Every finding on record at Mid Michigan Home Health & Hospice LLC.

It is required that the comprehensive assessment includes consideration of the following factors: Symptoms and symptom severity, including skin integrity. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 19 (5%) records reviewed it was revealed that the hospice agency did not ensure the comprehensive assessment included skin integrity. Document 10: Policy #1-014, titled Comprehensive Assessment (revised November 2021) sub-section one (1) stated in part, "During the comprehensive assessment, all baseline data and other relevant information will be documented in the patient's clinical record, including at least the following information: (B) An assessment of the severity of secondary symptoms, such as (4) skin integrity. (I) A physical assessment including skin and other relevant data related to the pertinent physical findings and the patient's terminal illness." Clinical Record 3: The hospice benefit election date was 4/25/2023. The patient resided in an Assisted Living Facility (ALF). The initial RN assessment dated 4/25/2023 identified a wound. The sub-section integumentary stated in part, "One (1) wound was a stage four (4), and the patient had two (2) wounds of pressure all stages". Sub-section narrative stated in part, "Wound on the left heel and coccyx. Patient is questioning of RN presence and agitation, and anxiety is present, wound assessment not completed due to this. Staff report coccyx wound is stage four (4)". The wound was first assessed on 6/12/2023 with a wound assessment tool. A joint record review and interview with the Alternate Administrator (staff 1) on 1/2/2024 confirmed the hospice did not ensure a complete comprehensive initial assessment was performed. The Alternate Administrator stated, "We did not assess the wound for over a month".

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review, interview and observation. In 1 of 4 (25%) home visit observations where medication reconciliation was completed, by comparing the hospice agency medication profile to the patient's current regimen, it was revealed that the hospice agency did not ensure the medication profiles were updated accurately and included the patient's current medication regimen. Document 7: Policy #2-004, titled Medication Profile (revised November 2021) sub-section seven (7) stated in part, "A drug regimen review will be performed at the time of the initial and the comprehensive assessment when updates to the comprehensive assessment are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication." Home Visit 4: The home visit was conducted on 1/4/2024 in the presence of the Administrator (staff). The hospice benefit election date was 2/6/2023 and the patient (record 11), resided in a Skilled Nursing Facility. The Skilled Nursing Facility (SNF) medication administration record/medication list dated 1/4/2023 stated in part, "Lexapro twenty (20) milligrams (mg). Give one (1) tablet by mouth one time a day. The active order date was 7/28/2023". The hospice agency medication list did not contain the medication Lexapro. The same medication administration record/medication list stated in part, "Morphine Sulfate twenty (20) milligrams (mg) per milliliter (ml) (20mg/ml). Give zero (0) point (.) two (2) five (5) (0.25) millimeters (ml) every two (2) hours. The active order date was 12/27/2023." The hospice agency medication profile stated in part, "Morphine Sulfate twenty (20) milligrams (mg) per milliliter (ml) (20mg/ml). Give zero (0) point (.) two (2) five (5) (0.25) millimeters (ml) every three (3) hours. The active order date was 11/13/2023." The agency medication list dated 1/4/2023 stated in part, "Morphine Sulfate twenty (20) milligrams (mg) per milliliter (ml) (20mg/ml). Give zero (0) point (.) two (2) five (5) (0.25) millimeters (ml) every three (3) hours." A joint record review and interview with the Alternate Administrator (staff 1) on 1/4/2024 confirmed the hospice agency medication profile was not updated to include the patient's current medication regimen.

It is required that each patient’s individualized written plan of care reflects patient and family goals, and 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, document review and interview. In 3 of 19 (16%) records reviewed it was revealed that the written plan of care did not contain all goals and interventions based on the problems that were identified in the initial assessment. Document 6: Policy #9-017, titled The Plan of Care (revised November 2021) sub-section twelve (12) stated in part, "The written plan of care will contain, but not be limited to the following: (B) Identification of patient/family/caregiver needs including physical, psychosocial, cultural, Spiritual, nutritional, educational and counseling. (G) Nutritional requirements. (L) Individual interventions to assist with end-of-life care. (N) Statement of treatment goals". Clinical Record 7: The hospice benefit election date was 9/11/2023 and the Certificate of Terminal Illness (CTI) stated in part, "Patient has a suprapubic catheter." The plan of care dated 9/11/2023-12/9/2023 that did not contain any problems, goals, or interventions related to the suprapubic catheter. Clinical Record 10: The hospice benefit election date was 11/28/2023. The (CTI) stated in part, "Patient has an ileostomy." The plan of care dated 11/28/2023-2/25/2024 did not contain any problems, goals, or interventions related to the ileostomy. Clinical Record 17: The hospice benefit election date was 6/15/2023. The initial RN assessment dated 6/15/2023 documented in part, "Patient is a new colostomy status times (Xs) one (1) month. Discharged yesterday from a rehab center." The plan of care dated 6/15/2023-9/12/2023 that did not contain any problems, goals, or interventions related to the colostomy. A joint record review and interview with the Alternate Administrator on 1/4/2024 (staff 1) confirmed the hospice did not ensure the written care plans contained all goals and interventions based on the problems identified in the initial assessments.

It is required that a hospice aide provide services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 19 (16%) records reviewed where hospice aide services were accepted it was revealed that the hospice agency did not ensure the hospice aide provided all of the services and tasks that were included in the plan of care. Document 6: Policy #9-017 titled, The Plan of Care (revised November 2021), sub-section stated in part, "The care provided to the patient must be in accordance with the plan of care". Clinical Record 4: The hospice benefit election date was 2/6/2023. The hospice aide care plan dated 11/3/2023-1/1/2024, stated in part, "Offer fluids." The hospice aide documented fluids were not offered on 12/21/2023, 12/18/2023, 12/14/2023, 12/11/2023, and 12/7/2023. The record did not contain evidence the hospice aide informed the RN that the intervention not performed. Clinical Record 5: The hospice benefit election date was 9/27/2023. The hospice aide care plan dated 9/27/2023-12/25/2023 and had a hospice aide intervention that stated in part, "Shower every visit.". The hospice aide documented on 10/21/2023 that they did not complete the shower because the facility had already completed'. The record did not contain evidence the hospice aide notified the RN that the task was not completed. Clinical Record 6: The hospice benefit election date was 11/30/2023. The hospice aide care plan dated 11/30/2023-2/27/2023, stated in part, "Routine ostomy care change gauze around PEG tube on 12/19/2023. The hospice aide documented the intervention was not completed. The record did not contain any evidence that the RN was notified that the intervention was not performed. Interview: A joint record review and interview with the Alternate Administrator on 1/2/2024 (staff 1) confirmed that the hospice aide did not perform all interventions ordered by the Interdisciplinary Group (IDG).

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) records reviewed it was revealed that the hospice agency did not ensure that the patient's clinical record contained all physician's orders. Clinical Record 7: The hospice benefit election date was 9/11/2023. The certificate of terminal illness (CTI) stated in part, "Patient has a suprapubic catheter." The Initial RN assessment dated 9/11/2023 sub-section genitourinary stated in part, "Suprapubic catheter 22 French changed one month ago as stated by the wife." The RN assessment dated 9/11/2023 indicated a "yes" by the sub-section if there was an order for irrigation and stated, "Normal Saline Flush, twenty (20) ml as needed." The RN visit note dated 10/6/2023 documented the RN changed the Foley catheter, but the record did not contain a physician's order changing or flushing a suprapubic catheter. Clinical Record 10: The hospice benefit election date was 11/28/2023. The (CTI) stated in part, "Patient has an ileostomy." There were no physician orders in the clinical record for ileostomy care. Clinical Record 17: The hospice benefit election date was 6/15/2023. The initial RN assessment dated 6/15/2023 documented under the sub-section genitourinary in part, "Abnormal GI findings, ostomy." The sub-section titled narrative stated in part, "Patient is a new colostomy status times (Xs) one (1) month. Discharged yesterday from the rehab center." The CTI dated 6/21/2023 stated in part, "Patient has an ostomy." The record did not contain any physician orders for ostomy care. In a joint record review and interview with the Alternate Administrator on 1/4/2024, the Alternate Administrator confirmed the records did not contain physician's orders for care.