Every finding on record at Arbor Vitae Hospice Care, Inc.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. Documentation includes the identification of each position that is occupied by a volunteer. The work time spent by volunteers occupying those positions and estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions. This standard was not met as evidenced by document review and interview. A review of the volunteer program documents revealed that the agency did not ensure the hospice volunteers provided an amount at a minimum equal five percent of total patient care hours. Agency's Policy H:2-009, Volunteer Services (dated 08/2012), stated in part, "The Volunteer Coordinator will track the use of volunteers, the cost saving achieved, and the hours of volunteer services will exceed 5% of the total patient care hours of paid and contracted hospice personnel.” On 09/18/2025 an interview with the Volunteer Coordinator/Volunteer, she reported that she was the only volunteer at this time and that she had been performing administrative duties. She said she was unaware that she was supposed to document the hours she volunteered and calculate the hours to meet the 5%. Both the Volunteer Coordinator and the Director of Patient Care Services reported they were unable to locate the volunteer hours for 2023, 2024, or so far in 2025. The agency did not ensure hospice volunteers provided amount at a minimum equal five percent of total patient care hours. They lack any tracking documentation to support percentage of hours or dollar cost savings.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary and the patient’s record, if requested. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 1 (100%) clinical records reviewed where the hospice patient was transferred to a Medicare/Medicaid certified facility, it was revealed that the agency did not ensure a copy of patient's discharge summary was forwarded to the facility. Agency Policy H:2-081, Transfer Information, stated in part "Completed transfer summaries will be given to a clinical records clerk who will send a copy to receiving organization within 72 hours of transfer." CLINICAL RECORD 12: The patient was admitted to hospice on 10/09/2024 and was transferred to a Medicare/Medicaid certified facility on 11/23/2024 due to fracture of right hip. Registered Nurse note (11/23/2024) noted transfer but there was no documentation that the discharge summary was forwarded to the receiving facility. In an interview on 09/18/2025 the Director of Patient Care Services acknowledged a discharge/transfer summary was created in the electronic medical record and confirmed there was no evidence of the summary forwarded to the Medicare/Medicaid certified facility.

It is required that a hospice aide provides services; ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by a review of clinical records and interviews. 3 of 7 (43%) records reviewed for patients receiving aide services revealed, the agency did not ensure the hospice aides provided services as ordered on the plan of care (POC) and consistent with hospice aide training. Clinical Record 4: The patient elected hospice care on 9/1/2022. The POC dated 9/1/2022 ordered Aide services three times weekly. A missed Aide visit was identified the week ending 8/3/2022. The record lacked documentation of why the visit was not provided as ordered and that the RN or Physician was notified. Clinical Record 11: The patient elected hospice care on 9/9/2022, and the patient died on 9/20/2022. The POC dated 9/9/2022 ordered Aide services three times weekly. Missed Aide visit were identified the weeks ending 9/10/2022, 9/17/2022 and 9/24/2022. The record lacked documentation of why the visits were not provided as ordered and that the RN or Physician were notified. Home Visit 1: A joint home visit conducted with the hospice aide on 10/20/2022. The aide was preparing to give the patient a bed bath and placed the bed in high position and lowered the bed rails. The aide stepped out of the room to obtain water for the bath and did not lower the bed or put the side rails up. Surveyor remained in the room to ensure patient safety. The Director of Patient Care Services was interviewed during a joint review of the clinical record on 10/20/2022. The Director confirmed that the aide visits were missed, and that the agency did not have documentation of missed visits or the reason(s) why the missed visits was not provided.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician; a copy of the hospice discharge summary, and the patient's record, if requested. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 1 (100%) records reviewed for patients discharged from services revealed the agency did not ensure that a discharge summary was sent to the physician. Clinical Record 9: The patient was discharged from services on 4/20/22. The record lacked evidence that the discharge summary had been forwarded to the patient's physician. The Director of Patient Care Services acknowledged in an interview on 10/20/22 that there was no documentation validating that the discharge summary was provided to the physician.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following; a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 1 (100%) record reviewed for patients discharged revealed that the hospice did not ensure that the discharge summary was completed. Clinical Record 9: The patient revoked hospice services on 4/20/2022. The record lacked evidence of a completed discharge summary. Review of the clinical record there was no evidence of discharge summary. The Director of Patient Care Services acknowledge in an interview on 10/20/22 that there was no documentation validating that the discharge summary was completed.