Hospice of Midwest

“Based on record review, policy review, and interviews, the hospice agency failed to have volunteer hours that equaled five percent (%) of total patient hours. This failure had the potential to affect all 37 patients receiving hospice services. Findings include: Review of the “Hospice Volunteer Requirement Report,” dated May 2025 through May 2026, provided by the facility, revealed the agency’s monthly volunteer hour percentages were as follows: May 2025 – 0.00%June 2025 – 0.00%July 2025 – 0.00%August 2025 – 0.00%September 2025 – 0.00%October 2025 – 0.00%November 2025 – 0.55%December 2025 – 0.33%January 2026 – 0.73%February 2026 – 0.34%March 2026 – 0.82%April 2026 – 0.69%May 2026 – 0.00% During an interview on 05/21/26 at 10:00 AM, the Volunteer Coordinator (VC) stated he/she began working at the agency in August 2025 and had one volunteer providing services to patients, but the volunteer had to resign due to going to college this year. The VC also stated that through recent recruitment efforts, he/she had four volunteers that had completed the orientation, and they would begin providing services next week. During an interview on 05/21/26 at 6:10 PM, the Director of Clinical Services (DCO) stated the former VC resigned in 2025 and he/she had been trying to recruit volunteers but was unsuccessful. The DCO also stated the current VC began employment in August 2025 and began recruitment efforts in 2026 at churches and the Veterans of Foreign War (VFW) as well as posting the need for volunteers on a website. The DCO indicated four volunteers completed the orientation and would begin volunteering next week. The DCO confirmed that the five percent volunteer requirement was not met because they only had one volunteer to provide services. Review of the hospice agency’s policy titled “Volunteer Services,” provided by the agency, revised 09/01/22, revealed “Purpose To ensure that qualified volunteers provide appropriate services in accordance with the plan of care and hospice needs … Procedure … 4. The Volunteer Coordinator will track the use of volunteers, the cost savings achieved, and that the hours of volunteer services will exceed 5% of the total patient care hours of paid and contracted hospice personnel …””

“Based on interview and record review, the Hospice agency failed to send the patient’s discharge summary to the attending physician when the hospice service was revoked for one of one patients (Patient (P) 13) reviewed for revocation out of a total sample of 14. This failure had the potential to disrupt the continuity of care by the physician for the patient. Findings include: Review of P13’s undated “Patient Profile,” located under the “Patient Profile” tab in the electronic medical record (EMR), revealed P13 was admitted to hospice services on 12/23/25 with the terminal diagnosis of congestive heart failure (CHF). Review of P13’s “Visit Note,” dated 01/05/26, located under the “Visit Notes” tab in the EMR, revealed Registered Nurse (RN) 1 contacted P13 confirming his/her visit appointment time and P13 stated that he/she did not want a visit and decided to revoke the service because he/she wanted treatment that was not included in the hospice plan of care (POC). Review of P13’s “Clinical Note,” dated 01/05/26, located under the “Coordination Notes” tab in the EMR, revealed the Director of Clinical Operations (DCO), master-level Social Worker (MSW), and RN1 had a conference call with P13’s primary physician regarding the revocation of hospice services, services P13 wanted moving forward, and care provided by the hospice agency. Review of P13’s “Hospice Discharge Summary,” dated 01/15/26, located under the “Coordination Notes” tab in the EMR, revealed P13 revoked hospice services on 01/05/26 to seek aggressive treatment and he/she wanted increased amounts of medications at home and to continue to seek specialist consultation throughout care. During an interview on 05/21/26 at 4:50 PM, the Team Coordinator (TC) stated he/she faxed the discharge summary to the patient’s physicians, if one was listed in the EMR, after the Interdisciplinary Group (IDG) meetings in which patient revocations and discharges were discussed every 14 days. The TC verified that P13’s referring physician was listed as his/her secondary physician and a fax cover sheet to P13’s secondary physician could not be found in the EMR. During an interview on 05/21/26 at 5:39 PM, the DCO stated P13 revoked hospice services and signed the revocation form on 01/05/26 due to the desire to receive aggressive treatment rather than palliative care. The DCO indicated the discharge summary was not sent to the referring physician because he/she was not listed as the attending physician in the EMR, however, P13’s discharge summary was discussed with the referring physician via telephone on 01/05/26. Review of the agency policy titled “Discharge Summary,” provided by the agency, revised 09/01/22, revealed “Purpose To define the requirements for documentation of a discontinuation of a service and when patients are discharged from hospice. Policy All patients discharged from a service and from hospice will have a discharge summary completed and filed in the clinical record. Procedure … 3. A copy of the discharge summary will be provided to the patent’s attending physician. If requested, the patient’s clinical records will be provided …””

“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. This standard was not met as evidenced by document review and interview. A review of the Hospice Volunteer Requirement Report revealed that hospice did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The Volunteer Requirement Report for 01/01/2024-12/31/2024 documented that the volunteer hours were at 0.49%. The Volunteer Requirement Report for 01/01/2025-12/31/2025 documented that the volunteer hours were at 1.65%. The Volunteer Requirement Report for 01/01/2026-03/02/2026 documented that the volunteer hours were at 0.35%. There was no documented evidence that the volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. During an interview on 03/06/2026, the Volunteer Coordinator agreed that there was no documented evidence that volunteer hours were at least five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. Additionally, the Volunteer Coordinator stated, “I just started last year. We are working on getting more patients to accept volunteers.” During an interview on 03/06/2026, the Director of Clinical Operations agreed there was no documented evidence that volunteer hours were at least five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. Additionally, the Director of Operations stated, “We didn’t have the right person in the role. We hired a dedicated volunteer and bereavement coordinator in 2025. We have a Performance Improvement Project in place and are working on it.” A review of the Hospice Volunteer Requirement Report revealed that hospice did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.”

“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, the patient’s record, if requested. This standard was not met as evidenced by clinical record review, document review and interview. 2 of 2 (100%) clinical records of patients who had a live discharge reviewed revealed that the hospice did not ensure the discharge summaries were sent to the patients’ attending physicians. Agency Policy, “Discharge Policy”, Policy No. 1-026.1, stated in part, “A copy of the discharge summary will be provided to the patient’s attending physician. Hospice will complete all necessary audits to determine the completeness of the patient’s clinical record within 30 days of the last hospice visit and discharge date. CLINICAL RECORD 15: The patient elected the hospice benefit on 09/06/2025 and was discharged due to revocation on 11/25/2025. A discharge summary, present in the record, was documented on 11/25/2025. There was no documented evidence that the discharge summary was sent to the patient’s attending physician. CLINICAL RECORD 16: The patient elected the hospice benefit on 10/24/2024 and was discharged due to no longer terminally ill on 08/15/2025. A discharge summary, present in the record, was documented on 08/15/2025. There was no documented evidence that the discharge summary was sent to the patient’s attending physician. During a joint record review and interview on 03/06/2026, the Director of Clinical Operations agreed there was no documented evidence that the discharge summaries were provided to the patients’ attending physicians. Additionally, the Director of Clinical Operations stated, “It is the responsibility of the Team Coordinator, and it was not getting done.” The Director of Clinical Operations agreed that the agency did not follow the Discharge Policy.”