Every finding on record at Schoolcraft Memorial Hospital

Based on record review and interview, the agency failed to ensure the comprehensive assessment included an initial bereavement assessment that identified all who would be affected by the patient’s death in 2 (P-1 and P-6) of 14 records reviewed, resulting in the potential for unmet bereavement care needs. Findings include: --- Patient #6 (P-6) was admitted to this hospice agency on 1/9/24 with the terminal diagnosis of lung cancer. During record review on 8/21/25, it was determined P-6’s son was the only individual listed on the initial bereavement assessment. Upon further review of the record, it was noted the social work evaluation (dated 1/9/24) documented the patient reported she felt her 2 sons would grieve for her. Additionally, the social work evaluation indicated the patient had authorized contact with both sons to complete the initial bereavement assessment. The administrator (Adm) reviewed and acknowledged the findings during an interview on 8/22/25 at 9:53 AM. Adm was unsure why the patient's other son had not been included in the initial bereavement assessment. Patient #1 (P-1): This 71-year-old was admitted to hospice on 7/23/25 with a terminal diagnosis of lung cancer. The medical record was reviewed on 8/19/25. During review, it was noted that the Medical Social Worker (MSW) completed an initial MSW Assessment on 7/23/25. In the initial MSW Assessment, the MSW documented that she asked P-1’s son (present for assessment) who he felt would grieve P-1’s death, and he responded both him and his brother would be grieving. Additionally, the MSW documented consent was received to contact the brother to provide an initial bereavement assessment. An initial bereavement assessment was completed for P-1’s son on 7/23/25 however, no further documentation or initial bereavement assessment information was found in the medical record regarding the brother at the time of the medical record review (27 days after start of care).On 8/22/25 during interview at 10:50 AM, the above findings were reviewed with the Administrator (Adm) and the Clinical Manager (CM). Adm stated the follow-up was “probably done”, but no follow-up documentation for initial bereavement needs of the brother was obtained prior to survey exit.

Based on record review and interview, the agency failed to ensure services were provided according to the plan of care in 3 (P-1, P-3, and P-7) of 11 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: --- Patient #7 (P-7) was admitted to this hospice agency on 7/8/25 with the terminal diagnoses of unspecified protein-calorie malnutrition, dementia, and chronic obstructive pulmonary disease (COPD). During record review on 8/21/25, it was noted the plan of care ordered hospice aide services 2-3 times per week. Upon further review of the record, it was determined the hospice aide wrote missed visit notes for 7/22/25 (P-7 received one aide visit this week), 8/12/25 and 8/15/25 (P-7 received no aide visits this week).  During an interview with the administrator (Adm) on 8/22/25 at 9:53 AM, Adm was asked about the agency’s expectation regarding missed visits. Adm stated it was the agency’s expectation to try to reschedule the visit for later that week to ensure the frequency in the plan of care was met. If the visit could not be scheduled, the doctor was contacted regarding a change in frequency via an automatic queue set up in the electronic medical record (EMR) system. Upon review of the missed visit documentation with Adm, it was noted there was no documentation regarding an attempt to reschedule the missed visits noted above. Adm was then asked for evidence that doctor was contacted regarding the change in frequency. During the interview, Adm discovered the EMR for the agency’s home health care EMR created a queue for missed visits, however, the hospice side did not. Adm admitted there was no evidence the doctor was contacted regarding the change in the plan of care frequency and acknowledged the findings. Patient #1 (P-1): This 71-year-old was admitted to the hospice on 7/23/25 with a terminal diagnosis of lung cancer. The medical record was reviewed on 8/19/25. During review, the following entries were noted:On 7/23/25, the Medical Social Worker (MSW) completed the “Chaplain/Counselor Assessment” to determine initial spiritual needs of the patient/family. The MSW documentation included the following details regarding P-1’s spiritual assessment: spirituality was a significant part of P-1’s life; spiritual views have had an influence on P-1’s life; and P-1’s son requested chaplain visits.On the plan of care (POC) dated 7/23/25, chaplain frequency was ordered for 1-3 times per month for 1 month.On 7/28/25, the MSW completed an “MSW Visit” and included the following documentation: “The MSW explored the patient’s spiritual beliefs, and the patient expressed openness to spiritual support.” Additionally, she wrote “MSW inquired if the patient had any spiritual concerns and the patient paused and shook her head yes... it is almost as if he isn't there sometimes seeming to refer to God." The MSW also documented that a chaplain visit was scheduled for 7/30/25.On 7/30/25, the chaplain completed a “Chaplain/Counselor Visit” and included documentation that P-1 “was agreeable to Chaplain visiting again and requested prayers for her health”. There was no documentation reflecting P-1 (or family) requesting chaplain visits to either stop, or to continue only if requested.On 8/6/25, the interdisciplinary group (IDG) note (which is the POC update) did not have a scheduled frequency or duration for more chaplain visits to be provided to P-1.On 8/20/25, the IDG note did not have a scheduled frequency or duration for more chaplain visits to be provided to P-1.No additional chaplain visits were entered into the medical record at the time of the medical record review (21 days after chaplain visit). On 8/22/25 during interview at 10:50 AM, the above findings were reviewed with the Administrator (Adm) and the Clinical Manager (CM). Adm was asked how it would be determined that a chaplain would make additional visits if there was no frequency or duration for staff to follow. Adm acknowledged that staff would not go for a regular visit with no frequency on the POC unless an issue was identified. Even though the hospice followed their own POC, they failed to ensure a continued frequency of spiritual care to support the spiritual needs that were clearly identified initially. Patient #3 (P-3): This 94-year-old was admitted to the hospice on 7/15/25 with a terminal diagnosis of heart failure. The medical record was reviewed on 8/22/25. During review, the following entries were noted:On 7/16/25, the MSW completed the “Chaplain/Counselor Assessment” to determine initial spiritual needs of the patient/family. The MSW documentation included the following details regarding P-1’s spiritual assessment: spirituality was a significant part of P-1’s life; spiritual views have had an influence on P-1’s life; spirituality makes the patient feel connected in life; and the caregiver requested a hospice chaplain to visit P-3 because it seemed to comfort her.On 7/29/25, the chaplain completed a “Chaplain/Counselor Visit” and documentation included concerns that P-3 had over a relationship; that P-3 enjoyed reciting the Lord’s prayer; and that P-3 requested prayer. There was no documentation reflecting P-3 (or family) requesting chaplain visits to either stop, or to continue only if requested.On 8/6/25, the IDG note did not have a scheduled frequency or duration for more chaplain visits to be provided to P-3.On 8/20/25, the IDG note did not have a scheduled frequency or duration for more chaplain visits to be provided to P-3.No additional chaplain visits were entered into the medical record at the time of the medical record review (24 days after chaplain visit). On 8/22/25 during interview at 10:50 AM, the above findings were reviewed with Adm and CM. Adm acknowledged that staff would not go for a regular visit with no frequency on the POC. The hospice failed to ensure a continued frequency of spiritual care to support the spiritual needs that were clearly identified initially.

Based on record review and interview, the agency failed to ensure patient spiritual needs were supported in 1 (P-5) of 11 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: --- Patient #5 (P-5) was admitted to this hospice agency on 3/13/25 with the terminal diagnoses of Alzheimer’s disease and dementia. During record review on 8/20/25, it was noted that the social worker (MSW) completed the spiritual assessment on 3/13/25. According to the spiritual care assessment, P-5’s guardian/daughter indicated, “…she is very spiritual and was a very active member of St. Francis de Sales.” P-5’s daughter also reported P-5, “…finds great comfort in her faith and has not been able to actively engage in her faith due to her declining health.” Additionally, MSW set the following spiritual care goal following the spiritual care assessment that, “(P-5) will be able to practice and engage in her faith.”  Upon further review of the spiritual care assessment, it was noted interventions included that the “Sacrament of the Anointing of the Sick” would be performed by a local Catholic priest and a Eucharistic Minister would deliver the “Sacrament of Communion” to P-5 weekly. However, upon review of the plan of care, it was noted there was no chaplain frequency ordered for return visits or follow-up by spiritual care to monitor P-5’s spiritual needs.  During a joint home visit with MSW on 8/20/25 at 2:30 PM, MSW and P-5’s daughter were asked if P-5 was still receiving visits from the church or receiving weekly communion (due to P-5’s Alzheimer’s diagnosis, P-5 was unable to answer for herself). P-5 and MSW were unsure if P-5 was still receiving any spiritual care. Upon return to the agency for further review of the record, it was confirmed there was no follow-up spiritual care documented to indicate whether the patient had been receiving visits from the Catholic church as planned or if her spiritual care needs were being met. During an interview with the administrator (Adm) on 8/22/25 at 9:53 AM, Adm was asked about spiritual care follow-up for this patient. Adm was unable to locate documentation that spiritual care needs were being monitored after identifying P-5’s strong faith during the initial spiritual care assessment.  Adm also reported the agency has 2 chaplains, however, they are both volunteers and are not always available. Adm stated the agency was working on getting a paid chaplain to improve spiritual care follow-up. However, the agency failed to provide spiritual care follow-up to ensure P-5’s spiritual care needs were being met. Adm acknowledged the findings at the time of interview.

Based on observation, record review, and interview, the hospice failed to ensure the clinical record reflected an accurate response to hospice aide services in 1 (P-1) of 11 records reviewed resulting in inaccurate documentation of the patient’s response in the clinical record. Findings include: --- Patient #1 (P-1): This 71-year-old was admitted to the hospice on 7/23/25 with a terminal diagnosis of lung cancer. During review of the hospice “Aide Care Plan” dated 8/19/25, it was noted that the following tasks were assigned for the hospice aide to complete each visit: foot care; peri-care; skin care; back rub/massage; check pressure areas; nail care; assist in transfer; incontinent care. On 8/20/25 at 10:00 AM, a joint home visit was conducted with the hospice aide (HA-1) to observe the aide’s adherence to the hospice aide care plan during patient care. During the visit, HA-1 was heard asking P-1 if she needed to use the rest room and P-1 stated “no”. HA-1 asked P-1 if she would like to have her fingernails painted, and P-1 said “yes”. HA-1 wheeled P-1 in her wheelchair (which she had been sitting in upon arrival) to the activity room and completed the task. P-1 stayed in the activity room after her nails were completed because bingo was the next activity scheduled immediately following the visit with HA-1 (at 11:00 AM). HA-1 was heard offering P-1 toileting assistance again prior to leaving the visit.On 8/21/25, the visit note completed by HA-1 for the joint home visit (on 8/20/25) was reviewed. It was noted that HA-1 documented P-1 “declined” all the hospice aide tasks on the aide care plan except nail care. Although P-1 did decline to use the restroom during HA-1’s visit, there was no observation of HA-1 offering foot care; skin care; back rub/massage; a check of pressure areas; or incontinence care (refusal was for toileting, not to monitor for incontinence).On 8/22/25 during interview at 10:50 AM, the above findings were reviewed with the Administrator (Adm) and the Clinical Manager (CM). Adm acknowledged that HA-1 should have documented that the tasks were not completed with an explanation, rather than to document that the patient declined the services.

Based on record review and interview, the Hospice agency failed to ensure the comprehensive assessment included a review of all medications for significant drug interactions and duplicate drug therapy in 7 (MR#'s 2, 3, 4, 5, 6, 8, and 11) of 11 sample records reviewed, resulting in the potential for unrecognized harmful medication effects for all 5 current patients serviced by this agency. Findings include: **Agency policy "Medication Management" Policy No. 11557778 stated, "Procedure: The Registered Nurse performs an assessment (medication reconciliation) of the medication profile once all medications have been entered into the electronic medical record. The nurse reviews and acts on any "Potential Interaction Risk" "Review Suggested" and contacts the physician immediately if "Intervention Required" is identified with the reconciliation. The report with potential drug/drug and drug/food or alcohol interactions are communicated to the physician." MR #2: This patient was admitted to the hospice on 4/9/22 with a terminal diagnosis of lung cancer. During record review on 8/23/22, it was noted on the medication profile dated 4/9/22 that the skilled nurse (SN) marked that there was no need to contact the physician regarding medication discrepancies because there were no discrepancies. When reviewing the medications for interactions or duplicative therapy using the agency's software, it was noted that there was a duplicative therapy with two medications which are inhaled, Ipatropium-Albuterol Solution and Advair Diskus. There was no documented evidence that the SN recognized or was aware of the duplicative therapy. There was no evidence that the physician was informed of the duplicative therapy. These findings were reviewed and acknowledged by the Clinical Manager (Staff A) and the Administrator (Staff B) during interview on 8/24/22 at 3:30 p.m. MR #3: This patient was admitted to the hospice on 7/30/22 with a terminal diagnosis of protein calorie malnutrition. During record review on 8/23/22, it was noted on the medication profile dated 7/30/22 that the SN marked that there was no need to contact the physician regarding medication discrepancies because there were no discrepancies. When reviewing the medications for interactions or duplicative therapy using the agency's software, it was noted that there was a duplicative therapy with two cardiac medications Metoprolol Succinate ER and Losartan Potassium. There was no documented evidence that the SN recognized or was aware of the duplicative therapy. There was no evidence that the physician was informed of the duplicative therapy. These findings were reviewed and acknowledged by Staff A and Staff B during interview on 8/24/22 at 3:35 p.m. MR #4: This patient was admitted to the hospice on 4/9/22 with a terminal diagnosis of malignancy of the retroperitoneum and peritoneum (tissues in the abdomen and pelvic areas). During record review on 8/23/22, it was noted on the medication profile dated 4/9/22 that the SN marked that there was no need to contact the physician regarding medication discrepancies because there were no discrepancies. When reviewing the medications for interactions or duplicative therapy using the agency's software, it was noted that there was a duplicative therapy with two medications which affect blood pressure, Atenolol and Lasix. There was no documented evidence that the SN recognized or was aware of the duplicative therapy. There was no evidence that the physician was informed of the duplicative therapy. These findings were reviewed and acknowledged by Staff A and Staff B during interview on 8/24/22 at 3:40 p.m. MR#5: The Start of Care (SOC) was dated 1/28/22. The Plan of Care (POC) identified terminal diagnoses of Lung Cancer, Chronic Obstructive Pulmonary Disease and Atrial Fibrillation. During record review on 8/23/22, it was noted that the "Medication Profile" stated, "Physician contacted regarding medication discrepancies: NA (No Discrepancies)." The Medication Interaction within the EMR (Electronic Medical Record) noted 3 Drug-Drug interactions and 2 Drug-Food/Alcohol with "Review Suggested." Furthermore, the EMR noted 7 Drug-Drug interactions and 6 Drug-Food/Alcohol with "Potential Interaction Risk." Additionally, 3 duplicate drug therapies were identified within the EMR. There was no evidence that a drug review was completed and communicated to the physician per the policy. MR#6: The Start of Care (SOC) was dated 8/5/22. The Plan of Care (POC) identified terminal diagnoses of Parkinson's, Chronic Kidney Disease and Congestive Heart Failure. During record review on 8/23/22, it was noted that the "Medication Profile" stated, "Physician contacted regarding medication discrepancies: NA (No Discrepancies)." The Medication Interaction within the EMR noted 3 Drug-Drug interactions and 4 Drug-Food/Alcohol with "Review Suggested." Furthermore, the EMR noted 14 Drug-Drug interactions and 6 Drug-Food/Alcohol with "Potential Interaction Risk." Additionally, 3 duplicate drug therapies were identified within the EMR. There was no evidence that a drug review was completed and communicated to the physician per the policy. MR#8: The Start of Care (SOC) was dated 1/4/22. The Plan of Care (POC) identified terminal diagnoses of Colon Cancer, Lung Cancer and Liver Cancer. During record review on 8/24/22, it was noted that the "Medication Profile" stated, "Physician contacted regarding medication discrepancies: NA (No Discrepancies)." The Medication Interaction within the EMR noted 2 Drug-Food/Alcohol with "Review Suggested." Furthermore, the EMR noted 1 Drug-Food/Alcohol with "Potential Interaction Risk." Additionally, 1 duplicate drug therapy was identified within the EMR. There was no evidence that a drug review was completed and communicated to the physician per the policy. These findings were reviewed with and acknowledged by the Administrator (Adm#1) during an interview on 8/24/22 at 4:10 pm. MR#11: The SOC date was 5/19/21, with identified terminal diagnoses of hypertensive heart disease with congestive heart failure and chronic kidney disease. During record review on 8/23/22, it was noted that SN at the SOC had used the Agency's EMR (Electronic Medical Record) software to run a medication reconciliation report. This report revealed a severe (highest level) drug to drug interaction which stipulated "Intervention Required" to the physician for further review. Additional medical record review found no evidence which indicated the physician was made immediately (per Agency policy) or at any other time aware of the above finding. During an interview on 8/24/22 at 12:35 PM., the Clinical Manager (Staff A) reviewed and acknowledged the findings above.

Based on record review and interview, it was determined that the Hospice failed to ensure the Initial Bereavement Assessment included the identification of the potential bereaved individuals, and the social, spiritual and cultural factors that may impact their ability to cope with the patient's death in 5 (MR's #5, 6, 8, 10, 11) of 14 records reviewed that required a bereavement assessment, from a total sample of 14 sampled records reviewed, and failed to develop a bereavement plan of care that incorporated the bereavement assessment, resulting in the potential for ineffective grieving and lack of bereavement support for the family members, caregivers and others that may be affected upon the patient's death. Findings include: **Agency policy "Bereavement and Spiritual Services" Policy No. 11650141 stated, "Purpose: To provide To provide appropriate and coordinated bereavement and spiritual services to families and/or caregivers. Procedure: The Hospice Social Worker completes the Bereavement Risk Assessment within 5 days of the patient's admission to hospice or within 72 hours of the patient's death (whichever is sooner) as part of the Comprehensive Assessment. The purpose of this assessment is to identify the name and contact information of the primary bereaved and/or other potential bereaved loved ones to determine Bereavement risks." MR#5: The Start of Care (SOC) was dated 1/28/22. The Plan of Care (POC) identified terminal diagnoses of Lung Cancer, Chronic Obstructive Pulmonary Disease and Atrial Fibrillation. During record review on 8/23/22, it was noted that the Medical Social Work (MSW) initial assessment dated 2/8/22 stated, "Psychosocial Assessment:...Patient has three daughters and one son..." The Bereavement Risk Assessment section stated, "Bereaved Person ... Daughter." The assessment contained no additional assessment of the 3 other children that would be affected upon the patient's death. MR#6: The Start of Care (SOC) was dated 8/5/22. The Plan of Care (POC) identified terminal diagnoses of Parkinson's, Chronic Kidney Disease and Congestive Heart Failure. During record review on 8/23/22, it was noted that the MSW Bereavement Assessment dated 8/5/22 stated, "Bereaved Person ... Son." Additionally, within the Summary/Comments section of the Bereavement Assessment it stated, "The son is currently living with MR#6 and is the primary caregiver for MR#6. MR#6 also has four other children ..." The assessment contained no additional assessment of the 4 other children that would be affected upon the patient's death. MR#8: The Start of Care (SOC) was dated 1/4/22. The Plan of Care (POC) identified terminal diagnoses of Colon Cancer, Lung Cancer and Liver Cancer. During record review on 8/24/22, it was noted that the MSW initial assessment dated 1/6/22 stated, "Psychosocial Assessment: ...MR#8 and wife have three children together, one who lives locally and the other two live in lower Michigan." The Bereavement Risk Assessment section stated, "Bereaved Person ... Wife." The assessment contained no additional assessment of the 3 other children that would be affected upon the patient's death. These findings were reviewed with and acknowledged by the Clinical Manager (Staff A) during an interview on 8/24/22 at 4:00 pm. MR#10: The Start of Care (SOC) was dated 6/9/22, with identified terminal diagnoses of congestive heart failure, chronic kidney disease, and chronic obstructive pulmonary disease. During record review on 8/23/22, it was noted the MSW's (Master of Social Work) initial Bereavement Assessment (BA) dated 6/10/22, identified only the patient's daughter. The BA documented the following: "(Daughter) has two brothers who she is rarely in contact with." However, during a scheduled home visit with MSW services on 8/23/22, the patient was interviewed concerning who would significantly grieve upon his passing. It was revealed relations with one of his sons is good/strong, and from the patient's perspective during the interview, the son was closer to the patient than that of the daughter. Further review found the BA had not been accurately updated and was solely completed from the daughter's point of view, not the patients. MR#11: The SOC date was 5/19/21, with identified terminal diagnoses of hypertensive heart disease with congestive heart failure and chronic kidney disease. During record review on 8/23/22, it was noted initial BA performed by MSW services on 5/19/22 identified only the patient's son and daughter in-law. However, review of the BA narrative revealed the following documentation: "(Son) and his wife have become the primary caregivers for (patient) following her move to Manistique from Wisconsin where she was cared for by her daughter. The family communicates openly and works together to make decisions." No evidence was found in the medical record which indicated the daughter who cared for the patient in Wisconsin was included on the initial BA. During an interview on 8/24/22 at 12:28 PM., the Clinical Manager (Staff A) reviewed and acknowledged the findings above. The Agency failed to incorporate Bereavement Assessments which were comprehensive and inclusive from the patient's perspective.

Based on record review and interview, the Agency failed to ensure the information in the clinical record was accurate and complete in 1 (MR# 9) of 11 records reviewed out of a total sample of 11 records, resulting in pertinent information to be inaccurate within the clinical record and the potential for poor patient outcomes for all 5 active patients currently receiving Hospice services. Findings included: Agency Policy: "Hospice Clinical Records" Policy Stat ID 11683106 (Revised 5/2022) stated, "The clinical record must contain correct clinical information that is available... All entries must be legible, clear, complete, and appropriately authenticated..." MR#9: The patient was admitted to Hospice on 3/4/2021 with a terminal diagnosis of gastro-intestinal cancer with corresponding significant weight loss. On 8/23/22, review of medical record noted the following clinical order labeled "Discharge-Live" by Social Work services on 3/10/21: "(Patient) has chosen to discontinue hospice services at this time. She had sought opinion of Green Bay Oncology provider and has chosen to pursue further cancer treatment." However, record documentation the next day (3/11/21), found 11 of 11 staff members (Physician-one, Skilled Nursing-seven, Social Work-two, and Hospice Aide-one) during an IDG (Inter-Disciplinary Group) meeting had failed to recognize the patient was already discharged from Hospice, and subsequently created a new Plan of Care (POC) order dated 3/11/21, with a "Benefit Period" of 3/4/21 through 6/1/21. Skilled Nursing and Medical Social Worker services were to continue with an effective date of 3/14/21, and all previous services/interventions were also ordered to continue. IDG documentation under "Details" found no evidence of the "Discharge-Live" within the clinical entry. During an interview on 8/24/22 at 12:18 PM., the Clinical Manager (Staff A) reviewed and acknowledged the findings above. Staff A stated, "We should have obviously caught this during our IDG meeting the next day." The Hospice agency failed to ensure the clinical record noted above was maintained to accurately reflect the status of the patient's POC, clinical treatments, and interventions.

Based on document review and interview, the Hospice failed to ensure the clinical record contained a discharge summary concerning a patient's revocation of hospice services in 1 of 1 record reviewed (MR#9) in which hospice services were revoked, from a total sample of 11 records reviewed, resulting in an incomplete clinical record for this patient. Findings include: Agency Policy: "Election of Revocation" Policy Stat ID 12262332 (Revised 9/2022) stated, "The RN (Registered Nurse) will complete a "Hospice Revocation/Discharge Summary" order in Kinnser (electronic medical record) and send to the medical director and patient's primary physician) as applicable)." MR#9: The patient was admitted to Hospice on 3/4/2021 with a terminal diagnosis of gastro-intestinal cancer with corresponding significant weight loss. During record review on 8/23/22, it was revealed the patient had sought out a second opinion for treatment and elected to revoke hospice services on 3/10/21. Further review of the record found no evidence of a discharge summary and no evidence that the physician had been sent a copy of "Hospice Revocation/Discharge Summary" as stipulated in the policy referenced above. During an interview on 8/24/22 at 12:12 PM., the Clinical Manager (Staff A) reviewed and acknowledged the findings above. Staff A stated, "Nope, she didn't do it." The Hospice agency failed to maintain required documentation of a discharge summary concerning revocation of services and documentation that the physician was notified.