Every finding on record at Advisacare Solutions of Northern Michigan, LLC

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 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, and 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 clinical record review, interview, and observation. In 1 of 3 (33%) home visit observations, the agency did not ensure a review of medications the patient was currently using was completed to identify any potential adverse effects and drug reactions. CLINICAL RECORD 1/HOME VISIT 1: This patient elected the hospice benefit on 02/09/2026 with a terminal diagnosis of hypertensive heart disease with heart failure. The registered nurse (RN) initial assessment dated 02/09/2026 stated that patient had oxygen in the room to be used prn. This was not listed on the drug profile which was reviewed for the dates of 02/09/2026-05/04/2026. During the home visit observation on 05/04/2026 with the Registered Nurse (Personnel Record 1), a medication review was completed by comparing the hospice drug profile to the medication list in the home. The home medication list included barrier cream N/A Oral (by mouth) apply barrier cream twice a day to affected area. The home medication list included documentation that this barrier cream was last administered on 05/04/2026 at 7:47am. The hospice drug profile dated 05/04/2026 did not include the barrier cream. The RN stated that this barrier cream should be on the hospice drug profile and that the incorrect route of the medication would be corrected. During a joint review and interview conducted on 05/04/2026, the Administrator (Personnel Record 6) stated that the hospice drug profile would be updated to include the barrier cream and oxygen.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 14 (14%) clinical records reviewed, and in 1 of 3 home visit observations, the agency did not ensure that the plan of care included interventions based on problems identified in the initial and updated comprehensive assessments CLINICAL RECORD 1: This patient elected the hospice benefit on 02/09/2026 with a terminal diagnosis of hypertensive heart disease with heart failure. The initial registered nurse (RN) comprehensive assessment dated 02/09/2026 stated the patient experienced nausea, vomiting, agitation and diarrhea. The drug profile included Zofran 1 tablet every 6 hours as needed for nausea/vomiting and Zofran 2 tablets (4mg tablets) 1 time a day routine. The patient also experienced anxiety/agitation/hallucinations and was administered haloperidol lactate 0.5 ml oral every 6 hours (2mg/ml) as needed for agitation and nausea/vomiting, and lorazepam for 0.25 ml oral every 4 hours (2mg/ml) as needed for anxiety/agitation and restlessness. The plan of care was reviewed for the dates of 02/09/2026-05/04/2026 and did not include interventions for nausea, vomiting, agitation, or diarrhea. CLINICAL RECORD 3/HOME VISIT 3: This patient elected the hospice benefit on 12/18/2024 with a diagnosis of Parkinson's Disease. Review of the clinical record revealed an RN visit note dated 04/24/2026 documented a red area to the patient's mid-back. The hospice plan of care was reviewed for the dates of 04/26/2026-05/06/2026 and did not include interventions for the red area. During a home visit conducted with the hospice aide (Personnel Record 3), the hospice aide was observed to remove a bandage from the patient's back which revealed an open area on the upper mid-section of the back. In joint review and interview with the Administrator (Personnel Record 6) conducted on 05/06/2026, the registered nurse case manager (RNCM)(Personnel Record 10) was contacted and stated that she made a visit to the patient to check the open area on Clinical Record 3. She stated that new orders had been received from the physician and the plan of care was updated to include interventions for the open area. The Administrator (Personnel Record 6) also stated that the plan of care for Clinical Record 1 would be updated to include interventions for nausea, vomiting, agitation, or diarrhea.

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, interview, and observation. In 3 of 10 (30%) clinical records reviewed in which hospice aide services were provided, the agency did not ensure that written patient care instructions for the hospice aide were clear and complete. CLINICAL RECORD 1: This patient elected the hospice benefit on 02/09/2026 with a terminal diagnosis of hypertensive heart disease with heart failure. The hospice plan of care dated 02/09/2026-05/04/2026 included orders for hospice aide visits two times a week (2XW). The hospice aide care plan prepared on 02/09/2026 and last reviewed by the registered nurse case manager (RNCM on 05/01/2026 instructed the hospice aide to provide a shower or bath every visit. In review of the HOSPICE AIDE visit note dated 05/01/2026, the hospice aide marked "acknowledged and completed shower or bed bath every visit". The HOSPICE AIDE care plan did not clearly instruct the hospice aide to give the patient a shower or bed bath. The RN comprehensive assessment dated 02/09/2026 stated the patient was diagnosed with dysphagia. The hospice aide care plan dated 02/09/2026-05/04/2026 instructed the hospice aide to encourage fluids but did not provide instructions for aspiration precautions related to dysphagia. CLINICAL RECORD 2: This patient was admitted 12/31/2025 with a terminal diagnosis of cerebrovascular disease. The RN initial comprehensive assessment dated 12/31/2025 documented that the patient "requires CGA with gait belt and pivot transfers only. She is no longer ambulating or propelling her wheelchair." The hospice plan of care dated 12/31/2025-03/31/2026 included orders for hospice aide visits three times a week (3XW). The hospice aide care plan dated 12/31/2025-03/31/2026 instructed the hospice aide to ambulate with caregiver assistance (CGA) and gait belt. This did not provide clear instructions for CGA and gait belt use were to be utilized for pivot transfers only. CLINICAL RECORD 3/HOME VISIT 3: This patient elected the hospice benefit on 12/18/2024 with a terminal diagnosis of Parkinson's Disease. The hospice plan of care was reviewed for the dates of 02/11/2026-08/20/2026 and included orders for hospice aide visits two times a week (2XW). The hospice aide care plan, which was last updated at 05/03/2026, assigned the hospice aide the task of "Shower at every visit." Review of the clinical record revealed an RN visit note dated 04/24/2026 documented a red area to the patient's mid-back. The hospice plan of care was reviewed for the dates of 04/26/2026-05/06/2026 and did not include interventions for the red area. During a home visit conducted with the hospice aide (Personnel Record 3) on 05/05/2026, the hospice aide was observed to remove a bandage from the patient's back which revealed an open area on the upper mid-section of the back. The hospice aide assisted the patient with her shower and applied a new bandage (plain gauze) to the open area on the patient’s back after the shower. The hospice aide care plan last updated 05/03/2026 did not include instructions addressing the wound dressing on the back should it become dislodged or wet during the shower. During a joint review and interview conducted on 05/06/2026, the Administrator (Personnel Record 6) stated that the hospice aide care plans needed to include more specific instructions for the hospice aide.

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. Review of the Volunteer Activity Report dated 01/01/2026 revealed that the volunteer utilization for the year of 2025 was 0.1%. This did not meet the requirement of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The Volunteer Coordinator (VC) stated that 4 new volunteers had just been onboarded and there was a performance improvement plan to increase the volunteer hours provided to patients. During the interview with the Administrator (Personnel Record 6) and the VC on 05/04/2026 the volunteer utilization was confirmed. An interview was conducted with the Administrator and the Volunteer Coordinator (VC) on 05/04/2026 and the Volunteer Activity Report dated 01/01/2026 was reviewed and revealed that the volunteer utilization for the year of 2025 was 0.1%. This did not meet the requirement of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The VC stated that 4 new volunteers had just been onboarded and there was a performance improvement plan to increase the volunteer hours provided to patients.

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. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical record reviews, the agency did not ensure that the patient's clinical record contained the physician orders. CLINICAL RECORD 1: This patient elected the hospice benefit on 02/09/2026 with a terminal diagnosis of hypertensive heart disease with heart failure. The RN initial assessment dated 02/09/2026 stated that the patient had oxygen in the room to be used prn. A review of the clinical record revealed that there was no order for oxygen. During a joint review and interview conducted on 05/06/2026, the Administrator (Personnel Record 6) stated that the physician would be contacted to obtain orders for oxygen.

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; includes at least the following the patient’s current plan of care; and the patient’s latest physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed for a patient discharged from service, the agency did not ensure the attending physician received a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; patient’s current plan of care; and the patient’s latest physician orders. CLINICAL RECORD 11: This patient elected the hospice benefit on 12/15/2025 with a terminal diagnosis of malignant neoplasm of the bladder and revocated on 04/24/2026. The clinical record did not include evidence that the attending physician received a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, current plan of care and the latest physician orders. During a joint review and interview conducted on 05/06/2026, the Administrator (Personnel Record 6) stated that the clinical record was thoroughly reviewed and there was no evidence that the attending physician received a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, current plan of care or the latest physician’s orders.

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. 2 of 2 (100%) records reviewed, revealed the hospice did not ensure the initial spiritual and psychosocial assessments were completed no later than five (5) calendar days after the patient’s election of hospice care. Clinical Record 1: The patient elected hospice care on 6/21/23. There was no evidence that an initial spiritual assessment was completed, and no documentation of the reason. Clinical Record 6: The patient elected hospice care on 6/20/23. The initial psychosocial assessment was dated 6/27/23. There was no evidence that an initial psychosocial assessment and spiritual assessment was completed, no later than five days after the election of hospice care. There was no documentation of the reason for the delay. During a joint record review and interview on 7/6/23, the Clinical Manager confirmed the finding. Record 1: The patient elected hospice care on 6/21/2023. There was no documented evidence that an initial spiritual assessment was completed and no documented reason for the delay. Record 6: The patient elected hospice care on 6/20/2023. The initial psychosocial assessment was completed on 6/27/2023. There was no documented evidence that an initial psychosocial assessment was completed no later than five days after the election of hospice care and no documented reason for the delay. Additionally, there was no documented evidence that an initial spiritual assessment was completed and no documented reason for the delay. During the joint record review on 7/6/2023, the Clinical Manager agreed, there was no documented evidence the initial assessments were completed no later than five days after the election of hospice care. The Director of Clinical Operations was interviewed by telephone on 7/6/2023 and stated, this was discovered on audits, training was provided, a performance improvement plan is in place, there has not been improvement, we need more accountability.

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 IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by clinical record review, observation, and interview. 1 of 4 (25%) records reviewed, revealed the hospice did not ensure the drug profile was updated. Clinical Record 1 / Personnel Record 2: The patient elected hospice care on 6/21/23. A home visit was conducted on 7/6/23, for a patient residing in an Independent Living Facility (ILF). A medication reconciliation was performed by comparing the hospice medication profile to the ILF medication profile. The hospice medication profile stated, Morphine 20mg/ml, 0.25ml every 2 hours, as needed for SOB. The ILF medication profile stated, Morphine 20mg/ml, 0.25ml every 3 hours as needed for SOB. During a joint record review and interview on 7/6/23, the Clinical Manager confirmed the finding. Record 1: The patient elected hospice care on 6/21/2023. A home visit was conducted in the presence of the Registered Nurse (Record 2) on 7/6/2023, for a patient residing in an Independent Living Facility (ILF). A medication reconciliation was performed by comparing the hospice medication profile to the ILF medication profile. The hospice agency medication profile stated, Morphine 20mg/ml, 0.25ml every 2 hours as needed for SOB. The ILF medication profile stated, Morphine 20mg/ml, 0.25ml every 3 hours as needed for SOB. During the joint record review on 7/6/2023, the Clinical Manager confirmed the finding.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care and ensure the implementation of the interdisciplinary plan of care. THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. 2 of 6 (33%) records reviewed, revealed the hospice did not ensure the coordination and implementation of the interdisciplinary plan of care. Clinical Record 2: The patient elected hospice care on 6/7/23. The plan of care dated 6/7/23 documented chaplain visits 1 x monthly. There was no evidence of a chaplain visit between 6/7/23 - 7/5/23. Clinical Record 3: The patient elected hospice care on 4/22/23. The plan of care dated 4/22/23 documented chaplain visits 1 x monthly. There was no evidence of a chaplain visit between 6/1/23 - 7/5/23. During a joint record review and interview on 7/6/23, the Clinical Manager confirmed the findings. Record 2: The patient elected hospice care on 6/7/2023. The plan of care dated 6/7/2023 ordered chaplain visits 1 x monthly. There was no documented evidence of a chaplain visit between 6/7/2023-7/5/2023. Record 3: The patient elected hospice care on 4/22/2023. The plan of care dated 4/22/2023 ordered chaplain visits 1 x monthly. There was no documented evidence of a chaplain visit between 6/1/2023-7/5/2023. During the joint record review on 7/6/2023, the Clinical Manager agreed, there was no documented evidence of chaplain visits for the timeframes identified.

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 IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. 1 of 4 (25%) records reviewed, revealed the hospice did not ensure that hospice aides were provided specific written instructions. Clinical Record 5: The patient elected hospice care on 2/27/23. The aide care plan dated 5/22/23, assigned the following tasks to be completed every visit: partial bed bath, complete bed bath, shower. The hospice aide visit dated 7/5/23 documented the following: partial bed bath completed, bed bath completed, and shower completed. The care plan did not provide specific instruction to the aide, on whether to provide a partial bed bath, complete bed bath, or shower. During a joint record review and interview on 7/6/23, the Clinical Manager confirmed the finding. Record 5: The patient elected hospice care on 2/27/2023. The aide care plan dated 5/22/2023 assigned tasks to be completed every visit: partial bed bath, complete bed bath, shower. The hospice aide documentation on 7/5/2023 revealed, partial bed bath completed, complete bed bath completed, and shower completed. The care plan did not provide specific instruction to the aide on whether to provide a partial bed bath, complete bed bath, or shower. During the joint record review on 7/6/2023, the Clinical Manager agreed, the aide care plan did not provide specific written instructions and needed to be updated.

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. The record may be maintained electronically or on paper. Each patient’s record includes physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) records reviewed, the hospice did not ensure the clinical record included physician orders. Clinical Record 2: The patient elected hospice care on 6/7/23. The physician order dated 6/7/23, documented the following: Acetaminophen 500mg tablet, every 6 hours, as needed; and Bisacodyl 10mg suppository, one time daily, as needed. The physician’s order did not include indications for as needed use. During a joint record review and interview on 7/6/23, the Clinical Manager confirmed the finding. Record 2: The patient elected hospice care on 6/7/2023. The physician’s order on 6/7/2023 documented Acetaminophen 500mg tablet every 6 hours as needed, Bisacodyl 10mg suppository one time daily as needed. The physician’s order did not include indications in which Acetaminophen tablet or Bisacodyl suppository should be administered. During the joint record review on 7/6/2023, the Clinical Manager agreed, the order was incomplete.

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, document review, observation, and interview. 3 of 14 (21%) records reviewed, revealed the hospice agency did not ensure accurate drug profiles were reviewed and updated at the time of the comprehensive assessment. Clinical Record 1: A home visit was conducted in the presence of the Clinical Manager and Registered Nurse (RN) on 5/23/23, for a patient with a hospice benefit election date of 5/18/23. A medication reconciliation was performed by comparing the hospice medication profile to the medications being taken by the patient. The hospice agency medication profile stated, " Aspirin 81 mg. Take one (1) chewable tablet orally one (1) time a day. The patient stated, "I haven't taken Aspirin for quite a while." The patient reported taking the following: Acetaminophen 500 mg, two (2) tablets orally as needed (PRN) for pain; and Ibuprofen 200 mg, two (2) tablets orally as needed (PRN) for headaches. However, the hospice medication profile did not include Acetaminophen or Ibuprofen. Clinical Record 2: A home visit was conducted on 5/24/23 for a patient with a hospice benefit election date of 1/11/23, residing in an Assisted Living Facility (ALF). A medication reconciliation was performed by comparing the hospice medication profile to the ALF medication profile. The hospice medication profile stated, "Xoponex HFA 45mg/ACT. Give one (1) aerosol inhalation every six (6) hours as needed for other symptoms". The ALF medication profile stated, "Xoponex HFA 45 mg/ACT. Give two (2) inhalations every four (4) hours as needed." Clinical Record 3: A home visit was conducted on 5/24/23 for a patient with a hospice benefit election date of 2/27/23, residing in an Independent Living Facility (ILF). A medication reconciliation was performed by comparing the hospice medication profile to the ILF medication profile. The hospice medication profile stated, "Furosemide twenty (20) mg. Take one (1) tablet orally as needed." The ILF medication profile did not contain the medication Furosemide twenty (20) mg. During a joint clinical record review and interview on 5/23/23 and 5/25/23, the Clinical Manager confirmed the findings.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. 3 of 14 (21%) records reviewed, revealed the agency did not ensure the coordination and implementation of the interdisciplinary plan of care Clinical Record 3: A patient with a hospice benefit election date of 2/27/23 had a plan of care (POC) dated 5/24/23. The POC did not contain an order for aide services. However, the aide was visiting the patient two (2) times weekly. In addition, the Registered Nurse (RN) orders stated, "RN two times weekly." There was only one RN visit the week of 5/8/23 - 5/14/23. The chart did not contain evidence of the physician or IDG being notified of the missed visit. Clinical Record 4: A patient with a hospice benefit election date of 3/11/23 had a care plan with an order for Chaplain services once a month. There was no evidence of Chaplain services for the months of March, April, or May. Clinical Record 6: A patient with a care plan dated 3/29/23 had orders for Chaplain services once a month. There was no evidence of Chaplain services for the months of March, April, or May. During a joint record review and interview, the Clinical Manager and Director of Clinical Operations confirmed the findings.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene, safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids, and safe handling of soiled items in the patient’s care environment. This standard was not met as evidenced by observation, document review, and interview. In 1 of 3 (33%) home visits conducted, it was revealed that the hospice agency did not follow accepted standards of practice to prevent the transmission of infections and communicable disease, including hand hygiene. Agency policy X.8, Standard Precautions (no revision date), stated in part, "The following precautions will be implemented to minimize infections... Hands must be washed before and after contact with each patient, after contact with potentially infectious material, before and after putting on and removing PPE (Personal Protective Equipment), including gloves." Home Visit 2 / Clinical Record 2: A home visit was conducted with a Licensed Practical Nurse (LPN) (Staff 6) at an Assisted Living Facility (ALF) on 5/24/23, in the presence of the Clinical Manager. The LPN did the following: wheeled the patient from the dining room to the patient's private space; gathered clean supplies for personal care; and removed the patient's soiled brief. No hand hygiene was performed until after the brief was removed. The LPN did not wear gloves when removing the soiled brief. During a joint observation and interview on 5/24/23, the Clinical Manager confirmed the finding.

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, document review, and interview. In 1 of 2 (50%) records reviewed, where hospice aide services were accepted, it was revealed that the hospice agency did not ensure written instructions and supervision were provided for the hospice aide. Agency policy III.31, titled Clinical Record Contents and Maintenance (no revision date), stated in part, "The record will contain pertinent past and current medical, nursing, social and other information as appropriate to the care and treatment of the patient. The patient's clinical record will contain data including but not limited to patient problems, and an individual plan of care for all disciplines providing services, including goals/outcomes". Clinical Record 3: A Patient with a hospice benefit election date of 2/27/23 had an aide plan of care dated 5/17/23 with hospice aide frequency two (2) times (X) weekly. The record contained hospice aide visits noted from the following dates: 3/10/23, 3/13/23, 3/21/23, 3/24/23, 3/28/23, 3/31/23, 4/4/23, 4/7/23, 4/11/23, 4/14/23, 4/18/23, 4/21/23, 4/25/23, 4/28/23, 5/2/23, 5/9/23, 5/12/23, and 5/16/23. There was no effective aide plan of care on these dates. A joint record review and interview was conducted on 5/23/23, the Director of Clinical Services confirmed the hospice aide completed visits on the referenced dates without an aide plan of care.

CONDITION OF PARTICIPATION: 418.78 Volunteers. The hospice must use volunteers to the extent specified in paragraph (e) of this section. These volunteers must be used in defined roles and under the supervision of a designated hospice employee. Volunteers are considered hospice employees to facilitate compliance with the core services requirement. 418.78(a) The hospice must maintain, document and provide volunteer orientation and training that is consistent with hospice industry standards. 418.78(b) Volunteers must be used in day-to-day administrative and/or direct patient care roles. 418.78(c) The hospice must document and demonstrate viable and ongoing efforts to recruit and retain volunteers. 418.78(d) The hospice must document the cost savings achieved through the use of volunteers. 418.78(e) Volunteers must provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff. The hospice must maintain records on the use of volunteers for patient care and administrative services, including the type of services and time worked It is required that a hospice ensures that “non-core” services are available and provided directly by the hospice or under arrangement. The hospice must use volunteers to the extent specified in paragraph (e) of this section. These volunteers must be used in defined roles and under the supervision of a designated hospice employee. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by document review, observation, and interview. Review of clinical records, administrative documents, and interviews with leadership revealed the hospice agency did not use volunteers in defined roles to facilitate compliance with the core services requirement. The hospice did not use volunteers in a day-to-day administrative and/or direct patient care role. (418.78(b)). Therefore the hospice did not document and demonstrate viable and ongoing efforts to recruit and retain volunteers (418.78(c)); did not document the cost savings achieved through the use of volunteers (418.78(d)); and did not ensure that volunteers provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff (418.78(e)). The cumulative effect of these deficient practices may pose a risk to patient safety and has resulted in a Condition Level finding under CFR 418.78 Volunteers.

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 personnel record review and interview. 1 of 10 (10%) personnel records reviewed, revealed the hospice did not assess the skills and competencies of all individuals providing care, including volunteers providing services. Personnel Record 1: Personnel with a hire date of 3/16/20 served multiple roles including Administrator, Chaplain, Bereavement Coordinator, and Volunteer Coordinator. There was a documented job description of Volunteer Coordinator. However, there was no evidence of assessed skills and competencies specific to Volunteer Coordinator. During a joint record review and interview on 5/24/23, the Administrator/Volunteer Coordinator confirmed the finding.