Every finding on record at Michigan Premier Hospice Care, LLC

Based on record review and interview, the agency failed to ensure the interdisciplinary group supervised the provision of care and services for 1 (P-1) of 3 records reviewed, resulting in the potential for unmet care needs for these patients (See L 539). --- The cumulative effect of these systemic problems resulted in the Hospice Agency's inability to ensure the provision of quality hospice care at the end of life, in a safe environment for the Condition of Participation: 45 CFR §418.56 Interdisciplinary Group, Care Planning, and Coordination of Services.

Based on record review and interview, the hospice failed to ensure the interdisciplinary group supervised the provision of care and services for 1 (P-1) of 3 records reviewed, resulting in the potential for unmet care needs for these patients. Findings include: --- A review of the agency policy: "Coordination of Patient Care" (Review 9/22/2022). The policy states, "4. Procedure: Hospice staff members regularly communicate to ensure that their efforts are coordinated effectively and ultimately support the objectives outlined in the IDG (Inter-disciplinary Group) plan of care. 3. Staff provides the physician, Medical Director and IDG with patient information on an ongoing basis regarding: Current condition and changes in condition…”Patient #1’s (P-1) admission to the hospice agency was on 4/22/24 with a terminal diagnosis of cerebral atherosclerosis. The Plan of Care (POC) for P-1 ordered Skilled Nursing services weekly. During record review on 6/5/25, it was noted that registered nurse (RN-2) completed a Skilled Nursing (SN) visit on 4/29/25 and documented, “Wound Assessment - …Wound has the following conditions: serosanguinous, purulent, odor…” The following SN visit was completed by RN-2 on 5/6/25 and stated, “Wound Assessment - …Wound has the following conditions: serosanguinous, odor…” The Inter-disciplinary Group (IDG) held a meeting on 5/8/25, which stated, “Skilled Nursing: Monitor skin condition regularly, especially pressure-prone areas. Assess patient’s pain can comfort level related to skin breakdown. Conduct a comprehensive skin assessment. Assess for signs and symptoms of skin infection, such as redness, swelling, pain, or fever.” Wound odor is a sign of skin infection. The IDG failed to supervise and ensure the provision of nursing care services. The Alternate Administrator (A-Adm) reviewed and acknowledged the findings listed about in an interview on 6/5/25 at 2:25 pm.

Based on record review and interview, the hospice failed to ensure the primary caregiver(s) received education and training regarding wound care treatments ordered in the Plan of Care for 1 (P-1) 3 records reviewed with wound care, out of a total sample of 3 records reviewed, resulting in the potential for unmet patient care needs and poor clinical outcomes. Findings include: --- This patient (P-1) was admitted to the Hospice agency on 4/22/24 with a terminal diagnosis of cerebral atherosclerosis. On 6/5/25, review of the medical record noted the face-to-face physician assessment dated 3/18/25 documented the following: "(P-1) continues to have a large fungating mass on her right ear that measures 4.5 cm. x 4.5 cm. x .2 cm. (length/width/depth). Wound bed is moist and erythematous (superficial reddening of the skin). Mild to moderate serosanguineous drainage present on dressing. Finding consistent with known basal cell carcinoma." Further review of the Inter-disciplinary Group (IDG) care plan dated 4/9/25, documented the following wound care orders: "SKILLED NURSING: Monitor skin condition regularly, especially pressure-prone areas. Assess patient's pain and comfort level related to skin breakdown. Conduct a comprehensive skin assessment. Assess for signs and symptoms of skin infection, such as redness, swelling, pain, or fever. MEDICATIONS: Metronidazole Powder (antibiotic used to treat bacterial and parasitic infections), Apply small amount of Powder to cover wound bed once daily for skin infection. WOUND ORDERS: Wound Order: Fungating Cancerous Mass; Right Ear; Cleanse with saline wound wash, pat dry with 4x4 gauze, apply Metronidazole powder, apply Xeroform to wound bed, cover with 4x4 gauze, secure to head with adhesive paper tape; Daily."The Plan of Care (POC) for P-1 ordered Skilled Nursing (SN) services weekly visits to provide wound care daily per orders above. When weekly SN visits are ordered but P-1 has daily wound care needs, the hospice agency must ensure that the primary care giver(s) at the ALF receive education and training provided by the Hospice's SN to adequately meet the needs of the patient. Subsequently, review of the weekly SN visits after the IDG meeting on 4/9/25 are detailed as follows: 4/15/25, wound assessment performed but no mention of ALF staff or education given; 4/22/25, wound assessment and dressing change performed but no mention of ALF staff or education given; 4/29/25, wound assessment performed (positive odor noted) but no mention of ALF staff or education given; 5/6/25, wound assessment performed (positive odor noted) and Wound care completed with facility staff" but no documentation of education given or return demonstration by ALF staff found.Additional record review revealed the Hospice agency was notified on 5/11/25 at 2:53 PM by the ALF that "Patient's right ear is swollen and red. Had a bug crawl out of it." Hospice performed SN visit that day and performed dressing change with no "bugs" noted. Another PRN (as needed) Hospice SN visit was performed the next day on 5/12/25 that documented, "Patient continues to pick at bandage. Advised staff to reinforce bandage and to keep patient busy with activity to prevent from taking off bandage. On 5/13/25, the Hospice agency was notified by the ALF that P-1's "ear is very swollen, filled with worms." That day, the Hospice provided another SN visit which documented, "Patient presented with maggots present in her right ear, attempted to remove them manually... going into skin. Contacted both attending and HMD (Hospice Medical Director) ... Patient sent out to hospital for debridement." Evidence that the Hospice agency provided education and wound care training to the ALF staff prior to the events on 5/13/25 were not found in the medical record. Further, evidence of verbal and physical return demonstration by ALF staff which showed appropriate knowledge and skills needed to perform the above wound care orders were not found. The Alternate Administrator (A-Adm.) reviewed and acknowledged the findings above during an interview on 6/5/25 at 3:50 PM. A-Adm. noted this did not meet Agency expectations or its policy referenced below.A review of the Agency's policy on 6/5/25 titled: "Patient Education" PC 09.23 (updated 9/22/2022) stated, "Hospice staff will provide initial and ongoing education to meet each individual patient's needs. The patient education provided will be: Coordinated among the disciplines providing care to the patient... Evaluated for patient's comprehension."

Based on record review and interview, the agency failed to ensure skilled nursing met the wound care needs in 1 (P-1) of 3 records reviewed with wound care, out of a total sample of 3 records reviewed (See L 591). --- The cumulative effect of this systemic problem resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 418.64 Core Services.

Based on policy review, record review and interview, the hospice failed to notify the physician in a change of condition and perform wound care per physician order in 1 (P-1) of 3 records reviewed in which patients had wounds, resulting in the potential for poor patient outcomes for all hospice patients with wounds. Findings include: --- A review of the agency policy on 6/5/25: "Coordination of Patient Care" (reviewed 9/22/2022). The policy states, "4. Procedure: Hospice staff members regularly communicate to ensure that their efforts are coordinated effectively and ultimately support the objectives outlined in the IDG plan of care. 3. Staff provides the physician, Medical Director and IDG with patient information on an ongoing basis regarding: Current condition and changes in condition…”Patient #1’s (P-1) admission to the Hospice agency was on 4/22/24 with a terminal diagnosis of cerebral atherosclerosis. The Plan of Care (POC) for P-1 ordered Skilled Nursing services weekly. The wound care order dated 3/31/25 states, “Wound Type: Fungating Cancerous Mass…Instructions: Unstageable. Dressing: Cleanse with saline wound wash, pat dry with 4x4 gauze, apply Metrodinazole powder, apply Xeroform to wound bed, cover with 4x4 gauze, secure to head with adhesive paper tape. Change Every: Daily.” During record review on 6/5/25, it was noted that RN-4 completed a Skilled Nursing (SN) visit on 4/2/25 and stated, “…Wound Assessment – Documented 1 wound(s). The wound is assessed with C44.202 (ICD-10-CM code) Unsp (unspecified) malig (malignant) neoplasm skin/right ear and external auric canal. Wound type is chronic. The wound can be described as other. Wound has the following conditions: purulent, odor. Surrounding skin is intact. Unable to measure, borders are irregular. Wound cleansed with ns (normal saline), patted dry with 4x4 gauze, xeroform applied, covered with bordered gauze and secured with mefix tape. Skin - …Instruction given on measure to manage skin integrity. Wound was identified and instruction was provided for care management and infection prevention…”  RN-1 completed the next SN visit on 4/8/25 and stated, “…Wound Assessment – Documented 1 wound(s). The wound is assessed with C44.202 (ICD-10-CM code) Unsp malig neoplasm skin/right ear and external auric canal. Wound type is chronic. The wound can be described as other. Wound has the following conditions: sanguinous. Surrounding skin is intact. Wound is not able to be measured…”  RN-1 completed the next SN visit on 4/15/25 and stated, “Coordination of care note: Writer observed patient lying in bed with facility staff at her side. Patient agreeable to visit. Patient wound care to her right ear cleansed and dressed per orders, patient tolerated well…Wound Assessment – Documented 1 wound(s). The wound is assessed with C44.202 Unsp malig neoplasm skin/right ear and external auric canal. Wound type is chronic. The wound can be described as other. Wound has the following conditions: slough, granulation. Surrounding skin is erythema. Unable to measure. Skin - …Instruction given on measures to manage skin integrity, prevent infections. Wound was identified and instruction was provided for care management and infection prevention…” RN-1 completed the next SN visit on 4/22/25 and stated, “…Wound Assessment – Documented 1 wound(s). The wound is assessed with C44.202 Unsp malig neoplasm skin/right ear and external auric canal. Wound type is chronic. The wound can be described as other. Wound has the following conditions: slough, granulation. Surrounding skin is intact. Cleansed with normal saline pat dry with 4x4 gauze, applied xeroform dressing and covered with dry dressing, patient tolerated well…” RN-2 completed the next SN visit on 4/29/25 and documented, “…Wound Assessment – Documented 1 wound(s). The wound is assessed with C44.202 Unsp malig neoplasm skin/right ear and external auric canal. Wound type is chronic. The wound can be described as other. Wound has the following conditions: serosanguinous, purulent, odor. Surrounding skin is intact. Skin - …Instruction given on measures to manage skin integrity. Wound was identified and instruction was provided for care management and infection prevention…Reports no pain at this time, mild pain during wound care removing dressing stuck to hair, denies need for pain medication…”  The next SN visit was completed by RN-2 on 5/6/25 and stated, “…Wound Assessment – Documented 1 wound(s). The wound is assessed with C44.202 Unsp malig neoplasm skin/right ear and external auric canal. Wound type is chronic. The wound can be described as other. Wound has the following conditions: serosanguinous, purulent, odor. Surrounding skin is intact. Wound care completed with facility staff. Skin - …Instruction given on measures to manage skin integrity. Wound was identified and instruction was provided for care management and infection prevention…”  The next SN visit was completed by RN-3 on 5/11/25 and stated, “Encounter info: PRN (as needed) Reason: ear red and irritated. Coordination of care note: Staff were concerned that they think they saw a bug come out of patient’s ear and it is reddened. Upon visit, staff stated that patient took off dressing. After assessment R (Right) ear appeared to be reddened but no bugs were noted at site at the time. Ear was cleansed, ointment was applied, and wound was dressed.”  The next SN visit was completed by RN-2 on 5/13/25 and stated, “Comprehensive assessment - ...Pt (patient) presented with maggots present in her right ear attempted to remove them manually used betadine and gauze rinsed area they were going into skin. Contacted both attending and HMD (Hospice Medical Director) for guidance spoke with nephew (DPOA) he is in agreeance of sending her out he will meet pt at hospital and speak with hospital to remove tumor at this time. [SIC]…Wound Assessment – Documented 1 wound(s). The wound is assessed with C44.202 Unsp malig neoplasm skin/right ear and external auric canal. Wound type is chronic. The wound can be described as other. Wound has the following conditions: odor. The wound image is attached as an attachment. The wound is 8 cm long, 6 cm wide, and 0 cm deep. Pt sent out to hospital for debridement…” The Electronic Medical Record (EMR) contains no evidence that the physician was notified of the wound containing the presence of odor, wound care being completed to order, and that the facility staff were trained and capable of providing wound care as ordered.  The Alternate Administrator (A-Adm) reviewed and acknowledged the findings listed about in an interview on 6/5/25 at 2:25 pm.

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed it was revealed that the agency did not ensure the plan of care (POC) included planned interventions and goals based on problems identified in the initial and updated comprehensive assessments. Clinical Record 6: The date of the election of benefits was 02/19/2024. The primary hospice diagnosis was cerebral atherosclerosis. The RN Initial Assessment dated 02/19/2024 and the RN Recertification assessment dated 05/07/2024 documented that the patient had a seizure disorder. The Plan of Care dated 02/23/2024 for the benefit period 02/19/2024-05/18/2024 and the Plan of Care Orders dated 05/23/2024 and 08/19/2024 documented the medication Levetiracetam 500mg twice daily. The Plan of Care and Plan of Care Orders lacked problems, interventions, and goals for potential seizure activity. Clinical Record 14: The date of the election of benefits was 01/17/2024. The primary hospice diagnosis was Parkinson's disease with dyskinesia, with fluctuations. The RN Skilled Nursing Visit assessment dated 02/27/2024 documented that the patient received Diflucan for a possible fungal infection. The On Call PRN visit assessment on 07/31/2024 documented that acyclovir and prednisone were ordered to treat the patient for shingles. The RN Skilled Nursing Visit assessment dated 08/05/2024 documented educating the facility staff on utilizing Personal Protective Equipment when providing care for the patient, as the physician felt it was a shingles rash. The IDG Meeting documents dated 02/29/2024, 08/01/2024, and 08/15/2024 lacked problems, interventions, and goals for infections. Clinical Record 17: The date of the election of benefits was 08/26/2023. The primary hospice diagnosis was unspecified sequelae of cerebral infarction. The RN recertification assessment dated 02/13/2024 documented that the patient had 2+ edema to the bilateral lower extremities and bowel and bladder incontinence. The RN Skilled Nursing Visit assessment dated 02/15/2024 documented that the patient had 2+ edema, shortness of breath with minimal exertion or with agitation, was using oxygen at 3 LPM via Nasal Cannula (NC), and was incontinent of bowel and bladder. The RN Skilled Nursing Visit assessment dated 02/26/2024 documented that the patient had 2+ edema, shortness of breath with minimal exertion or with agitation, was using oxygen at 2 LPM via NC, and was incontinent of bowel and bladder. The IDG Meeting documents dated 02/20/2024 and 03/05/2024 lacked problems, interventions, and goals for edema, the risk for skin breakdown, and impaired respiratory status. During a joint review of the record and an interview on 08/29/2024, the Administrator confirmed that there was no documented evidence that the plans of care included problems, goals, and interventions for the problems identified in the assessments.

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 hand hygiene. This standard was not met as evidenced by document review, interview and observation. In 1 of 4 (25%) home visit observations it was revealed that the organization did not ensure the staff followed the hand hygiene policy. Document 1: Agency Policy, Hand Hygiene Policy and Compliance Program, SOP# IC 05.10, dated 08/18/2022, stated in part, "Indications for hand hygiene are: before and after direct patient care... Hospice will follow the Centers for Disease Control and Prevention (CDC) guidelines for hand hygiene: After removing gloves (IB) Recommended. Category IB: Strongly recommend for implementation and strongly supported by certain experimental, clinical or epidemiologic studies and strong theoretical rationale." Home Visit 1: During the home visit (Clinical Record 7) on 08/27/2024 with the Registered Nurse (RN) (Staff 11), the RN was observed to don gloves and clean the wound to the coccyx. The RN removed the gloves, donned a new pair of gloves, and applied a cream and medication mixture to the wound. The RN removed the gloves, donned a new pair of gloves, and changed the brief. The RN removed the gloves, obtained linens from the closet/bathroom, and donned a new pair of gloves. The RN completed the care for the patient and picked up trash from the over the bed table and the floor. The RN removed the gloves and donned a new pair of gloves. The RN was not observed performing hand hygiene after removing gloves. During a joint document review and interview on 08/27/2024, the Administrator agreed the staff did not follow the hand hygiene policy. The Administrator stated that the staff are instructed to decontaminate the hands after removing gloves.