Every finding on record at Hospice of Michigan, Inc.

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. This standard was not met as evidenced by clinical record review, observation, and interview. 4 of 6 (67%) home visits performed revealed the agency did not ensure the drug profile contained the patient's current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. HOME VISIT 2/CLINICAL RECORD 2: The patient elected the hospice benefit on 12/21/2025 with a diagnosis of protein calorie malnutrition. The patient resided in a skilled nursing facility (SNF). During the observed home visit with the registered nurse (Personnel Record 6) on 01/05/2026, the hospice medication profile (printed on 01/05/2026) was compared to the SNF medication profile (printed on 01/05/2026). The hospice medication profile included the following medication that was not listed on the SNF medication profile: "Lorazepam 0.5 mg every 2 hours as needed (ordered 12/21/2025)." The last comprehensive nursing visit was dated 01/02/2026. HOME VISIT 3/CLINICAL RECORD 3: The patient elected the hospice benefit on 07/09/2025 with a diagnosis of chronic systolic heart failure. The patient resided in a SNF. During the observed home visit with a hospice aide (Personnel Record 10) on 01/06/2026, the hospice medication profile (printed on 01/05/2026) was compared to the SNF medication profile (printed on 01/06/2026). The SNF medication profile included the following medications that were not listed on the hospice medication profile: "Milk of Magnesia, give 30 ml every 24 hours as needed (ordered 11/04/2025). Plavix 75 mg, take 1 tablet daily (ordered 12/29/2023). Senna Plus, take 2 tablets twice daily (ordered 11/13/2025). Torsemide 20 mg, take twice daily (ordered 10/11/2024)." The following discrepancies were noted: The hospice medication profile included Metformin 500 mg, take 1 tablet twice daily (ordered 07/09/2025) and the SNF medication profile included Metformin 500 mg take 2 tablets twice daily (ordered 12/02/2025); the hospice medication profile included Lantus 28 units daily (ordered 11/04/2025) and the SNF medication profile included Lantus 33 units daily (ordered 11/25/2025). The last comprehensive nursing visit was dated 01/02/2026. HOME VISIT 4/CLINICAL RECORD 4: The patient elected the hospice benefit on 02/07/2025 with a diagnosis of dementia in other diseases. The patient resided in a SNF. During the observed home visit with the spiritual counselor (Personnel Record 9) on 01/06/2026, the hospice medication profile (printed on 01/05/2026) was compared to the SNF medication profile (printed on 01/06/2026). The hospice medication profile included the following medication that was not listed on the SNF medication profile: "Orajel gel, give twice daily as needed (ordered 02/07/2025). The following medications were listed on the SNF medication profile and not on the hospice medication profile: "Artificial tears, 1 drop twice daily (ordered 07/22/2025). Chlorhexidine 10 ml twice daily (ordered 04/08/2025). Lactulose 20gm/30 ml, give 30 ml two times a day (ordered 05/12/2025). Milk of Magnesia, give 20 ml daily as needed (ordered 07/20/2024). Phosphate enema, insert 1 daily as needed (ordered 07/20/2024). The following medication discrepancies were noted: the hospice medication profile included Trazadone 50 mg, take half tablet nightly (ordered 02/07/2025) and the SNF medication profile included Trazadone 50 mg, take 1 tablet nightly (ordered 10/25/2025.) The last comprehensive nursing visit was dated 01/01/2026. HOME VISIT 6/CLINICAL RECORD 6: The patient elected the hospice benefit on 08/14/2025 with a diagnosis of heart failure. The patient resided in an assisted living facility (ALF). During the observed home visit with a registered nurse (Personnel Record 7) on 01/06/2026, the hospice medication profile (printed on 01/05/2026) was compared to the ALF medication profile (printed on 01/06/2026). The ALF medication profile included the following medications not listed on the hospice medication profile: "Miralax, daily as needed (ordered 12/20/2024). The following discrepancies were noted: the hospice medication profile included Lasix 20 mg, one half tablet daily (ordered 08/14/2025) and the ALF medication profile listed Lasix 20 mg, one half tablet three times weekly (ordered 09/19/2025). The last comprehensive nursing visit was dated 12/30/2025. A joint clinical record review and interview was conducted with the Clinical Director and Operational Manager(s) on 01/08/2026 during which time the discrepancies were confirmed and they advised that "medication reconciliations should be conducted at every nursing visit."

It is required that spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. This standard was not met as evidenced by clinical record review and interview. 2 of 27 (7%) clinical records reviewed revealed that spiritual counseling services ordered on the Plans of Care (POC) did not follow the POC as ordered by the Interdisciplinary Group. CLINICAL RECORD 12: The Interdisciplinary Group POC, dated 05/21/2025, documented a visit frequency for "spiritual support 1-2 times monthly." The POC dated 06/04/2025 documented a visit frequency for the spiritual counselor of "1 time monthly." The POC dated 08/13/2025 spiritual counselor IDG documentation documented "spiritual counselor 2-3 times per month for companionship, encouragement, conversation, and prayer." A spiritual counselor visit on was documented on 05/13/2025 and the next visit was not documented until 10/27/2025. The clinical record lacked documentation for the missed visits between May and October 2025. These mostly occurred during Benefit Period 3, 07/08/2025 to 09/05/2025. CLINICAL RECORD 17: The Interdisciplinary Group POC dated 11/18/2025 documented a visit frequency for the spiritual counselor of "1x month." A clinical note from the spiritual counselor, dated 12/08/2025, included the following: "Missed visit. SCA (spiritual counselor advisor) reached out to patient and caregiver several times calling different phone numbers and leaving messages to set up next appointment. SCA I will continue to reach out to patient/caregiver and remain available." The clinical record did not contain further documentation of attempts to contact patient or caregiver to provide spiritual support or reschedule a visit. A joint clinical record review and interview was conducted with the Clinical Director and Operational Manager(s) on 01/09/2026. During the discussion of Clinical Record 12, they were "unsure of why the visits had not been completed as the IDG notes/POC reflected spiritual care involvement" but did agree the visits had not been completed during that timeframe. During the interview regarding Clinical Record 17 it was stated, "Believed more phone calls had been made however the clinical record did not include documentation to reflect this."

It is required that hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program also described below. This standard was not met as evidenced by document review, interview and personnel record review. 2 of 2 (100%) personnel records of hospice aides revealed that the agency did not ensure that competency assessments were completed prior to the hospice aides independently providing care. Agency policy No.0660 titled "Competency Assessment", effective 01/01/2021, read in part, "As a component of the orientation process, new staff complete a competency evaluation prior to providing care. PERSONNEL RECORD 10: This hospice aide was hired on 08/18/2025. The personnel record contained no evidence of a competency assessment prior to providing patient care. PERSONNEL RECORD 11: This hospice aide was hired on 11/22/2024. The personnel record contained no evidence of a competency assessment prior to providing patient care. The Statewide Director of Quality reported in an interview on 01/09/2026, "We will learn from this, we do not have a general competency assessment for aides on hire with all the elements. We just do the annual on-site." The annual on-site evaluation form did not include all of the required task elements to be validated.

It is required that 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. 1 of 25 (4%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the registered nurse provided specific written instructions for the hospice aide. CLINICAL RECORD 14: The hospice aide care plan dated 01/17/2025 assigned the following tasks: "Bed bath, commode bath, and shower." The hospice aide visit frequency was three times weekly. All tasks were to be completed every visit. The hospice aide care plan was updated on 03/25/2025 to reflect the following task: "Shower." The hospice aide care plan was updated on 04/21/2025 to assign the following tasks: "Shower and commode bath." These tasks were to be completed every visit with a visit frequency of three times weekly. On 06/18/2025, the hospice aide care plan was updated and the following bath types were included: "Bed bath, shower, and commode bath." All tasks were to be completed every visit. On 08/08/2025, the update appeared to remove the assigned task of "shower" but left the bed bath and commode bath. On 08/21/2025 the update added back the three types of baths: "bed bath, shower and commode bath." The care plan was updated on 09/05/2025 and 10/22/2025 but no changes were made to the types of baths. On 10/29/2025, the aide care plan was changed to "shower." The last updated was on 12/18/2025 and the bath remained at "shower." The assignment of multiple, different bath types "at every visit" can be confusing. A joint clinical record review and interview was conducted with the Clinical Director and Operational Manager(s) on 01/08/2026. It was agreed that the "registered nurse should provide the hospice aide with specific instructions on which type of bath should be given and all bath types should not be listed for every visit."

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. (L523) This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 16 (12%) records reviewed, revealed the hospice did not ensure the initial spiritual assessment was completed no later than five (5) calendar days after patients' election of hospice care. . Record 4: The patient’s date of election was 1/3/2023. The chaplain documentation on 1/4/2023 revealed, “non visit patient care: welcome having a visit from the SCA because she is from a religious background. The SCA will f/u on this phone call with a telephonic comp visit on 1/6.” There was no documented evidence the chaplain completed the initial on 1/6/2023 or no later than five (5) calendar days after the election of hospice care. The initial spiritual comprehensive was documented on 1/9/2023. There was no documented reason for the delay. Record 13: The patient’s date of election was 6/8/2021. The chaplain documentation on 6/11/2021 revealed, “made a number of attempts to contact patient's daughter to arrange a visit was unable to talk with her will continue to attempt to set a visit next week.” There was no documented evidence of follow up until 8/5/2021. There was no documented evidence an initial spiritual assessment was completed no later than five days after the election of hospice care. The Clinical Operations Manager was interviewed on 2/3/2022 and agreed, there was no documented evidence the initial spiritual assessments were completed no later than five days after the election of hospice care. Additionally, during interview on 2/3/2022, the Clinical Operations Manager agreed, there were no documented reasons for the further delays. The Administrator confirmed this finding on 2/3/2022. Record 4: The patient’s date of election was 1/3/2023. The chaplain documentation on 1/4/2023 revealed, “non visit patient care: welcome having a visit from the SCA because she is from a religious background. The SCA will f/u on this phone call with a telephonic comp visit on 1/6.” There was no documented evidence the chaplain completed the initial on 1/6/2023 or no later than five (5) calendar days after the election of hospice care. The initial spiritual comprehensive was documented on 1/9/2023. There was no documented reason for the delay. Record 13: The patient’s date of election was 6/8/2021. The chaplain documentation on 6/11/2021 revealed, “made a number of attempts to contact patient's daughter to arrange a visit was unable to talk with her will continue to attempt to set a visit next week.” There was no documented evidence of follow up until 8/5/2021. There was no documented evidence an initial spiritual assessment was completed no later than five days after the election of hospice care. The Clinical Operations Manager was interviewed on 2/3/2022 and agreed, there was no documented evidence the initial spiritual assessments were completed no later than five days after the election of hospice care. Additionally, during interview on 2/3/2022, the Clinical Operations Manager agreed, there were no documented reasons for the further delays. The Administrator confirmed this finding on 2/3/2022.

It is required that hospice care and services provided to patients and families follow the individualized plan of care established by: (L543) The hospice IDG in collaboration with the attending physician (if any); The patient or patient representative; The primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by a review of clinical records and interviews. In 3 of 16 (19%) revealed the hospice did not ensure spiritual counseling services and social work services were provided to patients and families in accordance with the plan of care. . Record 11: The patient’s date of election was 11/3/2022. A physician’s order effective 12/1/2022 ordered a social worker 1 x month for 1 month. During the month 12/1/2022-12/31/2022, there was no documented evidence of a social worker visit or reason for the missed visit. Record 13: The patient’s date of election was 6/8/2021. The plan of care reviewed by the physician and interdisciplinary group on 5/11/2022 ordered a social worker 2 x month for 1 month effective 5/1/2022. During the month 5/1/2022-5/31/2022, there was no documented evidence of a social worker visit or reason for the missed visits. Record 14: The patient’s date of election was 9/3/2020. A physician’s order effective 1/1/2023 ordered spiritual care 1 x month for 1 month. During the month 1/1/2023-1/31/2023, there was no documented evidence of a spiritual care visit or reason for the missed visit. The Clinical Operations Manager was interviewed on 2/3/2022 and agreed, there was no documented evidence of the missed visits or documented reasons for the missed visits. Additionally, during interview on 2/3/2022, the Clinical Operations Manager agreed, the chaplain and social worker did not provide services as ordered and included in the plan of care. The Administrator confirmed this finding on 2/3/2022. Record 11: The patient’s date of election was 11/3/2022. A physician’s order effective 12/1/2022 ordered a social worker 1 x month for 1 month. During the month 12/1/2022-12/31/2022, there was no documented evidence of a social worker visit or reason for the missed visit. Record 13: The patient’s date of election was 6/8/2021. The plan of care reviewed by the physician and interdisciplinary group on 5/11/2022 ordered a social worker 2 x month for 1 month effective 5/1/2022. During the month 5/1/2022-5/31/2022, there was no documented evidence of a social worker visit or reason for the missed visits. Record 14: The patient’s date of election was 9/3/2020. A physician’s order effective 1/1/2023 ordered spiritual care 1 x month for 1 month. During the month 1/1/2023-1/31/2023, there was no documented evidence of a spiritual care visit or reason for the missed visit. The Clinical Operations Manager was interviewed on 2/3/2022 and agreed, there was no documented evidence of the missed visits or documented reasons for the missed visits. Additionally, during interview on 2/3/2022, the Clinical Operations Manager agreed, the chaplain and social worker did not provide services as ordered and included in the plan of care. The Administrator confirmed this finding on 2/3/2022.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: (L579) Hand hygiene. This standard was not met as evidenced by a review of document reviews, interviews and observations. In 1 of 4 (25%) observations, revealed the hospice did not ensure adherence to agency infection control policies and procedures for hand hygiene. . Agency Policy #2915 [effective date 8/1/2020] titled Infection Control, stated in part, “Key situations where hand hygiene should be performed include: If hands will be moving from a contaminated-body site to a clean-body site during patient care.” During observation of Home Visit #2 on 2/1/2023 at 10:15 am, the Clinical Operations Manager (Staff #2) was present for the visit. The hospice aide (Staff #8) was observed donning gloves before providing peri care and cleaning up the patient after a bowel movement. The hospice aide then applied calmoseptine to the patient’s sacrum, dressed patient in clean briefs and pants, adjusted bed with remote and combed the patient’s hair. The hospice aide was not observed performing hand hygiene before moving from a contaminated-body site to a clean-body site during patient care. The Clinical Operations Manager was interviewed on 2/1/2022 and agreed, the hospice aide did not follow the infection control policy on hand hygiene. Agency Policy #2915 [effective date 8/1/2020] titled Infection Control, stated in part, “Key situations where hand hygiene should be performed include: If hands will be moving from a contaminated-body site to a clean-body site during patient care.” During observation of Home Visit #2 on 2/1/2023 at 10:15 am, the Clinical Operations Manager (Staff #2) was present for the visit. The hospice aide (Staff #8) was observed donning gloves before providing peri care and cleaning up the patient after a bowel movement. The hospice aide then applied calmoseptine to the patient’s sacrum, dressed patient in clean briefs and pants, adjusted bed with remote and combed the patient’s hair. The hospice aide was not observed performing hand hygiene before moving from a contaminated-body site to a clean-body site during patient care. The Clinical Operations Manager was interviewed on 2/1/2022 and agreed, the hospice aide did not follow the infection control policy on hand hygiene.

It is required that a hospice aide provides services: (L626) Ordered by the Interdisciplinary Group; Included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 15 (7%) records reviewed with a hospice aide ordered, revealed the hospice did not ensure hospice aide services were provided in accordance with the plan of care. . Record 2: The patient’s date of election was 6/20/2022. A physician’s order effective 9/18/2022 ordered a hospice aide 2 x week for 13 weeks. During the week 10/30/2022-11/5/2022, there was a hospice aide visit on 11/4/2022. There was no documented evidence of a second hospice aide visit or reason for the missed visit. Additionally, the hospice aide documentation on 11/4/2022 revealed, “pt was showered.” The hospice aide plan of care dated 9/8/2022 did not include shower as an assigned task. The Clinical Operations Manager was interviewed on 2/3/2022 and confirmed, there was no documented evidence of a second visit or documented reasons for the missed visit. Additionally, during interview on 2/3/2022, the Clinical Operations Manager agreed, the hospice aide did not follow the plan of care as ordered. The Administrator confirmed this finding on 2/3/2022. Record 2: The patient’s date of election was 6/20/2022. A physician’s order effective 9/18/2022 ordered a hospice aide 2 x week for 13 weeks. During the week 10/30/2022-11/5/2022, there was a hospice aide visit on 11/4/2022. There was no documented evidence of a second hospice aide visit or reason for the missed visit. Additionally, the hospice aide documentation on 11/4/2022 revealed, “pt was showered.” The hospice aide plan of care dated 9/8/2022 did not include shower as an assigned task. The Clinical Operations Manager was interviewed on 2/3/2022 and agreed, there was no documented evidence of a second visit or documented reasons for the missed visit. Additionally, during interview on 2/3/2022, the Clinical Operations Manager agreed, the hospice aide did not follow the plan of care as ordered. The Administrator confirmed this finding on 2/3/2022.