORD 1: The patient elected the hospice benefit on 10/16/2024 with a diagnosis of Alzheimer's disease. The nurse documented on the nursing comprehensive assessment dated 12/17/2024 Levothyroxine (thyroid medication) was to be discontinued. The medication profile was not updated on 12/17/2024 when the Levothyroxine was discontinued. The patient died 01/18/2025 with no updates to the medication profile. CLINICAL RECORD 2: The patient elected the hospice benefit on 01/27/2025 with diagnoses of acute myeloblastic leukemia and prostate cancer. The clinical record included documentation that the patient’s daughter called on 01/27/2025 and stated that she was picking up the oral Vancomycin (antibiotic) that the primary care doctor had prescribed for the patient. The hospice medication profile was not updated to include Vancomycin and there was no documentation of a medication review being completed after Vancomycin was prescribed for the patient. CLINICAL RECORD 12: The patient elected the hospice benefit on 10/16/2024 with a diagnosis of Alzheimer's disease. The nurse documented on the nursing comprehensive assessment dated 05/28/2024 that a B12 injection of 1000mcg intramuscular was administered during the visit. The medication profile was not updated to include the B12 injection. The medication profile was not updated as of the patient’s date of death on 06/05/2024. During the interview on 07/01/2025, the Administrator/Clinical manager stated that the medication profiles had not been updated and that the medication review should happen when the medication profile is updated.

It is required that the comprehensive assessment includes an initial bereavement assessment of 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 considered in the bereavement plan of care. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 9 (11%) clinical records reviewed of patients who were on service more than 5 days, the agency did not ensure the pre-bereavement assessment was completed as part of the initial comprehensive assessment no later than 5 calendar days after the election of benefit. Agency policy PC. B25 Bereavement Risk Assessment, required in part, "During the comprehensive assessment of the patient, an initial bereavement assessment is conducted to determine the cultural, social, and spiritual factors that may impact the ability of family members or other involved individuals to cope with the patient's death. Findings from the initial bereavement assessment are incorporated into the patient's plan of care and considered in the bereavement plan of care." CLINICAL RECORD 1: The patient elected the hospice benefit on 10/16/2025 with a diagnosis of Alzheimer's disease. Clinical record review revealed the pre-bereavement assessment was dated 10/23/2024, a total of 7 days after the election of benefit and 2 days outstanding. During an interview on 07/01/025, the Administrator/Case Manager reviewed the record and stated that the pre-bereavement assessment was not completed in the 5 days after the election of benefit.

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 7 of 14 (50%) clinical records reviewed, the agency did not ensure the individualized plan of care included planned interventions based on problems identified on the initial or updated comprehensive assessments. CLINICAL RECORD 1: The patient elected the hospice benefit on 10/16/2025 with a diagnosis of Alzheimer's disease. The updated comprehensive assessments dated 10/18/2024, 10/29/2224, and 10/31/2024, included documentation of instructions for Fall prevention as the patient had several falls during care. The comprehensive assessment dated 12/27/2024 included documentation that a chair alarm was added for patient safety. There was no documented evidence that the plan of care was updated to include planned intervention(s) related to the patient’s identified fall risk. The updated comprehensive assessment dated 11/14/2025 included documentation that the patient had compression stockings. The plan of care was not updated to include planned interventions related to the patient’s use of compression stockings. CLINICAL RECORD 6: The patient elected the hospice benefit on 11/17/2023 with a diagnosis of Alzheimer's disease. The updated comprehensive assessments dated 08/29/2023, 12/30/2023, 04/02/2024, 11/11/2024, and 11/25/2024 included documentation that the patient had skin tears (different locations at different times) with dressings ordered. The updated comprehensive assessment dated 12/09/2023 included documentation that the patient’s diet was changed to a pureed diet with thickening added, related to swallowing difficulty and concerns of aspiration. The plans of care were not updated to include planned intervention(s) related to the patient’s identified skin tears and diet change. CLINICAL RECORD 8: The patient elected the hospice benefit on 07/18/2024 with a diagnosis of chronic respiratory failure. The initial comprehensive assessment dated 07/18/2024 included documentation that the patient had a Foley catheter. The nurse documented on the nursing assessment dated 08/06/2024 that there were concerns related to skin breakdown and the nurse documented on the nursing assessment dated 08/12/2024 that instructions on repositioning the patient were provided. The updated comprehensive assessment dated 08/30/2024 included documentation of an open area on the right buttock, and barrier cream was started. There was no documented evidence that the plan of care was updated to include planned intervention(s) related to the patient’s Foley catheter and identified risk of skin breakdown. CLINICAL RECORD 9: The patient elected the hospice benefit on 08/23/2024 with a diagnosis of lung cancer. The initial comprehensive assessment dated 08/23/2024 included documentation that the patient had a supra pubic catheter to large drainage bag, the patient had a fall risk of 8 out of 10 (high), and the patient had pressure areas on the heels and coccyx. The plan of care did not include planned intervention(s) related to the patient’s supra pubic catheter, identified risk of falls, and pressure areas prior to the patient’s death on 08/27/2024. CLINICAL RECORD 10: The patient elected the hospice benefit on 06/24/2024 with a diagnosis of lung cancer. The initial comprehensive assessment dated 06/24/2024 included documentation that the patient had a right buttock wound that was treated with dressing changes. The updated assessment dated 06/25/2024 included documentation that orders were received to insert a Foley catheter and that a 14 French Foley catheter was inserted for large drainage bag. The initial plan of care and the updated plans of care did not include planned intervention(s) related to the patient’s Foley catheter and wound. CLINICAL RECORD 12: The patient elected the hospice benefit on 05/09/2024 with a diagnosis of congestive heart failure. The initial comprehensive assessment included documentation that the patient was identified as a fall risk of 14-High and a Foley catheter was in place with a large drainage bag and had been inserted on 05/02/2024. The Foley catheter was in place throughout the care of the patient. The initial plan of care and the updated plans of care did not include planned intervention(s) related to the patient’s Foley catheter and fall risk prior to the patient’s death on 06/05/2024. CLINICAL RECORD 13: The patient elected the hospice benefit on 03/18/2024 with a diagnosis of cerebral vascular accident. The initial comprehensive assessment included documentation that the patient used a condom catheter for incontinence and had a gastric tube and received Jevity 1.5 calories at 720 - 960 ml every day through the gastric tube. The initial plan of care and the updated plans of care did not include planned intervention(s) related to the patient’s condom catheter and gastric tube with Jevity feedings. During an interview on 07/01/2025, the Administrator/Case Manager reviewed the records and stated that the plans of care did not include interventions related to the problems found during assessments.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by document review, clinical record review, and interview. In 7 of 14 (50%) clinical records reviewed, the agency did not ensure the individualized plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Agency policy PC. P50 Plan of Care, required in part, "The interdisciplinary written plan of care is based on initial and updated patient-specific comprehensive assessments by members of the IDG [interdisciplinary group] and is developed with measurable goals and outcomes for planned interventions." CLINICAL RECORD 1: The patient elected the hospice benefit on 10/16/2025 with a diagnosis of Alzheimer's disease. The updated comprehensive assessments dated 10/18/2024, 10/29/2224, and 10/31/2024, included documentation of instructions for Fall prevention as the patient had several falls during care. The comprehensive assessment dated 12/27/2024 included documentation that a chair alarm was added for patient safety. There was no documented evidence that the plan of care was updated to include measurable goal(s) and outcome(s) related to the patient’s identified fall risk prior to the patient’s death on 01/18/2025. The updated comprehensive assessment dated 11/14/2025 included documentation that the patient had compression stockings. The plan of care was not updated to include measurable goal(s) and outcome(s) related to the patient’s use of compression stockings. CLINICAL RECORD 6: The patient elected the hospice benefit on 11/17/2023 with a diagnosis of Alzheimer's disease. The updated comprehensive assessments dated 08/29/2023, 12/30/2023, 04/02/2024, 11/11/2024, and 11/25/2024 included documentation that the patient had skin tears (different locations at different times) with dressings ordered. The updated comprehensive assessment dated 12/09/2023 included documentation that the patient’s diet was changed to a pureed diet with thickening added, related to swallowing difficulty and concerns of aspiration. The plans of care were not updated to include measurable goal(s) and outcome(s) related to the patient’s identified skin tears and diet change. CLINICAL RECORD 8: The patient elected the hospice benefit on 07/18/2024 with a diagnosis of chronic respiratory failure. The initial comprehensive assessment dated 07/18/2024 included documentation that the patient had a Foley catheter. The nurse documented on the nursing assessment dated 08/06/2024 that there were concerns related to skin breakdown and the nurse documented on the nursing assessment dated 08/12/2024 that instructions on repositioning the patient were provided. The updated comprehensive assessment dated 08/30/2024 included documentation of an open area on the right buttock, and barrier cream was started. There was no documented evidence that the plan of care was updated to include measurable goal(s) and outcome(s) related to the patient’s Foley catheter and identified risk of skin breakdown prior to the patient’s death on 09/02/2024. CLINICAL RECORD 9: The patient elected the hospice benefit on 08/23/2024 with a diagnosis of lung cancer. The initial comprehensive assessment dated 08/23/2024 included documentation that the patient had a supra pubic catheter to large drainage bag, the patient had a fall risk of 8 out of 10 (high), and the patient had pressure areas on the heels and coccyx. The plan of care did not include measurable goal(s) and outcome(s) related to the patient’s supra pubic catheter, identified risk of falls, and pressure areas prior to the patient’s death on 08/27/2024. CLINICAL RECORD 10: The patient elected the hospice benefit on 06/24/2024 with a diagnosis of lung cancer. The initial comprehensive assessment dated 06/24/2024 included documentation that the patient had a right buttock wound that was treated with dressing changes. The updated assessment dated 06/25/2024 included documentation that orders were received to insert a Foley catheter and that a 14 French Foley catheter was inserted for large drainage bag. The initial plan of care and the updated plans of care did not include measurable goal(s) and outcome(s) related to the patient’s Foley catheter and wound prior to the patient’s death on 06/26/2024. CLINICAL RECORD 12: The patient elected the hospice benefit on 05/09/2024 with a diagnosis of congestive heart failure. The initial comprehensive assessment included documentation that the patient was identified as a fall risk of 14-High and a Foley catheter was in place with a large drainage bag and had been inserted on 05/02/2024. The Foley catheter was in place throughout the care of the patient. The initial plan of care and the updated plans of care did not include measurable goal(s) and outcome(s) related to the patient’s Foley catheter and fall risk prior to the patient’s death on 06/05/2024. CLINICAL RECORD 13: The patient elected the hospice benefit on 03/18/2024 with a diagnosis of cerebral vascular accident. The initial comprehensive assessment included documentation that the patient used a condom catheter for incontinence and had a gastric tube and received Jevity 1.5 calories at 720 - 960 ml every day through the gastric tube. The initial plan of care and the updated plans of care did not include measurable goal(s) and outcome(s) related to the patient’s condom catheter and gastric tube with Jevity feedings. During the interview on 07/01/2025, the Administrator/Case Manager reviewed the records and stated that the goals were not documented on the plans of care.

It is required that the hospice assess the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provide in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, personnel record review, and interview. In 1 of 5 (20%) personnel records reviewed, the agency did not ensure staff skills and competencies were assessed as required by agency policy. Agency policy HR.C10 Competency Assessment, required in part, "Competency assessments occur during the orientation period, annually and as needed, when adverse patient outcomes are directly related to an individual's performance." PERSONNEL RECORD 5: Social Worker date of hire 10/13/2022. Personnel record review revealed no documented evidence of a competency assessment for 2023 and 2024. During an interview on 06/30/2025, the Administrator stated that there was no documentation of a competency assessment for the Social Worker for 2023 and 2024.

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. 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 a review of clinical records and interviews. In 3 of 11 (27%) clinical records reviewed, it was revealed that the agency did not ensure all prescription medications were documented on the patient's drug profile. . Clinical Record 10 The start of care was dated 8/6/2022. The date of death was 8/8/2022. The patient's terminal diagnosis was COPD. The admission orders dated 8/6/2022 included oxygen 2-4 liters nasal cannula, "PRN dyspnea". The nurse documented the patient was wearing oxygen at 3 liters per nasal cannula during the initial assessment. Oxygen was not documented on the drug profile. Clinical Record 7 The start of care was dated 1/30/2022. The patient's terminal diagnosis was CHF. The physician's order dated 2/1/2022 ordered oxygen 2 liters per nasal canula to maintain oxygen saturation greater than 90%. Oxygen was not documented on the drug profile. Clinical Record 2 The start of care was dated 9/2/2022. The patient's terminal diagnosis was Malignant Melanoma. The admission orders dated 9/2/2022 include oxygen 2 liters per nasal cannula. Oxygen was not documented on the drug profile. A physician order dated 9/2/22 required Roxicodone 5 mg oral every 6 hrs as needed (PRN). The order did not document the PRN reason for giving the medication. During interview with the Administrator on 9/14/2022, he stated he was aware that oxygen was required to be listed on the medication profile.

It is required that each patient’s individualized written plan of care reflects patient and family goals, and contains a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs;. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 11 (9%) clinical records reviewed of patients with an individualized written plan of care, it was revealed that the agency did not ensure the treatment order included the frequency that the treatment was to be performed. Clinical Record 6 The patient was admitted 7/20/2022 with a diagnosis of COPD. The treatment order dated 8/22/2022, read as follows: "TREATMENT ORDERS - DTI on L. heel, elevate to relieve pressure. Unstageable coccyx pressure injury, saturate gauze with Triad paste and pack wound, cover with ABD pad." The order did not include a frequency for the treatment to be performed. During joint record review and interview with the administrator on 9/14/2022, the treatment order was discussed and the administrator acknowledged the order did not include the frequency for the wound care to be performed.