Every finding on record at Great Lakes Home Health Services, Inc.

Upon patient record review 3 of 23 (Patient #6, 7, 11) 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 #6 - Patient admitted 03/05/25 Initial bereavement completed on 04/29/25. Patient #7 - Patient admitted 12/17/24 Initial bereavement completed on 12/30/24. Patient #11 Patient admitted 01/18/24 but Initial Bereavement not completed until 02/26/24.

Upon patient record review, 4 of 23 (Patient #8, 9, 14, 20) 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 #8 - Oxygen not on medication sheet but O2 equipment on POC. Patient #9 - Oxygen not on medication sheet but O2 equipment on POC. Patient #14 - Carbidopa 0.25mg Levodopa 100mg 1 tablet and Clonazepam 1 tablet as directed. Patient #20 - Medication sheet for hospice oxygen at 4L/min continuously per nasal cannula but SN has 3L/min.

Upon patient record review, 2 of 23 (Patient #7, 17) 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 #7 - No documentation of wounds times 3 weeks 03/19/25 to 04/09/25. Patient #17-Patient had an JG tube on admission 01/23/25 but no documentation of site on any visit through 04/23/25.

Upon patient record review, 3 of 23 (Patient #8, 9, 14) 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 #8 - Oxygen not on POC but O2 equipment on POC. Verified patient is on O2. Patient #9 - Oxygen not on POC but O2 equipment on POC. Verified patient is on O2. Wound care did not contain frequency. Patient #14 - POC contains Carbidopa 0.25mg Levodopa 100mg 1 tablet and Clonazepam 1 tablet as directed.

Upon client record review, 3 of 23 (Patient #6, 16, 18) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6 - SC visit frequency 1wk1, 1 q2wk 12 effective 03/05/25 made visit week of 03/30 and 04/07 without a PRN order. Patient #16 - SN flushed foley catheter on 04/29/25 but unable to find order for flushes. Patient #18 - During home visit SN noted dressing on suprapubic catheter - no order for dressing noted.  During visit nurse states it was wet and would get it changed.

Upon patient record review, 2 of 23 (Patient #11, 23) 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 #11 - Aide care plan updated on 04/14/25 task make bed does not contain a frequency. Patient #23 - Aide care plan 04/09/25 contains task: bed bath and shower every visit - does not have documented the patient is cognitively and functionally able to make decision and aide is not able to make decision.

Upon patient record review 3 of 23 (Patient #9, 12, 23) 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 #9 - Aide care plan to change linen first visit of every week - aide changed both visits week of 03/09/25. Patient #12 - Aide care plan had full sponge bath - Aide documented partial bath on 03/31/25 and 04/09/25. Patient #23 - Aide care plan 04/02/25 shower every visit - aide did bed bath on 04/07/25

Upon patient record review 3 of 23 (Patient #9, 10, 15) 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 #9 - Aide supervisory visit done on 04/01/25 then again on 04/16/25. Patient #10 - Aide supervisory visit on 03/20/25 then again on 04/07/25 greater than 14 days. Patient #15 - Aide supervisory visit on 04/07/25 then again on 04/24/25 great than 14 days.

Upon patient client record review, 5 of 23 (Patient #1, 3, 6, 8, 19) 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 #1 - SN documented on 01/04/25 that patient did not have any narcotics at time of death but patient was on Morphine, Oxycodone and Lorazepam. Patient #3 - SN documented on 12/11/24 "medication disposed of per facility policy" but patient died at home. Patient #6 - SN documented on 04/11/25 no changes in aide plan of care but aide has not made visit since 03/26/25. Patient #8 - MSW wrote order on 03/09/25 MSW evaluation complete - no further visit required then wrote visit frequency for 1 every wk5, 1 every week 4, 1 every week 3. Patient #19 - SN did not document on visit how INR was obtained on 02/07/25, 03/04,25 or 03/18/25.

Upon client record review, 2 of 23 (Patient #17, 20) 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 #17 - No orders on POC for JG tube. Orders are on SNF care plan. Patient #20 - Glucerna 1 can BID is not on agency POC but on SNF care plan.

Upon client record review, 1 of 23 (Patient #17) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #17 - No documentation on POC who is responsible for JG tube agency or SNF.

Upon patient record review, 12 of 20 (Patients #2,#3,#4,#5,#8,#10,#12,#14,#15,#16,#18,#19) 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. Patient 2: The medication list contained polyethylene glycol oral powder with no instructions for a diluent. The medical record also contained nursing documentation upon admission identifying patient use of oxygen. There was no oxygen listed on the medication profile. Corrected on site. Patient 3, 4, 5, 8, 10, 12, 16, 19: The medication list contained oxygen with no specified delivery method. Current patients corrected on site. Patient 14, 15, 18: The medication list contained polyethylene glycol oral powder with no instructions for a diluent. Current patients corrected on site.

Upon patient record review, 5 of 20 (Patients #1,#5,#9,#13,#16) did not have evidence that the written plan of care included all problems identified in the initial/comprehensive assessments. Patient 1: nursing documentation 2/24/22 identifying patient use of an indwelling catheter and need for colostomy care. There was no evidence of problems, goals, and interventions related to catheter and colostomy care, monitoring or education. Corrected on site. Patient 5: nursing documentation upon admission identifying patient required tube feeding via peg tube. There was no evidence of problems, goals, and interventions related to tube feedings or nutritional deficit included in the plan of care. The plan of care also included active social worker problems, goals, and interventions. There was no evidence the patient was receiving social worker visits. Corrected on site. Patient 9: nursing documentation 4/5/22 identifying patient had 3 falls over the weekend. There was no evidence of problems, goals, and interventions related to fall risk and safety. Patient 13: nursing documentation upon admission identifying patient required colostomy supplies and care oversight. There was no evidence of problems, goals, and interventions related to colostomy care included on the plan of care. Corrected on site. Patient 16: nursing documentation 1/21/22 identifying patient forgetfulness if administered insulin resulting in elevated blood glucose and mismanagement of medication administration. Nursing documentation also identified multiple patient falls. There was no evidence of problems, goals, and interventions related to fall risk, safety, medication management, or endocrine dysfunction included on the plan of care.

Upon patient record review, 14 of 20 (Patients #1,#2,#3,#4,#5,#6,#8,#10,#12,#14,#15,#16,#18,#19) 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 1: The medical record contained nursing documentation 2/24/22 identifying patient use of an indwelling catheter. There was no evidence of an order for catheter type, size, and maintenance. Corrected on site. Patient 2: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen. The medical record also contained an order for polyethylene glycol powder with no instructions for a diluent. Corrected on site. Patient 3, 4, 5, 8, 10, 12, 16, 19: The medical record contained an oxygen order with no specified delivery method. Current patients corrected on site. Patient 6: The medical record contained nursing documentation upon admission identifying patient use of CPAP. There was no evidence of an order for CPAP use and settings. Patient 14, 15, 18: The medical record contained an order for polyethylene glycol oral powder with no instructions for a diluent. Current patients corrected on site.

Upon patient record review, 8 of 20 (Patients #2,#3,#7,#8,#13,#17,#19,#20) 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 2: The medical record contained nursing documentation upon admission identifying patient use of oxygen, hospital bed, and bedside table. There was no evidence of the equipment included as DME on the plan of care. Corrected on site. Patient 3: The medical record contained nursing documentation 4/2/22 identifying patient use of hospital bed. There was no evidence of the bed included as DME on the plan of care. Corrected on site. Patient 7: Upon observation during home visit, it was witnessed that patient was in possession of a wheelchair. There was no evidence of the wheelchair included as DME on the plan of care. Corrected on site. Patient 8: Upon observation during home visit, it was witnessed that the patient was in possession of a hospital bed with bed rails. There was no evidence of the bed and rails included as DME on the plan of care. Corrected on site. Patient 13: The medication list contained oxygen and the medical record contained nursing documentation identifying patient need for colostomy supplies. There was no evidence of the oxygen equipment and colostomy supplies included on the plan of care. Corrected on site. Patient 17: The medical record contained nursing documentation 7/31/21 identifying patient use of hospital bed. There was no evidence of the bed included as DME on the plan of care. Patient 19: The medical record contained nursing documentation 7/29/21 identifying patient use of hospital bed. There was no evidence of the bed included as DME on the plan of care. Patient 20: The medication list identifying patient use of oxygen. There was no evidence of the oxygen equipment included on the plan of care.

Upon client record review, 1 of 20 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: The medical record contained nursing frequency ordered once weekly. There was no evidence of a visit completed the week of 4/3/22. Corrected on site. Additionally, the medical record contained an order 12/15/21 to change catheter monthly. Nursing documentation stated catheter changes were completed 12/23/21 and 3/24/22. There was no evidence of catheter changes completed in January and February.

Upon patient record review, 2 of 20 (Patients #2,#14) did not have evidence in the patient record that hospice aide assignments and duties include the tasks to be provided and the frequency of those tasks. Patient 2: The aide care plan contained task to shave patient if patient wants. There was no assigned frequency defined. Corrected on site. Patient 14: The aide care plan contained task to assist toilet per patient request and to change and wash linens per facility protocol. There was no assigned frequency defined. Corrected on site.

Upon patient record review, 1 of 1 applicable (Patient #7) did not have evidence that the hospice provided all required information to the SNF. Patient 7: Upon observation during home visit, there was no evidence of the current plan of care available in the patient's hospice binder at the nursing home. The plan of care present was from benefit period 11-12-21 to 12-7-21. There was also no evidence of a current medication profile and aide care plan.