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
231601 A. BUILDING __________
B. WING ______________ 		12/06/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
SEASONS HOSPICE & PALLIATIVE CARE OF MICHIGAN 27355 JOHN R RD, MADISON HEIGHTS, MI, 48071
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)
L0512      
27712 Based on record review and interview, it was determined the hospice failed to ensure the patient received effective symptom management related to her diagnosed terminal illness in 1 (MR #1) of 1 record with reported agitation, restlessness and hallucinations, from a total of 4 sampled records reviewed, resulting in the potential lack of peace and comfort during the end of life transition, and unmet care needs. Findings include: The Agency's "ComfortPak Assessment, Ordering, and Usage - 3005" policy, reviewed 12/29/17, was provided as requested and documented, "If the patient is symptomatic upon admission or becomes symptomatic before CP (ComfortPak) arrives at the patient's residence, the nurse and/or prescriber will contact a local pharmacy to provide the necessary medications to manage the patient's symptoms." MR #1: The patient's start of care (SOC) was 10/2/19 with a terminal diagnosis of Breast Cancer. The plan of care (POC) ordered Skilled Nursing, Hospice Aide and Medical Social Work services to be provided. The patient passed away on 10/14/19. On 12/4/19 at 10:15 a.m., during a telephone interview a family member (FM #1) reported, "We didn't receive the comfort pack for a whole week. I would say it was around the last day of the week and it was late in the evening. My mom had difficulty swallowing so we needed medications and something we could crush, in order for her to swallow. She was also having increased restlessness and agitation. The staff just kept telling me that her system was shutting down. We expressed our concerns to the social worker and said we would transfer our mother to another agency since we didn't get what we needed. We finally received the comfort pack the day after we said we were going to transfer her to another agency." Upon review of the record on 12/4/19 at 1:30 p.m., it was noted that on 10/3/19, the complainant called the agency's "Call Center" to request a "Comfort Pack" (medications). The documentation read that the script (prescription) had to be resent as the doctor's signature was cut off. There was no indication in the clinical record that the patient received the comfort pack as requested. On 12/6/19 at 10:36 a.m., an interview was conducted with the Administrator (Adm #1) and the Clinical Director (CD #1). When asked if the patient received the requested comfort pack, CD #1 reported, "I see in the record that Pharmacy delivered it on 10/9/19 (7 days after admission; 6 days after it was requested) in the evening. That's not the usual. We try to shoot for 48 hours. The script should have been signed on the 2nd day of admission. We use a faxed system. If the medications haven't been received, the nurses carry drug boxes they can leave with the patient, or the nurses should notify the doctor for a local fill (to be filled at a pharmacy) until the comfort pack comes." When asked what the comfort pack included, CD #1 responded, "Roxanol (Narcotic pain relief), Haldol (antipsychotic, decreases excitement and agitation), Ativan (Sedative, used to treat anxiety), Compazine (used for nausea and vomiting), and acetaminophen suppositories (used for pain and fever). The patient should have gotten the comfort pack sooner." When asked to view the patient's medication profile listing all current medications, CD #1 reported, "I don't see that it was filled out. We don't have it." When asked if the patient had enough medications on hand to treat the expressed symptomology until the comfort pack arrived, CD #1 stated, "I don't know." Adm #1 reported, "That's not normal and it's not acceptable." At the time of the clinical record review, there was no documented evidence the patient's symptoms were effectively managed by the hospice agency.