Every finding on record at Great Lakes Caring Hospice NW Mi

Upon patient record review 2 of 14 (Patient #12, 14) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #12 - There was no evidence of a spiritual care assessment of the patient or family until 05/16/24 - SOC was 05/09/24. Patient #14 - There was no evidence of a spiritual care assessment of the patient or family until 04/25/24 - SOC was 04/19/24.

Upon patient record review, 2 of 14 (Patient #6, 7) 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 #6 - Patient in ALF - Magnesium Oxide 500mg not on hospice medication profile but on facility med profile. Bisacodyl 10mg suppository not on facility med profile but on hospice medication profile. Patient #7 - Patient in ALF -Doxycycline and Gentle Tears on ALF med profile - not on hospice profile. Melatonin and Zolpidem on hospice med profile but not on ALF profile.

Upon patient record review, 1 of 14 (Patient #12) 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 #12 - The patient was admitted 05/09/24. There was no evidence of a bereavement risk assessment at the time of the survey.

Upon patient record review, 3 of 14 (Patient #6, 7, 13) 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 #6 - Patient in ALF - Magnesium Oxide 500mg not on hospice medication profile but on facility med profile. Bisacodyl 10mg suppository not on facility med profile but on hospice medication profile. Patient #7 - Patient in ALF -Doxycycline and Gentle Tears on ALF med profile - not on hospice profile. Melatonin and Zolpidem on hospice med profile but not on ALF profile. Patient #13 - Order written on 06/21/24 "paint wound with betadine, cover with band aid, wrap with Kerlix" no documentation of wound site or frequency.

Upon client record review, 1 of 14 (Patient #14) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #15 - RN completed assessment on 05/20/24 then again on 06/08/24 - 19 days between assessments.

Upon client record review, 1 of 14 (Patient #14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #14 - Order to change Foley catheter #18F 10cc monthly and PRN for leakage or dislodgement. Visit date 05/27/24 SN changed Foley catheter using #18F 10cc coude catheter.

Upon patient record review, 3 of 14 (Patient #6, 7, 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 #6 - Aide documented on visits 06/19, 06/24, 06/26, 07/01 declined or already provided by the caregiver. There was no evidence that the plan of care was updated. Patient #7 - Aide documented on visits 06/10, 06/12, 06/17, 06/19, 06/24, 06/26 declined or already provided by the caregiver. There was no evidence that the plan of care was updated. Patient #12 - Aide documented on visits 05/23, 05/28, 06/04, 06/08 declined or already provided by the caregiver. There was no evidence that the plan of care was updated.

Upon patient record review 2 of 14 (Patient #8, 14) 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 #8 - Aide visit note 06/14/24 "bottom red - applied cream" application of cream not on care plan. Patient #14 - Aide to provide shower 1 x week but provided 2 x week 05/05/24, 05/12/24 and 06/09/24.

Upon patient client record review, 3 of 14 (Patient #6, 8, 9) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #6 - MSW visit note 06/13/24 and 06/20/24 - MSW documented "evaluation completed, no further visit needed - will provide PRN visit as needed but visit frequency on POC is 1 every wk 2, 1wk1, 1 every 3 wk 3. Patient #8 - MSW visit note 06/13/24 and 06/20/24 - MSW documented "evaluation completed, no further visit needed - will provide PRN visit as needed but visit frequency on POC is 1 wk 1, 1 every 5 wks, 1 every 2 weeks 2. Patient #9 - MSW visit note 06/10/24 - MSW documented "evaluation completed, no further visit needed - will provide PRN visit as needed but visit frequency on POC remained 1 wk 1, 1 every 2 wks 2, 1 every 4 weeks 4. (While MSW updated frequency and performed visits per frequency, the charting did not align since visits were not performed PRN).

Upon client record review, 1 of 14 (Patient #3) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #3 - Discharge summary sent to hospice MD and not PCP