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
231677 A. BUILDING __________
B. WING ______________ 		12/14/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
FIRSTHEALTH HOSPICE 717 S ETON ST, BIRMINGHAM, MI, 48009
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)
L0545      
38304 Based on document review and interview, it was determined the hospice failed to ensure the plan of care included a time interval in which to change the patient's urinary catheter in 1 of 1 records reviewed (MR# 2) involving catheter care, and failed to have a plan of care in place prior to providing treatment/services in 1 of 4 records (MR# 2) reviewed out of a total sample of 4 records, resulting is the patient's needs not being met. Findings include: Agency policy: COC.63 "Plan of Care" HSP5-4A (Effective 01/02/2020) stated, "All members of the Hospice Interdisciplinary Team (IDT), including the patient and the family, participate in developing the care plan. Hospice will have a written plan of care established by the attending physician, the medical director and interdisciplinary team (IDT) prior to providing care. The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: Orders for specific hospice services and disciplines, treatments, procedures (specify amount/frequency)." MR#2: The patient's start of care (SOC) was 9/19/2020. The Plan of Care (POC) identified terminal diagnoses of metabolic encephalopathy (altered brain function), hallucinations, and malnutrition. The initial comprehensive assessment completed on 9/19/2020 by Staff-A/RN, identified a Foley catheter was placed on 9/17/2020 while in the hospital. The POC completed on 10/8/2020, 19 days after the SOC, ordered SN (skilled nursing) services once weekly for 90 days, Medical Social Worker (MSW) once a month for 90 days, and Chaplain services monthly for 90 days. Services/treatments documented prior to the POC being established are as follows: SN visits made on 9/23/20, and 10/2/20, MSW bereavement assessment and initial evaluation on 9/22/20, and Chaplain services on 10/6/20. The POC was initiated the day of the patient's first IDT meeting on 10/8/20. The POC dated 10/8/20 failed to include a timeframe in which to discontinue the catheter to avoid increased risk for infection and unnecessary complications. Review of the SN visit notes (all from Staff-A) concerning catheter care revealed the following: On 9/23/20, "Clear yellow urine flowing in foley bag after changing bag. Pt (patient) c/o (complains) catheter being uncomfortable. Some hematuria (blood in urine) noted in foley bag, but clear yellow urine flowing during visit." 10/2/20, "Clear yellow urine flowing in foley bag. Pt c/o catheter being uncomfortable. Female RN replaced foley bag. Some hematuria noted in foley bag, but clear yellow urine flowing during visit." 10/8/20, "Clear yellow urine flowing in foley bag sediment scant in bag. (sic) Pt c/o catheter being uncomfortable." The documentation on 10/13/20 and 10/22/20 noted the same language as the 10/8/20 visit. On 10/28/20, documentation noted "hematuria and sediment" with the "catheter being uncomfortable, foley was DC'd (discontinued). PRN anxiety medications working well pt far less frustrated. Confused constantly talking about events past like they are taking place at present. Spoke with (Family-B) about s/s (sign and symptoms) to watch for now that cath has been removed, both he and wife report understanding. Will call 4 hours from now to affirm she's voided." The visit noted dated 11/5/20 noted no issues with the patient since the last visit. However, the 11/12/20 visit note documented, "No acute changes since last visit no s/s of distress. Monday 11/9 received a call about possible UTI (urinary tract infection) antibiotics have been administered s/s of UTI haven't cleared up will continue course of medication at this time." (sic). No further SN visit notes were noted in the clinical record. The catheter was changed 41 days after insertion, with no communication with the physician noted concerning the clinical findings documented in the SN visit notes 9/23/20 through 10/28/20. During an interview on 12/14/20 at 1520 PM, CD#1 (Clinical Director of Operations) acknowledged the above findings and confirmed the POC should have had more details as stipulated by agency policy to include frequencies concerning treatments/procedures (urinary catheter changes).