Arbor Hospice

“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.”