DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
231524 A. BUILDING __________
B. WING ______________ 		10/28/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
KINDRED HOSPICE I 4458 OAKBRIDGE DRIVE, SUITE D, FLINT, MI, 48532
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0648      
34701 Based on record review and interview, the hospice failed to receive Medicare approval before providing hospice services at a proposed multiple site location, see (L-656), and failed to ensure the proposed multiple location was part of the hospice and shared administration, supervision, and services with the hospice parent site, see (L-657). Findings include: 1: Failed to receive Medicare approval for multiple location (L-656). 2: Failed to ensure the multiple location shared administration, supervision, and services with the parent site (L-657). The cumulative effect of these systemic problems resulted in the hospice's inability to ensure the provision of quality care in a safe environment and has the potential to adversely affect all patients served.
L0656      
34701 Based on record review and interview, the hospice failed to receive Medicare approval before providing hospice services at 1 of 1 proposed multiple locations, which resulted in the potential for poor patient outcomes. Findings include: During review of the proposed multi site staff sheet (Attachment #11), it was discovered that the list documented, "*all 3 Flint (Parent site) chaplains helping cover Saginaw until Saginaw hires."[sic]. Further review of the agency's organizational chart (Attachment #8) for the parent site and the proposed multiple site (Saginaw) on 10/28/21, also noted that Chaplain #1 was documented as a chaplain for both sites. The proposed multiple site was noted to be providing hospice Spiritual Counseling services with staff from Kindred Hospice. During a 10/28/21 onsite visit to the proposed branch site, the location of 231594 Southern Care Hospice, 6270 State St., Saginaw, was observed to be present and engaged in providing hospice services independent of the Kindred Hospice parent.
L0657      
34701 Based on document review and interview, it was determined the hospice failed to ensure all multiple locations shared supervision with the parent site for 1 of 1 proposed multiple locations, which resulted in the potential for poor patient outcomes due to lack of supervision by the parent office. Findings include: *** Policy: Nurse Practitioner (NP) job description, dated 9/2020, "If the NP identifies the need for updates to the plan of care to include additions/changes to the patient's medications and/or treatments/interventions, they will contact Medical Director/Hospice Physician ...." During an interview with the administrator (Adm#1) on 10/28/21 at 10:00 a.m., Adm#1 was asked how the parent site (Kindred-Flint) oversees the proposed multi-site (6270 State St., Saginaw), Adm#1 stated, "Southern Care Hospice (Branch site in Saginaw) is its own entity (It has its own provider number 231594), so it would not have oversight from Kindred Hospice until the transition (to a multiple site)." When asked who orients and supervises the NPs at the branch location, Adm#1 responded, "The orientation is online. I am new in this position, and I would like to have the regional director (RD#1) on a call with us to help answer questions." During a phone interview on 10/28/21 at 11:30 a.m., RD#1 was asked how the parent site (Kindred-Flint) oversees the multi-site (Saginaw), RD#1 stated, "Southern Care Hospice (proposed branch site in Saginaw) is its own entity, so it would not have oversight from Kindred Hospice until it is approved and under the Kindred provider number." When asked how the nurse practitioner (NP) at the branch site is supervised, RD#1 stated, "We normally have an Executive Director at the branch site that oversees that site, but the position is vacant at the moment, so Adm#1 is also the interim Executive Director (ED#1) overseeing the Saginaw location and the NPs. "An organizational chart was provided that documents Adm#1 as the administrator for the Flint site and ED#1 as the Executive Director for the Saginaw site. (ED#1 no longer occupies the Executive Director position in Saginaw). When asked what the involvement of the Medical Director is with the NPs, RD#1 responded, "The NPs work for the agency, not the doctor. They report to the administrator. The NPs only do the Face-to-Face visits and the History and Physical (H&P) visits. They do not prescribe medications or oversee patients. The NPs would call the doctor if they had questions, just like a nurse would." (See NP policy above). During a 10/28/21 onsite visit to the proposed branch site, Southern Care Hospice, 6270 State St., Saginaw, CM#1 was asked about oversite of the branch site and she said Adm#1 is currently overseeing the branch site. When asked when the last time Adm#1 was at the branch site CM#1 responded, "Just a few days ago." It was also observed that Southern Care Hospice 231594 was present at that location and engaged in providing hospice services independent of the Kindred Hospice parent.