Every finding on record at Transitions Michigan II LLC

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) records reviewed it was revealed that the agency did not ensure that the initial comprehensive assessment was completed by all members of the interdisciplinary group within 5 days. Clinical Record 2: The election of benefit date was 8/24/2023. The initial Plan of Care (POC) dated 8/24/2023 to 11/21/2023 had an order for the Chaplain to evaluate and develop a plan of care. The Chaplain evaluation was dated 9/5/2023, 11 days after election date and 6 days late. Clinical Record 6: The election of benefit date was 06/28/2023. The comprehensive assessment completed on 06/28/2023 documented the Chaplain to evaluate and treat. The Interdisciplinary Group (IDG) note dated 07/12/2023 documented that the chaplain was not requested at this time. This was day 14 and was 9 days late. There was no other documentation that the chaplain had spoken with the family. During interview with the Regional Director, and Administrator on 10/3/2023 at 4:15pm, they stated that the agency requires every nurse to do abbreviated spiritual assessment on admission. They agreed it was not a comprehensive spiritual assessment and the patient and family did not decline chaplain services.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 14 (14%) records reviewed it was revealed that the agency did not ensure that all interventions were documented and updated from the comprehensive assessment. Document 5: Policy 9-017 The Plan of Care [revision date 12/2018] stated in part, "The written plan of care will contain, but not be limited to, the following: Individualized intervention to assist with end-of-life care." Clinical Record 14: The patient was admitted 04/11/2023 with a diagnosis of Senile Dementia and documented history of frequent falls while receiving hospice care. The nursing assessment dated 05/28/2023, the nurse documented that the patient had a fall and a laceration over the left forehead at the hairline. Steri-strips were applied at this visit. The Plan of Care was not updated to include skin integrity interventions or goals. The patient had several falls and on 05/04/2023 there was documentation of scabs from a skin tear and 05/13/2023 documentation of a healing skin tear but the plan of care had no documented interventions or goals for skin tears as of discharge 06/05/2023. Clinical Record 13: The patient was admitted 05/05/2023 with a diagnosis of Nutritional Marasmus with declining weight and mobility noted. On the aide visit dated 05/18/2023 the aide documented the family was giving the patient Milk of Magnesia for constipation. The nursing visit dated 05/19/2023 also noted patient taking Milk of Magnesia with success. The Plan of care was not updated for any interventions or goals for constipation as of the discharge dated 08/04/2023. During interview with the Administrator and Director of Nursing on 10/03/2023 who reviewed the record for content, it was stated that the update of interventions to the plan of care was not documented.

It is required that each patient’s individualized written plan of care Includes all services necessary for the palliation and management of the terminal illness, including the following: Drugs and treatment necessary to meet the needs of the patient; (L549) This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 14 (21%) records reviewed it was revealed that the agency did not ensure that a full medication review was completed for all medications that the patient was taking to identify potential interactions. Document 5: Agency policy 9-017 titled The Plan of Care [Revision date 12/2018] stated in part, "The written plan of care will contain but not be limited to, the following: Drugs and treatments. Clinical Record 13: The patient was admitted 05/05/2023 with a diagnosis of Nutritional Marasmus with declining weight and mobility noted. On aide visit 05/18/2023 the aide documented the family was giving the patient Milk of Magnesia for constipation. The nursing visit dated 05/19/2023 also noted the patient was taking Milk of Magnesia with success and using Mucinex. The medications for Mucinex and Milk of Magnesia were not updated on the plans of care prior to 08/04/2023 for these medications. Clinical Record 12: The patient was admitted 11/07/2022 with diagnoses of Nutritional Marasmus and Dementia. The recertification assessment documented that the patient was using Gentamycin eye drops for conjunctivitis. The plan of care was not updated with this medication to review potential side effects as of the discharge dated 09/05/2023. Clinical Record 9: The patient was admitted 08/25/2023 with diagnoses of End Stage Chronic Pulmonary Disease and End Stage Heart Failure. During the nursing visit dated 09/08/2023 the nurse reviewed bowel program and stated to use Milk of Magnesia on Sunday if no bowel movement. The medications were not updated with Milk of Magnesia to review for potential side effects on the plan of care. During interview with the Administrator, Director of Nursing and Regional Director, it was stated that the medications were not updated on the plan of care and had not been documented as reviewed for all potential interactions.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: (L596)The types of bereavement services to be offered; and the frequency of service delivery. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 2 (100%) clinical records of patients who were discharged due to death, it was revealed that the agency did not ensure that the bereavement plan of care documented the frequency of service delivery." Document 5: 9-023 Bereavement Services [revised December 2018] stated in part, "Bereavement interventions will be reflective of the family/caregiver's choices to participate in the bereavement program. Clinical Record 7: The date of death was 08/14/2023. The bereavement risk level was moderate. The plan documented an initial sympathy card/letter, follow up call/visit 7-14 days after death, standard bereavement form letters, quarterly correspondence, and final follow up at 13 months. The standard form letters were not identified as to the timing of the letters. Clinical Record 9: The date of death was 9/9/2023. The bereavement risk level was low. The plan of care documented the initial sympathy card and 1 month letter was sent. The plan of care documented initial sympathy card/letter, standard bereavement form letters, quarterly correspondence, cards/newsletters, and final follow up letter at end of 13 months. The only timeline documented was 13 months. had no measurable timelines. The bereavement coordinator stated during interview on 10/3/2023 that the mailings for low risk are 1 month, 6-month, 11-month and 13 months, but the plan of care did not document that timeline. During interview with the Administrator and Regional Director on 10/04/2023, they stated that the bereavement process and care plan documentation had been self-identified, and a current process improvement plan was implemented effective 09/14/2023.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed of patients with aide services, it was revealed that the agency did not ensure that the hospice aide followed the plan of care as ordered. Clinical Record 1: The aide plan of care created 6/16/2023 and updated 6/21/2023, 6/23/2023, 7/9/2023, and 9/13/2023 ordered aide services 2 times a week and assigned tasks to check vital signs every visit, turn and reposition every visit, transfer from bed to chair every visit, and transfer from chair to bed every visit. The aide documented "Not Required" for these assigned tasks dated 7/9/2023 through 9/15/2023. Clinical Record 8: The aide plan of care dated 03/01/2023 assigned the task of bed bath 2nd visit of the week and shower first visit of the week. On the following dates a bed bath and a shower were documented as both provided: 4/28/2023, 5/2/2023 and 5/16/2023. The nursing visit dated 5/16/2023 was at the same time as the aide visit and documented that a bed bath was provided as the patient was agitated. Clinical Record 14: The aide plan of care dated 04/13/2023 ordered the task to check the patient's weight the first week of the month. The aide visiting 2 x a week and did not document a weight on 05/01/2023 or 06/03/2023, the first visits of the month. The aide documented on these notes "Not Required". During interview with the Regional Director, Administrator, and Director of Nursing on 10/2/2023 at 4:15pm, it was stated that the aide's documentation of "not required" was not within aide scope of practice. The regional director reached out to the software vendor to have this option removed.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) records reviewed that required physician orders, it was revealed that the agency did not ensure all physician orders were documented or if documented were clear for location of treatment to be applied. Clinical Record 7: The patient was admitted 03/02/2022 with a diagnosis of Alzheimer's, Dementia and history of falling. The nursing visit dated 05/02/2023 documented a skin tear 3 inches long on right elbow was cleaned with wound cleanser and steri-strips were applied and covered with a transparent dressing. There was no order documented for this wound care. On 06/02/2023, the physician order stated, "Hospice nurse or Facility nurse to cleanse skin with soap and water and wound cleaner, and cover with bordered gauze and change 2 times a week." This order was missing the location of the wound. The nursing assessment documented that the skin tear was on the left mid forearm. Clinical Record 8: The physician order written and signed on 06/09/2023 documented: "Nystatin, apply topically to affected area twice a day." The area was undefined. The nursing note from 06/09/2023 documented that the patient's buttocks and scrotum were excoriated, and the nystatin cream was started. Clinical Record 13: The patient was admitted 05/05/2023 with diagnoses of Senile Dementia and Nutritional Marasmus. On nursing visit note dated 05/18/2023, the documentation stated that, "The Milk of Magnesia was helping with the constipation and the Mucinex was helping with the respiratory congestion." There were no physician orders written for these medications as of the discharge dated 08/04/2023. Clinical Record 14: The patient was admitted 04/11/2023 with the diagnoses of Senile Dementia and multiple falls. The nursing visit note dated 05/28/2023, documented a laceration on the left forehead hairline and that steri strips were applied. There was no documented physician order for the steri strips. During an interview with the Regional Director and the Administrator who reviewed the records, they agreed that the orders were not documented, and the location of wound care was missing but education and a process improvement were in place as this had been self-identified.