Every finding on record at Cardinal Hospice South, LLC

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. Volunteer Program: A review of the cost savings report revealed that the agency did not ensure 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. The total volunteer hours reported, from April 2024 through April 2025, was equal to 2.77%. During an interview, on 05/21/2025, the Administrator said that they have struggled with recruiting volunteers and that they were looking to hire a full-time volunteer coordinator.

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 certification and recertification of terminal illness as required. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 14 (14%) clinical records reviewed it was revealed that the agency did not ensure the written certification of terminal illness included a brief narrative, written by the physician, as required. CLINICAL RECORD 9: The patient elected the hospice benefit on 04/13/2025. The initial certification of terminal illness (CTI) was signed by the physician designee on 05/22/2025 however, the narrative section of the CTI was left blank. CLINICAL RECORD 13: The patient elected the hospice benefit on 08/04/2023. The initial certification of terminal illness (CTI) was signed by the physician designee on 08/09/2023 however, the narrative section of the CTI was left blank. PERSONNEL RECORD 1: During the joint clinical record review, conducted on 05/23/2025, the Administrator confirmed that the physician designee had signed the CTI without completing the narrative. She also stated that the physician had the ability to document the narrative directly on the CTI through the EMR (electronic medical record) or could dictate the narrative but was unable to provide evidence that either was completed for these records.