Every finding on record at Great Lakes Caring Hospice E Mi

Upon patient record review, 8 of 19 (Patient #4,5,6,11,12,13,14,15) 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 Upon review, nursing note stated to discontinue Amlodipine,Januvia, Metformin and Melatonin on 8/26/24, however medications remain on the medication profile. Patient #5 Upon review, patient has orders for Norco 5-325mg Q6, Tylenol 325mg 2 tabs BID, Tylenol 325mg 2 tabs Q4 PRN and Acetaminophen suppository 650mg Q6 PRN which exceeds the max dose of 4000mg daily. Patient #6 Upon review, visit note on 8/27/24 states to discontinue Digoxin and visit note on 8/8/24 states to discontinue Eliquis, medications remain on the medication profile. Patient #11 Upon review, medication profile includes Biofreeze 5% topical TID, no evidence of a location to apply. Miralax does not include diluent or mixing instructions on medication profile. RN visit 9/9/24 documents increased Morphine ER is effective, no evidence to increase the Morphine ER on medication profile. Patient #12 Upon review medication profile includes oxygen 2-4L and no evidence of a route indicated for administration. Patient #13, 15 Upon review, Miralax did not include diluent or mixing instructions on medication profile. Patient #14 Upon review, Budesonide on 4/9/24 states to "stop when Ellipta is exhausted" however both medications remain active on the medication profile. Medication profile includes Metronidazole 7/30/24 states for the medication to be administered for 7 days, however the medication remains active on the medication profile. Medication profile includes Cephalexin 7/31/24 states for the medication to be administered for 7 days, however the medication remains active on the medication profile. Visit note on 8/21/24 states patient taking Tylenol, however medication is not on the medication profile. Visit note on 8/26/24 and 9/4/24 states patient taking Mucinex, however medication is not on the medication profile.

Upon patient record review, 2 of 19 (Patient #2, 11) 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 #2 Upon review, patient was admitted 6/27/24, no evidence of an initial bereavement risk assessment. Patient #11 Upon review, patient was admitted 8/21/24, no evidence of an initial bereavement risk assessment.

Upon patient record review, 1 of 19 (Patient #12) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #12 Upon review, RN visit completed on 8/19/24 includes updated comprehensive assessment, the next updated comprehensive assessment completed by the RN was on 9/6/24.

Upon patient record review, 1 of 19 (Patient #12) 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 #12 Upon review, visit 8/19/24 documents wound assessments for the coccyx and buttock wounds, no assessment of these wounds completed after 8/19/24 to current.

Upon patient record review, 1 of 19 (Patient #11) 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 #11 Upon review the patient had order to place a foley and nursing visits document foley in place, no evidence of a care plan for the foley.

Upon patient record review, 9 of 19 (Patient #4,5,6,11,12,13,14,15,16) 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 Upon review, visit note stated to discontinue Amlodipine,Januvia, Metformin and Melatonin on 8/26/24, no evidence of an order. Patient #5 Upon review, patient has orders for Norco 5-325mg Q6, Tylenol 325mg 2 tabs BID, Tylenol 325mg 2 tabs Q4 PRN and Acetaminophen suppository 650mg Q6 PRN which exceeds the max dose of 4000mg daily. Patient #6 Upon review, visit note on 8/27/24 states to discontinue Digoxin and visit note on 8/8/24 states to discontinue Eliquis, no evidence of an order. Patient #11 Upon review, order for Biofreeze 5% topical TID, no evidence of a location to apply. Miralax order does not include diluent or mixing instructions. Order on 8/27/24 for a foley, does not include the size and details for care and changing the foley. RN visit 9/9/24 documents increased Morphine ER is effective, no evidence of an order to increase the Morphine ER. Patient #12 Upon review oxygen 2-4L ordered and no evidence of a route indicated for administration. Patient #13, 15 Upon review, Miralax ordered and did not include diluent or mixing instructions. Patient #14 Upon review, order for Budesonide on 4/9/24 states to "stop when Ellipta is exhausted" however both medications remain with active orders. Order for Metronidazole 7/30/24 states for the medication to be administered for 7 days, however medication order remains active. Order for Cephalexin 7/31/24 states for the medication to be administered for 7 days, however the medication order remains active. Visit note on 8/21/24 states patient taking Tylenol, however there is no Tylenol order in place. Visit note on 8/26/24 and 9/4/24 states patient taking Mucinex, however there is no order in place. Patient #16 Upon review, the order for wound care on 7/29/24 does not have a frequency for the wound care to be performed.

Upon patient record review, 2 of 19 (Patient #6,8) 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 equipment and supply needs. Patient #6 has documentation on 7/25/24 in the SOC narrative that the patient utilizes a wheelchair and on 8/13 the visit narrative states the patient was in the wheelchair upon arrival by staff, however no wheelchair orders in DME. Patient #8 has documentation in the visit narrative on 3/5/24 that the patient utilizes a wheelchair, however no wheelchair order in DME.

Upon patient record review, 1 of 19 (Patient #12) 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 #12 Upon review, Oxygen ordered on 6/24/24, no evidence that the care plan was updated to include oxygen precautions.

Upon client record review, 4 of 19 (Patient #3, 8, 15, 16) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3 Upon review, had orders written for MSW frequency of 1WK1 and 1EVERY4WK12 on 5/10/24 for effective date of 5/7/24, 1EVERY5WK5, 1EVERY4WK4. On 6/7/24 for effective date of 6/2/24, 1EVERY5WK5 on 6/27/24 for effective date of 6/30/24. Order on 7/30/24 for effective date of 7/28/24 to discontinue MSW visits. There is no evidence of MSW visits or evidence of missed visit documentation after the initial visit on 5/10/24. Patient #8 Upon review the patient has orders for a foley catheter on 8/7/24 to be changed and on 8/7/24 there were 2 nursing visits made and documentation states they were unable to re-insert the foley, however no order to discontinue the foley were obtained. On 8/14/24 the visit note states the foley was re-inserted. Patient #15 Upon review, order on 5/28/24 effective 6/23/24 for MSW 1w1. Order on 6/18/24 effective 7/21/24 for SW 1w1, 1every4w8. Order on 7/21/24 for SW 1every5w5, 1every4w4. MSW missed visit notes on 6/25/24 and 8/23/24 document no answer to call, no evidence of MSW visits completed or refusal of visits. Patient #16 Upon review orders written on 6/17/24 for MSW frequency 1wk1 and 1EVERY4WK12 effective 6/20/24. On 7/14/24 MSW frequency orders for 1EVERY5WK5, 1EVERY4WK4, however no evidence of visit or refusal the week of 7/14/24.

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#5, during Aide visit with Surveyor, the aide placed her tablet on a table in the patients room and a table in the dining hall without a barrier or disinfection of tablet per agency policy.

Upon patient record review, 3 of 19 (Patient #17,18, 19) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #17 Upon review, the 75-day letter was due to be sent on 5/12/24 and was not sent until 6/17/24 Patient #18 Upon review, the 75-day letter was due to be sent on 5/9/24 and was not sent until 6/17/24 Patient #19 Upon review, the bereavement card was due to be sent on 3/18/24, the 30-day letter was due to be sent on 4/9/24, the 60-day letter was due to be sent 5/9/24, the 75-day letter was due to be sent on 5/24/24 and the 90-day letter was due to be sent on 6/8/24, the bereavement card and letters at 30-60-75-90 days were not sent.

Upon patient record review, 1 of 19 (Patient #12) 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 #12 Upon review, Oxygen ordered on 6/24/24, no evidence of Oxygen precautions on the aide care plan.

Upon patient record review 2 of 19 (Patient #12,16) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #12 Upon review, aide care plan included nail care every visit. Aide visits on 8/29/24 and 9/6/24 documented nail care not needed this visit. Patient #16 Upon review, the aide care plan includes weekly nail care and shaving every visit. Aide visits on 9/3/24,8/30/24, 8/27/24, 8/23/24, 8/20/24 documented nail care and shaving not needed to be done this visit.

Upon patient record review 1 of 19 (Patient #16) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #16 Upon review, aide visits completed from 6/17/24-8/15/24, no evidence of aide supervision completed.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Parent volunteer utilization at 2.22% for 2023, branch at 2.02% for 2023. Total volunteer percentage less than 5% for 2023.

Upon client record review, 1 of 19 (Patient #1) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility.

Upon client record review, 2 of 19 (Patient #7, 12) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #7 Upon review, on 5/29/24 Jevity order states 40ml/hr x20 hr (total of 800ml) on 8/2/24 SN visit states decreased Jevity from 55ml/hr to 45ml/hr however there is no documentation of the order change. Patient #12 Upon review, LPN visit on 8/27/24 documented wound care provided to coccyx, nursing visits documents 2 active wounds on the coccyx and buttocks. No evidence of a wound care order.