Every finding on record at Hospice of Hillsdale County, Inc

Based on record review and interview, the agency failed to develop an Emergency Preparedness (EP) Plan that was based on both a facility-based and community-based all-hazards risk assessment, resulting in the potential for being unprepared to respond effectively in the event of an actual emergency. This deficient practice could negatively affect the health and safety of all 40 patients currently being serviced by this agency in the event of an emergency or disaster.  Findings include: --- On 11/18/25, review of the agency's EP binder revealed no evidence of that the agency had assessed and updated its facility and community-based risk assessment within the last 2 years as required. Documentation of an all-hazards risk assessment which identified and incorporated high priority or potential emergencies were not evidenced. The agency failed to develop a risk assessment that was comprehensive and identified the likeliness of emergencies that would endanger patient care within the agency and the community itself. The above findings were reviewed with and acknowledged by the agency's alternate administrator (A-Adm) during an interview on 11/18/25 at 3:25 PM.

Based on record review and interview, the agency failed to provide documentation that it had participated in the community-based, full-scale exercise required every two years, resulting in the potential for the current 40 patients and staff not being properly prepared in the event of an actual emergency. Findings include: --- On 11/18/25, review of the agency's Emergency Preparedness binder found no evidence that the agency had conducted a full-scale community-based exercise every two years as required. No communication or documentation was found that the agency had reached out to the local incident command center to participate in the community-based exercise within last 2 years. The above findings were reviewed with and acknowledged by the agency's alternate administrator (A-Adm) during an interview on 11/18/25 at 3:28 PM.

Based on record review and interview, the agency failed to ensure initial bereavement assessments were performed on individuals identified as needing bereavement services following the patient’s death for 8 (Patient/P-2, P-9, P-11, P-12, P-15, P-17, P-18, and P-19) of 19 records reviewed, resulting in the potential for unmet bereavement needs. Findings include: --- A review of agency policy titled “Bereavement Services on Admission and Throughout Care” (dated 8/29/25) revealed, “At the initial Social Work visit a bereavement assessment will be completed on the patient’s family members that are present. Utilizing the My Support System & Bereavement Follow-Up form, individuals most affected by the patient’s death will be contacted with the patient’s permission and bereavement assessments will be conducted by the Bereavement Coordinator. It is the responsibility of the RN, the Social Worker, and the Bereavement Coordinator to ensure bereavement assessments are completed.”Patient #17 (P-17) was admitted to this hospice agency on 9/18/24 with the terminal diagnosis of atherosclerotic heart disease of the coronary artery.  During record review on 11/20/25, it was noted P-17’s wife, 1 son, and a stepdaughter were identified as low risk during the initial social work assessment for bereavement needs. Upon further review of the record, it was determined the bereavement coordinator (BC #1) spoke with another son on 9/20/24 to explain bereavement services, however, there was no bereavement risk assessment completed. BC #1 also left messages for another son and daughter on 9/20/24, however, there was no documentation that follow-up contact was made to assess the bereavement risk level of these individuals. Additionally, another son was identified on a form titled “My Support System & Bereavement Follow-Up,” however, there was no documentation that this son was ever contacted or assessed. During an interview with BC #1 on 11/20/25 at 1:30 PM, BC #1 acknowledged bereavement risk assessments were not completed on all individuals identified. BC #1 acknowledged the findings at the time of interview.Patient #18 (P-18) was admitted to this hospice agency on 3/1/25 with the terminal diagnosis of essential (primary) hypertension (high blood pressure). During record review on 11/20/25, it was noted the initial social work visit dated 3/3/25 indicated “Psychosocial, Spiritual, and Bereavement Assessments completed with input from [son] and CL staff.” The “My Support System & Bereavement Follow-Up” form identified this son and his wife as P-18’s primary support system. Upon further review of the record, it was determined a risk assessment was not completed for either individual. During an interview with BC #1 on 11/20/25 at 1:30 PM, BC #1 stated she knows the social worker (MSW #1) made a phone call to assess these individuals, however, MSW #1 did not fill out the risk assessment form for some reason. BC #1 acknowledged the findings at the time of interview.Patient #19 (P-19) was admitted to this hospice agency on 6/24/25 with the terminal diagnosis of multiple myeloma (cancer of the plasma). During record review on 11/20/25, it was noted the initial social work visit dated 6/24/25 identified P-19’s wife and 1 daughter as individuals who would need bereavement services following P-19’s death. However, it was determined there was no documentation the risk level was assessed for either individual. During an interview with BC #1 on 11/20/25 at 1:30 PM, BC #1 acknowledged the risk level assessment was not completed for the individuals identified during the initial social work assessment.The administrative director (AD #1) also reviewed and acknowledged the findings during an interview on 11/21/25 at 10:15 AM. Patient #9’s (P-9) Start of Care (SOC) was dated 9/4/25. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 11/21/25, it was noted that the bereavement risk assessment was completed by the Medical Social Worker (MSW) on 9/4/25 for the patient’s son and daughter. The Summary & Care Plan Update stated, “…P-9 is supported by his children and extended family...” The bereavement risk assessment failed to include any of the patient’s extended family.Patient #11’s (P-11) Start of Care (SOC) was dated 8/2/25. The Plan of Care (POC) identified a terminal diagnosis of Coronary Artery Disease. During record review on 11/19/25, it was noted that the bereavement risk assessment was completed by the MSW on 8/4/25 for the patient’s son and daughter in law (DIL). On 8/2/25, the Registered Nurse (RN) stated, “Environment: …Others in home: Other family member(s): Son, DIL, grandchildren.” The bereavement risk assessment failed to include the patient’s grandchildren within the home.Patient #12’s (P-12) Start of Care (SOC) was dated 9/2/25. The Plan of Care (POC) identified a terminal diagnosis of Coronary Artery Disease. During record review on 11/19/25, it was noted that the bereavement risk assessment was completed by the MSW on 9/3/25 for the patient’s wife. On 9/3/25, the MSW completed an Initial Social Work Visit stating, “…P-12 has two sons…” The bereavement risk assessment failed to include the patient’s two sons.Patient #15’s (P-15) Start of Care (SOC) was dated 9/16/21. The Plan of Care (POC) identified a terminal diagnosis of Alzheimer’s. During record review on 11/14/25, it was noted that the bereavement risk assessment was completed by the MSW on 10/1/21 for the patient’s Husband. . The Summary & Care Plan Update stated, “Patient/Family Support: …Daughter lives out of town but does visit…” The bereavement risk assessment failed to include the patient’s daughter.The Alternate Administrator (A-Adm.) and Clinical Director (CD #1) reviewed and acknowledged the findings listed above in an interview on 11/21/25 at 11:15 am. P-2: This 72-year-old patient was admitted to the Hospice agency on 10/8/25, with a terminal diagnosis of multiple myeloma (type of blood cancer). During a joint home visit with Hospice's skilled nursing on 11/14/25 at 1:20 PM, it was revealed that a very close cousin that the pt identified as someone who would significantly mourn upon her passing was later cross-checked with the initial and follow-up bereavement assessments. No evidence was found that this cousin was included in any of the bereavement assessments conducted by Hospice staff.Subsequently, an additional interview was conducted on 11/19/25 at 2:15 through 2:37 PM with 2 (VC #1 and MSW #1) of 4 employed hospice social workers to better ascertain how well the Hospice agency involved significant individuals identified for significant grieving into the bereavement risk assessment(s). A joint focused review was performed on 10 sampled bereavement charts, which were based off the Hospice’s form titled “My Support System and Bereavement Follow-Up”. This form identified individuals that needed a bereavement risk assessment (initial or follow-up). During the review, only 4 of 10 sampled bereavement charts which included an initial and follow up bereavement risk assessments, had matched all individuals identified in the “My Support System…” These findings were reviewed and acknowledged by VC #1 and MSW #1 at time of discovery, and the alternate administrator (A-Adm) during an interview on 11/19/25 at 2:40 PM. A-Adm noted this did not meet agency expectations or its policy referenced below. Agency Policy: "Bereavement Services on Admission and throughout Care" Section O (reviewed 8/29/25) stated, "Utilizing the My Support System & Bereavement Follow-Up form, individuals most affected by the patient's death will be contacted with the patient's permission and bereavement assessments will be conducted by the Bereavement Coordinator."

Based on record review and interview, the agency failed to ensure its IDG (Inter-Disciplinary Group) provided comprehensive supervision of LPN (Licensed Practical Nurse) patient care services in 6 (Patient/P-5, P-9, P-11, P-14, P-15, P-16) of 7 records reviewed with LPN services supervised, out of a total sample of 16 records reviewed, resulting in a lack of supervision and the potential for unmet patient and family care needs. Findings include: --- Patient #9’s (P-9) Start of Care (SOC) was dated 9/4/25. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 11/21/25, it was noted that the Registered Nurse (RN) completed supervised visits on 9/15/25, 9/18/25, 10/2/25, 10/6/25, 10/9/25, 10/17/25, and 11/6/25. The RN documented for all supervised visits, “LPN (Licensed Practical Nurse)/LVN (Licensed Vocational Nurse) Supervision: Was the Plan of Care reviewed? Yes. Was treatment directed towards goals? Yes. Was treatment observed? No.” The agency failed to follow policy and include patient and family satisfaction with care received.  Patient #11’s (P-11) Start of Care (SOC) was dated 8/2/25. The Plan of Care (POC) identified a terminal diagnosis of Coronary Artery Disease. During record review on 11/19/25, it was noted that the RN completed supervised visits on 8/21/25, 8/25/25, 9/4/25, 9/19/25, 9/24/25, 10/23/25, and 11/7/25. The RN documented for all supervised visits, “LPN/LVN Supervision: Was the Plan of Care reviewed? Yes. Was treatment directed towards goals? Yes. Was treatment observed? No.” The agency failed to follow policy and include patient and family satisfaction with care received.  Patient #14’s (P-14) Start of Care (SOC) was dated 10/25/24. The Plan of Care (POC) identified a terminal diagnosis of Lung Cancer. During record review on 11/18/25, it was noted that the RN completed supervised visits on 11/4/25, 11/7/25, 11/12/25, 11/15/25, 11/19/25 and 11/22/25. The RN documented for all supervised visits, “LPN/LVN Supervision: Was the Plan of Care reviewed? Yes. Was treatment directed towards goals? Yes. Was treatment observed? No.” The Electronic Medical Record (EMR) failed to document that a LPN completed any skilled nursing visits.Patient #15’s (P-15) Start of Care (SOC) was dated 9/16/21. The Plan of Care (POC) identified a terminal diagnosis of Alzheimer’s. During record review on 11/14/25, it was noted that the RN completed supervised visits on 8/20/25, 9/3/25, 9/24/25, and 10/23/25. The RN documented for all supervised visits, “LPN/LVN Supervision: Was the Plan of Care reviewed? Yes. Was treatment directed towards goals? Yes. Was treatment observed? No.” The agency failed to follow policy and include patient and family satisfaction with care received.  Patient #16’s (P-16) Start of Care (SOC) was dated 10/17/25. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 11/14/25, it was noted that the RN completed a supervised visit on 11/4/25. The RN documented for all supervised visits, “LPN/LVN Supervision: Was the Plan of Care reviewed? Yes. Was treatment directed towards goals? Yes. Was treatment observed? No.” The agency failed to follow policy and include patient and family satisfaction with care received.  The Alternate Administrator (A-Adm.) and Clinical Director (CD #1) reviewed and acknowledged the findings listed above in an interview on 11/21/25 at 11:45 am. Patient #5 (P-5): This patient was admitted to the Hospice agency on 10/22/23, with a terminal diagnosis of malignant neoplasms of the lung and COPD (chronic obstructive pulmonary disease). On 11/20/25, record review under "LPN/LVN Supervision" noted the following documentation in its entirety: "Was the Plan of Care Reviewed? Yes"; "Was treatment directed towards goals? Yes"; "Was treatment observed? No." No other aspects of LPN services/care were supervised such as patient/family satisfaction of the care received.This finding was reviewed and acknowledged by the Alternate Administrator (A-Adm.) during an interview on 11/18/25 at 3:15 PM. A-Adm further acknowledged that their EMR (electronic medical record) does not incorporate patient/family satisfaction when evaluating LPN supervision of the care rendered. This did not meet agency expectations (per A-Adm.) or its policy referenced below.Agency Policy: "Licensed Practical Nurse Supervision" Section E (Reviewed 4/29/25) stated, "The supervising nurse must assess an LPN's ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include but is not limited to: Creating successful interpersonal relationships with the patient and family."

Based on record review and interview, the Hospice agency failed to ensure the plan of care (POC) included patient specific measurable goals in 16 (Patients/P-1, P-2, P-3, P-4, P-5, P-6, P-7, P-8, P-9, P-10, P-11, P-12, P-13, P-14, P-15, P-16) of 16 records reviewed for IDG (inter-disciplinary group) POC content, from a total sample of 19 records reviewed, resulting in the potential for unmet patient care needs and goals for all 40 patients currently receiving services. Findings include: --- P-1 through P-16: During record review from 11/13/25 through 11/21/25, it was noted that the POC's were generic and not measurable as required. Subsequently, progress made (or lack of) could not be tracked and trended to enable Hospice staff to accurately perform an objective evaluation of the patient's progress concerning the specified goal. Examples include: "G01: Progressive decrease in loose stools; G02: Acknowledges disease process verbally and through appropriate action; ... G07: Daily Coping with Grief." The number of goals between P-1 through P-16 varied between 12 and 19, all were written in non-measurable terms as required.These findings were reviewed with and acknowledged by the alternate administrator (A-Adm) during an interview on 11/21/25 at 1:20 PM.

Based on record review and interview, the Hospice agency failed to ensure that the IDG (Inter-Disciplinary Group) maintained responsibility for addressing and coordinating patient care needs in 1 (Patient/P-4) of 1 record reviewed with ineffective coping skills related to dying, out of a total sample of 16 records reviewed, resulting in the potential for unmet psychosocial needs. Findings include: --- P-4: This patient was admitted to the Hospice agency on 10/24/23, with a terminal diagnosis of malignant neoplasm (cancer) of the kidney with secondary malignant neoplasm of other specified sites. The Plan of Care (POC) ordered monthly MSW (Master of Social Work) visits since 10/24/23. The IDG schedules a team meeting every 2 weeks to discuss the well-being and care needs of patient(s) and family members. On 11/20/25, record review noted an ongoing psychosocial issue found in multiple MSW clinical visit notes. For example, an MSW visit note dated 8/19/25 that documented, "P-4 gets anxious when thinking of dying, still an issue." Another MSW note in the IDG meeting dated 9/2/25 documented, "Goals for the next two weeks: (P-4) need to get his POA (Power of Attorney) changed due to the current one being ill." Further record review revealed the last MSW visit occurred on 9/10/25, which failed to have any documentation which addressed the above concerns with death anxiety and whether his POA had been changed yet. There was an MSW phone call note dated 10/27/25 which noted a voice mail was left (no content was documented in the note). The remaining documentation found in the medical record concerning P-4's psychosocial needs were the scheduled IDG bi-monthly meetings under the MSW section and the findings are as follow: On 9/16/25, "(P-4) still has anxieties about his end of life." On 9/30/25, "(P-4) get anxious when thinking of dying, still an issue." On 10/14/25, "(P-4) still gets anxious when thinking of dying." On 10/28/25, "(P-4) still gets anxious when thinking of dying." On 11/11/25, "(P-4) still gets anxious when thinking of dying." As of 11/20/25, the Hospice agency failed to ensure that MSW services had followed up to verify if P-4's POA had ever changed since the clinical entry on 9/2/25. Further, the Hospice agency failed to ensure its IDG had coordinated care to implement interventions to help relieve P-4's anxiety over dying since it had been an ongoing issue since 8/19/25.The above findings were reviewed and acknowledged by the Alternate Administrator (A-Adm.) and Clinical Director (CD #1) during an interview on 11/20/25 at 12:58 PM.

Based on record review and interview, the Hospice agency failed to ensure the patient's nursing needs were adequately met in 1 (Patient/P-6) of 1 record reviewed with symptomatic hypoxia, from a total sample of 16 records reviewed, resulting in the potential for poor patient outcomes and unmet care needs during the end of life. --- Patient #6 (P-6): This patient was admitted to the Hospice agency on 10/15/25, with a terminal diagnosis of heart failure and chronic respiratory failure. The Plan of Care (effective 10/15/25) ordered weekly skilled nursing (SN) visits. On 11/21/25, record review of the initial comprehensive assessment on 10/15/25 by SN documented P-6 had labored breathing and had supplemental oxygen (O2) at 3 liters continuous. Assessment(s) of a baseline O2 level to verify the respiratory needs of P-4 relating to comfort and overall wellbeing were not evidenced within the assessment. Further, SN's initial assessment documented: "(P-6) is on 3 liters O2 (oxygen) per NC (nasal cannula). She is pale and very fragile. Ambulates to the bathroom and spouse removes her oxygen as the tubing isn't long enough. Patient was blue around her lips, and her fingers were blue. SN instructed family that she must wear her oxygen to the bathroom for her safety. SN will get more tubing for them so she can wear oxygen to the bathroom for her safety (which was done on 10/16/25)." All Sn visits (8 of 8) reviewed noted P-4 as being SOB (short of breath) with periods of dyspnea. No evidence was found in the medical record of SN performing an O2 finger check (non-invasive test of approximately 10 seconds) to verify if the supplemental oxygen was adequate to optimize respiratory comfort and overall well-being. The agency failed to ensure and verify consistent compromised respiratory findings of P-4 were adequately met through oxygen therapy.The above findings were reviewed with and acknowledged by the agency's alternate administrator (A-Adm) and Clinical Director (CD #1) during an interview on 11/20/25 at 2:50 PM.

Based on record review and interview, the agency failed to ensure bereavement services post-death were provided according to the bereavement plan of care and per agency policy for 3 (P-17, P-18, and P-19) of 3 bereavement records reviewed, from a total of 27 records reviewed, resulting in the potential for unmet bereavement needs. Findings include: --- A review of agency policy titled “Bereavement Services After Death” (updated 5/20/24) revealed the following:“After the death of the patient the Office Assistant will mail the sympathy card within five (5) business days.”“One week after the patient’s death, the primary caregiver will receive a call from a member of the team that cared for the patient. This call will be documented in the EMR.”“Two (2) weeks after the death and again at four (4) weeks, family/caregivers will be contacted by telephone by a staff member or bereavement volunteer to offer support. At the two-week phone call a visit is also offered….This contact is documented in the EMR and placed in the bereavement file.”“A bereavement visit will be offered after four (4) weeks to all the patient’s family/caregivers listed on the My Support System & Bereavement Follow-Up form.”“A bereavement assessment will be done at four (4) weeks by the Bereavement Counselor/Coordinator if phone contact has been made….Mailings, visits, and phone calls are to be documented in the EMR.”Patient #17 (P-17) was admitted to this hospice agency on 9/18/24 with the terminal diagnosis of atherosclerotic heart disease of the coronary artery. During review of the record 11/20/25, it was noted the bereavement plan of care included interventions that the family would be contacted via phone call at 2 weeks and 4 weeks post-death. There was no documentation that these calls occurred. Additionally, there was no documentation a call was made 1 week after the patient’s death per agency policy.Patient #18 (P-18) was admitted to this hospice agency on 3/1/25 with the terminal diagnosis of essential (primary) hypertension (high blood pressure). Following review of the agency policy above on 11/20/25, the office assistant (OA #1) was asked for evidence a sympathy card was sent to the family of P-18 within 5 days of the date of death. Upon review of the list filled out on the computer by OA #1, it was noted the card was lost during signing and was never sent. Additionally, there was no documentation a call was made 1 week after the patient’s death per agency policy.Patient #19 (P-19) was admitted to this hospice agency on 6/24/25 with the terminal diagnosis of multiple myeloma (cancer of the plasma) in relapse. During review of the record on 11/20/25, it was noted the bereavement plan of care included interventions that the family would be contacted via phone call at 2 weeks and 4 weeks post-death. There was no documentation that these calls occurred. Additionally, there was no documentation a call was made 1 week after the patient’s death per agency policy.The bereavement coordinator (BC #1) reviewed and acknowledged the findings during an interview on 11/20/25 at 1:30 PM. The administrative director (AD #1) also reviewed and acknowledged the findings during an interview on 11/21/25 at 10:15 AM.

Based on record review and interview, the Hospice agency failed to ensure clinical record entries were authenticated with a date and time of submission in 9 (Patient/P-1, P-2, P-3, P-6, P-7, P-8, P-12, P-14, P-16) of 16 total sampled records reviewed; and failed to ensure clinical records submitted timely and accurately in in accordance to Hospice policy in 13 (Patient/P-1, P-2, P-3, P-4, P-5, P-6, P-7, P-8, P-9, P-10, P-11, P-13, P-14) of 16 total sampled records reviewed, resulting in unauthenticated clinical entries, the delay of clinical documentation for the Hospice team to evaluate, and the potential for unmet care needs and poor clinical outcomes.  Findings include: --- Patient #9’s (P-9) Start of Care (SOC) was dated 9/4/25. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 11/21/25, it was noted that on 10/23/25 the Licensed Practical Nurse (LPN) completed a Skilled Nursing (SN) visit and stated, “…Patient is sitting at her dining table in her room in her nightgown, she just woke up. Female name is sleeping more in the morning, she is normally an early riser and the past week she has been sleeping more. LPN got her to her recliner...” The “Patient Information” sheet stated, “Sex: M (Male).” The LPN failed to accurately document the correct patient. Furthermore, the Registered Nurse (RN) completed a SN visit on 9/18/25 and electronically signed the visit on 9/21/25. The RN failed to complete documentation per policy within 2 business days of occurrence.  Patient #10’s (P-10) Start of Care (SOC) was dated 8/14/25. The Plan of Care (POC) identified a terminal diagnosis of Colon Cancer. During record review on 11/20/25, the RN completed a SN visit on 8/15/25 and electronically signed the visit on 8/21/25. On 8/18/25, the RN completed a visit and electronically signed the visit on 8/27/25. On 8/25/25, the RN completed a visit and electronically signed the visit on 9/4/25. On 8/28/25, the RN completed a visit and electronically signed the visit on 9/4/25. On 9/8/25, the RN completed a visit and electronically signed the visit on 9/22/25. On 9/11/25, the RN completed a visit and electronically signed the visit on 9/22/25. On 9/15/25, the RN completed a visit and electronically signed the visit on 9/22/25. On 9/18/25, the RN completed a visit and electronically signed the visit on 9/21/25. On 10/21/25, the RN completed a visit and electronically signed the visit on 10/28/25. On 10/22/25, the RN completed a visit and electronically signed the visit on 10/28/25. On 10/23/25, the RN completed a visit and electronically signed the visit on 10/28/25. On 10/27/25, the RN completed a visit and electronically signed the visit on 10/31/25. On 11/10/25, the RN completed a visit and electronically signed the visit on 11/13/25. Additionally, the Medical Social Worker (MSW) completed a visit on 11/11/25 and electronically signed the visit on 11/17/25. The RN and MSW failed to complete documentation per policy within 2 business days of occurrence.  Patient #11’s (P-11) Start of Care (SOC) was dated 8/2/25. The Plan of Care (POC) identified a terminal diagnosis of Coronary Artery Disease. During record review on 11/19/25, the RN completed a SN visit on 8/7/25 and electronically signed the visit on 8/21/25. On 8/21/25, the RN completed a visit and electronically signed the visit on 8/28/25. The RN failed to complete documentation per policy within 2 business days of occurrence.  Patient #12’s (P-12) Start of Care (SOC) was dated 9/2/25. The Plan of Care (POC) identified a terminal diagnosis of Coronary Artery Disease. During record review on 11/19/25, it was noted that the RN completed a Hospice Initial Visit on 9/2/25, but the electronic signature had no date or time stamp with the authentication. The agency failed to accurately authenticate the medical record per policy.Furthermore, the RN completed a SN visit on 9/25/25 and electronically signed the visit on 9/29/25. On 10/21/25, the RN completed a visit and electronically signed the visit on 10/28/25. The MSW completed a visit on 9/9/25 and electronically signed the visit on 9/17/25. The RN and MSW failed to complete documentation per policy within 2 business days of occurrence.  Patient #13’s (P-13) Start of Care (SOC) was dated 8/25/25. The Plan of Care (POC) identified a terminal diagnosis of Parkinson’s. During record review on 11/18/25, the RN completed a SN visit on 8/27/25 and electronically signed the visit on 9/1/25. On 9/2/25, the RN completed a visit and electronically signed the visit on 9/7/25. On 9/9/25, the RN completed a visit and electronically signed the visit on 9/14/25. On 9/16/25, the RN completed a visit and electronically signed the visit on 9/23/25. On 10/21/25, the RN completed a visit and electronically signed the visit on 10/29/25. On 10/29/25, the RN completed a visit and electronically signed the visit on 11/4/25. On 11/5/25, the RN completed a visit and electronically signed the visit on 11/10/25. On 11/12/25, the RN completed a visit and electronically signed the visit on 11/17/25. The RN failed to complete documentation per policy within 2 business days of occurrence.  Patient #14’s (P-14) Start of Care (SOC) was dated 10/25/24. The Plan of Care (POC) identified a terminal diagnosis of Lung Cancer. During record review on 11/18/25, it was noted that the MSW completed an Initial Visit on 10/25/25, but the electronic signature had no date or time stamp with the authentication. The agency failed to accurately authenticate the medical record per policy.Furthermore, the RN completed a visit on 10/25/24 and electronically signed the visit on 10/29/24. On 10/26/24, the RN completed a visit and electronically signed the visit on 10/30/24. On 11/14/24, the RN completed a Oncall/Unscheduled visit and electronically signed the visit on 11/25/24. On 11/18/24, the RN completed a Oncall/Unscheduled visit and electronically signed the visit on 11/21/24. On 11/19/24, the RN completed a visit and electronically signed the visit on 11/25/24. On 11/4/24, the RN completed a visit and electronically signed the visit on 11/10/24. On 11/7/24, the RN completed a visit and electronically signed the visit on 11/10/24. On 11/15/24, the RN completed a visit and electronically signed the visit on 11/21/24. On 11/22/24, the RN completed a visit and electronically signed the visit on 11/25/24. The RN failed to complete documentation per policy within 2 business days of occurrence.  Patient #16’s (P-16) Start of Care (SOC) was dated 10/17/25. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 11/14/25, it was noted that the MSW completed an Initial Visit on 10/27/25, but the electronic signature had no date or time stamp with the authentication. The agency failed to accurately authenticate the medical record per policy. A review of the agency policy occurred on 11/21/25 titled "Documentation" (Revised 8/21/23). The policy states, "… interdisciplinary team will document appropriate data. This data will be completed and synchronized within 2 business days of occurrence... Documentation will be completed as follows: Time Log, Assessment, Problem Charting ...Procedure: Documentation will be completed as follows: A. Using the Electronic Medical Records software, skilled nursing… will complete the following fields with each patient visit: …Assessment…Clinical Notes...”The Alternate Administrator (A-Adm.) and Clinical Director (CD #1) reviewed and acknowledged the findings listed above in an interview on 11/21/25 at 11:25 am. Patient #1 (P-1): The patient was admitted to the Hospice agency on 12/11/24, with a terminal diagnosis of malignant neoplasm (cancer) of the pancreas. On 11/18/25, record review noted the initial comprehensive assessment performed by skilled nursing (SN) on 12/11/24 had no time log or stamp of submission in 7 of 7 pages. Patient records P-2, P-3, P-6, P-7, and P-8 all had examples of this deficient practice. Additional review of P-1's record noted a SN visit performed on 12/17/24 with a time log submission of 12/25/25, 6 business days after occurrence. Other examples of late SN visit note submission include: Visit on 1/13/25, submitted on 1/18/25; Visit on 4/14/25, submitted on 4/18/25, Visit on 5/20/25, submitted on 5/26/25, Visit on 6/26/25, submitted on 7/1/25, Visit on 7/31/25, submitted on 8/5/25, and a Social Work visit note on 6/18/25 with submission on 6/24/25. Patient records P-2, P-3, P-4, P-5, P-6, P-7, and P-8 all had further examples of this deficient practice.The findings above were reviewed and acknowledged by the Alternate Administrator (A-Adm.) and Clinical Director (CD #1) during an interview on 11/19/25 at 10:45 AM. An audit by the A-Adm. later at 11:20 AM noted the lack of a time log entry was due to a systemic issue that when documentation was completed with the office desktops, no time stamp was created. A-Adm. noted the agency will correct this issue as soon as possible and this did not meet agency expectations or its policy referenced below.Agency Policy: "Documentation" Section G (Revised 8/21/23) stated, "Hospice of Hillsdale County interdisciplinary team will document appropriate data. This data will be completed and synchronized within 2 business days of occurrence... Documentation will be completed as follows: Time Log, Assessment, Problem Charting ..."

Based on observation, interview and record review, the agency failed to ensure the initial bereavement assessment identified the social, spiritual and cultural needs of all family members and other individuals that may be affected by the patient's death in 7 (MR's # 1, 2, 3, 4, 6, 7 and 8) records, from a total of 14 records reviewed, which included 2 bereavement records, resulting in the potential for unmet needs for bereavement support and grieving during the end of life. Findings include: Policy: "Bereavement Services on Admission and Throughout Care", 5/10/23 stated, "At the initial social Work visit a bereavement assessment will be completed on the patient's family members that are present, as well as all person's most affected by the patient's death..." --- MR #1: The patient was admitted to Hospice services on 3/28/20. The certification period of review was 3/28/23 through 5/19/23 with a terminal diagnosis of Cerebellar Stroke Syndrome. The clinical record review was conducted on 5/17/23 at 10:45 a.m. and revealed the patient had 2 sons and a daughter that assisted in the provision of care. On 5/16/23 at 1:00 p.m., during a scheduled home visit with the Hospice Aide, it was noted that the patient had pictures of her 3 grandchildren on the wall of her room and spoke very fondly of them and their accomplishments. The patient further discussed her recent Mother's Day visit with family. The Initial Bereavement Assessment from 2020, and current Medical Social work assessments failed to include all parties who would be affected by the patient's death. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 5/18/23 at 11:27 a.m. MR #2: The patient was admitted to Hospice on 4/18/23 with a terminal diagnosis of Congestive Heart Failure. during the clinical record review on 5/17/23 at 1:00 p.m., it was noted that the patient had 2 daughters and 2 sons. The Initial Bereavement Assessment dated 4/20/23 only made mention of one of the patient's sons and one of her daughters. The Initial Bereavement Assessment failed to include all parties who be affected by the patient's death. These findings were reviewed with the Administrator and Clinical Manager during an interview on 5/18/23 at 11:42 a.m. MR #3: The patient was admitted to Hospice on 3/26/22. The certification period of review was 3/26/23 through 5/19/23 with a terminal diagnosis of Congestive Heart Failure. during the clinical record review on 10:20 a.m., it was noted that the patient had 6 living children (2 daughters and 4 sons). One of the patient's sons was listed as "not involved." The Initial Bereavement Assessment dated 3/31/22 made no mention of one of the patient's sons who took part in the provision of care. The Initial Bereavement Assessment failed to include all parties who be affected by the patient's death. These finding were reviewed with and acknowledged by the Clinical Manager during an interview on 5/19/23 at 9:30 a.m. MR #7: This 48-year-old patient was admitted to Hospice on 7/20/22 with the terminal diagnoses of cholangiocarcinoma (cancer of the bile duct) and extensive liver masses. During record review on 5/16/23, it was noted the narrative portion of the initial bereavement assessment performed on 7/25/22 identified the patient lived with his wife and a 12-year-old daughter. Upon further review of the record, it was determined that the "Assessments" section under "Bereavement Services" that identified risk, only included the patient's wife. It failed to address the potential risk and needs of his daughter. MR #8: This 30-year-old patient was admitted to Hospice on 4/8/23 with the terminal diagnoses of testicular cancer with an intra-abdominal pelvic mass. During record review on 5/16/23, it was noted the narrative portion of the initial bereavement assessment performed on 4/10/23 identified the patient lived with his mother, father and grandmother and that all were present during the initial assessment. Upon further review of the record, it was determined that the "Assessments" section under "Bereavement Services" that identified risk, only included the patient's mother and father. It failed to identify the risk level and potential needs of the grandmother. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 5/18/23 at 3:00 p.m. MR #4: This 79-year-old was admitted to the agency on 4/5/23 with a terminal diagnosis of atherosclerotic heart disease (arteries in heart are narrow and hard). The medical record was reviewed on 5/16/23. During review of the ";Comprehensive Assessment" dated 4/5/23, it was noted the patient had 3 daughters involved in the patients life. An ";Initial Bereavement" phone visit was completed on 4/7/23 and included bereavement assessment with one daughter (the primary caregiver), whom the patient lived with. It was documented that bereavement needs for other family members occurred on 3/6/23 (prior to admission date). No other bereavement assessments were identified in the medical record. The agency failed to provide the patients 2 other daughters with a bereavement needs assessment. MR #6: This 72-year-old was admitted to the agency on 1/26/22 with a terminal diagnosis of atherosclerotic heart disease. The medical record was reviewed on 5/17/23. During review of the ";Comprehensive Assessment" dated 1/26/22, it was noted that the patient lived with 2 sons and had a daughter who visited monthly. A ";Bereavement Initial Visit" was completed on 1/27/22 and included a bereavement risk assessment for one son (the primary caregiver). No other bereavement assessments were identified in the medical record. The patient was discharged after a fall to seek additional services on 3/20/22 and was readmitted on 3/23/22. A ";Bereavement Initial Visit" was completed on 3/23/22 which again only included the son listed as the ";primary caregiver". The agency failed twice to provide the patients 2 other children with a bereavement needs assessment. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 5/18/23 at 2:30 p.m.

Based on record review and interview, the hospice failed to ensure services were provided at the frequency ordered in the plan of care for 1 of 12 (MR# 11) from a total sample of 12 records reviewed, resulting in the patient not receiving care as ordered. Findings include: --- **Agency Policy: Plan of Care (Board Approved Change: 11/21/22) states, "The interdisciplinary Plan of Care for each patient is started at the time of the initial referral and continues through bereavement services. The Plan of Care (POC) is developed with the input, consent and approval of the patient/family and includes individualized, measurable and achievable goals and interventions to meet the specific needs of the patient/family... A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs..." MR#11: The Start of Care (SOC) was dated 5/11/22. The Plan of Care (POC) identified terminal diagnosis of Breast Cancer. During record review on 5/16/23, it was noted that the Medical Social Services (MSS) was ordered at a frequency of 2m3 (2 times a month for 3 months). On 5/12/22, the MSS documented a visit stating, "...Problems identified include: Lack of support, need for more caregivers in the home or placement for patient. Social Work visits discussed and scheduled 2X/MO as agreed upon by patient/family. This worker has accepted the assignment..." MSS failed to complete a visit up to the completed revocation of the hospice benefit on 6/14/22. The agency failed to provide services as ordered. These findings were reviewed with and acknowledged by the Administrator (Adm#1) and Director of Nursing (DON#1) during an interview on 5/19/23 at 9:50 am.

Based on record review and interview, the Hospice Agency failed to ensure the plan of care contained patient specific measurable outcomes and goals of care in 9 (MR's #1, 4, 6, 7, 8, 9, 10, 11 and 12) records, from a total of 12 records reviewed, resulting in the potential for lack of progress in meeting the identified goals and unmet care needs during the end of life. Findings include: Policy: "Plan of Care" 11/21/22 stated, "The Plan of care (POC) is developed with the input, consent and approval of the patient/family and includes individualized, measurable and achievable goals and interventions to meet the specific needs of the patient/family..." --- MR #7: This 48-year-old patient was admitted to Hospice on 7/20/22 with the terminal diagnoses of cholangiocarcinoma (cancer of the bile duct) and extensive liver masses. During record review on 5/16/23, it was noted the goal for pain management stated, "pain control with appropriate analgesic" and the goal for constipation stated, "adherence to bowel regime". Neither goal provided any details regarding measurable data. MR #8: This 30-year-old patient was admitted to Hospice on 4/8/23 with the terminal diagnoses of testicular cancer with an intra-abdominal pelvic mass. During record review on 5/17/23, it was noted the goal for pain management stated "pain control with appropriate analgesic" without any details regarding measurable data. MR #9: This 82-year-old patient was admitted to Hospice on 4/13/23 with the terminal diagnoses of Alzheimer's Disease and atherosclerotic heart disease. During record review on 5/17/23, it was noted the goal for nausea and vomiting stated "comfort" without any details regarding measurable data. Findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 5/18/23 at 3:00 p.m. MR #1: The patient was admitted to Hospice on 3/28/20. The certification period of review was 3/28/23 through 5/19/23 with a terminal diagnosis of Cerebellar Stroke Syndrome. During the record review on 5/17/23 at 10:45 a.m., it was noted that the plan of care (POC) goals were non-patient-specific and immeasurable such as, "Constipation: regular bowel movements; Coping: to stimulate coping skills; Fatigue/Weakness: Acceptance of fatigue...; Pain/Comfort: pain control with appropriate analgesic; End of Life Care: die at home/place of preference..." The Agency failed to ensure goals were patient-specific, measurable, and addressed the individualized needs of the dying patient. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 5/18/23 at 11:27 a.m. MR #4: This 79-year-old was admitted to the agency on 4/5/23 with a terminal diagnosis of atherosclerotic heart disease (arteries in heart are narrow and hard). The medical record was reviewed on 5/16/23. During review of the ";Team Care Plan" dated 4/5/23, it was noted that team goals were not objectively measurable. Examples of goals found in the Team Care Plan include the following: anxiety minimized/controlled (sic); verbalizes understanding of oxygen use and safety; acceptance of disease process; verbalize understanding of pain management. It is unclear how these goals would be objectively measured to ensure the hospice agency was meeting the goals, needs, and outcomes of the patient/family through the dying process. MR #6: This 72-year-old was admitted to the agency on 3/23/22 with a terminal diagnosis of atherosclerotic heart disease. The medical record was reviewed on 5/17/23. During review of the ";Team Care Plan" dated 3/23/22, it was noted that team goals were not objectively measurable. Examples of goals found in the Team Care Plan include the following: daily adherence of wound care; pain control with appropriate analgesic; patient/family will understand grieving process and relevance to current situation. It is unclear how these goals would be objectively measured to ensure the hospice agency was meeting the goals, needs, and outcomes of the patient/family through the dying process. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 5/18/23 at 2:30 p.m. MR#10: The Start of Care (SOC) was dated 10/7/22. The Plan of Care (POC) identified terminal diagnosis of Prostate Cancer. During record review on 5/16/23, it was noted the goals were not measurable. Examples of goals on this patient's POC included: "Assess bowel program with appropriate interventions-including increasing laxative with each opioid increase. Assess location, intensity, character of pain. Assess pain med effectiveness." The goals in this plan of care were not specific to the patient's hospice needs, nor were the goals objectively measurable to determine if the patient was progressing toward meeting each goal. MR#11: The Start of Care (SOC) was dated 5/11/22. The Plan of Care (POC) identified terminal diagnosis of Breast Cancer. During record review on 5/16/23, it was noted the goals were not measurable. Examples of goals on this patient's POC included: "Assess bowel program with appropriate interventions-including increasing laxative with each opioid increase. Instruct in nonpharmacologic methods of pain control. Assess level of comfort/discomfort. Assess pain med effectiveness." The goals in this plan of care were not specific to the patient's hospice needs, nor were the goals objectively measurable to determine if the patient was progressing toward meeting each goal. MR#12: The Start of Care (SOC) was dated 4/6/23. The Plan of Care (POC) identified terminal diagnosis of Congestive Heart Failure. During record review on 5/17/23, it was noted the goals were not measurable. Examples of goals on this patient's POC included: "Assess level of comfort/discomfort. Assess location, intensity, character of pain. Assess pain med effectiveness." The goals in this plan of care were not specific to the patient's hospice needs, nor were the goals objectively measurable to determine if the patient was progressing toward meeting each goal. These findings were reviewed with and acknowledged by the Administrator (Adm#1) and Director of Nursing (DON#1) during an interview on 5/19/23 at 10:00 am.

Based on record review and interview, it was determined that the Hospice failed to ensure the Quality Assessment Performance Improvement program documented actions taken to track performance measures to ensure improvements are sustained affecting all patients serviced by this agency, resulting in the potential for poor patient outcomes. Findings include: --- During a review of the agency's Quality Assessment Performance Improvement (QAPI) documents on 5/18/23 at 10:00 am, it was noted that the agency would start and complete each performance improvement project (PIP) quarterly, thus there was no measurable data collected that demonstrated improvements in the hospice performance over time. This finding was reviewed with and acknowledged by the Administrator (Adm#1) during an interview on 5/18/23 at 10:30 am.

Based on record review and interview, it was determined the Hospice Agency failed to provide Medical Social Services that empathetically addressed the patients needs and concerns in 1 (MR #12) of 12 records, resulting in the potential for further decline in emotional status, psychological decline, and unmet care needs. Findings include: --- MR#12: The Start of Care (SOC) was dated 4/6/23. The Plan of Care (POC) identified terminal diagnosis of Congestive Heart Failure. During record review on 5/17/23, it was noted that on 4/17/23, Medical Social Service (MSS) stated, ";MR12 voices that she does not believe she is dying. She continues to state that she is supposed to live for 15 more years. This worker speaks to her about this. The doctor signed a certification stating that she had 6 months or less to live, this worker reviewed this with her. She was tearful throughout the visit. She appears to be in denial..." The MSS failed to compassionately address the patients emotional factors related to the terminal illness, thus not meeting the patient's needs. This finding was reviewed with and acknowledged by the Administrator (Adm#1) and Director of Nursing (DON#1) during an interview on 5/19/23 at 9:30 am.

Based on observation, record review and interview, the hospice failed to ensure the registered nurse prepared written patient specific care instructions that included the frequency and duration of visits for the aide and care based on the individualized needs of the patient, for 1 (MR #1) record reviewed in which aide services were provided, from a total of 14 sampled records reviewed, resulting in a lack of direction, poor hygiene and the potential for unmet care needs. Findings include: --- Policy: "Hospice Aide and Homemaker Services" 2/21/22 stated, "Written patient care instructions/task list for a hospice aide must be prepared by a registered nurse..., hospice aide provides services that are ordered by the interdisciplinary group, included in the plan of care..." MR #1: The patient was admitted to Hospice on 3/28/20. The certification period of review was 3/28/23 through 5/19/23 with a terminal diagnosis of Cerebellar Stroke Syndrome. On 5/16/23 at 1:00 p.m. a scheduled home visit was conducted with the Hospice Aide. During the visit, the aide provided a sponge bath and assisted the patient with dressing. During the visit, the patient was observed to have a whitish substance near the corners of her mouth. During the sponge bath, the aide wiped the patient's face, however, no oral care was provided. On 5/17/23 at 10:45 a.m., during the clinical record review, it was noted that the aide care plan failed to include instructions to provide oral care/hygiene. The Registered Nurse failed to develop the aide care plan based on the individualized needs of the patient. Additionally, there was no frequency noted that instructed the aide on the frequency of visits to be made. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 5/18/23 at 11:27 a.m.

Based on record review and interview, the agency failed to ensure that care and services needed specifically delegated which provider was responsible for performing the respective functions agreed upon in the hospice plan of care in 3 (MR's # 3, 6 and 9) patients who resided in a Skilled Nursing Facility, from a total of 12 sampled records reviewed, resulting in the potential for unmet or overlooked care needs. Findings include: Policy: "Plan of Care" 11/21/22 stated, "Detailed modifiers are present in the electronic medical record for all, including those patients in AFC (Adult foster Care) and SNF (Skilled Nursing Facility), identifying which discipline from each facility will perform tasks and how often those tasks will be performed." --- MR #3: This Skilled Nursing Facility resident was admitted to Hospice on 3/26/22. The certification period of review was 3/26/23 through 5/19/23 with a terminal diagnosis of Congestive Heart Failure. On 5/18/23 at 10:20 a.m., during a review of the hospice "Team Care Plan", it was noted that it could not be determined which provider (Hospice or Skilled Nursing Facility) would be responsible for the overall provision of care and services, and how often the services would be provided by the responsible entity. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 5/19/23 at 9:30 a.m. MR #9: This 82-year-old patient was admitted to Hospice on 4/13/23 with the terminal diagnoses of Alzheimer's Disease and atherosclerotic heart disease. During record review on 5/16/23, it was noted the plan of care identified which services would be provided by each discipline, but it did not specify which staff (Hospice or Skilled Nursing Facility) would be responsible for each task. Findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 5/18/23 at 3:00 p.m. MR #6: This 72-year-old was admitted to the agency on 3/23/22 with a terminal diagnosis of atherosclerotic heart disease (arteries in heart are narrow and hard). The medical record was reviewed on 5/17/23. During review of the ";Comprehensive Assessment" dated 3/23/22, it was noted that the patient resided in a skilled nursing facility. The ";Team Care Plan" dated 3/23/22, included a task list for all disciplines with interventions and goals however, the task list did not specify which interventions would be performed by the hospice agency staff and which would be performed by the skilled nursing staff. This finding was reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 5/18/23 at 2:30 p.m.