Every finding on record at Guardian Angel Home Care and Hospice of Rochester Hills LLC

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 clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the hospice did not ensure that an initial psychosocial assessment was completed no later than five days after the election of hospice care. Clinical Record 5: The patient elected hospice care on 03/04/2024. The Social Worker (SW) documented an initial psychosocial assessment on 03/13/2024, with eight (8) days outstanding. There was no documented evidence that the initial psychosocial assessment was completed no later than five (5) calendar days after the election of hospice care. There was no documented reason for the delay. Clinical Record 13: The patient elected hospice care on 06/15/2023. The SW documented an initial psychosocial assessment on 06/26/2023, with 11 days outstanding. There was no documented evidence that the initial psychosocial assessment was completed no later than five (5) calendar days after the election of hospice care. There was no documented reason for the delay. During a joint record review and interview on 09/05/2024, the Director of Patient Care Services agreed there was no documented evidence that the initial psychosocial comprehensive assessment was completed in the first five days. The Director of Patient Care Services stated, "I don't see anything documented as to why the Social Worker did these visits after the five-day requirement."

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 clinical record review and interview. In 1 of 7 (14%) clinical records reviewed for patients who elected Hospice Aide (HA) services, the hospice did not ensure the HA reported changes in the patient's needs to the Registered Nurse (RN). Clinical Record 1: The patient elected hospice care on 06/28/2024 with a diagnosis of Alzheimer's disease. The HA visit notes dated 08/15/2024 and 08/30/2024 documented that the patient refused the assigned tasks of bed bath and shampoo. There was no documented evidence that the hospice aide reported the changes to the HA care plan to the Registered Nurse. During a joint record review and interview on 09/05/2024, the Director of Patient Care Services agreed there was no documented evidence that the HA reported the change to the RN.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met, as evidenced by document review, interview, and personnel record review. In 1 of 10 (10%) personnel records reviewed, the hospice did not ensure a criminal background check was completed for the Hospice Medical Director. Contract 1: A review of the Hospice Medical Director’s contract dated 08/01/2023 revealed that a background check was required upon hire. Personnel Record 4: The Hospice Medical Director was hired as a contracted employee on 08/01/2023. The personnel record did not include documented evidence that a background check was completed. During a joint record review and interview on 09/05/2024, the Director of Compliance agreed there was no documented evidence that a background check was completed as required in the Hospice Medical Director’s contract.