Call us now

About — Quality & Safety

Quality of Care & Patient Safety Standards

How we measure what we promise — and how you can verify it for yourself.

Medicare-Certified Since 2015

CHAP-accredited • Publicly reported quality data

The Honest Version

Open any hospice website and you'll find a quality page. They almost all say a version of the same line: "We provide compassionate, high-quality care."

That sentence appears on hundreds of sites. It tells you almost nothing about whether the care is actually any good.

Quality in hospice should be measurable. It should be reported publicly. It should be reviewed by people outside the hospice itself. Below is what that looks like in practice at St. Marie's — in concrete terms families can verify, including how to check any hospice's quality record yourself.

Verifiable, Not Just Claimed

The Public Quality Record

Hospice quality data isn't private. It's publicly reported, and most families don't realize how much information is already available to them.

St. Marie's Hospice has been Medicare-certified since 2015. That isn't a one-time award. It requires ongoing compliance with the federal Conditions of Participation — the regulatory framework that governs every hospice in the country — and routine recertification surveys conducted by state surveyors. The certification renews only if standards continue to be met.

We're also accredited by the Community Health Accreditation Partner (CHAP), an independent non-profit accrediting body recognized by CMS. CHAP visits hospices on its own schedule, against its own standards, beyond what Medicare requires. Accreditation is voluntary — which is the point. It signals a hospice willing to be measured against a higher bar than the regulatory floor.

If you want to check our public quality data directly, Medicare publishes it on the Care Compare tool at medicare.gov/care-compare. You can compare hospices side by side on family satisfaction scores, clinical measures, and inspection results. Most families don't know the tool exists. We'd rather you use it than take our word for any claim on this page.

Federally Reported

The Clinical Quality Measures We're Held To

Every hospice in the country reports a standardized set of clinical measures to Medicare through the Hospice Item Set (HIS) — every patient, every admission, every discharge. The measures matter because they’re tied to specific care actions, with specific timeframes attached.

The standards include:

✓A pain assessment within 48 hours of admission for patients reporting pain

✓Treatment of dyspnea (breathlessness) initiated within 24 hours of reported symptoms

✓A bowel regimen initiated whenever opioids are prescribed — small but specific, and one of the most common opioid complications when it isn't done

✓Patient preferences regarding resuscitation, hospitalization, and life-sustaining treatment documented at the initial assessment

✓Spiritual and existential concerns assessed within the first five days of care

These aren’t internal aspirations. They’re federal reporting requirements with audit trails, and performance against them is part of public CMS data. A hospice that takes a casual approach to any of them is creating a measurable gap that shows up in the data, not just in the care.

Day-to-Day Discipline

Patient Safety Protocols

Regulatory measures only describe part of what keeps patients safe. The rest is in day-to-day operational discipline.

Medication safety Hospice patients usually take multiple medications, often including opioids. Our nurses follow strict protocols for medication reconciliation, controlled-substance documentation, and safe storage. Families receive specific training on administration and disposal as part of initial caregiver education — which matters more than most people realize. A common issue we see in hospice across the industry is medication confusion in the home during the first week, when families are most overwhelmed.

Infection control Post-COVID, hospice infection control has tightened across the industry. Hand hygiene, PPE in appropriate situations, and disinfection of equipment between patient visits are routine. The team follows CDC infection-control guidance, with protocols adjusted whenever public-health conditions shift

Fall prevention Hospice patients are at high risk for falls — from weakness, medication effects, and changes in mobility. Nurses and aides assess fall risk on admission and at every visit, and family education on the bedroom environment is built into the initial care plan. One of the most common practical mistakes families make: leaving familiar furniture in walkways once mobility drops.

Skin integrity Bed-bound or chair-bound patients are at high risk for pressure injuries — wounds that can develop within hours of unrelieved pressure on the same area. Repositioning schedules, skin assessment intervals, and pressure-relief surfaces are part of standard care, and family caregivers receive hands-on training in safe repositioning that protects both the patient and their own back.

Personal care safety Bathing, transfers, and other personal care are handled using techniques that protect dignity and safety at the same time. In hospice, the two aren't separate concerns. They're the same concern.

Independent. Third-Party. Public.

The Family Experience Survey

Clinical measures tell half the story. The rest is what families actually experienced.

Every Medicare-certified hospice is required to participate in the CAHPS Hospice Survey — a standardized family experience survey administered by an independent third-party vendor after a patient’s death. The survey asks family caregivers about communication with the team, symptom management, emotional and spiritual support, and overall care quality.

Results are publicly reported. Families considering a hospice can review CAHPS scores on CMS Care Compare. We don’t see the surveys before they’re sent. We don’t choose which families are surveyed. That independence is what makes the data meaningful. A hospice that controls its own feedback isn’t producing quality data — it’s producing marketing.

The Step Most Programs Skip

How Feedback Becomes Improvement

Measurement only matters if it leads to change.

Clinical leadership reviews HIS data, CAHPS results, internal incident reports, and family feedback on a regular cycle. When patterns surface — a delay in a specific intervention, recurring concerns about communication, a measure trending in the wrong direction — the quality improvement team works on root cause and implements a corrective change. Then the metric gets monitored to confirm the change held. That last step is the one most programs skip.

Families have a direct line into this process. Concerns get documented, escalated to clinical leadership, and answered in writing. If a concern can't be resolved with us, families have the right to escalate to CHAP, to Medicare, or to the Michigan Department of Licensing and Regulatory Affairs (LARA), and we provide the contact information without resistance. A hospice that resists external review is signaling something a family should pay attention to.

Bring the Harder Questions

Questions Every Family Should Ask Any Hospice

When you're evaluating a hospice — including ours — these are the questions worth asking. A hospice that takes quality seriously will answer them directly. A hospice that doesn't will deflect.

01Are you Medicare-certified and currently in good standing?

02Are you accredited by CHAP, ACHC, or The Joint Commission?

03What were your most recent CAHPS family experience survey scores?

04Can I see your latest Medicare Care Compare report?

05How do you handle medication safety, particularly with opioids?

06What's your nursing-to-patient ratio on weekends and overnight?

07When was your last regulatory survey, and what were the findings?

We’ll answer all of these directly. If another hospice doesn’t, that itself tells you something — and what they choose not to say is often more informative than what they do.

Quality You Can Verify

If you're evaluating hospice for a loved one

in Detroit, Southfield, Troy, Warren, Sterling Heights, or anywhere across the Michigan tri-county area, we welcome the harder questions. The right hospice doesn’t ask you to take quality on faith — it shows you the record.

Call (800) 489-7977 or reach us through our contact page. Bring the questions. We’d rather earn your trust through a real conversation than ask for it on a webpage.

QUICK ACCESS