Every finding on record at Compassus Aah of Michigan II, 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 measures 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 clinical record review, document review, and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the drug profile included all the patient's current medications. Clinical Record 8: The patient elected hospice care on 05/23/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). The comprehensive nursing assessment completed by the skilled nurse (SN) on 05/23/2024 documented, "Oxygen 3 LPM via nasal canula." The hospice medication profile did not document the oxygen noted in the comprehensive assessment. During the joint record review and interview on 04/09/2025, the Area Executive of Clinical Operations confirmed that the medication profile did not accurately represent the medications the patient received.

It is required that each patient’s individualized written plan of care reflects patient and family goals 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 19 (11%) clinical records reviewed, the agency did not ensure that the patient’s plan of care reflected the patient's and family's goals based on problems identified in the initial and comprehensive assessments. Clinical Record 2: The patient elected hospice care on 12/12/2024 with a diagnosis of senile degeneration of the brain. On 02/26/2025, the physician ordered Amoxicillin 875mg Potassium Clavulanate 125mg, one (1) tablet by mouth twice daily for 7 days for pneumonia. The skilled nursing (SN) visit note dated 02/26/2025 documented, "Patient's primary physician started the patient on Amoxicillin 875mg Potassium Clavulanate 125mg, one (1) tablet by mouth twice daily for 7 days for pneumonia with start date 02/20/2025 and end date 02/27/2025." The "Hospice Interdisciplinary Group (IDG) Comprehensive Assessment" and "Plan of Care Update" reports dated 03/05/2025 and 03/19/2025 did not document patient and family goals for the identified respiratory infection. Clinical Record 16: The patient elected hospice care on 11/26/2024 with a diagnosis of malignant neoplasm of the prostate. The SN visit note dated 01/08/2025 documented that the patient reported "difficulty getting his urine started and is only dribbling and burns." On 01/08/2025, the SN received a physician order for Bactrim DS 800 mg - 160 mg tablet, two (2) tablets by mouth two times daily for a UTI (Urinary Tract Infection. The "Hospice IDG Comprehensive Assessment" and "Plan of Care Update" reports dated 01/15/2025 and 01/29/2025 did not document patient and family goals for the identified UTI. During the joint record review and interview on 04/09/2025, the Area Executive of Clinical Operations confirmed that the plans of care for clinical records 2 and 16 did not include goals related to the infections.

It is required that each patient’s individualized written plan of care: includes all services necessary for palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy and procedure #HOS-C_09A “Individualized Plan of Care” (review date 12/27/2024) stated in part, “2. Content of the Plan of Care: e. Drugs and treatments necessary to support patient care needs. i. The complete medication and treatment profile includes all medications the patient is currently consuming, whether prescribed, over the counter, herbal preparations, or Oxygen.” In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the patient’s individualized plan of care included the drugs and treatments necessary to meet the patient’s needs. Clinical Record 8: The patient elected hospice care on 05/23/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). The recertification assessment completed by the skilled nurse (SN) on 02/27/2025 documented, “94% at rest on 4 L...Indicate respiratory treatments utilized at home-continuous oxygen.” The “Hospice Interdisciplinary Group (IDG) Comprehensive Assessment” and “Plan of Care Update” reports (individualized plan of care), dated 03/12/2025 and 03/26/2025, did not document oxygen. During the joint record review and interview on 04/09/2025, the Area Executive of Clinical Operations confirmed that the plan of care did not include oxygen.

It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy and procedure #HOS-C_12A "Supervision of Hospice Aides and LP/VN Colleagues" (review date 12/31/2024) stated in part, "The RN is responsible to perform a supervisory visit of the LPN/LVN at least every 30 days." In 1 of 16 (6%) clinical records reviewed of patients who received Licensed Practical Nurse (LPN) visits, the agency did not ensure that a Registered Nurse (RN) provided supervision of the LPN services as per agency policy. Clinical Record 13: The patient elected hospice care on 10/31/2024 with a diagnosis of heart failure, unspecified. The hospice recertification plan of care dated 01/29/2025 through 04/28/2025 ordered skilled nursing (SN) services once (1) weekly beginning 01/29/2025. The LPN completed a skilled nursing (SN) visit on 02/25/2025. A LPN supervisory visit was completed by the RN on 04/08/2025. A clinical record review revealed no evidence that LPN supervisory visits were completed every 30 days per agency policy. During a joint record review and interview on 04/09/2025, the Area Executive of Clinical Operations confirmed that LPN supervisory visits were not completed per agency policy, at least every 30 days.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure that all physician orders for care and services were documented in the patient's clinical record. Clinical Record 3: The patient was admitted for hospice services on 3/15/2023 with the diagnosis of End Stage Renal Failure. The Initial Skilled Nurse assessment dated 3/15/2023 documented that the patient had an indwelling catheter. The Plan of Care dated 3/15/2023 did not include physician orders for an indwelling catheter. No other verbal orders were located in the clinical record for an indwelling catheter. During a joint record review with the Area Manager, she validated that there was no physician order for the indwelling catheter.

It is required that the Hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by review of clinical records, document review, and interview. In 2 of 11 (18%) records reviewed failed to follow agency policy for comprehensive assessment within five calendar days of the election of hospice care. Record #65955: The patient election for the Hospice benefit occurred on 11/21/2021. A documented phone call by the Medical Social Worker changed the visit date at the family's request to 12/01/2021. The psychosocial assessment was documented on 12/01/2021. The MSW assessment occurred on day ten and was five days late. Record #89920: The patient election for the Hospice benefit occurred on 10/20/2021. The interdisciplinary note on 11/05/2021 documented that the Chaplain was refused; this was days 16 and 11 days late. The Registered Nurse recorded that all disciplines were accepted except volunteers on the admission assessment. Agency Policy C 08C Initial and Comprehensive Assessments [revision date 7/26/2021] stated in part, "The first comprehensive assessment for psychosocial and spiritual needs is completed not more than five days following the date of the election." Interview with the Regional Director/Acting Administrator on 06/02/2022 stated that documentation of contract with patients and family was self-identified and is a process improvement.

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 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 a new medication is added, or changes are made to existing medication. This standard was not met as evidenced by review of clinical records, document review, and interview. In 1 of 11 (09%) records reviewed failed to include all over-the-counter medications on the medication profile and consequently failed to review the medications for all potential side effects and interactions. Record #83100: The interdisciplinary meeting on 05/04/2022 documented that Aleve (pain medication) was working well to control breast pain. The medication profile documentation was not updated to include Aleve as of review 06/01/2022. The medication profile reviewed on 06/03/2022 included the medication of Aleve. Agency Policy C15C Medication Reconciliation [revision date 1/30/2019] stated in part, "if the medication lists do not match, the nurse ensures the incorrect list is promptly updated to reflect the correct orders and the medication reconciliation process is completed." An interview on 06/02/2022 with the Director of Quality Outcomes stated that the medication profile was not updated timely.

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 review of clinical records, documentation review, and interview. In 4 of 11 (36%) records reviewed failed to document intervention and goals identified in updated comprehensive assessments. Record #46796: The updated nursing assessment on 03/09/2022 added a problem with constipation that required medication changes and upper respiratory infections requiring medication changes on 03/22/2022. There were no interventions or goals documented for constipation or respiratory status as of review 06/02/2022. Record #83100: The updated nursing assessment documented a wound. There were no goals noted for skin integrity as of review 06/02/2022. The goals were written on 06/03/2022. Record #36796: The updated nursing assessment on 10/02/2021 documented the need and delivered music therapy service. There were no interventions or goals established for music therapy on the plan of care before death on 11/12/2021. Record #51919: The updated nursing assessment on 04/15/2022 documented constipation. The plans of care were not updated with interventions or goals for constipation as of review 06/01/2022. Agency Policy C9 Written Interdisciplinary Plan [revision date 9/27/2019] stated in part, "the plan of care reflects updated patient and family/caregiver needs as determined in updated comprehensive assessments. Measurable goals and outcomes for planned interventions." Interview with the Regional Director/Acting Administrator and Director of Quality Outcomes stated that updated intervention and goals were self-identified and a work in progress.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan: a revised plan of care includes a record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by review of clinical records, document review, and interview. In 4 of 11 (36%) records reviewed failed to document updated progress toward patient goals during the interdisciplinary meeting. Record #83100: The RN documented on 04/20/2022 interdisciplinary meeting that the Social Worker and Chaplain were yet to see the patient. The record documented visits from both the Social Worker and the Chaplain on 04/19/2022 and was incorrect. An update from nursing on the wound progress was not documented during this meeting. Record #49796: In the interdisciplinary meeting on 03/23/2022, the RN failed to include the progress of the patient's severe constipation, which required medication changes on 03/09/2022, and the upper respiratory infection that required medication interventions of antibiotics, decongestants, and inhalers on 03/22/2022. Record #36796: Music therapy visits were ordered on 10/02/2021. The interdisciplinary meeting documented from 10/06/2021 through 11/12/2021 failed to report music therapy progress or update from music therapy. Record #51919: At the interdisciplinary meeting on 04/20/2022, the RN documented no update on the interventions for constipation started on 04/15/2022 of increased medications and treatments. Agency Policy C09E Interdisciplinary Team Meeting, [revision date 5/7/2020] stated in part, "Documentation for the meeting includes the summary of discussion points, changes in the plan of care updates to visit frequency, and changes in interventions for the patient." Interview with the Regional Director/Acting Administrator and Director of Quality Outcomes stated that the interdisciplinary meetings focus on the agency to improve the process.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene and use of gloves, masks, eye protection, or face shield depending on anticipated exposure. This standard was not met as evidenced by observation, documentation review, and interview. In 1 of 3 (33%) observed home visits, professional staff failed to follow agency policy for Bag Technique. Observed home visit #35311 with Registered Nurse #45639 on 06/02/2022 at 11 am at a SNF facility. The nurse donned gloves and disinfected equipment of blood pressure cuff, oxygen saturation finger monitor, and stethoscope. The equipment was returned to the nursing bag as each piece was cleaned. Gloves were not removed, and hands were not sanitized prior to returning clean equipment to the nursing bag. Agency Policy C-11G Bag Technique Standard Precaution revision date 4/22/2020 stated in part, "When care delivery is completed, and reusable supplies are to be returned to bag...wipe down with alcohol pad to disinfect, remove gloves and discard and perform hand hygiene and place supplies in a bag.” The interview with the Registered Nurse on 06/02/2022 revealed that gloves were not doffed, and hand hygiene was not performed before returning equipment into the nursing bag because there was no room on the barrier.

It is required that hospice aides are assigned to a specific patient by a Registered Nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by a review of clinical records and interview. In 1 of 9 (11%) records for which a hospice aide was accepted, reviewed revealed a lack of clear and specific written instruction for the aide assignment, thus leaving the aide to make decisions outside of the aide's scope of practice. Record #36796: A documented hospice aide plan dated 03/09/2021 assigned transfer patient with one person transfer. Interdisciplinary meeting documentation on 10/08/2021 documented patient is dependent on Hoyer lift transfer. Patient condition documented in nursing visit notes of a rapid decline to bedbound status. There was no documented update to the aide's written instruction as of the death date 11/17/2021. An interview with the Director of Quality Outcomes on 06/03/2022 stated that the Hoyer update should have been on the aide plan.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by review of clinical records, document review, and interview. In 2 of 9 (22%) records of patients that accepted hospice aides reviewed, the aide failed to provide the services in accordance with the documented plan of care. Record #36796: The hospice benefit of the election date was 10/02/2021. The hospice aide ordered visit frequency was 1 week 2, 3 weeks 6, and 1 week 1. The hospice aide care was provided at 1 week 2, and then 2 weeks 1 and 3 times a week. There was no documentation of the reason for the one missed visit in the third week. Record #51919: The hospice aide's written instruction by the RN was documented on 01/31/2022 and updated on 04/04/2022, assigned the task of shampoo every visit. Aide visit note 04/01/2022 documented shampoo, 'not required.' Agency Policy C9A Missed Visits [revision date 04/16/2019] stated in part, "The OMIT visit form may be used when an interdisciplinary team member is unable to visit due to the following (list of reasons for a missed visit) and documented." An interview with the Director of Quality Outcomes on 06/03/2022 stated that the aide also did not document notification of the nurse and that the visit was missed.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a Registered Nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by review of clinical records and interview. In 2 of 9 (22%) records reviewed in which ordered care tasks for the hospice aide were ordered and not completed, the aide failed to document notification of the nurse. Record #35311: The hospice aide visit note on 05/31/2022 documented patient refused bed bath and perineal care. The patient is wheelchair-bound and incontinent. The task to report to the nurse was documented as "not required this visit." Record #51919: The hospice aide visit note on 04/01/2022 documented shampoo ordered every visit as 'not required.' The task to report to the nurse documented "no." Interview with the Regional Director and Acting Administrator stated that the nurse should have been notified.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: A copy of the hospice discharge summary and the patient's record if requested. This standard was not met as evidenced by clinical record review, documentation review, and interview. 2 of 2 (100%) records reviewed that included live discharges failed to document that a discharge summary was sent to the physician as required by agency policy. Record #89920: documented a live discharge on 11/5/2021 to home health for wound care. There was no documentation that the discharge summary was sent to the attending physician as of review on 6/2/2022. Record #38637: documented a live discharge for revocation on 1/4/2022; patient admitted to a hospital for aggressive treatment. There was no documentation that the discharge summary was sent to the attending physician as of review on 6/2/2022. Agency Policy C04 Discharge/Transfer/Revocation [revision date 8/19/2019] stated in part, "will provide a discharge summary to the attending physician or receiving facility containing: treatment, symptoms, and pain management information, the current plan of care, latest physician orders, other documentation facilitating continuity of care and requested by the attending physician or receiving facility." Interview of Director Quality Outcomes on 6/3/2022 stated that the Attending Physician was the Medical Director for both discharges #89920 and #38637 and that the discharges were discussed in the interdisciplinary team meeting. Director Quality Outcomes stated there was no discharge summary documentation being sent to the Attending Physician for both clinical records reviewed.

It is required that drugs and biologicals related to the palliation and management of the terminal illness and related conditions are: identified in the plan of care and provided to a patient while under the care of the hospice. This standard was not met as evidenced by review of clinical records, document review, and interview. In 1 of 11 (09%) records reviewed, the agency failed to correctly identify hospice provider coverage of medications for related diagnosis and prognosis, as required. Record # 51919: Hospice Benefit of Election date 01/29/2022 and plan of care 01/29/2022 - 04/28/2022 and 04/29/2022 - 07/27/2022 documented primary diagnosis Moderate Protein-Calorie Malnutrition, related hospice diagnosis not limited to: Essential Hypertension, Generalized Anxiety, Cerebrovascular Disease, Dysphagia, and Seizures. The following medications on the plans of care document medication are not covered related to primary diagnosis: Baclofen (muscle relaxant), Cymbalta (antidepressant), Haloperidol (anxiety), Keppra (seizures), and Metoprolol (blood pressure). Documented order on 06/01/2022 for the benefit to begin 01/29/2022 to cover the following medications: Baclofen, Cymbalta, Haloperidol, Keppra, and metoprolol. Agency Policy C03B1 Competing Medicare Election [revision date 12/01/2021] stated in part, "The clinical reason for not covering a service, item, or medication is that it is not considered reasonable or necessary for the palliation and management of the terminal illness or related conditions." Agency Policy C29 Drugs, Biologicals, Medical Supplies [revision date 02/27/2020] stated in part, "The medication review process during the interdisciplinary team meeting includes a determination by the hospice physician of the nature of the relationship of medications to the patient terminal diagnosis and /or related conditions. Medications unrelated to the patient's terminal diagnosis and/or related conditions will not be paid for." An interview on 06/02/2022 with the Director of Quality Outcomes stated that the medications should have been covered.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: Hospice election form and physician certification of the terminal illness. This standard was not met as evidenced by document review, observation, and interview. In 1 of 1 (100%) observations during a visit at a skilled nursing facility failed to provide evidence of all required documentation to the skilled facility. Observed visit on Patient #35311 on 06/02/2022 at 11:00 AM at a Skilled Facility; the Hospice Facility Binder was reviewed with the Registered Nurse and failed to provide evidence of the hospice benefit of the election, the initial certification of terminal illness, and the initial hospice plan of care. The patient was transferred to this facility on 05/19/2022. Agency policy C26 Care in the Nursing Facility [revision date 5/17/2018] stated in part, "(hospice agency) provides the SNF/NF...with the following information: (b) hospice election form (c) physician certification...of the terminal illness specific to the patient." The interview of the Registered Nurse revealed that the election form and initial certification were missing from the hospice patient binder as of 6/2/2022. The Director of Quality Outcomes said that the nurse took the documentation to the facility on 06/03/2022 again but that the record did not document that the forms were taken to the facility on admission.