Every finding on record at Thi of Michigan at Detroit, LLC

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, [and] ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care. This standard was not met as evidenced by clinical record review and interview. 1 of 5 (20%) clinical records reviewed, the hospice did not ensure the registered nurse (RN) provided coordination of patient care, continuous assessment of the patient and family’s needs, and implementation of the interdisciplinary plan of care. Clinical Record 4: The patient elected hospice care on 01/11/2023 with the primary hospice diagnoses of sepsis and pneumonia. The comprehensive assessment completed on 01/11/2023 documented the patient's increased respiratory distress, which was not manageable at home. The patient was admitted to GIP (General Inpatient Care) and the physician ordered "oxygen to 40 Liter HHFNC (Humidified High Flow Nasal Cannula)….decrease liter flow by 5 Liters every couple of hours to patient comfort." The skilled nursing visit note completed on 01/12/2023 documented that the oxygen liter flow was "35 Liters...the oxygen was 40 Liter HHFNC and was to be titrated down this past two days...For reasons unknown, this did not happen." The visit note completed by the hospice nurse on 01/12/2023 documented the instruction of the hospital nurse of the order for titration of the oxygen as the patient and family had complained about the discomfort of the patient at the high flow of oxygen, and that the order to titrate had not been followed in the previous 24 hours. Prior to this visit, the plan of care had not been implemented as ordered by the physician.

It is required that a hospice that provides short-term inpatient care under arrangement with a facility has a written agreement describing the arrangement and how the hospice coordinates the care; it includes at a minimum: the inpatient provider establishes patient care policies consistent with those of the hospice and agrees to abide by the palliative care protocols and plan of care established by the hospice for its patients. This standard was not met as evidenced by clinical record review and interview. 1 of 5 (20%) clinical records reviewed, the hospice did not ensure that the inpatient provider followed the plan of care established by the hospice. Clinical Record 4: The patient elected hospice care on 01/11/2023 with the primary hospice diagnosis of sepsis and pneumonia. the patient was admitted to General In-patient care (GIP). The plan of care dated 01/11/2023 through 04/10/2023, ordered, "oxygen at 40 Liters HHFNC (Humidified High Flow nasal cannula)…. decrease liter flow by 5 Liters every couple of hours to patient comfort." The skilled nursing visit note dated 01/12/2023, documented the oxygen liter flow was "35 Liters," and the patient was uncomfortable from the high flow of oxygen. In addition, the SN documented that the oxygen had not been titrated down to patient comfort as ordered in the hospice plan of care.

It is required that a hospice that provides short-term inpatient care under arrangement with a facility has a written agreement describing the arrangement and how the hospice coordinates the care; it includes at a minimum: the hospice retains responsibility for ensuring that training has been provided to personnel who will be providing the patient’s care; a description of the training and names of personnel trained are documented. This standard was not met as evidenced by document review and interview. 2 of 2 (100%) facility contracts reviewed, the agency did not ensure documentation of education provided to the facility personnel providing hospice care to the patient. Contract 1: The facility contract signed on 02/01/2022 for General Inpatient Care (GIP) and Respite stated in part, "All facility personnel consistently providing care to Hospice patients shall attend programs planned and provided by Hospice...Inservice programs will be provided by Hospice to all inpatient caregivers as needed for quality care and communication." There was no documented evidence that education was provided to the inpatient personnel as of review 05/16/2023. Contract 2: The facility contract signed on 02/01/2022 for General Inpatient Care (GIP) and Respite stated in part, "All facility personnel consistently providing care to Hospice patients shall attend programs planned and provided by Hospice...Inservice programs will be provided by Hospice to all inpatient caregivers as needed for quality care and communication." There was no documented evidence that education was provided to the inpatient personnel as of review 05/16/2023.

Based on record review and interview, the Hospice agency failed to ensure and maintain effective communication between the Hospice and the inpatient facility during the provision of care and services; and failed to establish a written plan of care that instructed on the individualized needs of the patient with clear delineation of duties, for 1 (MR #1) of 2 records of patients who received services from an inpatient facility, from a total of 2 sampled records reviewed, resulting in lack of coordinated care and the potential for omission of needed care and services. Findings include: --- MR #1: On 4/20/23 at 11:30 a.m., during a review of the subject of the complaints clinical record, it was noted that the patient was admitted to Hospice on 1/11/23 with a terminal diagnosis of Sepsis (generalized infection). The patient received GIP (General Inpatient) services and was hospitalized during the course of care. The Hospice plan of care ordered Skilled Nursing services to be provided at a frequency of 4x/wk. x 1 wk., 7x/wk. x 12 wks., 2x/wk. x 1 wk.; Medical Social Work 1x/M x 1 M.; Chaplain services 3x/M. x 1 M, 1x/M x 1 M. During the above record review, the Director of Clinical Services (DCS #1) was asked for permission to review the Hospice plan of care that would be provided to the hospital and replied, "I can access their (hospital) system so let me see what I can find. Upon his (DCS #1) return, he reported that he was unable to see a care plan that would be used by the hospital as a guide to be used for the provision of Hospice care. When asked if, in fact, the Hospice agency had provided the hospital with a written plan of care detailing the care needs of the patient with a clear delineation of duties, DCS #1 responded, "No. We didn't give them a plan of care. We just send an order and they (hospital) generate the plan of care..." DCS #1 submitted a copy of the written instructions dated 1/11/23, which he stated had been provided to the inpatient facility (Hospital) that read, "Admit - inpt - hospice - Dr Thomas Anan - Severity of illness. Code status - DNR/DNI. Vital signs - Q12HR. Diet: Regular. Please call Hospice 800 248 2298 at time of death. Insert or Maintain foley catheter for patient comfort. No xrays, labs, treatments, DC previous orders & Medications..." [sic] There were no additional orders provided for review. Upon review of the above information, it was noted that there were no instructions to monitor/assess pain with reportable parameters, and no additional guidance for symptom management. Further, during the review, it was noted that the patient was admitted to hospice on hi flow oxygen which was to be titrated (lowered). There was no mention oxygen or the required steps for titrating the patient's oxygen noted on the plan of care. The Hospice failed to provide the inpatient facility/Hospital with a plan of care that included all the required elements for the provision of quality care, including comfort measures and oxygen maintenance that clearly delineated who would be responsible for the specified tasks. These findings were reviewed with and acknowledged by DCS #1 during the review/at the time of discovery.

Based on the record review and interview, it was determined the physician failed to meet the medical needs of the patient for 1 (MR #1) of 2 records of patients who received services from an inpatient facility, resulting in lack of coordinated care and unmet care needs. Findings include: --- MR#1: This patient was admitted to the hospice agency on 1/11/23 with the terminal diagnoses of Sepsis and Pneumonia. The Health Facility Complaint Form signed 1/19/23 stated, ";On Wednesday (1/11/23), PCP #1 told my family that MR#1 would receive regular shots of morphine and anti-anxiety medicine. PCP #1 also stated that the amount of oxygen she received would be regularly (every two hours) lowered along with the medicine.... On Thursday (1/12/23), my husband and I spoke to PCP #1 during his visit to MR#1. He was genuinely surprised that his orders had not been followed by nurses or any respiratory staff as far as lowering MR#1s oxygen levels. Oxygen was still being blasted into MR#1s nose and the same apparatus was still being used to supply high levels of oxygen. PCP #1 used the words ";MR#1 is suffering" and suggested the suffering was being caused by the apparatus ";blasting" oxygen into MR#1 body. PCP #1 stated he had written orders that the oxygen levels be reduced every two hours and that the apparatus doing the blasting be removed prior to his visit that morning. Subsequent to PCP #1s visit, a pulmonary technician came to the room and made an incremental reduction in the flow of oxygen. When we asked the pulmonary technician why the flow had not been reduced every two hours throughout the night/early morning hours, the pulmonary technician stated, ";We did not receive an order."" During record review on 4/20/23, it was noted that the agency completed a ";Complaint Report" on 1/25/23, pertaining to MR#1, which states, ";Investigation: 1/11/23: Referral with same day admission > PCP #1 gives order to wean off high flow (Oxygen) 3PM." It was noted that the EMR (Electronic Medical Record) failed to contain an order to lower oxygen. DCS #1 was questioned regarding PCP #1s order and acknowledged, ";There is no order in our or the hospitals EMR to wean off the oxygen." The hospice agency failed to address the patient's physical needs and document orders to promote the patient's needs and dignity throughout the patient's last days of the dying process.

Based on interview and record review, the Hospice agency failed to ensure that personnel from the inpatient facility, with whom a contractual agreement was established, had been provided with training on the Hospice philosophy and care of the dying patient, resulting in the potential for lack of needed care and services and unmet care needs during the end of life. Findings include: A complaint on file alleged that Hospital staff caring for the hospice patient were "uncomfortable dealing with hospice patients. They have not been trained in hospice. This is what I was told by one of the floor nurses. She (floor nurse) said several times, that they were uncomfortable doing the things that they needed to do." MR #1: On 4/20/23 at 11:30 a.m., during a review of the subject of the complaints clinical record, it was noted that the patient was admitted to Hospice on 1/11/23 with a terminal diagnosis of Sepsis (generalized infection). The patient received GIP (General Inpatient) services and was hospitalized during the course of care. The Hospice plan of care ordered Skilled Nursing services to be provided at a frequency of 4x/wk. x 1 wk., 7x/wk. x 12 wks., 2x/wk. x 1 wk.; Medical Social Work 1x/M x 1 M.; Chaplain services 3x/M. x 1 M, 1x/M x 1 M. On 4/20/23 at 10:52 a.m., the Area Executive of Clinical Operations (Administrator/ACO#1) was queried about the training provided to the Hospital staff on the Hospice philosophy and care of the dying patient and responded, "We provide training on Hospice 101 which includes symptom management. A request was made to review documented evidence of the training that had been provided to the Hospital staff to which ACO #1 replied, "I can get that for you. I'm sure it (training) is in the back of our contract." Upon receipt and review of the contract between this Hospice and Ascension Providence Park-Novi Hospital, it was noted that the contract documented, "All facility personnel consistently providing care to Hospice patients shall attend hospice care training programs planned and provided by Hospice. Inservice programs will be provided by Hospice to all inpatient caregivers as needed for quality care and communication purposes... Hospice retains responsibility for ensuring that the hospice care training of personnel who will be providing care to Hospice patients in the facility has been provided and that a description of the training and the names of those giving the training are documented." On 4/20/23 at 12:50 p.m., an additional request was made to review documented evidence to support that the Hospice provided training on the Hospice philosophy to the GIP/Hospital staff. ACO #1 and the Director of Clinical Services (DCS #1) both acknowledged there was no documented evidence to support that training had been provided to the GIP/Hospital staff. These findings were reviewed with and acknowledged by ACO #1 and DCS #1 at the time of the above interview.