Every finding on record at Transitions Michigan III LLC

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. Review of the Volunteer Cost Savings report for 2024 and interview with the Administrator revealed that the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The annual hospice volunteer percentage for 2024 in the Volunteer Cost Savings Report data for value of volunteer hours was documented as (1.3%). In an interview conducted on 05/14/2025 with The Hospice Administrator, it was stated that hospice volunteers did not provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff for the year of 2024. This standard was not met as evidenced by review of the Volunteer Cost Savings report for 2024 and interview with the Administrator. The agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The annual hospice volunteer percentage for 2024 in the Volunteer Cost Savings Report data for value of volunteer hours was documented as (1.3%). In an interview conducted on 05/14/2025 with The Hospice Administrator, it was stated that hospice volunteers did not provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff for the year of 2024.

Upon patient record review 2 of 5 records (Patient #1, #3) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process Patient 1 and 3: There was no evidence of a spiritual assessment as part of the comprehensive assessment.

Upon patient record review, 5 of 5 records (Patient #1, #2, #3, #4, #5) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient 1: Medication profile did not included reason for the PRN Oxygen or a route for medications. Corrected on site. Patient 2: Order dated 4/8/2022 O2 2L/M via NC. There was no evidence of O2 on Medication profile. Corrected on site. Patient 3: There was no evidence of a route for medications and oxygen on medication profile. Corrected on site. Patient 4, 5: There was no evidence of a route for medications on medication profile.

Upon patient record review, 5 of 5 records (Patient #1, #2, #3, #4, #5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1: Order did not included reason for the PRN Oxygen or a route for medications. Corrected on site. Patient 2: Order dated 4/8/2022 O2 2L/M via NC. There was no evidence of a reason for O2 prn. Corrected on site. Patient 3: There was no evidence of a route for medications and oxygen within the order. Corrected on site. Patient 4, 5: There was no evidence of a route for medications within the order.

Upon patient record review, 3 of 4 applicable records (Patient #1, #2, #3) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 1: Tasks on HHA Care plan include per pt request, shower/tub,shampoo hair, shave, change linens. Corrected on site. Patient 2; Pt on O2 therapy, there was no evidence of O2 precautions on HHA care plan. Tasks on HHA Care plan include per pt request, comb hair, clean hand/foot file nails, change bed linens. Corrected on site. Patient 3:Tasks on HHA Care plan include per pt request, type of bath, shampoo hair, mouth care, hand/foot care file nails, change bed lines, straighten room, make bed. Corrected on site.

Upon observation, there was no evidence the The Emergency Preparedness plan addresses patient population, including, strategies for addressing emergency events identified by the risk assessment, including the management of the consequence of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. The EPP binder hazard and risk assessment document was blank.

Upon observation, there was no evidence the Emergency Plan communication plan included names and contact information for all of the following: • Hospice employees • Entities providing services under arrangement • Patients' physicians

Upon observation, there was no evidence the Emergency Plan communication plan includes contact information for Federal, state, tribal, regional, or local emergency preparedness staff. The designated are in the emergency plan for communication contact with federal, state, tribal and local entities had been left blank.

Upon observation, there was no evidence the Emergency Plan communication plan included a method for sharing information and medical documentation for patients under the hospice's care, as necessary, with other health care providers to maintain the continuity of care, a means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii) and a means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4) The EPP binder had reference to out of state entities for evacuation such as: McCarren airport and Wyoming state. The EPP patient binder had no information in designated area.

Upon patient record review, 4 of 5 applicable (Patient #1, #3, 4 and #5) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #1 The bereavement assessment in the record was not dated. Patient #3, 4, 5 There was no evidence of an initial bereavement assessment on the record..

Upon patient record review, 5 of 6 (Patient #1, #3, #4, #5 and #6) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1 This patient had a rollator, scooter, O2, OBT, shower chair, hospital bed with APP mattress, raised toilet seat and cane. These items were not included on the Plan of Care. Patient #3 This patient had a walker. This item was not included on the Plan of Care. Patient #4 The record reflected that this patient had a hospital bed, over-bed table, wheel chair, oxygen and nebulizer. These items were not included on the Plan of Care. Patient #5 The record reflected that this patient had a nebulizer for HHN treatment. The nebulizer was not included on the Plan of Care. Patient #6 The record reflected that this patient had an oxygen order. The oxygen equipment was not included on the Plan of Care.

Upon client record review, 1 of 6 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 SC visit performed on 11-17-21. There was no evidence of an order for SC.

Upon patient record review 2 of 3 applicable (Patient #4 and #6) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group Patient # 4 The aide visit frequency ordered was 3 x week to begin on 8/21/21. There was no evidence of aide visits the first week. Patient #6 The aide visit frequency ordered was 2 x week on 8/16/21. There was no evidence of aide visits the first week.

Upon patient record review, 2 of 6 (Patient #1, 2) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. Patient #1 The physician CTI had incorrect Benefit Period (BP) dates listed as 11/16/21 to 2/14/22. The accurate dates for BP are 11/16/21 to 2/13/22. Also, EOB indicated Dr. Mendoza, Medical Director as attending physician. The CTI was signed by Dr. Mendoza as Medical Director and Dr. Raffe as the attending physician. There was no change of attending physician documented in patient chart. Patient #2 The physician CTI had incorrect Benefit Period (BP) dates listed as 10/29/21 to 1/27/22. The accurate dates for BP are 10/29/21 to 1/26/22.

Upon patient record review, 6 of 6 (Patient #1, #2, #3, #4, #5 and #6) did not have evidence that each patient record contains a signed election statement in accordance with 418.24 Patient #1, 2, 3, 4, 5, 6: The EOB did not have the following requirements: Notification of the individual's (or representative's) right to receive an election statement addendum if there are conditions, items, services, and drugs the hospice has determined to be unrelated to the individual's terminal illness and related conditions and would not be covered by the hospice; And, Information on the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), including the right to immediate advocacy and BFCC-QIO contact information.

Upon personnel record review, 1 of 7 applicable (Personnel #12) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel #12 Volunteer did not have criminal background check at start of survey. This was corrected on site and criminal background check obtained during survey.