Every finding on record at Chs Hospice and Palliative Care Services, Inc

Based on volunteer recruiting notes, volunteer list review and interview, the facility failed to maintain a viable ongoing recruitment program for volunteers. This had the potential to affect all 342 patients. Findings include: --- Review of the Volunteer Recruiting Notes dated January 2025 through December 2025 revealed no evidence of a viable, ongoing hospice volunteer recruitment program.  Further review revealed the agency's 2025 recruiting program between January 2025 and December 2025 included monthly posts on a social media platform and flyers were left at the library (four times), post office (once), high school (twice) and four local businesses (twice).  Volunteers were discussed at staff meetings twice and no active recruitment efforts were documented as being completed, except mailing out applications to specific people, between 03/16/25 and 07/15/25. Review of the active Volunteer List revealed the hospice provider had only two active volunteers for all locations. During an interview on 02/18/26 at 10:07 A.M., Director of Operations (DO) #102 stated the agency's Volunteer Coordinator had left the company as of 02/13/26 and he was assuming the role until the position was filled.  DO #102 further stated the agency had identified through it's Quality Assurance (QA) program that they were finding it difficult to recruit new volunteers and were currently recruiting by posting on social media, distributing flyers and in schools.  DO #102 stated this had been in the QA process for at least two years and verified there was no evidence of tracking or trending of what had worked in the past and stated the focus was on retention. A follow-up interview on 02/19/26 at 2:15 P.M. via electronic mail (e-mail) with DO #102 verified the agency only had two active volunteers as of this date for the hospice provider.

Based on volunteer hour review and interview, the facility failed to ensure five percent (%) of total patient care hours was provided by volunteers. This had the potential to affect all 342 patients participating in the hospice program.  Findings include: --- Review of the Volunteer Cost Savings dated January 2025 through December 2025 revealed total frontline patient hours were 157,384 hours, with 562.7 hours provided by volunteers.  This translated into a 3.6% total for patient care provided by volunteers in 2025.   Interview on 02/18/26 at 10:07 A.M. with Director of Operations (DO) #102 verified the facility had not met the required five percent volunteer hours and further stated the facility had not met the benchmark for at least two years.

Based on document review and staff interview, the agency failed to ensure all locations were approved by Medicare.  This has the potential to affect all 342 patients. Findings include: --- Review of the agency's list of locations revealed the parent, or primary location, was at 1122 Taylor Street, Zanesville, Ohio 43701.  A second location was located at 3379 Main Street, Suites A and B, Mineral Ridge, Ohio 44440.  There were sites listed at 856 South Riverside Drive, McConnelsville, Ohio 43756; 860 West Emmitt Avenue, Suite 6, Waverly, Ohio 45690; 1069 Klotz Road, Bowling Green, Ohio 43402; 600 East Smith Road, Medina, Ohio 44256; and 544 Enterprise Drive, Lewis Center, Ohio 43035. Review of the agency's website at BuckeyeHospice.com revealed the agency identified five offices.  The South East office was located at 856 South Riverside Drive, McConnelsville, Ohio .  A phone number and hours of Monday through Friday 8:00 A.M. to 4:30 P.M. were listed.  The North East office was located at 3379 Main Street, Suites A and B, Mineral Ridge, Ohio.  A phone number and hours of Monday through Friday 8:00 AM to 4:30 P.M. were listed.  The South Central office was located at 860 West Emmitt Avenue, Suite 6, Waverly, Ohio.  A phone number and hours of Monday through Friday 8:00 A.M. to 4:30 P.M. were listed.  The North Central office was located at 600 East Smith Road, Medina, Ohio.  A phone number and hours of Monday through Friday 8:00 A.M. to 4:30 P.M. were listed.  The Central office was located at 544 Enterprise Drive, Lewis Center, Ohio.  The hours of Monday through Friday 8:00 A.M. to 4:30 P.M. were listed.  The website did not list a Zanesville location. During an interview on 02/18/26 at 1:55 P.M., Alternate Administrator (AA, #100) and Director of Operations (DO) #101 stated they covered the northern half of the state.  They stated the satellite location in Mineral Ridge took referrals for the satellite location and the northern part of the state.  Human Resources Representative (HR) #105 did the hiring for the satellite office and the northern part of the service area.  There was a clinical lead at each drop site and they did their own scheduling. During an interview on 02/18/26 at 5:35 P.M., DO #101 stated the drop sites were used by staff for documentation or phone calls and they could pick up supplies or paperwork.  HR #105 would go to each drop site for interviews and orientation so applicants did have to drive a couple of hours to get to the Mineral Ridge or the Zanesville office.  DO #101 stated they sometimes did education at the drop sites.  Staff generally participated by video conference for interdisciplinary meetings but could come to the drop site for that as well.  Additionally, DO #101 stated the marketing team used the drop sites. During an interview on 02/19/26 at 1:45 P.M., DO (#102) stated the drop sites were not staffed and were used for staff in those areas to pick up supplies and documents.  The drop sites were used as flexible space and meetings were held there as well.

Based on document review and staff interview, the agency failed to clearly delineate in the hospice's organizational structure and how the lines of authority and professional and administrative control come from the primary or parent location.  This has the potential to affect all 342 patients. Findings include: --- Review of the Organizational chart revealed Administrator #103 reported to Director of Operations (DO) #102, who reported to Chief Operating Officer (COO) #104.  Alternate Administrator (AA) #100 reported to DO #101, who reported to COO #104.  The clinical staff reported to Clinical Supervisors.  Some Clinical Supervisors reported to Administrator #103, while others reported to AA #100.  Human Resources Representative (HR) #105 reported to COO #104. Review of the Office Reporting Structure chart revealed the drop sites located in Bowling Green, Ohio and Medina, Ohio reported to the satellite office in Mineral Ridge.  The satellite office and the drop sites in Waverly, Ohio, McConnelsville, Ohio, and Lewis Center, Ohio reported to the home, or parent office, in Zanesville, Ohio. During an interview on 02/18/26 at 1:55 P.M., AA #100 and DO #101 stated they covered the northern half of the state.  They stated they worked remotely and did not have a home location in any of the offices.  They stated the satellite location in Mineral Ridge, Ohio took the referrals for the satellite location and the northern part of the state.  HR #105 did the hiring for the satellite office and the northern part of the service area.  They stated HR #105 did the orientation at the satellite office and personnel files for the northern staff were stored at the satellite office.  They stated that the personnel files were on-line but the paper forms were stored here.  They stated that  HR #105 was based at the satellite office but did the HR functions for all of the locations.  They stated there were office assistants in the Zanesville, Ohio office who worked under HR #105 and could access the personnel files for the southern employees that were stored in the Zanesville office.  They stated that the satellite office and the Zanesville office functioned the same.  The satellite office did everything for the northern half of the state and the Zanesville office did everything for the southern half of the state.  Due to the agency's growth, Administrator #100 covered the southern half of the state and AA #101 covered the northern half of the state.  There was a clinical lead at each drop site and they did their own scheduling. During an interview on 02/18/26 at 2:39 P.M., Chaplain #106 stated there was no overall Bereavement Coordinator.  The chaplains in the north handled bereavement for the northern half of the service area and the south did their own bereavement services.  Chaplain #106 stated they should be doing the same bereavement services but they were separate. During an interview on 02/18/26 at 5:35 P.M., DO #101 stated the drop sites were used by staff for documentation or phone calls and they could pick up supplies or paperwork.  HR #105 would go to each drop site for interviews and orientation so applicants did not have to drive a couple of hours to get to the Mineral Ridge office or the Zanesville office.  Education was also sometimes completed at the drop sites.  Staff generally participated by video conference for interdisciplinary meetings but the could come to the drop site for that as well.  The marketing team also used the drop sites. During an interview on 02/19/26 at 1:45 P.M., DO #102 stated that COO #104 had his office at the Zanesville location.  A lot of the administrative staff worked remotely and went to where they were needed.  They traveled to the offices and buildings they service and communicate through phone calls, text messages, video conference, and electronic mail (email).  DO #102 stated the Zanesville office had a pod of work stations with an office for Administrator #103.  There was an office which was flexible space that HR #105 used when in Zanesville.  There were a few additional work spaces as well.  DO #102 stated HR #105 worked remotely and the office that HR #105 was observed in at the Mineral Ridge office was a flexible space and not her dedicated space.  DO #102 stated the drop sites were not staffed and were used for staff in those areas to pick up supplies and document.  The drop sites were used as flexible space and meetings were held there as well.

Based on closed record review, staff interview, and policy review, the agency failed to ensure discharge summaries were thoroughly completed.  This affected one (#2) of two patients reviewed for discharge.  The agency census was 342.Findings include: --- Review of the closed medical record revealed Patient #2 was admitted to hospice services on 12/10/25, with a terminal diagnosis of senile degeneration of the brain. The patient was discharged from the hospice provider on 01/20/26. Review of the Facsimile (fax) Transmittal Sheet dated 01/20/26 revealed Patient #2's records were requested to be transferred to a new hospice provider per family request. Further review of the medical record revealed no social service or nursing note regarding the request for medical records or transfer of services to the new provider.  An undated Discharge Summary revealed Patient #2 was transferred to another hospice provider on 01/20/26; however, there was no documentation of the patient's treatments, symptoms, pain management; physician orders or other documentation provided to ensure continuity of care in the record. On 02/19/26 at 3:30 P.M., an interview with Alternate Administrator (AA) #100 verified the facility had discovered concerns regarding completion of patient discharge summaries and had provided staff education on 12/22/25; however, there was no evidence of the above information documented for Patient #2's discharge as required.  AA #100 verified the discharge summary for Patient #2 did not meet the requirements. Review of the agency policy titled, "Live Discharges & Readmissions", undated, revealed live discharges were to have a discharge note charted, a discharge care level charted and any current medications discontinued. The policy did not address discharge summaries as required for live discharges.

Upon patient record review, 1 of 5 (Patient #3) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #3 RN visit on 10/5/21 documented Miralax recommended to the patient. No evidence of Miralax on medication profile.

Upon patient record review, 4 of 5 (Patient #1, #2, #3, and #5) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1 Nursing assessments document pain as an active problem. Order for chaplain frequency of 1x/month. No evidence of patient/family goals for pain or spiritual problems identified. Patient #2 Order for chaplain frequency of 1x/month and social work frequency of 1x/month. Patient with terminal diagnosis of COPD and oxygen ordered. Patient with order for Plavix. No evidence of patient/family goals related to spiritual, psychosocial, bleeding risks, respiratory or oxygen safety problems identified. Patient #3 RN assessments document PEG tube. No evidence of patient/family goals regarding nutritional problems identified. Patient #5 Terminal diagnosis of senile degeneration of the brain. No evidence of patient/family goals for neurological problems identified.

Upon patient record review, 1 of 5 (Patient #3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #3 RN visit on 10/5/21 documented Miralax recommended to patient. No evidence of an order for Miralax. RN visits documented patient with a PEG feeding tube. No evidence of an order to care for the PEG tube site.