Every finding on record at Great Lakes Healthcare Inc.

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 clinical record review, document review and interview. In 2 of 19 (11%) clinical records reviewed it was revealed that the agency did not ensure that each patient's written plan of care included the anticipated outcomes from the implementation of the new interventions that were added to the plan of care. Document 1: The agency's policy "Plan of Care - Hospice" (Reference #1000) effective 09/01/2014 and revised 01/12/2021 included in part, "Purpose ... to enable the achievement of patient's/family's desired outcomes for the patient's Hospice experience ... the plan of care shall reflect patient and family goals ... based on problems identified in the initial, comprehensive, and going comprehensive assessments ... Using data obtained during the initial and ongoing Hospice assessments, the interdisciplinary group members shall develop a list of patient problems and needs with corresponding goals ..." Clinical Record 3: The patient elected the hospice benefit on 01/03/2024. A physician's order was documented on 03/06/2024 for Macrobid 100mg by mouth twice daily for seven days to treat a urinary tract infection. On 03/07/2024, a physician's order was documented for Divalproex 125mg by mouth twice daily for behavior issues. The patient's written plan of care did not include any measurable outcomes expected from the medication changes. Clinical Record 4: The patient elected the hospice benefit on 10/19/2023. A physician's order was documented on 04/08/2024 for Keflex 250mg by mouth every six hours for seven days to treat a wound infection. On 04/09/2024, another physician's order was documented to discontinue the Keflex and start Cefdinir 300mg by mouth twice daily for the wound infection. The patient's written plan of care did not include any measurable outcomes expected for the intervention of antibiotic therapy for the patient's wound infection. Personnel Record 3: During a joint clinical record review and interview with the Clinical Operations Manager (Personnel Record 3) on 04/24/2024, it was confirmed that the patient's written plans of care were not updated with goals from implementing changes to the plans of care.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care and documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 1 (100%) clinical record reviewed in which volunteer services were accepted it was revealed that the agency did not ensure that the volunteer visits were provided as ordered on the plan of care. Document 1: Volunteer Services (Reference #403) effective 10/01/2014 and with the revised date of 01/19/2018 read in part, "The Volunteer Services Coordinator (VSC) will participate in the Interdisciplinary Group meeting and care plan process and is the coordinator of volunteers providing Hospice services ....The Hospice VSC shall arrange for volunteers to provide volunteer support to the patient, family, or caregiver according to the interdisciplinary plan of care. Interdisciplinary plan of care and ongoing RN/MSW assessment may assist in determining scope and frequency of services... Volunteers shall document their activities on Volunteer Notes and submit this documentation to the VSC for the patient's clinical records." Clinical Record 7: The patient elected the hospice benefit on 12/27/2023. On 03/07/2024, an order was documented for the patient to begin to receive volunteer visits for the remainder of the certification period. The order was included in the Interdisciplinary Group Meeting (IDG) documented on 03/14/2024 for the benefit period 12/27/2024 to 03/25/2024. During the IDG meetings on 03/28/2024 and 04/11/2024 for the benefit period of 03/26/2024 to 06/23/2024, there was no documentation about volunteers included in the plan of care, no documented visits in the electronic medical record or scanned into the patient's documents, and no coordination of care note addressing volunteer visits. There had been no order since 03/07/2024 confirming a volunteer visit frequency or an order to discontinue volunteer services. Personnel Record 4: During a joint record review and interview with the Volunteer Manager (Personnel Record 3) on 04/25/2024, it was confirmed that the order for volunteer services was documented on 03/07/2024. She also confirmed that there were no volunteer visits documented in the Volunteer Console of the electronic medical record and no paper volunteer visit documentation could be located. The Volunteer Coordinator was able to follow up during the Interdisciplinary Group Meeting on 04/25/2024 with the patient's Social Worker and discovered, per the Social Worker, that due to so much family visiting the patient, they ended up deciding not to have volunteer services and the plan of care had not updated to reflect that the family had changed their mind about volunteer services and no discontinue order was documented. The Volunteer Coordinator stated, "That is on me." On 04/25/2024, the plan of care was updated to discontinue volunteer visits.

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. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 2 (50%) clinical records reviewed where there was a live discharge from hospice service, the agency did not ensure that the patient's discharge summary or any clinical information was forwarded to the patient's attending physician. Document 1: The agency policy, Discharge from Hospice (Reference #1010), effective 07//01/2015 and revised 04/01/2016, read in part, "Prior to discharging a patient, Hospice shall obtain a written discharge order from the Hospice Medical Director after team consultation that includes the patient's attending physician...If a patient has an attending physician involved in his/her care, this physician shall be consulted before discharge and his/her review and decision shall be included in the discharge note. The Hospice agency shall ensure that the necessary paperwork is completed at the time of discharge. (This may include a signed Revocation Form, if necessary, and completion of a discharge summary). Hospice staff shall file the appropriate discharge documentation in the clinical record... A discharge summary shall include a summary of patient care, treatments, symptoms, and pain management, current plan of care, latest physician orders". Clinical Record 16: The patient elected the hospice benefit on 9/29/2023 and was discharged from the hospice for an extended prognosis on 03/26/2024. The Registered Nurse (RN) documented the patient's discharge note on 03/26/2024. The note indicated that teaching was performed with the facility RN about the patient's medications at discharge. The narrative stated in part that the patient was, "Being discharged due to extended disease progression. Narcotics counted and disposed of per facility policy with .... RN. All hospice equipment removed. MD office called and informed of discharge by RNCM. DTR notified of discharge". Additionally, on 03/26/2024, the MSW performed a visit and documented in part that "Collaboration is done with RNCM and facility RN... MSW left message today with POA reminding that [pt] is discharging today from hospice and that incontinence products will be responsibility of family going forward". No discharge summary was documented in the clinical record, including a description of the patient's hospice stay and any symptom management issues overseen by the hospice, the patient's plan of care, or the latest physician orders. There was no narrative, communication note, or scanned evidence that the discharge summary or any clinical information was forwarded to the attending physician to facilitate continuity of care. After a joint clinical record review and interview on 04/24/2024 with the Clinical Operations Manager (COM) (Personnel Record 3), it was confirmed that the patient's clinical record did not contain a discharge summary but just the nurse's discharge note dated 03/26/2024. After further investigation and running a workflow report, the COM confirmed no information was faxed to the patient's physician. The data was sent by the end of the site visit.