Every finding on record at Arbor Hospice, Inc

It is required that the hospice provides information on advance directives upon initiation of hospice care. Whether or not the patient has executed an advance directive is documented in a prominent part of the patient’s record. This standard was not met as evidenced by clinical record review and interview. 4 of 23 (17%) clinical records reviewed revealed that the agency did not ensure that the patients' advanced directives were documented in a prominent part of the charts, in accordance with agency policy. Policy and Procedures: Agency Policy #1000, titled "Do not Resuscitate - Advanced Directives", effective date 02/01/2020, read in part, "2. If available, a copy of any advanced directive is placed in the patient's clinical record and the patient wishes, including the DNR (do not resuscitate) status is included in the care planning for the patient." CLINICAL RECORD 8: The patient was admitted on 11/12/2025. The initial plan of care, dated 11/12/2025-02/09/2026, did not identify the patient's choice for advanced directives. The Advanced Directives section on the plan of care was blank. CLINICAL RECORD 9: The patient was admitted on 11/17/2025. The initial skilled nursing assessment did not include documentation of the patient's advanced directives. Advanced directives were not noted on the initial plan of care. Advanced directives were not included in the prominent "Patient Notification" area of the face sheet. CLINICAL RECORD 12: The patient was transferred from another hospice on 01/02/2026. The benefit period was 01/02/2026-01/07/2026 and new benefit period began 01/08/2026. The plans of care did not address the patient advanced directives. The nursing assessment on 01/02/2026 did not address the patient's advanced directives. There was documentation of a DNR found in the transfer records of the previous hospice. CLINICAL RECORD 15: The patient was admitted on 12/10/2025. The initial skilled nursing assessment did not evidence that the advanced directives and DNR status were addressed. In the initial plan of care dated 12/10/2025, the Advanced Directives section was blank. The prominent "Patient Notification" area of the face sheet read, "Advanced Directives (0)." The Social Work assessment dated 12/13/2025 documented that the patient was a DNR, but the document was not in a prominent place in the chart that would be easy to find in the event of an emergency. The Statewide Director of Compliance reviewed clinical records on 01/08/2026 and confirmed that the advanced directives were not documented in a prominent part of the clinical records.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. 3 of 23 (13%) clinical records reviewed revealed that the agency did not ensure that all patients had a comprehensive assessment within 5 days after the election of hospice care. CLINICAL RECORD 8: The patient elected hospice on 11/12/2025. The initial nursing comprehensive assessment was completed on 11/12/2025. The sections for psychosocial factors that may impact care, living arrangements, social service screening, financial assessment, and psychosocial/environmental summary of problems were left blank in the assessment. The section for spiritual issues in the comprehensive nursing assessment was left blank. The patient refused Social Work and Chaplain visits. The clinical record provided no evidence that a comprehensive psychosocial assessment and spiritual assessment were completed within 5 days of the election of hospice care. A Social Worker completed a psychosocial assessment on 11/18/2025 (6 days). CLINICAL RECORD 9: The patient elected hospice on 11/17/2025. The skilled nursing comprehensive assessment was completed on 11/17/2025. The sections for psychosocial factors that may impact care, living arrangements, social service screening, financial assessment, and psychosocial/environmental summary of problems were left blank. The section for spiritual issues in the comprehensive nursing assessment was left blank. The patient refused Social Work and Chaplain visits. The clinical record provided no evidence that a comprehensive psychosocial assessment and spiritual assessment were completed within 5 days of election of hospice care. CLINICAL RECORD 11: The patient elected hospice on 12/20/2025. The nursing comprehensive assessment was completed on 12/20/2025. The sections for psychosocial factors that may impact care, living arrangements, social service screening, financial assessment, and psychosocial/environmental summary of problems were left blank. The section for spiritual issues in the comprehensive nursing assessment was left blank. The patient refused Social Work and Chaplain visits. The clinical record provided no evidence that a comprehensive psychosocial assessment and spiritual assessment were completed within 5 days of election of hospice care. The Statewide Director of Compliance confirmed that the clinical records did not contain evidence of a spiritual assessment or psychosocial assessment within the first 5 days of care and noted that in the the skilled nursing assessments, the psychosocial and spiritual assessment areas were blank.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. 1 of 23 (4%) clinical records reviewed revealed that the agency did not ensure that the medication profile was updated on each patient. CLINICAL RECORD 15: The patient was admitted on 12/12/2025 at home. The nursing comprehensive assessment documented that the patient is utilizing continuous oxygen. The medication profile did not include oxygen. As of the date of review, on 01/08/2026, although the oxygen dosage was documented in the IDG notes, the oxygen is not included on the medication profile. In an interview on 01/08/2025, the Statewide Director of Compliance stated, "You are right" after reviewing the clinical record.

It is required that all hospice aide services must be provided by an individual who has successfully completed one (1) of the four (4) training and competency evaluations programs described below. The individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program also described below. The hospice maintains documentation that each hospice aide has met the requirements. The competency evaluation addresses each of the following subject areas from item 2, above; they are evaluated by observation of an aide’s performance with a patient or pseudo-patient, including: a) Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; b) Reading and recording temperature, pulse, and respiration; c) Appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: i. Bed bath; ii. Sponge, tub, and shower bath; iii. Hair shampoo (sink, tub, and bed); iv. Nail and skin care; v. Oral hygiene; vi. Toileting and elimination; d) Safe transfer techniques and ambulation; e) Normal range of motion and positioning. The remaining subject areas in item 2 above may be evaluated through written examination, oral examination, or after observation of a hospice aide with a patient or a pseudo-patient during a simulation. The competency evaluation is performed by a registered nurse in consultation with other skilled professionals, as appropriate. This standard was not met as evidenced by document review, interview and personnel record review. 2 of 2 (100%) personnel records of hospice aides reviewed revealed that the agency did not ensure that the aides completed competency assessments upon hire prior to providing patient care. Policy and Procedures: Agency policy No.0660 titled "Competency Assessment", effective 01/01/2021, read in part, "As a component of the orientation process, new staff complete a competency evaluation prior to providing care." PERSONNEL RECORD 3: This hospice aide was hired on 02/17/2025. The personnel record contained no evidence of an initial competency assessment upon hire prior to performing patient care. PERSONNEL RECORD 5: This hospice aide was hired on 07/17/2025. The personnel record contained no evidence of an initial competency assessment upon hire prior to providing patient care. The Statewide Director of Quality reported in an interview on 01/09/2026, "We will learn from this, we do not have a general competency assessment for aides on hire with all the elements. We just do the annual on-site." NOTE: The annual on-site evaluation form did not include all of the required task elements to be validated..

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. 1 of 16 (6%) clinical records reviewed with hospice aide services revealed that the agency did not ensure that the hospice aide (HA) care plans included complete care instructions to meet the needs of the patient. CLINICAL RECORD 18: The patient was admitted on 11/03/2025 with a diagnosis of lung cancer. The initial nursing comprehensive assessment documented that the patient had a large skin tear on his back, and also continued to smoke despite using oxygen. The plan of care dated 11/03/2025 included an order for oxygen and wound care. The HA care plan dated 11/03/2025 did not include oxygen safety precautions and the Oxygen Use field was left blank. The HA care plan included an assignment to provide a shower but did not address how the HA should handle the wound dressing on the patient's back. In an interview on 01/09/2025, the Statewide Director of Compliance stated, "You are right" after reviewing the clinical record.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, interview and personnel record review. 1 of 1 (100%) personnel record of a registered nurse (RN) hired within the past three years reviewed revealed that the agency did not ensure that a competency assessment was completed upon orientation prior to providing patient care. Policy and Procedures: Agency policy No.0660 titled "Competency Assessment", effective 01/01/2021 read in part, "As a component of the orientation process, new staff complete a competency evaluation prior to providing care. PERSONNEL RECORD 6: This RN was hired on 09/09/2024. The record contained no documented evidence of a competency assessment upon hire. In an interview on 01/09/2026, the Statewide Director of Quality stated, "We had staff changes in the last three years and they must have made changes that don't meet the standard. We will get it fixed."

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. 1 of 23 (4%) clinical records reviewed revealed that the agency did not ensure that physician orders were clear and complete. CLINICAL RECORD 18: The patient was admitted on 11/03/2025. The initial nursing comprehensive assessment identified and documented a skin tear on the patient's back that was 6cm x 3cm x 0.1cm in size. The plan of care dated 11/03/2025 included an order that read "Integumentary Interventions: cleanse with soap and water, cover with non-adherent pad, if wound opens, secure with Tegaderm or paper tape, start effective date 11/03/2025. The order did not specify where the wound was located. The Statewide Director of Compliance reviewed the clinical record and confirmed that the intervention order for wound care did not include a location of the wound.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by a review of clinical records, document reviews and interviews.1 of 16 (6%) records revealed the agency did not ensure documentation of the required pre-bereavement assessment with in 5 calendar days of the hospice benefit of election. Agency Policy 0695 [effective date 02/03/2020] stated in part, "The comprehensive assessment of the patient is completed by designated members of the interdisciplinary team in consultation with the patient attending physician no later than five calendar days after the patient elects the hospice benefit. The comprehensive assessment of the patient consists of discipline-specific assessment templates that address the following factors: an initial assessment of the bereavement needs of the patient family and other involved individuals." Record 2: The hospice benefit of election was signed on 09/17/2022. The Nurse on admission 09/17/2022 documented "there was no one to assess for bereavement." Social work visit 09/20/2022 did not document pre bereavement assessment and no reason why it was not completed. The patient was discharge 09/23/2022 to another location so stepson could be closer. During an interview with the quality management team who provided support during the clinical records review, it was stated that the bereavement assessment was never documented in the required 5 calendar days from the benefit of election.

It is required that the documented comprehensive assessment includes: a drug profile that contains the patient's current: Prescription and over the counter (OTC) Supplements; Herbal remedies; Other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: The effectiveness of drug therapy; Drug side effects; Actual or potential drug interactions; Duplicate drug therapy; Drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records, document reviews and interviews 2 of 14 (14%) records, the agency did not ensure update of the medication profile to include all medications and consequently review all medications for potential interactions. Agency Policy 1926 [effective date 03/27/2019] stated in part, "A medication profile is maintained for every patient in the electronic medical records system and includes a listing of the current medication orders for each patient and specifies whether the medication is or is not related to the patient terminal illness. Upon admission and with any newly added medication, the documenting Registered Nurse will complete a medication evaluation of medications listed in the medication profile of the electronic medical record. The Registered Nurse will complete a drug interaction assessment and notify ordering physician of any moderate and/or severe interactions that are identified." Record 6: Patient elected Hospice benefit on 01/13/2022. On 01/18/2023 patient symptomatic and was febrile and symptomatic for UTI (urinary tract infection). A call was received by triage nurse and consequently a Nurse Practitioner visited the patient and ordered for Cipro (antibiotic) 500mg BID (two times a day) x 7 days for UTI. The Medication profile was not updated as of review 02/02/2023. Clinical Record 8 Admitted 10/28/2022 diagnosis of cancer of gallbladder with metastasis. Patient was having increased symptoms of constipation not resolving and a physician visit was made to the home 12/19/2022 and documented may increase senna (stool softener) from 1-2 tabs daily to 2 tabs two times a day and to try magnesium citrate (stool softener) but the Medication profile was not updated for these changes as of review 02/02/2023. During an interview with the quality management team stated that medication profiles were not updated as expected.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by a review of documents, clinical records, and interviews. 1 of 16 (6%) records reviewed revealed the agency did not ensure documentation of a pre bereavement risk assessment prior to discharge. Consequently, no opportunity to develop a plan of care for bereavement needs. Agency Policy # 0695 [effective date 02/03/2020] stated in part, "The comprehensive assessment of the patient consists of discipline-specific assessment templates that address the following factors: an initial assessment of the bereavement needs of the patient's family and other involved individuals." Record 2: Patient elected Hospice benefit on 09/17/2022 following a cerebral vascular accident. The nurse on admission documented "not applicable" in the location of the pre bereavement assessment and "no one to assess" for bereavement. Multiple phone calls made with stepson prior to care and each day on service (the patient spoke another language, so stepson assisted with assessments) after the initial nursing assessment. Social work visit 09/20/2022 did not document pre bereavement assessment and no reason why it was not completed. Patient was discharged 09/23/2022 to another location so stepson could be closer to assist with care. During an interview with the quality management team who provided support during clinical record review, who stated that the pre bereavement assessment was not documented prior to a live discharge of the patient.

It is required that each patient’s individualized written plan of care: reflects patient and family goals; Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments; Includes all services necessary for the palliation and management of the terminal illness, including the following: Intervention to manage pain and symptoms; A detailed statement of the scope and frequency of services necessary to meet specific patient and family needs; Measurable outcomes anticipated from implementing and coordinating the plan of care; Drugs and treatment necessary to meet the needs of the patient; Medical supplies and appliances necessary to meet the needs of the patient; Includes the Interdisciplinary Group’s documentation of the patient’s or representative’s level of understanding, involvement, and agreement with the POC. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. 3 of 15 (20%) records that required an update, revealed the agency did not ensure that documentation of current changes for patient care were documented on the Plan of Care (POC). Agency Policy 0830 [effective date 03/27/2017] stated in part, "All members of the interdisciplinary team, participate in care planning based on the assessed needs of the patient/caregiver and document problems, interventions, goals, observations, and outcomes." Record 6: Patient elected the Hospice benefit on 1/13/2022. The nursing comprehensive clinical visit note documented on 12/10/2022 a fever of 102 degrees and monitoring related to respiratory complications. The POC and concurrent interdisciplinary group meetings did not update the POC for infections until 12/27/2022. A goal to prevent infections was identified on admission but no documented update occurred until 12/17/2022. Additionally, on 01/18/2023 a nursing comprehensive assessment documented patient symptomatic for urinary infection symptoms and antibiotics prescribed but the interdisciplinary POC did not document an update to the infection goal as of review 02/03/2023. A nursing comprehensive assessment on 10/26/2022 identified constipation with no bowel movement for 6 days and several medication changes but with no documented update to the POC until 12/22/2022. Record 7: Patient elected the Hospice benefit on 4/28/2022. Nursing clinical notes documented increased respiratory distress on 07/15/2022 with orders for oxycodone and prednisone. There was no update to the POC for the exacerbation of symptoms of respiratory distress. Record 8: Patient elected the Hospice benefit on 10/28/2022. The problem of constipation was identified, and on care plan of 11/06/2022. The nursing visit notes documented that the patient was identified with increased constipation starting 12/5/2022 and a physician visit on 12/19/2022 with medication changes made related to no bowel movement in over 7 days. The Interdisciplinary group met on 12/28/2022 and documented no update for the identified constipation. During an interview with the quality management team who assisted with clinical record review stated that the updates to the POC were not well documented.

It is required that each patient’s individualized written plan of care; Reflects patient and family goals; Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments; Measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. 2 of 16 (12%) records revealed the agency did not ensure that the plans of care documented interventions and measurable goals for all care provided by the team. Agency Policy 0830 [effective date 03/27/2017] stated in part, "All members of the interdisciplinary team, participate in care planning based on the assessed needs of the patient/caregiver and document problems, interventions, goals, observations, and outcomes." Record 6: The Medical Social Worker (MSW) documented on 01/18/2022 an initial assessment and continued contact with family as care concerns and potential placement needs were identified. Frequent telephone calls with spouse and father were documented. The Plan of Care (POC) documented no intervention or goals for the social worker as of review 02/02/2023. Record 11: Patient elected Hospice benefit on 01/07/2023. A documented virtual visit with physician on 01/10/2023 related to increased agitation and anxiety and medication changes of Effexor 150mg was started. The interdisciplinary team meeting documented on 01/12/2023 and 01/26/2023 did not document any intervention or goals for anxiety. During an interview with the quality management team who provided support during joint clinical record review stated that the plans did not document expected goals in the plan of care.

It is required that medical social services are provided. Based on a psychosocial assessment. The psychosocial assessment addresses: The patient’s and the family’s adjustment to the terminal illness. The presence or absence of adequate coping mechanisms. Family dynamics and communication patterns. The caregiver’s ability to function effectively. The psychosocial assessment is revised as new information is acquired and as progress toward goals is made. This standard was not met as evidenced by a review of document reviews, clinical records, and interviews. 1 of 15 (7%) records in which Medical Social Worker (MSW) was accepted, revealed the agency did not ensure that a complete psychosocial assessment was documented. Agency Policy # 0695 (effective date 02/03/2020) stated in part, "Each member of the interdisciplinary team provides input into the comprehensive assessment within the scope of this/her practice and in accordance with the needs and desires of the patient." Record 9: Patient elected Hospice benefit on 11/5/2022 with diagnosis of Cerebral vascular accident. Initially MSW was declined by the family but as the patient's condition declined the daughter requested MSW assist. Initial visit for MSW was 01/18/2023 and was documented on a routine visit form with no subsequent visits as of review 02/02/2022. The comprehensive social work form was not completed and did not include the items of a comprehensive assessment, the family's adjustment to terminal illness, presence or absence of adequate coping mechanisms, family dynamic and communication patterns and the caregiver's ability to function effectively. During an interview with the management team who provided support during record review, it was stated that the assessment was not complete for documentation of the requirements for a psychosocial assessment.