Every finding on record at Community Health Hospice Care Inc.

Upon patient record review, 1 of 5 (Patient #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 #4 with documented COPD and smokes 2 packs per day of cigarettes, however there is no respiratory interventions or goals in place.

Upon patient record review, 2 of 19 (Patients #4, and 9) 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 #4: Patient on Oxygen 4liters per minute. Oxygen is not on the medication list. Patient is also prescribed Miralax. The medication profile did not include instructions for reconstitution of the medication. Patient #9: This patient is prescribed Acetaminophen ES 500mg. 2 tablets three times daily as needed. Acetaminophen 650mg Suppositories 1 suppository every 4 hours as needed, and Hydrocodone/Acetaminophen 10/325 one tablet 4 times daily as needed. The medication profile did not specify a maximum does of acetaminophen within 24 hours.

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

Upon patient record review, 5 of 19 (Patients #3, 5, 9, 11, 13) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #3: Patient was seen on 10/07/24 and wound care orders were changed to daily, with Hospice nurse to perform wound care twice weekly and Facility to perform 5 days per week, however, there was no further RN visit until 10/17/24. During this time Wound #3 on the coccyx changed from a stage 1 on 10/07/24 to a stage 3 on 10/17. Patient #5: On 05/11/24 at 10:28pm, facility called and patient fell, no reported injury. There was no visit made to the patient until 5 days later. On 05/31/24 at 7:51am - after hours call received from ALF staff. Patient reporting pain over fractured rib. ALF staff advised to give first dose of morphine without nurse visit. RN did visit later that day and stat X-rays were ordered. No visits or nurse documentation of X-ray results until next visit on 06/05/24. On 06/22/24 at 1:44AM, call from ALF that patient was complaining of pain and wondered if dementia patient was med seeking. No visit by nurse, next follow up was 06/26/24. Patient #9: RN did after hours visit on 10/12/24 for complaints of chest pain. There was a bruise on her chest and she was having difficulty with ambulation. Advised to give Norco and Morphine for prn pain per orders, no follow up visit until 10/16/24. On 10/17/24, PRN visit performed as patient was having chest pain during an aide visit. Patient had been put on oxygen and Morphine due to accompanying SOB. It was thought that chest pain was due to the previous fall. As of time of record review, no follow up had been completed. Patient #11: Patient was found on 10/09/24, at admission visit, in fetal position with breath that smelled of bile and stool. She was vomiting stool and was refusing food or fluids. She was mottling and cyanotic in lower extremities. She was seen on 10/10/24 and complained of 10/10 nausea/vomiting, also was still vomiting stool. No evidence that MD was notified, no change in POC, and no follow up visit for 5 days. Patient was seen on 10/18/24 and had "facial grimacing and loud moaning". Patient started on Fentanyl patch and Dilaudid liquid prn, as of 10/21/24, there had been no follow up visit in the record. Patient 13: On 09/09/24, on call received call from ALF staff. Patient fell and "hit her head pretty hard." She had bruising and swelling above right eye. No visit from nurse until 09/11/24. On 09/13/24 at 6:10am, ALF staff called to report another fall with no injury, no visit from nurse until 09/18/24.

Upon patient record review, 8 of 19 (Patients #2, 4, 5, 7, 8, 10, 11, 12) 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 #2: Although the patient POC included prevention of skin breakdown, the patient had a wound. There was no interventions or goals in the POC that included wound care. Patient #4: Patient is admitted to Hospice with COPD. There is not a Respiratory Problem with interventions and goals, and including oxygen on the patient's POC. Patient #5: Patient is prescribed Oxygen and nebulized medications. She also uses a Vape. There are no interventions or goals for Respiratory on the patient POC. Patient #7: Patient is on oxygen, though does not have interventions or goals for respiratory including use of oxygen. Patient #8: Patient is on Oxygen and nebulized medications, There are no interventions or goals for Respiratory on the patient's POC. The patient has a history of seizures and there are no interventions or goals for seizure precautions on the patient POC. patient #10: Patient POC included prevention of skin breakdown, and the patient had a wound. There was no interventions or goals in the POC that included wound care. Patient #11: This patient was brought on service with severe nausea and vomiting including vomiting stool. There is no POC or interventions and goals for nausea and vomiting. There also were no interventions or goals for imminent dying. Patient #12: The patient has documented dysphagia. The POC does not include interventions or goals for dysphagia. The Neuro Pathway on POC has interventions but no goals. The nutrition pathway on the POC has interventions, but no goal.

Upon patient record review, 2 of 19 (Patient #4, 9) 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 #4: Patient is also prescribed Miralax. The order did not include instructions for reconstitution of the medication. Patient #9: This patient is prescribed Acetaminophen ES 500mg. 2 tablets three times daily as needed. Acetaminophen 650mg Suppositories 1 suppository every 4 hours as needed, and Hydrocodone/Acetaminophen 10/325 one tablet 4 times daily as needed. None of these orders specify a maximum does of acetaminophen within 24 hours.

Upon patient record review, 5 of 19 (Patient #3, 4, 5, 6, 13) 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 #3: The patient has had several instances of infections treated with antibiotics. There was no update to the POC to include interventions and goals for the infections. Patient #4: The patient also had multiple infections requiring medications. No infection interventions or goals were added to the POC. Patient #5: The patient has experienced numerous falls. There is a home safety POC, but it does not mention falls, or contain any updates as interventions of a gerichair, full side rails with padding, and a floor mat were added. Patient #6: Patient had several instances of infection, though POC was not updated to include interventions and goals for infection. Patient #13: There were no changes in the safety pathway after numerous falls.

Upon patient record review, 4 of 19 (Patients #2, 3, 13, 14 ) 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 #2: The Aide POC states Shower, then states, "Assist patient to shower, patient may want to wash up instead." The use of per patient choice, for any task, whether personal care or non-personal care tasks, are not acceptable. Patient #3: The Aide POC states toilet "if needed"; Change Linens "if soiled"; and Clean under nails and file "if jagged". The use of PRN or, in this case, if needed, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #13: The Aide POC states "Hair care - towel dry or blow dry" The Aide cannot discern whether to towel dry or blow dry - the task must be concrete. Patient #14: The Aide POC states, "Assist with bedpan - total assist if patient requests", "Hair care, towel dry or blow dry". The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable.

Upon SNF/NF contract review, 1 of 2 (Maple Woods contract) did not have a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation. Contract #3: This contract had not been updated and did not contain the provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation.

Based on record review and interview, the hospice failed to ensure that primary caregivers received education and training regarding medication administration in 1 of 4 (P-1) sample records reviewed resulting in the patient receiving medications that were discontinued potentially contributing to a poor patient outcome (See L544); failed to ensure services were provided at the frequency ordered in the plan of care for 2 of 4 (P-1, 4) records reviewed, resulting in the patient not receiving care as ordered (See L547); failed to ensure the care and services were provided based on all assessments of the patient and family needs in 1 of 4 (P-1) sampled records reviewed resulting in poor communication between the hospice staff and family (See L556); and failed to ensure the ongoing sharing of information with a non-hospice pharmacy furnishing services that were unrelated to the terminal illness and related conditions in 1 of 4 (P-1) sample records reviewed resulting in medications that should have been discontinued to still be given to the patient and potentially resulting in a poor patient outcome (See L558). --- The cumulative effect of these systemic problems resulted in the Hospice Agency's inability to ensure the provision of quality Hospice care at the end of life, in a safe environment for the Condition of Participation: 42 CFR §418.56 Interdisciplinary Group, Care Planning, and Coordination of Services.

Based on record review and interview, the hospice failed to ensure that primary caregivers received education and training regarding medication administration in 1 of 4 (P-1) sample records reviewed resulting in the patient receiving medications that were discontinued potentially contributing to a poor patient outcome. Findings include: --- Agency policy titled ";Coordination of Care", PC.110, was reviewed on 8/8/24. On page 1., it stated ";The Hospice will provide for and ensure the ongoing sharing of information between disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement, by the Hospice, or by other providers... IV. The IDG/IDT will maintain responsibility for directing, coordinating, and supervising the care and services provided by all medical entities... V11. All communications and coordination of care is documented in the clinical record." P-1: This 86-year-old was admitted to agency on 4/6/24 with a terminal diagnosis of Senile Degenerative Brain Disease (mental deterioration associated with old age). The patient lived in an Assisted Living Facility (ALF) while on hospice services. During medical record review on 8/8/24, it was noted that the start of care (SOC) was completed by a Registered Nurse (RN), Staff E, on 4/6/24 and included a list of medications which had been continued, new medications, and the following list of discontinued medications: Atorvastatin (to lower cholesterol); Eliquis (anticoagulant); Meloxicam (anti-inflammatory); Exelon patch (treatment of dementia); Memantine (also known as Namenda, treatment of dementia); and some supplements/laxatives. Documentation includes that communication was done with the ALF staff and that patient/caregiver was instructed in medication management (no specific education). Following an RN visit on 4/29/24, a physician order was written on 4/30/24 which included that the following medications (previously discontinued) be stopped: Atorvastatin, Eliquis, Meloxicam, some supplements, (and other medications which had been started between 4/6/24- 4/30/24). It was unclear why a physician order would have to be written on 4/30/24 to discontinue medications which had already been discontinued by Staff E at the start of care on 4/6/24. There was no additional information documented in the medical record which explained this. Although medications were reviewed with family on 4/29/24, no medication education was documented regarding the ALF staff. During review of uploaded attachments in the medical record on 8/8/24, it was noted that an attachment was faxed to the hospice agency on 5/15/24 and uploaded into P-1s medical record on 5/16/24 from the ALF in which P-1 resided. The attachment was titled ";Physicians Orders Current Orders as of 15-May-2024 5:27 PM". It was P-1s medication list from the ALF and included: Atorvastatin; Eliquis; Memantine; Exelon Patch; (and other medications which had been prescribed and not discontinued). It was unclear in the medical record why this list was faxed on this day, who requested this list be faxed to the hospice agency, or if the hospice RN or physician were made aware of the discrepancies between the ALF medication list and the hospice medication list. No education was documented as a result of the uploaded medication list to the ALF staff. On a nurse note, dated 5/21/24 (45 days after start of care, 15 days after medication discontinue order on 4/30/24), a different RN (Staff G) made a visit to the ALF following a fall with head involvement. Staff G documented that she went through the medications ";in the room" with an ALF staff member to compare them with the hospice medication record. Staff G documented ";At this time multiple medications were found in the room that needed to be removed because they were discontinued." Staff G also documented that the ALF staff could not find 2 other medications which had been prescribed by the hospice. On 5/22/24, the hospice was notified by the ALF that P-1 had died. P-1 continued to receive medications which had been discontinued by the hospice agency on 4/6/24 and again on 4/30/24 as evidenced by the ALF medication list uploaded into the medical record on 5/16/24, and the RN visit on 5/21/24 in which the discontinued medications were found in P-1s room indicating that the ALF staff were not properly educated regarding the medications. These findings were reviewed on 8/8/24 with the Administrator (Staff A) during interview at 2:30 p.m.

Based on record review and interview, the hospice failed to ensure services were provided at the frequency ordered in the plan of care for 2 of 4 (P-1, 4) from a total sample of 4 records reviewed, resulting in the patient not receiving care as ordered. Findings include: --- **Agency Policy: Plan of Care Process (PC.30 Last Reviewed: 012624) states, "Purpose: To ensure that the care provided is in accordance with the written Plan of Care (POC), appropriately planned, and delivered in a timely manner to meet the patient's and familys specific needs. Procedure: B. 10. The need for referrals and further evaluation by appropriate health professionals, and/or referrals to appropriate financial, economic and community resources." P-1: This 86-year-old was admitted to agency on 4/6/24 with a terminal diagnosis of Senile Degenerative Brain Disease (mental deterioration associated with old age). During record review on 8/8/24, the signed ";Hospice informed consent/election of hospice benefit" for documented, ";I understand that a Registered Nurse (RN) will case manage all services and I have accepted the following services: RN, Hospice Aide, Social Worker, Dietician, Volunteer, Massage Therapy." The Plan of Care (POC) dated 4/6/24 stated, ";Frequency/Duration of Visits: ...HHA (Home Health Aide) effective 4/7/24 2wk13 (2 visits a week for 13 weeks) ... Order of Discipline and Treatments: Massage therapist to provide message therapy services to improve patient comfort. Volunteer services will be available to the patient/caregiver as needed. Registered dietician to be consulted PRN." Furthermore, on 4/26/24 noted a ";Care Conference" which states, ";...Staff I to look for nutritional consult..." It was noted that HHA completed all visits as ordered, which were dated: 4/8/24, 4/11/24, 4/15/25, 4/18/24, 4/22/24, 4/25/24, 4/28/24, 5/1/24, 5/8/24, 5/9/24, 5/13/24, 5/16/24 and 5/20/24. There was no documented evidence that massage therapy, volunteer and dietician were provided as ordered. P-4: This 86-year-old was admitted to agency on 1/30/24 with a terminal diagnosis of Atherosclerotic Heart Disease. During record review on 8/8/24, the signed ";Hospice informed consent/election of hospice benefit" for documented, ";I understand that a Registered Nurse (RN) will case manage all services and I have accepted the following services: RN, Hospice Aide, Social Worker, Chaplain, Volunteer, PT (Physical Therapy), Music Therapy." The Plan of Care (POC) dated 1/30/24 stated, ";Order of Discipline and Treatments: Massage therapist to provide message therapy services to improve patient comfort. Physical Therapist to evaluate and setup a plan of care as needed. Volunteer services will be available to the patient/caregiver as needed." Furthermore, on 2/1/24 noted a Chaplain ";Coordination Note" which states, ";...Chaplain to update the IDT team and also believes the patient would benefit from a volunteer..." There was no documented evidence that massage therapy and PT were provided as ordered.

Based on record review and interview, the hospice failed to ensure the care and services were provided based on all assessments of the patient and family needs in 1 of 4 (P-1) sampled records reviewed resulting in poor communication between the hospice staff and family. Findings include: --- Agency policy titled ";Implementing Care and Treatment", PC.35, was reviewed on 8/8/24. On page 1., it stated ";The Hospice designates a qualified Registered Nurse (RN)... who will oversee the following when coordinating the assignments of patient care... B. The implementation of the IDG/IDT Plan of Care (POC) for each patient and family". Interview was conducted on 8/6/27 at 3:08 p.m. with P-1s daughter, Com-1. During the interview, Com-1 stated that P-1 had dual power of attorneys for healthcare which were the patients wife, and Com-1. Com-1 stated that all the family agreed that the other daughter, Com-2, would be the primary contact regarding all care received by the hospice, and that Com-2 would relay information from the hospice to the rest of the family because P-1s wife was hard of hearing and was not able to relay details to the family well. P-1: This 86-year-old was admitted to agency on 4/6/24 with a terminal diagnosis of Senile Degenerative Brain Disease (mental deterioration associated with old age). During medical record review on 8/8/24, the following were noted: The Healthcare Durable Power of Attorney paperwork was uploaded at the start of care and gave evidence that P-1s wife and daughter (Com-1) were both identified as ";Co-Patient Advocates" for medical treatment and stated that the daughter (Com-2) could be appointed as successor by both P-1s wife and Com-1. On 4/12/24, the Clinical Team Lead (Staff C) documented a ";Family Conference" which included the RN case manager (Staff F); daughters, Com-1 and Com-2; and P-1s wife. The meeting note documented that Com-2 was to be the ";main point of contact" for P-1s wife and that Com-2 would relay information to the rest of the family to reduce miscommunication. On 4/26/24, Staff C documented a ";Care Conference" which included the ";Branch Director", Staff D; the ";Business Development Manager", Staff I; Com1; and Com-2. The meeting note documented that all communication be made with Com-2, all medication changes be addressed through Com-2, and that the RN case manager would notify Com-2 after each visit. The Interdisciplinary Group (IDG) met on 4/10/24; 4/24/24; 5/8/24; and 5/22/24. The level of involvement requested by the patient's representatives were not noted on any of the IDG meetings. On 5/11/24 an RN on-call visit related to fall (change in condition) was made. Documentation only notes that P-1s wife was notified, not Com-2. On 5/20/24 an RN on-call visit related to fall (change in condition) was made. Documentation only notes that P-1s wife was at the visit. There was no documentation that this change in condition was communicated to Com-2. On 5/21/24 an RN case manager visit was made. The documentation only notes that P-1s wife arrived and discussion of P-1s condition occurred. No update to Com-2 was documented. On 5/21/24 an RN on-call visit related to change in mental condition was made. Documentation only notes that POA was contacted, it does not state name of person contacted and does not state that Com-2 was contacted. The hospice failed to clearly communicate who staff should primarily contact for all care issues.

Based on record review and interview, the hospice failed to ensure the ongoing sharing of information with a non-hospice pharmacy furnishing services that were unrelated to the terminal illness and related conditions in 1 of 4 (P-1) sample records reviewed resulting in medications that should have been discontinued to still be given to the patient and potentially resulting in a poor patient outcome. Findings include: --- Agency policy titled ";Coordination of Care", PC.110, was reviewed on 8/8/24. On page 1., it stated ";The Hospice will provide for and ensure the ongoing sharing of information between disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement, by the Hospice, or by other providers... IV. The IDG/IDT will maintain responsibility for directing, coordinating, and supervising the care and services provided by all medical entities... V11. All communications and coordination of care is documented in the clinical record." P-1: This 86-year-old was admitted to agency on 4/6/24 with a terminal diagnosis of Senile Degenerative Brain Disease (mental deterioration associated with old age). During medical record review on 8/8/24, the following were noted: The start of care (SOC) was completed by a Registered Nurse (RN), Staff E, on 4/6/24 and included a list of medications which had been continued, new medications, and the following list of discontinued medications: Atorvastatin (to lower cholesterol); Eliquis (anticoagulant); Meloxicam (anti-inflammatory); Exelon patch (treatment of dementia); Memantine (also known as Namenda, treatment of dementia); and some supplements/laxatives. During review of uploaded attachments in the medical record on 8/8/24, it was noted that an attachment was faxed to the hospice agency on 5/15/24 and uploaded into P-1s medical record on 5/16/24 from the Assisted Living Facility (ALF) in which P-1 resided. The attachment was titled ";Physicians Orders Current Orders as of 15-May-2024 5:27 PM". It was P-1s medication list from the ALF and included: Atorvastatin; Eliquis; Memantine; Exelon Patch; (and other medications which had been prescribed and not discontinued). On 8/8/24 at 2:30 p.m., during discussion with the Administrator, Staff A, about medication passers at ALFs not being able to take or receive physician orders, Staff A was queried regarding how collaboration between the hospice and ALF pharmacy occurred. Staff A stated that all medications must be approved through the hospice pharmacy and that the ALF pharmacy should have been getting notice from the hospice pharmacy that they would not pay for certain medications. Staff A was not able to determine why the medications which had been discontinued by the hospice on 4/6/24 had still been on the ALF medication list as evidenced by the fax sent by the ALF to the hospice and uploaded to P-1's medical record on 5/16/24.

Based on record review and interview, the agency failed to ensure dietary counseling provided services for 1 (P-1) of 4 records reviewed, resulting in the hospice not meeting the counseling and dietary support needs of the patient and family. Findings include: --- P-1: This 86-year-old was admitted to agency on 4/6/24 with a terminal diagnosis of Senile Degenerative Brain Disease (mental deterioration associated with old age). During record review on 8/8/24, the signed ";Hospice informed consent/election of hospice benefit" for documented, ";I understand that a Registered Nurse (RN) will case manage all services and I have accepted the following services: RN, Hospice Aide, Social Worker, Dietician, Volunteer, Massage Therapy." Staff F completed the comprehensive assessment on 4/6/24 and documented a ";Narrative" stating, ";Frequencies requested: ... Dietician: Consult..." The Plan of Care (POC) dated 4/6/24 stated, ";Order of Discipline and Treatments: ... Registered dietician to be consulted PRN." Furthermore, on 4/26/24 noted a ";Care Conference" which states, ";...Staff I to look for nutritional consult..." The agency failed to provide dietary counseling as ordered.

Based on observation, record review, and interview, the agency failed to ensure locations identified as where the hospice agency ";Teams" meet for Interdisciplinary Group (IDG) meetings in Grand Rapids, Farmington Hills, and Saginaw had approval to operate as multiple locations for their provider number, resulting in the agency operating unapproved multiple locations (see L0656). --- The cumulative effect of these systemic problems resulted in the hospice's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation,42 CFR §418.100 Organization and administration of services.

Based on observation, record review, and interview, the agency failed to ensure locations identified as where the hospice agency ";Teams" meet for Interdisciplinary Group (IDG) meetings in Grand Rapids, Farmington Hills, and Saginaw had approval to operate as multiple locations for their provider number, resulting in the agency operating unapproved multiple locations. Findings include: --- On 8/7/24 at 8:45 a.m., entrance was made for complaint investigation of intake #108314. Request was made to the Administrator (Staff A) for an unduplicated list of patients for the past 6 months. Once the unduplicated list was received, the subject of the complaint was not found. Staff A stated that the patient must be from one of their other locations (Farmington Hills, Grand Rapids, Lansing, or Saginaw). When queried to whether those locations were hospice multiple sites under the Flint provider number, Staff A requested the Director of Compliance (Staff B) to assist with an explanation. Staff B explained that the Flint hospice agency had ";Teams" in Flint, Farmington Hills, Saginaw, Lansing, and Grand Rapids. Staff B continued to explain that these ";Teams" were all directed under the Flint provider number. Staff B stated that Farmington Hills, Saginaw, and Grand Rapids do have home health agency locations (by same corporation). Staff B also stated that staff sometimes refer to the ";Teams" as ";branches" because that is how the electronic medical record system identifies each Team. Staff B also stated that training of staff for all Teams is done by the Flint office other than precepting which may be done by a member of the location Team. A request was made for an organizational chart. Staff A wrote the scheduled Interdisciplinary Group (IDG) meeting locations and times for each Team IDG and the following was noted: ";Flint Team" with a census of 81 patients- meetings occurred at Flint Hospice Office: 5401 Gateway Blvd Flint, MI 48507 on every other Tuesday at 1:00 p.m., and every other Thursday at 9:30 a.m. ";Lansing Team" with a census of 35 patients- meetings occurred via Microsoft Teams Meeting on every other Tuesday at 3:00 p.m. ";Grand Rapids Team" with a census of 22 patients- meetings occurred at ";Grand Rapids Home Care Office": 756 Fulton St. Suite 203 Grand Rapids, MI 49504 on every other Tuesday at 1:00 p.m., (or meeting may also occur on Microsoft Teams). ";Saginaw Team" with a census of 137 patients- meetings occurred at ";Saginaw Home Care Office": 3226 Fashion Square Blvd Saginaw, MI 48603 on every other Wednesday at 9:00 a.m., (or meeting may also occur on Microsoft Teams). ";Farmington Hills Team" with a census of 83 patients- meetings occurred at ";Farmington Home Care" office: 30600 Northwestern Hwy Farmington Hills, 48334 on every other Wednesday at 9:30 a.m., (or meeting may also occur on Microsoft Teams). On 8/7/24, it was noted when reviewing the hospice agency organizational chart that Staff A was noted as the ";Administrator/Branch Director" and Staff D was identified as the Saginaw Team ";Clinical Manager". On 8/7/24, a Saginaw Team staff list was received and listed staff according to their role. It was noted that Staff D was identified as the ";Branch Director", and a different person was identified as the ";Clinical Manager" (Staff C). Staff A was not listed on the Saginaw Team staff list. On 8/12/24, at 8:35 a.m., a survey site visit and observation of the Saginaw Home Care Office, 3226 Fashion Square Blvd Saginaw, where the Saginaw Team had their hospice IDG meetings was completed. There were no hospice staff present at the time of the observation. The home care agency receptionist, Staff H, was able to identify the ";conference room" where the Saginaw Team hospice staff attended IDG meetings. Staff H stated that hospice staff did come to the location to pick up items such as incontinence briefs, wipes, and miscellaneous other items that may be needed such as catheter supplies. Staff H denied that any patient referrals or personnel training of hospice staff occurred at that location. Staff H stated that if patients or healthcare personnel called the Saginaw home care site for referral to hospice, Staff H forwarded the call to the Flint office. In conclusion, the hospice utilizes the Farmington home care office, Grand Rapids home care office, and Saginaw home care office each as a multiple locations of the Flint hospice agency as evidenced by the use of those locations for conducting services, including IDG meetings, on behalf of the hospice. On 8/12/24 at 10:34 a.m., this concern was stated during the exit conference with Staff A, Staff B, and the Regional Director of Operations (Staff J).

Upon patient record review 4 of 16 (Patients #5, #8, #12, and #14) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #5 start of care of 10/4/2021. The Social Worker did not complete the psychosocial assessment until 10/14/2021 (Day 10). Patient #8: start of care of 11/18/2021. The Social Worker did not complete the psychosocial assessment until 11/24/2021 (Day 6). Patient #12: start of care of 11/10/2021. The Chaplain did not complete the spiritual assessment until 11/23/2021 (Day 13). Patient #14: start of care of 10/12/2021. The Chaplain did not complete the spiritual assessment until 10/18/2021(Day 6).

Upon patient record review, 8 of 16 (Patients #3, #5, #6, #8, #9, #10, #12, and #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. Patient #3: start of care of 12/1/2021 and the initial bereavement assessment was not completed until 12/8/2021. Patient #5: start of care of 10/4/2021 and the initial bereavement assessment had not been completed as of the survey date of 12/30/2021. Patient #6: start of care of 10/27/2021 and the initial bereavement assessment was not completed until 11/24/2021. Patient #8: start of care of 11/18/2021 and the initial bereavement assessment had not been completed as of the survey date of 12/30/2021. Patient #9: start of care of 10/22/2021 and the initial bereavement assessment was not completed until 12/27/2021. Patient #10: start of care of 10/22/2021 and the initial bereavement assessment was not completed until 12/6/2921, Patient #12: start of care of 11/10/2021 and the initial bereavement assessment was not completed prior to the patient's discharge of 12/18/2021. Patient #14: start of care of 10/12/2021 and the initial bereavement assessment was not completed until 11/2/2021.

Upon patient record review, 3 of 16 (Patients #5, #8, and #12) did not have evidence that the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #5: Physician wound care orders dated 12/9/2021 and 12/14/2021. Neither order listed the location of the wound or who was responsible for providing the wound care. Patient #8: Physician wound care orders dated 12/7/2021 and 12/14/2021. Neither order listed who was responsible for providing the wound care. Patient #12: Physician wound care order dated 12/2/2021. The order did not include the location of the wound, the frequency of wound care or who was responsible for providing the wound care.

Upon personnel record review, 1 of 1 applicable (Personnel #5) did not have evidence in the personnel file that the following competency assessment was performed.