Every finding on record at Henry Ford Health System

It is required that each patient’s individualized written plan of care include medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 27 (4%) clinical records reviewed revealed the agency did not ensure the plan of care included all the medical supplies and appliances necessary to meet the needs of the patient. CLINICAL RECORD 7: The patient elected the hospice benefit on 10/18/2025 with a diagnosis of non-small cell lung cancer. The initial nursing assessment on 10/18/2025, the nurse identified that the respirations were 10 and oxygen was ordered. The plan of care dated 10/18/2025 included an order for oxygen 2L/min per NC as needed. The plan of care did not include any oxygen supplies and noted "none" in the supply category. The Director of Clinical Services reviewed the clinical record on 11/11/2025 and confirmed that the plan of care did not include oxygen supplies and read "none" under supplies.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 22 (5%) clinical records reviewed with a home health aide revealed that the agency did not ensure that the home health aide care plan was updated to address changes in the care plan. CLINICAL RECORD 4: The patient elected the hospice benefit on 10/28/2025 with a diagnosis End Stage COPD. The plan of care was updated on 11/06/2025 to included wound care to the left inner glute including foam dressing. The aide care plan initiated on 11/01/2025 read wound -N/A. The aide care plan was not updated on 11/06/2025 or after to reflect instructions to the aide related to the new wound dressing. The Director of Clinical Services reviewed the clinical record on 11/12/2025 and confirmed that the changes were not added to the aide care plan.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: Prescription and over the counter (OTC) drugs; Supplements; Herbal remedies; and Other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 2 of 20 (10%) records with medications identified on admission or changed during care, the agency did not ensure the medication profile was updated so that all medications were reviewed for potential or adverse interactions. Agency Policy #12712773, reviewed date 11/21/2022, stated in part: "Medications are reconciled upon admission, upon transfer into or out of the hospital or hospice setting and with each routine visit." Clinical Record 3: Hospice benefit of election date was 10/21/2022. Nursing visit note dated 12/5/2022 documented patient finishing antibiotic for UTI (urinary tract infection). As of review on 01/04/2023, no antibiotic was documented on the medication profile to be reviewed for potential interactions. Clinical Record 9: Hospice benefit of election 2/22/2022. Nursing visit note dated 7/21/2022 documented that the patient should take Benadryl for itching. As of review on 01/04/2023, the medication profile was not updated to include this medication and it was not included in the review for adverse reactions. During interview, the Hospice Quality Manager reviewed the finding and confirmed that the medications were not listed on the medication profile as expected.

It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 1 of 20 (5%) records reviewed, the agency did not ensure accuracy of all interventions documented on the plan of care. Agency policy, 12798076, reviewed date 12/7/2022, stated in part: "The hospice must develop an individualize written plan of care for each patient. The plan of care must reflect patient and family goals and interventions based on the problems identified in the initial comprehensive and updated comprehensive assessments." Clinical Record 2: Hospice benefit of election date was 12/14/2022 and the patient was admitted with an infusion port that was not being accessed. Interventions documented on the initial plan of care and all updated plans of care described a dressing change that was to be completed every 7 days and completion of a port flush for maintenance. Interview with the Hospice Quality Manager verified that the port was not accessed and had no dressing in place, so the interventions listed on the plan of care were incorrect. This port was never documented as requiring or being flushed during the care provided.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan. A revised plan of care includes: Record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 1 of 16 (6%) records in which care was provided longer than 15 days, the agency did not ensure all updates were documented on the plan of care or that all discipline documented a note of current status or change. Agency policy, 12798076, reviewed date 12/7/2022, stated in part: "The interdisciplinary team reviews and revises the primary concerns, goals and care changes and updates the plan of care. The plan of care reflects the care changes, the outcomes of the goals... The plan of care is a comprehensive document that includes all items, each assessing discipline documents a note of current status or changes." Clinical Record 3: Interdisciplinary team meeting (IDG) was documented as completed every 2 weeks. On 11/30/2022 the meeting attendance included all IDG members, but the update note from the nurse was blank. During this interval of care, the patient's skin tears had all healed and their coccyx wound no longer required a dressing and a zinc salve was being applied for the coccyx care. This update was not included in the documented update at the IDG, and the nursing update was blank as of review on 12/14/2022. The Hospice Quality Manager stated during interview that the software was being updated at that time and discussion with the nurse and the nurse manager revealed that the area was noted as blank and that the nurse was to complete the entry but forgot to finish it.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 2 of 20 (10%) clinical records the agency did not ensure physician orders were documented for all medication used by the patient. Agency policy, "12712773 Medication Management", effective 11/21/2022, stated in part: 'All medications should have an order from a provider." Clinical Record 3: Hospice benefit of election was 10/21/2022. Documentation on the nursing visit note dated 12/5/2022 stated the patient was finishing an antibiotic for a urinary tract infection. There was no documented physician order present for the antibiotic at the time of review on 1/04/2023. Clinical Record 9: Hospice benefit of election was 02/22/2022. Documentation on the nursing visit note dated 7/21/2022 stated the patient was to use Benadryl for itching. There was no documented physician order present for the Benadryl at the time of review on 1/4/2023. During interview and review of the finding with the Hospice Quality Manager, they confirmed the antibiotic and Benadryl should have had a physician order, and this deficiency was identified in one of the hospice's process improvement goals for the last 2 quarters.