Survey Report for 231601

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
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	231601	A. BUILDING __________ B. WING ______________	10/23/2019
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)
L0648
L0648	30524 Based on observation, record review and interview, the hospice failed to obtain Medicare approval before providing hospice care and services at 2 of 2 unapproved multiple locations (Detroit, Wyandotte), resulting in no basis to bill Medicare for services provided from these two locations. This practice impacts the 6 active patients receiving hospice care at the two unapproved multi sites. The cumulative effect of these systemic problems resulted in the hospice's inability to ensure it is complying with all applicable participation requirements at the two locations for the condition of participation of 42 CFR §418.100 Organization and administration of services. Findings include: 1. The hospice failed to obtain Medicare approval of two multiple locations before providing hospice care and services. (See L656).
L0656
L0656	30524 Based on observation, record review and interview, the hospice failed to ensure Medicare approval before providing hospice care and services at 2 of 2 unapproved multiple locations (Detroit, Wyandotte), resulting in no basis to bill Medicare for all services provided from these two locations. This practice impacts the 6 active patients receiving hospice care at the two unapproved multiple locations. Findings include: The hospice maintains two unapproved multi-sites that are each located within hospitals. DMC Harper University Hospital in Detroit: The hospice opened January 2015 and is located on the fifth floor (5 Brush South) of DMC Harper University Hospital, which is 12 miles from the parent site. An unannounced visit was conducted on 10/2/19. After exiting the elevator, it was observed that the hospice had an established presence within the hospital. The words "Seasons Hospice" were on the walls and doors leading to the hospice unit. At 10:10 a.m., an interview was conducted with Director-A (Inpatient Services Director, RN) and Director-B (Senior Director of Clinical Operations, RN). Director-A stated the hospice maintains a 16-bed hospice unit within the hospital. Currently there are 4 patients. The hospice provides general in-patient (GIP) services only. Respite services are not provided. Clinical record reviews indicate patients were admitted to the hospice unit for symptom management. The average census is 4 patients per day with an average length of stay at 3.1 days. The unit is staffed by Seasons Hospice employees and all hospice services are provided by Seasons staff (medical director, nursing, social work, chaplain, aide, music therapy and volunteers). The hospital provides food services, janitorial services, laundry, security, maintenance, and medications. Interdisciplinary Group meetings are held in a conference room on the hospice unit on Tuesdays with the hospice Medical Director or another hospice team physician. Seasons Hospice has contracts to accept GIP patients of three other local hospices (Universal Hospice, Residential Hospice, and Hospice of Michigan). Seasons Hospice staff provide the moment to moment nursing care as dictated by the plan of care from the contracted hospice. The contracted hospice provides a daily nursing visit to direct patient care and provides their own other hospice services such as: social work, chaplain, and volunteer services. Review of patient census data for 10/2/18 to 10/2/19 indicates that Seasons Hospice has had 418 unduplicated admissions to this unit in the past year and 12 of those patients were from the 3 other contracted hospices. The 16-bed hospice unit was toured with Director-A on 10/2/19 at 10:40 a.m. During the tour it was observed that Seasons Hospice maintains an unapproved multi-site within DMC Harper University Hospital. No documentation that this multiple location had been approved by Medicare was provided for review. The hospice failed to receive Medicare approval for this multiple location before providing hospice care and services to Medicare patients. 20987 Henry Ford Wyandotte Hospital: The hospice opened August 2017 and is located on the fifth floor (5 South) of Henry Ford Wyandotte Hospital, which is 25 miles from the parent site. An unannounced onsite visit was conducted on 10/2/19. After exiting the elevator, it was observed that the hospice had an established presence within the hospital. The words "Seasons Hospice" were on the walls and doors leading to the hospice unit. At 9:45 a.m., an interview was conducted with RN #5 who stated the hospice maintains a 12-bed capacity hospital unit within the hospital that offers 24-hour nursing services. Currently there were 2 active patients on the unit. A tour of the unit was provided. Observations of the unit noted plenty of physical space for private patient and family visiting. Each room had a couch that converted into a bed in order to accommodate family members desiring to stay with patients, along with a private bathroom and shower. There are separate private meeting rooms that family members can retire to for privacy. Director-A was asked about the visiting hours for the IPC unit, her reply was that visitors can come to see a patient at any time as long as the patient wants visitors. During an interview conducted at 10:20 a.m. with Manager-D (Staff Development Manager) she stated the hospice maintains a 12-bed capacity unit and provides general in-patient (GIP) services only. Clinical record reviews indicate the patients were admitted to the hospice unit for symptom management. The average length of stay was 3 to 5 days. The unit is staffed by Seasons Hospice employees and all hospice services are provided by Seasons staff (medical director, nursing, social work, chaplain, aide, music therapy and volunteers). The hospital provides food services, janitorial services, laundry, security, maintenance, and medications. The Interdisciplinary Group meetings are held on the hospice unit on Tuesdays with the hospice Medical Director and all other team members are present. The hospice unit follows the policies and procedures of the hospital regarding emergency/disaster drills. The hospice participates in emergency drills as dictated by the hospital. The hospice follows the hospital's policies and procedures regarding infection control but does not participate in infection control committee meetings. Director-A participates in the quality assessment and performance improvement (QAPI) meetings that are held at the parent site in Madison Heights. The hospice does not participate in the hospital's QAPI meetings. Seasons Hospice has contracts to accept GIP patients of four other local hospices (Universal Hospice, Residential Hospice, Angela Hospice and The Care Team Hospice). Seasons Hospice staff provide the moment to moment nursing care as dictated by the plan of care from the contracted hospice. The contracted hospice provides a daily nursing visit to direct patient care and provides their own other hospice services such as: social work, chaplain, and volunteer services. Review of patient census data for 10/2/18 to 10/2/19 indicates that Seasons Hospice has had 462 unduplicated admissions to this unit in the past year and 7 of those patients were from the other contracted hospices. During the tour it was observed that Seasons Hospice maintains an unapproved multi-site within Henry Ford Wyandotte Hospital. No documentation that this multiple location had been approved by Medicare was provided for review. The hospice failed to receive Medicare approval for this multiple location before providing hospice care and services to Medicare patients.
L0704
L0704	18299 Based on observation, record review and interview, the hospice failed to ensure that inpatient care for pain control and symptom management were provided in a Medicare certified hospice that provides inpatient care directly or in a Medicare certified hospital or skilled nursing facility that provides inpatient care, resulting in the potential for substandard and unaccountable patient care being provided, affecting all 6 of the patients currently under care at both of the hospice's Inpatient Care Centers. The cumulative effect of these systemic problems resulted in the hospice's inability to ensure the provision of quality end of life care for the condition of participation of 42 CFR §418.108 Short-term inpatient care. Findings include: 1. The hospice provides general inpatient care for pain control and symptom management at two unapproved multiple sites located within hospitals. (See L706) 2. The hospice provides general inpatient care in a home-like environment utilizing their own staff to provide 24-hour nursing services at two unapproved multiple sites located within hospitals. (See L707)
L0706
L0706	18299 Based on observation, record review and interview, the hospice failed to ensure that inpatient care for pain control and symptom management were provided in a Medicare certified hospice that provides inpatient care directly, resulting in the potential for substandard and unaccountable care being given affecting all 6 of the patients currently under care at both of the hospice's Inpatient Care Centers. Findings include: **Agency Policy "General Inpatient Protocol" (2044A); "To meet the needs of the hospice patient requiring symptom management that cannot be managed in the home/residential setting." DMC Harper University Hospital in Detroit: On 10/2/19 at 10:10 a.m., an interview was conducted with Director-A (Inpatient Services Director, RN) and Director-B (Senior Director of Clinical Operations, RN). Director-A stated the hospice maintains a 16-bed hospice unit within the hospital that offers 24-hour nursing services as well as all other customary hospice services being available. Currently there are 4 patients. The hospice provides general in-patient (GIP) services only. Respite services are not provided. Clinical record reviews indicate the patients were admitted to the hospice unit for pain control and symptom management. The average census is 4 patients per day with an average length of stay at 3.1 days. The unit is staffed by Seasons Hospice employees and all hospice services are provided by Seasons staff (medical director, nursing, social work, chaplain, aide, music therapy and volunteers). The hospital provides food services, janitorial services, laundry, security, maintenance, and medications. A tour of Seasons Hospice DMC Harper University Hospital Inpatient Care Center (IPC) was conducted with Director-A on 10/2/19 at 10:40 am. Observations of the unit noted the 16 rooms had ample physical space for private patient and family visiting, pull out beds to accommodate family members desiring to stay with patients and a bathroom with a shower. There are separate private meeting rooms that family members can retire to for privacy. Director-A was asked about the visiting hours for the IPC unit, her reply was that visitors can come to see a patient at any time as long as the patient wants visitors. Henry Ford Wyandotte Hospital: During an interview conducted on 10/2/19 at 10:20 a.m. with Manager-D (Staff Development Manager) she stated the hospice maintains a 12-bed capacity unit and provides GIP services only. Manager-D stated the hospice maintains a 12-bed hospice unit within the hospital that offers 24-hour nursing services as well as all other customary hospice services being available. Currently there are 2 patients. The hospice provides GIP services only. Respite services are not provided. Clinical record reviews indicate the patients were admitted to the hospice unit for pain control and symptom management. The average length of stay was 3 to 5 days. The unit is staffed by Seasons Hospice employees and all hospice services are provided by Seasons staff (medical director, nursing, social work, chaplain, aide, music therapy and volunteers). The hospital provides food services, janitorial services, laundry, security, maintenance, and medications. A tour of Seasons Hospice Henry Ford Wyandotte Hospital IPC was conducted with Manager-D on 10/2/19 at 10:40 am. Observations of the unit noted the 12 rooms had ample physical space for private patient and family visiting, pull out beds to accommodate family members desiring to stay with patients and a bathroom with a shower. There are separate private meeting rooms that family members can retire to for privacy. Manager-D was asked about the visiting hours for the IPC unit, her reply was that visitors can come to see a patient at any time if the patient wants visitors. The IPC units at both Harper Hospital and Henry Ford Wyandotte are home like with comfortable accommodations for patients and visitors consistent with a multiple site that offers inpatient care directly. The agency failed to offer these hospice inpatient services from a location that is a Medicare approved facility.
L0707
L0707	18299 Based on observation, record review and interview, the hospice failed to ensure that inpatient care for pain control and symptom management were provided in a Medicare certified hospital or skilled nursing facility that provides inpatient care, resulting in the potential for substandard and unaccountable care being given, affecting all 6 of the patients currently under care at both of the hospice's Inpatient Care Centers. Findings include: DMC Harper University Hospital: On 10/2/19 at 10:10 a.m., an interview was conducted with Director-A (Inpatient Services Director, RN) and Director-B (Senior Director of Clinical Operations, RN). Director-A stated the hospice maintains a 16-bed hospice unit within the hospital that offers 24-hour nursing services as well as all other customary hospice services being available. Currently there are 4 patients. The hospice provides general in-patient (GIP) services only. Respite services are not provided. Clinical record reviews indicate patients were admitted to the hospice unit for pain control and symptom management. The average census is 4 patients per day with an average length of stay at 3.1 days. The unit is staffed by Seasons Hospice employees and all hospice services are provided by Seasons staff. A tour of Seasons Hospice Inpatient Care Center (IPC) was conducted with Director-A on 10/2/19 at 10:40 am. Observations of the unit noted the 16 rooms had ample physical space for private patient and family visiting. Each room had a couch that converted into a bed in order to accommodate family members desiring to stay with patients, along with a private bathroom and shower. There are separate private meeting rooms that family members can retire to for privacy. Director-A was asked about the visiting hours for the IPC unit, her reply was that visitors can come to see a patient at any time as long as the patient wants visitors. Henry Ford Wyandotte Hospital: During an interview conducted on 10/2/19 at 10:20 a.m. with Manager-D (Staff Development Manager), she stated the hospice maintains a 12-bed capacity unit and provides GIP services only. Manager-D stated the hospice maintains a 12-bed hospice unit within the hospital that offers 24-hour nursing services as well as all other customary hospice services being available. Currently there are 2 patients. The hospice provides general in-patient services only. Respite services are not provided. Clinical record reviews indicate the patients were admitted to the hospice unit for pain control and symptom management. The average length of stay was 3 to 5 days. The unit is staffed by Seasons Hospice employees and all hospice services are provided by Seasons staff. A tour of Seasons Hospice IPC was conducted with Manager-D on 10/2/19 at 10:40 am. The nurse's station was centrally located, and all patient rooms were visible from that vantage. Observations of the unit noted the 12 rooms had ample physical space for private patient and family visiting. Each room had a couch that converted into a bed in order to accommodate family members desiring to stay with patients, along with a private bathroom and shower. There are separate private meeting rooms that family members can retire to for privacy. Manager-D was asked about the visiting hours for the IPC unit, her reply was that visitors can come to see a patient at any time as long as the patient wants visitors. The IPC units that Seasons Hospice maintains within the two hospitals conform with the standard requirements regarding 24-hour nursing services (418.110(b)) and patient areas (418.110(e)), however the IPC units are not approved by Medicare as multiple sites for Seasons Hospice. The agency is offering hospice inpatient services from locations that are not Medicare approved facilities.