Every finding on record at Seasons Hospice & Palliative Care of Michigan, LLC

Based on record review and interview, the agency failed to ensure services were provided in accordance with an established plan of care in 3 (P-1, P-2, and P-3) of 3 records reviewed, resulting in patients not receiving care and services in accordance with their identified needs and the potential for poor patient outcomes. Findings include: --- Patient #2 (P-2) was admitted to this hospice agency on 6/16/25 with the terminal diagnoses of functional quadriplegia, osteoarthritis, and adult failure to thrive. During record review on 10/9/25, it was noted the plan of care (dated 6/16/25) indicated, "NURSE WILL OBTAIN WOUND CARE ORDERS AND FOLLOW WOUND CARE PROTOCOL FOR ASSESSMENT AND DOCUMENTATION." Upon further review of the record, it was determined the order for wound care dated 6/18/25 indicated, "FACILITY NURSE TO CLEANSE WOUND TO COCCYX WITH SOAP AND WATER, PAT DRY, APPLY TRIAD AND COMFORT FOAM DAILY AND PRN IF SOILED. HOSPICE NURSE TO ASSESS WEEKLY." [sic]Upon further review of the skilled nursing notes, it was determined P-2 received hospice care from this agency for 6 weeks prior to passing away. During this time, 15 of 16 skilled nursing notes documented that somebody other than the hospice nurse provided wound care for P-2 or that it wasn’t ordered for that visit. Although the assessment section of the wound care note was filled out weekly and weeks 3 and 4 included updated measurements, there was no evidence the hospice nurse saw and assessed the wound herself because the wound care was being performed by somebody else. The only note that provided documented evidence the hospice nurse removed the wound dressing and performed the wound care was dated 7/14/25. Patient #3 (P-3) was admitted to this hospice agency on 5/29/25 with the terminal diagnoses of a malignant neoplasm of the left lung (lung cancer), anemia, and chronic obstructive pulmonary disease (COPD). During record review on 10/10/25, it was noted the plan of care (dated 5/29/25) indicated, "NURSE WILL CHANGE DRESSING DURING WEEKLY VISIT IF SOILED OR DISLODGED MEDILODGE STERLING STAFF ARE ORDERED TO CHANGE DRESSING Q2 DAYS AND IF SOILED OR DISLODGED." [sic]A follow-up order added to the plan on 5/30/25 indicated, "R ISHIUM: CLEANSE WITH WOUND CLEANSER. PACK WITH IODOFORM GAUZE. APPLY FOAM BORDER DRESSING. FACILITY STAFF AT MTB TO CHANGE DAILY AND PRN IF LOOSE OR SOILED. HOSPICE NURSE TO ASSESS WEEKLY." [sic]During review of skilled nursing notes between 5/29/25 and 8/5/25, it was noted the weeks of 6/1/25 and 7/13/25 failed to include updated measurements or assessments of the wound. Although the skilled nursing notes during the weeks of 6/8/25, 6/22/25, 6/29/25, 7/6/25,7/20/25 and 7/27/25 included wound measurements, it was documented the hospice did not perform the wound care, therefore, there was no evidence the hospice nurse saw the wound to assess it. It was documented the measurements on 7/10/25 (during the week of 7/6/25) were obtained from the wound care nurse at the facility.During an interview with Director of Clinical Operations (DCO #1) on 10/10/25 at 1:18 PM, DCO #1 was asked how new measurements for the weekly assessment could be documented during a visit if wound care was not provided by the hospice nurse. DCO #1 stated some facilities have a wound care nurse who also assesses and measures the wound, and sometimes staff records the measurements from them. However, DCO #1 stated it should be documented who made the measurements if it is somebody other than the hospice nurse. Additionally, DCO #1 was asked about the agency expectation regarding weekly wound assessment by the hospice nurse, even if another nurse was also assessing the wound. DCO #1 stated the hospice nurse should be doing their own assessment weekly per the plan of care.The agency failed to ensure the hospice nurse assessed the wounds weekly per the plan of care. DCO #1 acknowledged the findings during the interview. Patient #1 (P-1) was admitted to Hospice on 10/31/24 with terminal diagnoses that included Alzheimer’s Disease, Dementia and Heart Failure.  The Plan of Care (POC) ordered Skilled Nursing, Medical Social Work, Spiritual Care and Hospice Aide services to be provided.  During the clinical record review on 10/9/25, it was noted that the patient resided in a skilled nursing facility (SNF).  A Physician’s order dated 2/4/25 stated, “Order signed in facility EMR (Electronic Medical Record) – Wound care – Facility staff to complete wound care as ordered below, hospice nurse to complete wound care at weekly visits – coccyx, cleanse with wound cleanser pat dry apply Medihoney (wound gel) and cover with foam dressing change daily; Right heel cleanse with wound cleanser pat dry apply Medihoney and wrap with kerlix. Change daily.” A Physician’s order dated 2/25/25 stated, “Hospice nurse to provide instruction related to prevention/management of skin breakdown. Goals: Facility staff will verbalize/demonstrate measures to prevent/manage skin breakdown AEB (As Evidence By) no further progression if impaired skin integrity x 14 days.” [sic] A Physician’s ordered dated 3/11/25 stated, “Need prn (as needed) visits.” A Physician’s order dated 4/4/25 stated, “Order signed in facility EMR. L calf skin tear – Optalis staff to cleanse with wound cleanser, pat dry, apply foam dressing and change QOD (every other day), hospice nurse to change at weekly visits.” On 10/10/25 at 1:55 p.m., during an interview with the Executive Director (ED #1) and the Director of Clinical Operations (DCO #1), a request was made to review P-1's Plan of Care (POC) in order to determine if the ordered tasks to be carried out was clearly defined between the SNF and the Hospice.  On 10/10/25 at 1:57 p.m., upon receipt and review of P-1's POC titled “Hospice POC Report”, it was noted that there was no clear delineation of tasks to be completed by the SNF vs Hospice Staff.   The POC read, “NDP (unknown): altered skin integrity-Hospice; NDP: Need for wound care-Hospice; NDP: Need for facility staff care coordination; I (intervention): Reviewed Hospice plan of care with facility staff – added-no...”  The Executive Director (ED #1) and the Director of Clinical Operations (DCO #1) were queried as to the meaning of NDP; and stated that it stands for Nursing Diagnosis Pathway. However, both parties acknowledged the POC did not reflect delineation of duties for the Hospice and the SNF.  Additionally, there was no documented evidence that the above Physician’s orders had been incorporated into the POC to allow for coordinated care between the two entities.   The facility failed to provide care and services in accordance with an established plan of care that clearly established the roles and tasks to be carried out by the Hospice and Skilled Nursing Facility.  The Executive Director and Director of Clinical Operations reviewed and acknowledged the above findings during an interview on 10/10/25 at 1:55 p.m.

Based on observation, interview and record review, the agency failed to ensure nursing needs of the patient were assessed for 3 (P-1, P-2, P-3) of 3 patients with identified wounds (L591). --- The cumulative effects 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: 42 CFR §418.64 Core Services.

Based on record review and interview, the agency failed to ensure nursing needs of the patient were assessed for patients with wounds in 3 (P-1, P-2, and P-3) of 3 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: --- A review of agency policy titled “Wound Care” (revised 12/14/22) revealed, “The Hospice nurse will assess wounds at least once per Medicare week.” Patient #2 (P-2) was admitted to this hospice agency on 6/16/25 with the terminal diagnoses of functional quadriplegia, osteoarthritis, and adult failure to thrive. During record review on 10/9/25, it was noted P-2 also received wound care for a stage III pressure ulcer on her coccyx.During review of the record, it was determined P-2 received hospice services from this agency for 6 weeks prior to passing away.  Upon further review of the skilled nursing notes, it was noted the weeks of 6/22/25 and 7/20/25 failed to include updated measurements or assessments of the wound. Although the skilled nursing notes during the weeks of 6/29/25 and 7/6/25 included wound measurements, it was documented the hospice nurse did not perform the wound care, therefore, there was no evidence the hospice nurse saw the wound to assess it. Patient #3 (P-3) was admitted to this hospice agency on 5/29/25 with the terminal diagnoses of a malignant neoplasm of the left lung (lung cancer), anemia, and chronic obstructive pulmonary disease (COPD). During record review on 10/10/25, it was noted P-3 was also receiving wound care for a pressure ulcer on her right ischium (buttock).During review of skilled nursing notes between 5/29/25 and 8/5/25, it was noted the weeks of 6/1/25 and 7/13/25 failed to include updated measurements or assessments of the wound. Although the skilled nursing notes during the weeks of 6/8/25, 6/22/25, 6/29/25, 7/6/25,7/20/25 and 7/27/25 included wound measurements, it was documented the hospice nurse did not perform the wound care, therefore, there was no evidence the hospice nurse saw the wound to assess it. It was documented the measurements on 7/10/25 (during the week of 7/6/25) were obtained from the wound care nurse at the facility.During an interview with Director of Clinical Operations (DCO #1) on 10/10/25 at 1:18 PM, DCO #1 was asked how new measurements could be documented during a visit if wound care was not provided by the hospice nurse. DCO #1 stated some facilities have a wound care nurse who also assesses and measures the wound, and sometimes staff records the measurements from them. However, DCO #1 stated it should be documented if somebody other than the hospice nurse made the measurements. Additionally, DCO #1 was asked about the agency expectation regarding weekly wound assessments, even if another nurse was also assessing the wound. DCO #1 stated the hospice nurse should be doing their own assessment weekly per the plan of care and per agency policy. The agency failed to provide the necessary nursing assessment of wounds per agency policy. DCO #1 acknowledged the findings at the time of interview.  Patient #1 (P-1) was admitted to Hospice on 10/31/24 with a terminal diagnosis of Alzheimer’s Disease.  The Plan of Care (POC) ordered Skilled Nursing, Medical Social Work, Spiritual Care and Aide services to be provided.  During the clinical record review on 10/9/25, it was noted that P-1 initially began care with this agency on 10/31/24 and was recertified for continuing care on 11/6/24 and again on 2/4/25.  During the review, it was noted that a Physician’s order dated 1/20/25 ordered, “Hospice nurse to education wound care and complete care at weekly visits-Optalis SNF (Skilled Nursing Facility) staff to complete wound care as follows: L (left) hip: cleanse with wound cleanser, pat dry, apply nickel thick layer of Medihoney (wound gel) and cover with border foam nightly and prn (as needed) when loose or soiled; L heel: cleanse with wound cleanser, pat dry and apply skin prep allow to dry and leave open to air/float heels while in bed; Sacrum: cleanse with wound cleanser, pat dry and apply nickel thick layer of Medihoney to wound bed and cover with boarder form dressing.” A Physician’s order dated 2/19/25 stated, “Order signed in facility EMR (Electronic Medical Record). Cleanse with wound cleanser, pat dry, apply Medihoney, cover with foam dressing. Facility staff to change daily and hospice nurse to change at weekly visits.”  There was no indication of which wound this order was in reference to. A Physician’s order dated 2/25/25 stated, “Hospice nurse to provide instruction related to prevention/management of skin breakdown. Goals: Facility staff will verbalize/demonstrate measures to prevent/manage skin breakdown AEB no further progression if impaired skin integrity x 14 days.” [sic] A Physician’s order dated 3/19/25 stated, “Right heel wound, cleanse with wound cleanser, pat dry, paint with betadine and cover with border dressing. Facility staff to complete care to right heel wound daily, Hospice RN to complete care during weekly visits.”  A Physician’s order dated 4/4/25 stated, “Order signed in facility EMR. L calf skin tear – Optalis staff to cleanse with wound cleanser, pat dry, apply foam dressing and change QOD (every other day), hospice nurse to change at weekly visits.”   A review of the Hospice Nursing visit notes revealed that no wound care or wound care assessments had been conducted by the Hospice Nurse during visits to the SNF on the following dates: 2/4/25 Mid Sacral, Rt Heel “caregiver completed care.”2/11/25 Mid Sacral, Right Heel “caregiver completed care."2/25/25 Mid Sacral, Iliac Crest, Lt, healed, Right Heel “caregiver completed care.”3/13/25 Mid Sacral, Right Heel "caregiver completed care.” 3/19/25 Mid Sacral (says healed, but wound care done) “caregiver completed care.” Per note, wound care was performed on right heel only.3/24/25 Right Heel “caregiver completed care.”4/4/25 Proximal Calf Lt, Skin Tear, Right Heel “Refused care to right heel..., new wound to left calf.”4/8/25 Proximal Calf, Lt, Skin Tear, Right Heel “Refused care.”4/14/25 “Refused care”  4/14/25 "SIX wounds identified during this visit: LEFT POSTERIOR POPLITEAL, RIGHT CALF X2, LEFT HEEL, RIGHT HIP, RIGHT ISCHIUM."The Hospice Visit Note dated 4/14/25 documented, “FACILITY NURSE ABLE TO PROVIDE WOUND CARE, PATIENT REFUSING MEASUREMENTS AT THIS TIME. PATIENT HAS 6 TOTAL WOUNDS, 2 DOCUMENTED IN HCHB (Electronic Medical Record system/Home Care Home Base), WILL ADD 4 ADDITIONAL AFTER MEASUREMENTS AND STAGING ARE OBTAINED BY WOUND CARE AT FACILITY.” During the review, it was noted that it could not be determined who the "Caregiver" was reported to have completed the wound care. On 10/10/25 at 4:26 p.m., an interview was conducted with P-1's Primary Caregiver (PCG #1).  When asked if PCG #1 performed wound care for P-1, PCG #1 reported, "There were care conferences at the SNF. We were kept up to date with P-1's progress; however, we were never trained to perform wound care." Upon further review, there was no documented evidence that the Hospice nurse performed consistent, direct wound care and assessments of P-1's wounds during the Hospice Nurse’s scheduled visits in accordance with the Physician's orders.  It could not be ascertained how many wounds had actually been identified.   Further, there was no Physician’s order in place for the Hospice Nurse to forego wound care in the instances where the “caregiver” provided wound care, and no documented evidence that the Physician had been notified of the above instances where the Hospice nurse did not provide direct wound care.   The Executive Director and Director of Clinical Operations reviewed and acknowledged the above findings during an interview on 10/10/25 at 1:55 p.m.

Observed in Record Review. In 1 of 20 patient records reviewed, The organization failed to ensure documentation of patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services. On review of RRNHV#2 there was documentation of a goal for the patient's post surgical site to not become infected. However there was no documentation of a wound assessment. This observation was reviewed with the Director of Clinical Operations.

Observed in Record Review. In 3 of 20 patient records reviewed, The organization failed to ensure documentation of patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services. On review of RRHV#5 there was documentation of an after hours call to report 3 unstageable wounds to the patient's bottom. On the next documented visit there was no documentation of a comprehensive wound assessment. The nurse noted an abrasion to the buttocks yet no specifics such as size, color, odor, and drainage as required. In RRNHV#10 the patient had dry gangrene wounds to the foot yet the wounds were not assessed weekly as per policy as the documentation noted the wound was not assessed on week 2 or week 4 of hospice care. In review of RRNHV#13 the patient was admitted with Thyroid cancer with a mass to the neck that affected swallowing also a mass to the ribs per the documentation yet there was no documentation of a comprehensive assessment of the masses such as size, shape, color, and surrounding area. These observations were reviewed with the Director of Clinical Operations.

Observed in Record Review. In 1 of 20 patient records reviewed, it was noted that plan of care goals were not individualized. For example, in record RRHV#3 no goals included any time frames. Goal example: Patient will receive assistance with personal care and hygiene and other activities of daily living as needed. Patient name will have safety needs met. This was discussed with the Director of Clinical Operations. Observed in Record Review. In 3 of 20 patient records reviewed, the organization failed to ensure the plan of care was based on the patient's goals that were individualized, specific, measurable and time-bound. On review of RRHV#6 the goal for the patient's infection was noted to not be specific and time-bound such as patient/caregiver will verbalize/demonstrate understanding of management of UTI. In RRNHV#8 there were also goals that were not specific, measurable and time bound such as medication will be managed appropriately as evidenced by steady symptom control. In RRNHV#10 an example of a non-specific, not measurable goal was staff verbalize adequate knowledge of required care to manage suprapubic catheter at every visit. These observations were reviewed with the Director of Clinical Operations.

Observed in Record Review. In 5 of 20 patient records reviewed, the organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. On review of RRHV#4 the documentation noted issues with respiratory where Oxygen was started yet there was no respiratory care plan initiated to guide the care. There were infections with antibiotics of a UTI in November and URI in December yet the issues were not reflected in the plan of care. In RRHV#5 the documentation noted the patient with hearing issue related to ear wax build up with medication added to treat, yet the issue was not reflected on the plan of care. Further, the patient had a primary terminal diagnosis of Parkinson's disease, yet there was no neuro care plan to guide the care. In RRNHV#8 there was documentation of the patient's alcohol use and risk for seizures yet the issue was not reflected in the plan of care. Further the patient was noted to have issues with respiratory status with shortness of breath. Oxygen safety and use was noted on the plan of care but there was no care plan for the patient's shortness of breath and respiratory to guide the care. In RRNHV#11 there was documentation of the patient with a cough that was treated with Benzonatate yet the issue was not reflected in the patient's plan of care. In RRNHV#13 there was documentation of a Shingles infection with antiviral medication yet the issues was not reflected on the plan of care. The patient had a tumor to the neck area affecting swallowing, and a tumor to the rib area yet no care plan to guide the care. These observations were reviewed with the Director of Clinical Operations.

Observed in Record Review. In 2 of 20 patient records reviewed, the plan of care did not included all services needed for the palliation and management of care including a statement of the scope and frequency of the services necessary to meet the patient's needs. For example, in record RRHV#3 it was noted in the initial assessment that the patient stated that Yes she would like to have volunteer visits. However, volunteers were not included on the POC with no frequency, goals or interventions. In record RRNHV#2 the goal Staff at (facility name) will verbalize measure to manage patient's post surgical site on left breast as evidence by no s/s infection to area within 14 days. However, there was no documentation on the POC for the wound care intervention to be provided. This was discussed with the Director of Clinical Operations.

Observed in Record Review. In 2 of 20 patient records reviewed, the organization failed to ensure the plan of care include all services need for the palliation of the terminal illness and related conditions. On review of RRNHV#8 the documentation noted the patient was using home oxygen, yet there was no physicians order for the oxygen noted on the plan of care. In RRNHV#10 the wound care order noted on the plan of care was incomplete as it stated cleanse with wound cleanser, pat dry, apply triad. The order lacked a frequency and if the wound was open to air or to be covered. This observation was reviewed with the Director of Clinical Operations.

Observed in Record Review. In 2 of 20 patient records reviewed, The organization failed to provide the patient with care, treatment, and services in accordance with the patient's individualized plan of care. On review of RRHV#4 the hospice aide was ordered a frequency of 2 times a week per the plan of care yet the last two weeks of December there was only one visit documented. In RRNHV#12 the hospice aide was ordered per the plan of care a frequency of 2 times a week yet review of the record noted multiple weeks in the 1st benefit where only one aide visit was documented. This can be seen in the 5th week of November, the 2nd, 3rd, 4th and 5th week of December. These observations were reviewed with the Director of Clinical Operations. Observed in Patient Home. In 1 of 6 home visits conducted, it was noted that care was not provided according to hospice plan of care. For example, during RRHV#2 the nurse performed wound care. The plan of care stated the wound was to be cleansed with NS then apply Betadine. However the nurse cleansed with Betadine. This was discussed with the Team Director present.

Observed in Patient Home. In 2 of 6 home visits conducted, the organization failed to ensure it implemented activities for the prevention and control of infections and communicable diseases. On home observation for RRHV#1 the hospice aide during home observation was noted to miss opportunities for hand hygiene. The Aide provided the patient with a shower and upon completion of the shower to include perineal care, the aide failed to remove gloves and sanitize hands prior to completing the tasks assigned such as dressing and skin care. Further, upon removing gloves the Aide failed to sanitize hands and proceeded to provide care for the patient. In RRHV#6 the RN was observed to provide perineal care to the patient with a diaper change, yet failed to remove gloves and sanitize hands per policy prior to continuing care with clean tasks. These observations were reviewed with the RN and the Director of Clinical Operations.

Observed in Record Review. In 1 of 20 patient records reviewed, the organization failed to ensure the registered nurse supervising the hospice aide provide written patient care instructions. On review of RRNHV#10 the documentation noted the patient with dry gangrene to the foot yet there were no specific instructions to the aide on how to handle the wounds while providing care. This observation was reviewed with the Director of Clinical Operations.

Observed in Tracer Activities. During a review of the volunteer program, the Volunteer Coordinator and Director of Patient Experience confirmed that the volunteers did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff last year. Volunteers provided 1.82% in 2024.

Observed in Patient Home. In 1 of 6 home visits conducted, the organization failed to ensure the patient record contain all information to reflecte the patient's care, treatment, or services. On home observation for RRHV#6 during the medication reconciliation it was noted the medications being administered in the home were not reflected on the patient's medical record. For example: the patient was taking Cipro for UTI but the med was not on the medication profile. The caregiver noted the supplements magnesium, mecobalamin, and vitamin d3 had been stopped in November, yet were still noted as active on the medication profile. This observation was reviewed with the RN and the Director of Clinical Operations.

Observed in Record Review. In 1 of 3 patient records reviewed, for discharge it was noted that the inpatient facility was not provided with a summary of care on transfer. For example, in record RRDC#2, the patient was transferred to the hospital for aggressive treatment and there was no documentation that the discharge summary had been provided to the hospital. This was discussed with the Team Director and Director of Clinical Operations.

Observed in Patient Home. In 2 of 6 home visits conducted, the organization failed to ensure it implemented activities for the prevention and control of infections and communicable diseases. On home observation for RRHV#2 the hospice nurse during home observation was noted to miss opportunities for hand hygiene. The nurse performed wound care and multiple times upon removing gloves the nurse failed to sanitize hands and proceeded to provide care for the patient. The organization's Hand Hygiene 4003 Protocol policy stated that upon removing gloves hands were to be sanitized. On home visit RRHV#1 the bedbound patient's call button was on the floor throughout the visit and the MSW step on it. At the end of the visit the MSW pick the call button up off the floor and attached it to the patient's bedding with no cleaning or disinfection. This observation was reviewed with the Director of Clinical Operations.

Observed in Individual Tracer. In 2 of 3 home visits conducted, HV1, HV2 standard precautions were not followed per accepted practices. For example, HV1(IPU), the nurse was observed performing wound care to a buttock wound. The nurse opened dressing supplies, removed the old dressing, cleansed wound and applied clean dressing without changing gloves. HV2, the aide failed to change gloves and conduct hand hygiene prior to direct contact with patient. This was not compliant with the organization's hand hygiene policy and validated by the Senior Director of Clinical Operations who was present at the visits.

Observed in Individual Tracer. In 1 of 3 home visits conducted, HV2, the organization failed to show evidence it had prepared complete written patient care instructions for the hospice aide. For example, HV2 the surveyor noted the aide care plan did not included whether or not the patient was to use oxygen during the bed bath. The oxygen ordered as continuous. There was no indication of oxygen usage or precautions noted on the aide plan. In addition, the plan stated the aide was to perform routine catheter care however, the patient had a suprapubic catheter and the aide stated she did not touch it. There was no indication on the aide assignment sheet that the indwelling catheter was a suprapubic catheter or any precautions related to this type of catheter. This was not compliant with the organization's policy and validated by the Senior Clinical Director.

Observed in Patient Home. In 1 of 2 tracers conducted, the surveyor observed that the staff member did not follow organization policy on Bag Technique. For example, during the home visit for HV1, the surveyor observed that the staff member wore gloves to wipe down her reusable medical equipment and then replaced it immediately in her equipment bag wearing the same contaminated gloves. Per policy, used gloves were not to be worn when entering the clean area of the bag. This was observed by the Senior Director Clinical Operations also present on the visit.

Observed in Tracer Activities. In 1 of 6 patient records reviewed, with hospice aide services ordered, the surveyor noted that the aide had not followed the aide plan of care. For instance, during the home visit for HV1, the patient caregiver stated that the aide had been assisting the patient with a bed bath. The nurse, during the visit, stated she would need to update the aide plan of care for the bath change because at the time of the visit, the aide plan of care listed a shower with chair bath. This was discussed with the Senior Director Clinical Operations at the time of the visit and validated through subsequent record review

Observed in Record Review. In 1 of 8 patient records reviewed, the surveyor noted that information was not accurate for the patient. For example. in review of the medical record for RR5, the patient was assessed to have a 16FR suprapubic catheter and there was also an order for a 16FR 10cc suprapubic catheter. Multiple subsequent notes documented an 18FR suprapubic catheter. In discussion with the staff member, it was found that the patient had a 16FR catheter and not the 18FR documented. This was confirmed by the Senior Director Clinical Services.

Observed in Record Review. In 2 of 8 patient records reviewed, the surveyor found that all information related care and services provided had not been documented. For example, in review of RR2 the record reflected a BP of 192/122 and pulse of 106. There was no documentation to indicate the physician had been notified. In discussion with the staff member related to this, she stated that discussion with the physician had taken place and that it was thought the elevated BP and pulse were due to the patient's elevated pain levels and no antihypertensives had been ordered for that reason. In review of DC2, the patient was discharged for an extended prognosis. In review of the medical record, documentation was found in IDG notes that the patient was to be assessed by the physician to determine potential discharge. The physician encounter note stated that the patient met criteria to be recertified. Further review of the record found that the patient had been discharged and there was no discharge order. In discussion with the nurse it was learned that the nurse and physician had discussed the patient's status after both had seen the patient and agreed the patient could be discharged for an extended prognosis and received an order to discharge. This discussion and the order to discharge were not found in the medical record. These observations were verified by the Senior Director Clinical Services and the Regional Director of Quality assisting with record review.

Observed in Record Review. In 2 of 2 patient records reviewed, where they patient had been in a SNF, the surveyor did not find where the organization had identified the care and services that were needed and identified which provider was responsible for performing the functions that had been agreed upon and included in the plan of care. For example. in HV1, the patient was transferred to a SNF for a respite stay. The plan of care did not identify what care and services were needed for the respite stay and did not identify which provider was responsible for the services. The Facility Integration form was not found in the record. In review of the medical record for RR4, the Facility Integration form that would indicate the provider responsible for the services in the plan of care was not found. The Facility Integration form was required documentation per organization process. This was verified by the Regional Director of Quality assisting with review of the record.

Observed in Record Review. In 1 of 5 patient records reviewed, the surveyor noted that the organization had not consistently identified measurable outcomes to be obtained. For example, in review of the medical record for RR2, the plan of care contained outcomes that stated the patient would demonstrate a breathing pattern within his normal parameters and that he would verbaliza/demonstrate understanding of manageing cardiopulmonary symptoms within constraints of the disease. This observation was discussed with the leadership team to include the Regional Vice President of Operations, Director of Patient Experience and the Director of Clinical Operations who were present during the review of the EMR.

Observed in Record Review. In 1 of 5 patient records reviewed, the surveyor noted that the plan of care was not specific for the needs of the patient. For example, in review of the medical record for RR3, the plan of care had that the foley catheter could be flushed with normal saline (NS), as needed. It was not specific for the amount of normal saline, the frequency of the as needed flush or an indication for the as needed flush. This observation was discussed with the leadership team to include the Regional Vice President of Operations, Director of Patient Experience and the Director of Clinical Operations who were present during the review of the EMR.

Observed in Patient Home. In 1 of 1 home visits conducted, the surveyor observed that the nurse did not follow orders for wound care. During the home visit for HV1, the nurse was observed applying skin prep to the peri-wound area on the leg and foot and then redressed with a nonadherent dressing and rolled gauze. The wound was not cleaned with wound cleanser prior to redressing as required by the order. This observation was discussed with the leadership team to include the Regional Vice President of Operations, Director of Patient Experience and the Director of Clinical Operations who were present during the review of the EMR.

Observed in Patient Home. In 1 of 1 home visits conducted, the surveyor observed that the nurse did not follow organization accepted standards of practice during the wound care. During the home visit for HV1, the surveyor observed that the nurse did not change gloves between cleaning the wound and redressing the wound.. Information provided by the organization showed that this did not follow their accepted standards of practice. This observation was discussed with the leadership team to include the Regional Vice President of Operations, Director of Patient Experience and the Director of Clinical Operations..

Observed in Record Review. In 1 of 20 patient records reviewed, the organization had not assessed its patient. In the chart for RR#3, the patient was identified as having an implanted port in his chest upon admission to the inpatient unit from the home program. The initial comprehensive assessment to the hospice (home program) did not identify that the patient had a port. This was confirmed with the Clinical Director.

Observed in Record Review. In 1 of 20 patient records reviewed, it was noted that in review of record for visit #5, a patient in the IPU the bereavement risk assessment did not include his significant other with whom the patient had lived prior to hospitalization. Additionally for this same patient it was noted that in three of three nursing assessments review at the beginning of each 12 hour shift there was no documentation of lung sounds or respiratory status for this patient with ES CHF who had recently been extubated. Lastly there was no documentation in six days of the patient's wound or wound measurements. This was observed by the Senior Director of Clinical Services.

Observed in Record Review. In 1 of 20 patient records reviewed, the organization had not provided education and training to the primary caregiver. In the chart for RR#6, the patient had a stage 4 decub with daily dressing changes required. When the patient transferred out of the Inpatient unit to home, there was no documentation found in the chart that the caregiver had been instructed to provide care for the patients wound. The hospice RN was visiting the patient weekly.

Observed in Record Review. In 20 of 20 patient records reviewed, the written plan of care (POC) was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In no charts were there time frames for anticipated goal achievement included as confirmed with the Clinical Director, as this was not the agency practice. Additional examples included, in the chart for HV#3, the patients stated goal for depression scale was 0 on a 1-10 scale in the SN assessment. This goal was not on the patient's POC. In the chart for RR#5, the Social Worker wrote a goal that the patients suicidal thoughts/isolation would reduced or eliminated, however there was no timeframe associated with the anticipated achievement of the goal. In the chart for RR#2, the RN documented in the assessment that the patient had a self-identified target for pain management goal, however this goal was included in the POC.These were confirmed with the Clinical Director. Observed in Record Review. In 7 of 20 patient records reviewed, it was noted that there were no measurable goals stated on the plan of care. For example, the following goals were documented in multiple charts;caregiver will demonstrate proper wound care, pt/cg will have understanding of skin care, pt/cg will have understanding of pain scale, pt/cg will verbalize effect of pain meds on bowel function. Other examples include pain will be maintained at an acceptable level and relief of cardiopulmonary symptoms. The goals were without any measures or time frames. This was observed in record reviews #11-15 and home visits #4 and 5 and confirmed by nursing staff assisting with record review.

Observed in Record Review. In 9 of 20 patient records reviewed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: Medications and treatment necessary to meet the patient’s needs. In the chart for RR#7, the patient was at risk for falls, had oxygen ordered, was using Ensure as confirmed in the assessment and with facility staff. There were no interventions related to these treatments on the POC. The order for foley catheter was incomplete and read May irrigate with 10c without indication of irrigant, clarity of volume measurement, nor frequency. In the charts for HV#1, HV#2, HV#3, RR#1, RR#2 (upon admission to the inpatient unit) and RR#3, these patients were all at fall risk. The POCs did not include any interventions related to this risk. In the chart for RR#5, the patient resided in a nursing facility with primary diagnosis of dementia and schizo-affective disorder. The POC orders included the RN to instruct on the medication schedule, however did not indicate who was to be instructed; the patient or the nursing facility staff. Additionally, the RN documented the patients blood sugar ranges were 100-200. there were no orders for blood sugar monitoring on the POC. This was confirmed with the Clinical Director. In the chart for RR#3, the patient in the Inpatient hospice unit, there were no physician orders documented to access the patient's implanted port upon admission as confirmed with the Clinical Director and Inpatient Unit Manager. Observed in Record Review. In 1 of 20 patient records reviewed, it was noted that in review of record for IPU patient, visit #5 there were no orders in the plan of care for care of the jugular central line. This was observed by the Senior Director of Clinical Operations. Observed in Record Review. In 3 of 20 patient records reviewed, it was noted in record review for home visit #4 that the aide visits were increased in December to twice per week however there was no order to increase the visits. In record review #12 the aide visits were started, discontinued, restarted and discontinued during a period of three months and there were no orders to discontinue the services and the most recent order to restart did not contain the duration for the current week. In review of record #8 it was noted that only one aide visit was made however the order was stated as 1 x 11 wks, however there was no order to discontinue the service. This was confirmed by nursing staff assisting with record review.

Observed in Record Review. In 2 of 20 patient records reviewed, the plan of care (POC) revisions were not based on information from updates to the patient’s comprehensive assessment and did not address the patient’s progress toward goals and outcomes. In the chart for RR#7, the patient developed COVID19 at the end of the previous benefit period, yet the plan of care was not updated with any new interventions/goals. The facility was refusing aide visits due to COVID visitation policies, yet the aide visits remained on the POC. There was no documentation of progress toward goals in any patient chart. This was confirmed with the Clinical Director. In the chart for RR#6, the MSW assessed the patient's pain to be uncontrolled at 10/10 with patient's behavior changed to aggressive, described as throwing furniture, expressing feelings of fear and grief. The plan of care was not updated with any interventions related to this change in status. This was confirmed with the Director of Patient Experience assisting with chart review. There was no documentation of progress toward goals in any patient record reviewed. Observed in Record Review. In 7 of 20 patient records reviewed, it was noted that the plan of care had not been revised or updated. For example, in review of record #14 the plan of care was not updated to show decrease in LOC and safety issues in December, also in February new issues with skin integrity, pain and dyspnea were documented but the plan of care was not updated. In another example, in record review #11 there is documentation of goals being met however the plan of care still lists them as Not Met. In record review #10 the plan of care was not updated related to new issue of edema and profuse itching. In record review #12 the recert plan of care stated no unmet goals. In record review for home visit #5 the plan of care listed goals not met but also stated that there were no goals not met. In review of record for home visit #4 it was noted that the plan of care had not been updated and oxygen was ordered as continuous however both the nurse and the aide stated that the patient rarely uses oxygen. This was all confirmed by the nursing staff assisting with record review. In review of record #8 the patient depression and suicidal ideation was increasing as evidenced by depression screening, had multiple falls, was having pain management issues, losing weight and becoming weaker however the plan of care was not revised to increase nursing visits or implement any other interventions to address the changes.

Observed in Record Review. In 2 of 20 patient records reviewed, it was noted that care was not provided according to the individualized plan of care. For example, in review of record for a General Inpatient and visit, it was noted that the orders for wound care were to be completed every 72 hours however there was no documentation that wound care had been done in the past six days. Additionally, there were orders for central line flushes, 3 ml of NS after all medications administered. There was no documentation that this was done. In another example, record review #13 it was noted that home health aide services were ordered however they were never made and there was no order to discontinue the service and no missed visit notes. This was observed by the Senior Director of Clinical Operations. Observed in Record Review. In 1 of 20 patient records reviewed, the organization had not provided care according to the patient's individualized plan of care. In the chart for RR#6, the patient was admitted to service into the Inpatient unit. The patient had Hydromorphone ordered 4mg IVP every 3 hours prn pain. In the majority of the documented administrations on the MAR available in the hospice chart, the nurses were administering 2-3mg of Hydromorphone. This was observed by and discussed with the Director of Patient Experience assisting with chart review.

Observed in Record Review. This finding contributed to the immediate threat to health and safety decision and cannot be clarified. in 1 of 20 patient records reviewed, the hospice had not provided care and services that were based on updated assessments of the patient's needs. In the chart for RR#6, the RN made a home visit and determined the patient had no pain, no depression. The next day, the MSW made a visit and assessed the patient to have anger, pain not managed at 10/10, grief and fear. The PHQ2 was performed which triggered the PHQ9 which should have demonstrated a score of 5, which would have triggered a further assessment of depression/suicide risk - the Columbia assessment which is the organizational protocol. During the chart review, attended by the Director of Patient Experience (a MSW on the suicide prevention work team) and the Administrator, it was observed that the EMR did not auto-calculate this risk accurately and the total was documented as 0 on the PHQ9, so the Columbia assessment did not automatically trigger the MSW to perform it. This assessment tool is available in a manual process within the EMR so the clinician could have accessed the tool without the automated trigger. Immediate Mitigation Activities Implemented: Scheduled a mandatory town hall to discuss training; All staff enrolled in mandatory training course; Suicide screening was forced as required function 1/26/22.

Observed in Record Review. In 1 of 20 visits, the organization had not provided interdisciplinary care and had not informed the hospice physician with an unanticipated change in condition. During an SN visit, the RN arrived at the facility where the patient was temporarily residing for respite care to make a routine assessment. She was rounding in collaboration with the facility physician. She, and the physician were informed by the facility nurse that sometime prior to the hospice nurse arrival, the facility nurse had observed the patient with a handful of unknown pills in the bed and when she asked about them, the patient took them all and swallowed them. There was no further detail about the amount of time that lapsed between this observation by the facility nurse and the arrival of the hospice RN. There was no documentation in the record that the RN inquired of the patient about what he took, the reasoning why he took them and no indication that the RN notified the Hospice physician or Medical Director as confirmed with the Clinical Director. The patient died later that day. Prior to the respite stay for this patient, the RN saw the patient at home and assessed no pain, no depression. The next day, the MSW saw the patient who complained of uncontrolled pain at 10/10 (resolved to 7 at end of visit), aggressive behavior he and the PCG related to fear and grief. There was no indication that the MSW contacted the RN to discuss the drastic change in assessment from one day to the next, except for a general care collaboration note, with no detail, that was seen in every patient chart on every visit.

Observed in Data Session. During data session, review of documentation and discussion with leadership it was noted that the governing body had not been responsible for making sure that the QAPI program met the criteria for complexity, all services, demonstration of improvement. There had been only one PIP for 2020 on bereavement services and one in 2021 related to volunteer hours being increased. There were no quality initiatives for contract services, pharmacy or HME. Observed in Data Session. During data session, review of documentation and discussion with leadership it was noted that there was no documentation to demonstrate the operation of the QAPI program for 2020 and 2021. While areas for improvement were identified there was no follow up or initiation of group activities to implement change or documented improvement.

Observed in Tracer Activities. The organization had not implemented preventative actions and mechanisms that included feedback and learning throughout the organization from the action plan related to the suicide incident of June 2021. Observed in Record Review. In 1 of 20 patient records reviewed, the organization had not tracked adverse patient events. In the chart for HV#3, the patient had multiple falls during his admission with the organization. There was no documentation that these events had been reported as is required by organizational policy for aggregation, analysis and performance improvement as confirmed with the Clinical Director.

Observed in Data Session. During discussion with leadership in the data session it was noted that for 2020 and 2021 the number of performance improvement projects did not reflect the scope or complexity of the organization. For example, for 2021 the only project that was implemented related to increasing volunteer hours. A project on facility integration of plan of care and another on medication reconciliation were identified in the first quarter of 2021 but no progress had been documented for the remainder of the year. In 2020 there was only one project on bereavement services.

Observed in Data Session. During the data session it was noted that for 2021 the only project that was implemented related to increasing volunteer hours. A project on facility integration of plan of care and another on medication reconciliation were identified in the first quarter of 2021 but no progress had been documented for the remainder of the year which demonstrated documentation of why the project was chosen, what activities were conducted or any data to demonstrate improvement.

Observed in Tracer Visit. In 1 of 5 home visits conducted, it was noted that standard precautions were not followed per accepted practices. For example, in the IPU HV#5 the nurse was observed performing wound care to a sacral wound. She removed the old dressing, cleaned the buttocks with stool present, washed the wound and applied the clean dressing without changing gloves. This was observed by the Senior Director of Clinical Operations who was present at the visit.

Observed in Record Review. In 1 of 20 patient records reviewed, the organization had not implemented its infection prevention and control activities, including surveillance, to minimize, reduce, or eliminate the risk of infection. In the chart for RR#7, the patient developed COVID19 approximately 1 week prior to the current benefit period. There was no infection control report created when this infection was diagnosed. This was confirmed with the QA Documentation Manager who was assisting with chart review. Observed in Data Session. During discussion in data session and review of data it was noted that for 2020 and 2021 the only infections which were reported were Covid 19 infections. There was no other data collection or surveillance activities for any other infections. Additionally, the Covid 19 data for 2020 and 2021 was raw data which had not been aggregated, analyzed or trended to identify any issues of transmission between patients and staff.

Observed in Data Session. During review of data, documents and discussion in data session it was noted that there were no goals for the prioritized risks of UTI with foley and Wound infections. Additionally, the goals for Covid and flu were not specific or measurable.

Observed in Record Review. In 2 of 3 patient records reviewed, it was noted that bereavement services were not performed per policy and plans of care were not updated to reflect the needs of the bereaved. For example, in bereavement record review #2 and #3 the risk level was determined to be of moderate risk however the plan of care did not reflect any additional needed services and in fact the proposed interventions of phone calls did not either take place at all or voice messages were left with no follow up. In review of record #2 the bereaved daughter was at moderate risk, no initial bereavement call was made, a one month call with voice message was made, one month later another voice message was left, the next month the planned call was not made, and finally at the 6 month mark a call was made where the daughter stated she was struggling, having a hard time she was encouraged to attend support group and call if needed. Another call was made one month later and documentation indicated that she thought about hurting herself daily. She indicated that she would not carry out a suicide attempt but was provided with the suicide hotline # and it was noted that she was receiving care from a private therapist and attempting to get medications. Another call was not placed until one month later with only a voice message left, three weeks later another call with voice message left and one month later she was determined to be low risk because she was receiving outside resources for her depression. In review of bereavement record #2 the bereaved husband was identified as moderate risk but the proposed calls at six month and 12 month were only voice mail message left. This was confirmed by the bereavement coordinator.

Observed in Record Review. In 1 of 20 patient records reviewed, the written aide care plan was not appropriately individualized to the patient. In the chart for RR#7, the aide care plan ncluded instruction to care for both a foley catheter, drainage bag and urinal. The patient did not have a foley catheter. The Aide care plan had not been updated with the actual frequency of visits and still stated 1w1 which was the effective frequency at the admission which was more than 14 months prior to this survey. This was discussed with the Clinical Director. Observed in Tracer Visit. In 1 of 5 home visits conducted, it was noted that during home visit #4 the aide care plan did not include whether or not the patient was to use her oxygen during the shower although the oxygen order was stated as continuous. Additionally the aide care plan did not indicate any reasons for which the nurse should be contacted and lastly it did not contain any instructions related to the management of a wound on the patient's right lower leg. This was confirmed by the aide and the team lead who were present on the visit.

Observed in Tracer Activities. In 1 of 5 home visits conducted, it was noted that in home visit #4 the aide was performing wound care to the patient's right lower leg. She was observed removing the dressing prior to the shower and stated that after the shower she would apply neosporin ointment and a telfa pad and kling. This was observed by the Team Nurse present on the visit.

Observed in Record Review. In 1 of 20 patient records reviewed, it was noted that the nurse was not notified of changes in the patient's needs by the aide. For example, in review of hospice record #12 the aide documented on 12/9/21 that the pt refused all care and was not feeling well and then documented on 12/15/21 that a bed bath was given instead of shower as stated in the aide plan of care. There was no documentation of nurse being notified and no changes made to the aide plan of care. This was confirmed by the nursing staff assisting with record review.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: - §418.100, §418.60, §418.116, §418.56, §418.58, §418.76, §418.104, §418.54, §418.64.

Observed in Record Review. In 2 of 20 patient records reviewed, the patient record did not include all pertinent information. In the chart for RR#2, the patient was admitted to the inpatient unit and the RN documented insertion Huber needle. There was no documentation about the size needle, securement device, etc. as confirmed with the Clinical Director. In the chart for RR#5, the RN documented in the EMR under how often are blood sugars checked Gabapentin BID. Additionally, she indicated the patient was on Lexapro for his depression as of the admission; the patient was not on Lexapro. This was also confirmed with the Clinical Director. Observed in Record Review. In 6 of 20 patient records reviewed, it was noted that the clinical records did not contain accurate or complete information. For example, in record review #15 a patient in the IPU the following was noted; pt was on a ventilator however the admission documentation stated that the patient was dyspneic at rest and had a shortness of breath score of 10. The patient had a sacral wound however this was not identified on the body figure document, there was documentation that the pt/cg had been instructed on when to call the hospice nurse for urinary issues, the use of an interpreter, and the availability of 24 hour on-call. The patient was in the IPU and spoke English as a primary language. In another example, record review #14 the nurse documented in the most recent IDT meeting that the patient had Alzheimer's however this was not a current diagnosis for this patient. In record review #13 the nurse documented on admission that the patient was obtunded, stuporous or in a coma however she fed her graham crackers during the visit. In review of record for visit #5 it was noted that the MSW documented that the patient was non-verbal but also that he self identified, additionally there were inconsistencies related to names of siblings documented. In another example, in record review #13 there was conflicting documentation related to the patient's advance directive. For example, DNR was Iisted on hospice documents but there was order for DNR, in the SNF facility EMR it was stated as Partial DNR, no resuscitation, but ok to hospitalize, give fluids, xrays, labs and antibiotics. It also stated a copy was obtained but was not present in the hospice record. In another example in record review #8 the following was documented Pain has been well controlled with MASCOT twice a dayPt is not required in a 200 for breakthrough pain. This was confirmed by nursing staff assisting with record reviews.

Observed in Record Review. In 2 of 2 patient records reviewed, in which a live discharge occurred, the discharge summary did not include the patients current plan of care, a summary of the patient's stay including treatments, symptoms and pain management, latest physician orders. These items were not included in the discharge summaries for RR#1 and RR#3 as confirmed with the Clinical Director.

Observed in Tracer Activities. During the tour of the IPU it was noted that there were unlabeled atropine drops at the patient bedside in visit #5. Additionally during a tour of the medication room an unopened vial of Haldol was loose in a bin on the counter. It was not labeled for a particular patient or if it was to be a stock medication. This was confirmed by the Senior Director of Clinical Operations.

Observed in Record Review. In 7 of 7 patient records reviewed, for those patients that resided in a SNF it was noted that there was no plan of care which identified the care and services that are needed and identified which provider is responsible for performing the functions that have been agreed upon and included in the plan of care. This was noted in record reviews #5, 7, 11, 12 and 13 and in record review for home visits #2 and #3. This was confirmed by nursing staff assisting with record review.

Observed in HR File Review. In 1 of 5 HR files reviewed, in which licensure was required, the organization had not verified and documented credentials of care when credentials were renewed. In the file for RN1, the primary source verification of current license renewal was completed more than 3 months past the expiration date.