Every finding on record at Gencare Hospice LLC

It is required that the hospice designates a registered nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any); the patient or patient representative; the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) records reviewed, it was revealed that the hospice did not ensure the registered nurse followed the plan of care as ordered. Clinical Record 1: The patient’s date of election of benefits was 10/3/2022. A physician’s order on 2/14/2023 ordered SN (skilled nurse) to perform wound care to left heel M W F (Monday, Wednesday, Friday). During the week 2/19/2023-2/25/2023, there was a nursing visit with wound care documented on 2/22/2023. There was no documented evidence of a second or third nursing visit or documented reason for the missed visits. During the week 2/26/2023-3/4/2023, there was a nursing visit with wound care documented on 3/1/2023. There was no documented evidence of a second or third nursing visit or documented reason for the missed visits. During the week 3/5/2023-3/11/2023, there was a nursing visit with wound care documented on 3/8/2023. There was no documented evidence of a second or third nursing visit or documented reason for the missed visits. During the week 3/12/2023-3/18/2023, there was a nursing visit with wound care documented on 3/15/2023. There was no documented evidence of a second or third nursing visit or documented reason for the missed visits. During the week 3/19/2023-3/25/2023, there was a nursing visit with wound care documented on 3/22/2023. There was no documented evidence of a second or third nursing visit or documented reason for the missed visits. During the week 3/26/2023-4/1/2023, there was a nursing visit with wound care documented on 3/29/2023. There was no documented evidence of a second or third nursing visit or documented reason for the missed visits. The Administrator was interviewed on 4/6/2023 and stated, “we are having a nurse at the assisted living facility do it but there is no documentation it was done, it's all discussed verbally,” The Administrator agreed, there was no documented evidence that the wound care was provided as ordered by the physician.

It is required that the hospice ensures that each patient and the primary caregiver(s) receive education and training, provided by the hospice, as appropriate to their responsibilities for care as stated in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) records reviewed of a patient with a wound, it was revealed that the hospice did not ensure that the facility nurse responsible for wound care received education and training provided by the hospice as appropriate to their responsibilities for the wound care. Clinical Record 1: The patient’s date of election was 10/3/2022 with a primary hospice diagnosis of senile degeneration of the brain. A physician’s order on 2/14/2023 ordered SN (skilled nurse) to perform wound care to left heel M W F (Monday, Wednesday, Friday). During the weeks 2/19/2023-2/25/2023, 2/26/2023-3/4/2023, 3/5/2023-3/11/2023, 3/12/2023-3/18/2023, 3/19/2023-3/25/2023, 3/26/2023-4/1/2023, there was a nursing visit with wound care documented by the hospice registered nurse one time weekly. There was no documented evidence that the hospice provided education and training to the facility nurse as appropriate to their responsibilities for the wound care. The Administrator was interviewed on 4/6/2023 and stated, “We are having a nurse at the assisted living facility do the wound care a few times a week but there is no documentation of education with the facility staff or nurse on the specifics of the wound care, it’s all done verbally.”

It is required that each patient’s individualized written plan of care reflects patient and family goals, 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 and interview. In 2 of 2 (100%) records reviewed with wounds, the hospice did not ensure the plan of care was updated with patient and family goals and planned interventions for the wounds. Clinical Record 1: The patient’s election of benefits form was dated 10/3/2022. A Registered Nurse assessment was documented as completed on 2/14/2023 and documented a left heel eschar open wound. The plan of care for the benefit period 2/14/2023-4/5/2023 was reviewed. There was no documented evidence that the written plan of care was individualized to reflect patient and family goals with planned interventions for the wound. Clinical Record 2: The patient's election of benefits form was dated 1/9/2023. A Registered Nurse assessment completed on 3/22/2023 documented a skin tear to the shin. The plan of care was reviewed for the benefit period dated 3/22/2023-4/5/2023. There was no documented evidence that the written plan of care was individualized to reflect patient and family goals with planned interventions for the wound. The Administrator was interviewed on 4/6/2023 and agreed, there was no documented evidence that the plan of care included planned interventions or patient and family goals for the wounds identified.

It is required that counselling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counselling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: the types of bereavement services to be offered; the frequency of service delivery. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 1 (100%) record reviewed with a discharge due to death, it was revealed that the hospice did not ensure adherence to the agency’s bereavement policy. Document 2: Stated in part, “The hospice will make bereavement services available to the family and other individuals in the bereavement plan of care (POC) before, and for up to one year following the death of the patient. Patient and family privacy rights and confidentiality will be maintained throughout the bereavement period.” Clinical Record 5: The patient’s date of election was 10/6/2022. The bereavement record was reviewed and revealed the patient died on 10/10/2022. A bereavement assessment on 10/11/2022 identified the son as the bereaved with a low risk. There was no documented evidence of other bereaved individuals to include in bereavement. The bereavement plan of care listed, sympathy card, 1 month letter, and 3-month letter. Bereavement mailings were documented as sent on 10/11/2022, 11/11/2022 and 1/11/2023 to a different name and address than the son. There was no documented evidence the son received bereavement services. The Bereavement Coordinator was interviewed on 4/6/2023 and stated, “They declined Chaplain service, so I didn’t send any bereavement,” and “I am not familiar with that name the letters went to.” The Administrator was interviewed on 4/6/2023 and stated, “it looks like the letters went to the wrong person” and agreed, there was no documented evidence bereavement was provided to the son. Additionally, during interview on 4/6/2023, the Administrator confirmed, there was no documented evidence that bereavement care was declined by the son prior to March 2023.

It is required that the hospice maintains a written comprehensive emergency preparedness program that demonstrates compliance with applicable federal, state, and local emergency preparedness requirements, uses an “all hazards” approach, describes the hospice’s approach to meeting the health, safety, and security of the staff, the patient population, with attention to their mobility, [and] describes how the hospice coordinates with other healthcare facilities, as well as the community, during an emergency or disaster situation. This standard was not met as evidenced by document review and interview which revealed the agency failed to ensure to develop and implement an EP plan that was based on a hospice-based and community-based risk assessment, using an “all-hazards” approach [HSEP.2.D/E6; failed to ensure that the EP plan included a process for cooperation and collaboration with local, tribal, regional, State, or Federal emergency preparedness officials [HSEP.2.D/E9]; failed to ensure the EP plan addressed the use of volunteers, off-duty hospice employees and other emergency staffing strategies [HSEP.3.D/E24]; failed to ensure the EP plan addressed informing local and state emergency officials about patients in need of evacuation [HSEP.3.D/L19]; failed to ensure the communication plan included the primary and alternate contact information for federal, state, tribal, regional, or local emergency management agencies was develop and maintain [HSEP.4.D/E32]; failed to ensure the communication plan included the contact information for federal, state, tribal, regional, or local emergency management agencies was develop and maintain [HSEP.4.D/E31]; and failed to ensure the EP plan included a process to release patient medical information to ensure continuity of care [HSEP.4.D/E33]. The cumulative effect and scope of this deficiency could negatively impact the agency's ability to provide safe, quality care that meets the needs of patients, families, and caregivers for the palliation and management of the terminal illness and related conditions.

It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two(2) years. The plan is based on and includes a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served and includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural or man-made disasters, emerging infectious diseases (EIDS) that place the health and safety of patients and employees at risk; and other anticipated emergencies that could affect the hospice’s ability to provide care. This standard was not met as evidenced by document review and interview. The agency did not ensure to develop and implement an EP plan that was based on a hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served. A review of the agency's "Emergency Policies and Procedures" dated 8/16/2022 revealed that the agency had emergency policies and procedures but had not developed an agency-specific EP plan based on the completion of a community hazard vulnerability analysis using an “all-hazards” approach specific to the geography and population served. During an interview on 2/21/2022, the Administrator confirmed the finding and stated there was no hospice or community hazard vulnerability analysis documented. No further evidence of a hospice-based and community-based risk assessment was provided as of the conclusion of the site visit. A review of the Emergency Policies and Procedures and the agency's plan from 8/16/2022 through/20/2023 revealed that while the agency did have a policy, the policy had not been implemented, as evidenced by no documented all-hazards approach that was specific to the hospice's geographical area and common emergencies that occur in that area. Review of EC.40 (effective 8/16/2022 through 2/20/2023), on page 4 under the heading of "Identification and Assessment of Risks, the policy states that the hospice would review the All Hazards Community/Hospice Based Risk Assessment for Potential Disasters in order to ensure that hospice staff understood each emergency type that could pose a risk for the hospice and the community. This portion of the policy had not been implemented as evidenced by a missing Hazard Vulnerability Analysis (HVA). In an interview with the administrator on 2/21/2022, she confirmed that there was no hospice or community hazard vulnerability analysis documented. At the time of the survey, the Administrator was unable to produce an HVA or describe what an HVA was or how to perform an HVA.

It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two(2) years. The plan includes a process for cooperation and collaboration with local, tribal, regional, State, or Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency. This standard was not met as evidenced by document review and interview. The agency did not ensure that an EP plan was developed and included a process for cooperation and collaboration with local, tribal, regional, State, or Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency. A review of the agency's "Emergency Policies and Procedures" dated 8/16/2022 revealed that the agency had emergency policies and procedures and an EP plan template. The EP plan template was not completed with the agency's specific information. There was no evidence that the agency's EP plan identified the local, tribal, regional, state and federal emergency preparedness officials' to maintain an integrated response during a disaster or emergency. During an interview on 2/22/2023, the Administrator confirmed that the agency did not develop and implemented the agency's EP plan that contained the required contact information for the local, tribal, regional, state, or federal levels. A review of the Emergency Policies and Procedures and the agency's plan from 8/16/2022 through 2/20/2023 revealed that while the agency did have a policy, they had not implemented the policy by developing its own agency-specific emergency plan that contained contact information for local, regional, tribal, state, and/or federal emergency management officials in order to assist with emergency response during a disaster. Review of EC.40 (effective 8/16/2022 through 2/20/2023), the agency had not implemented the portion of the policy that requires cooperation and collaboration with local, regional, state, and federal emergency officials with the purpose of maintaining an integrated response during a disaster. In an interview on 2/22/2023 with the Administrator, she confirmed that the agency did not ensure the emergency plan contained the required contact information for the local, tribal, regional, state, or federal levels. At the time of the survey, the Administrator was unable to produce any emergency official contact information nor discuss any contacts made with emergency management officials.

It is required that the hospice implements emergency preparedness (EP) policies and procedures based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address development and inclusion of a plan for each hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment, the documented discussion of the plan provided to the patient/family, and maintained by the hospice, follow up with patients/families to determine needs in the event that care is interrupted during or due to an emergency, arrangements with facilities and other providers to receive patients to maintain the continuity of care to patients, and informing local and state emergency officials of any on-duty employees that the hospice is unable to contact. This standard was not met as evidenced by document review and interview. A review of the agency's "Emergency Policies and Procedures" dated 8/16/2022 and the EP plan template revealed no evidence of a communication plan to address agency-specific procedures to follow up with patients/families to determine needs in the event that care is interrupted during or due to an emergency and informing local and state emergency officials of any on-duty employees that the hospice is unable to contact. During an interview on 2/22/2022, the Administrator confirmed that there was no documented process for primary and alternate methods of communication in the event of phone or power disruption, and there was no agency-specific plan documenting how follow-up would occur with patients, staff, or emergency officials. A review of the Emergency Policies and Procedures effective from 8/16/02022 through 2/20/2023 revealed that this policy had not been implemented as evidenced by no documentation of any agency-specific information for a system of communication and alternate means of communication with patients, staff, other healthcare providers, or emergency management officials. There is no documented agency-specific plan as to when and how emergency officials would be contacted as needed if the hospice was unable to make contact with patients or staff in an emergency. Additionally, the agency had not documented the process for how and when to follow up with patients, staff, healthcare providers, and/or emergency officials. A review of the EC.40 Policy effective 8/16/2022 through 2/20/2023 on page 10 under the heading of " The Response and Recovery Phase," the policy stated the agency would define a primary and alternate mode of communication or alert systems in the event of telephone or power failure. The policy also stated the hospice would document a method for sharing information and medical documentation with other healthcare providers. during a disaster. Additionally, the policy stated the agency would document procedures for follow-up and communicate with staff, patients, or local, state, and federal emergency m management agencies and other healthcare providers and suppliers to determine services that are needed. And finally, the policy stated that the agency would have a procedure to inform state and local officials of any on-duty staff or patients that this hospice is unable to contact. These components of the policy were not implemented, as evidenced by no documentation in an agency-specific plan for how the hospice planned to communicate with patients and/or staff in the event of a failure of the primary means of communication. There is no direction in the agency plan to describe how they will share patients' medical documentation with other healthcare providers if needed. The plan doesn't include a description of how the agency will follow up with patients, staff, or emergency management officials. And finally, there is no documentation as to how and when local and/or state emergency officials are informed of any on-duty employees that this hospice is unable to contact. In an interview with the Administrator on 2/22/2022, she confirmed that there was no documented process for a primary and alternate method of communication in the event of phone and/or power disruption, there was no agency-specific plan documenting how follow-up would occur with patients, staff, or emergency official, and there was no documentation of an agency-specific plan for a system or process for sharing patients' medical information with other healthcare providers or emergency officials. During the interview, the Administrator offered no information verbally on how these components plan would be met, nor was the Administrator able to produce any of these areas of documentation.

It is required that the hospice implements emergency preparedness (EP) policies and procedures based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address informing local and state emergency officials about patients in need of evacuation from their residence at any time due to the emergency based on the patient’s medical or psychiatric condition, or home environment. This standard was not met as evidenced by document review and interview. The hospice did not ensure the EP plan addressed how the agency would inform local and state emergency officials about patients in need of evacuation from their residence at any time due to the emergency based on the patient’s medical or psychiatric condition, or home environment. A review of the agency's "Emergency Policies and Procedures" dated 8/16/2022 and the EP plan template revealed that the EP plan did not identify which local and state emergency officials would be informed for patients in need of evacuation. During an interview on 2/22/2023, the Administrator confirmed the finding and stated that the agency's emergency plan did not contain a information for contacting and sharing medical information with local and state emergency officials in case of evacuation. A review of the Emergency Policies and Procedures and the agency plan effective from 8/16/2022 through 2/20/2023 revealed that this component of the policy had not been implemented, as evidenced by no documentation on how the hospice would inform local and state emergency officials about hospice patients may need evacuation from their residences during a disaster and how they would provide those officials with necessary medical information for the patients. A review of the EC.40 Policy effective 8/16/2022 through 2/20/2023 on page 5, the policy stated that the agency would include a procedure to inform state and local officials about hospice patients in need of evacuation from their residences at any time due to an emergency situation. This section of the policy was not implemented as evidenced by no documented process for informing local officials about patients in need of evacuation. In an interview with the Administrator on 2/22/2023, it was confirmed that the agency's emergency plan did not contain a process for how to contact and share medical information with local and state emergency officials to assist hospice patients with evacuation as needed during a disaster. During the interview, the Administrator was unable to verbalize how the agency would meet this requirement, nor was the Administrator able to produce any documented parts of the agency-specific plan to meet this regulation.

It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address the use of volunteers, off-duty hospice employees and other emergency staffing strategies, including the process and role for the integration of State and Federally designated health care professionals to address surge patient care needs during an emergency. This standard was not met as evidenced by document review and interview. A review of the agency's "Emergency Policies and Procedures" dated 8/16/2022 revealed that the agency had emergency policies and procedures and an EP plan template. The EP plan template was not completed to describe how the hospice would address the use of volunteers, off-duty hospice employees and other emergency staffing strategies, including the process and role for the integration of State and Federally designated health care professionals to address surge patient care needs during an emergency. During an interview on 2/22/2023, the Administrator confirmed that the agency had no documented process of how it planned to communicate agency or their patients' needs to emergency management officials. A review of the Emergency Policies and Procedures effective from 8/16/2022 through 2/20/2023 revealed that the agency did have an Emergency Policy, but the policy had not been implemented as evidenced by no documented agency-specific strategies for staffing issues that could a disaster. Furthermore, there was no documented process for ways in which hospice staff could assist state and federal emergency officials to address increases in patient care needs in the area during an emergency. And finally, there was no documented process for when and how the hospice would request assistance from emergency officials. Review of the EC.40 Policy (effective 8/16/2022 through 2/20/2023) on page 10, under the heading of "The Response and Recovery Phase," the policy stated that the emergency preparedness and response plan for the hospice would describe a means of providing information to the authority having jurisdiction information about the hospice's needs and its ability to provide assistance. There is no documentation included in the agency's specific emergency plan on the process the agency would utilize to contact emergency officials and communicate the hospice's needs or how the agency would provide emergency officials on how the hospice staff could assist with any local surges in patient care needs. This portion of the policy had not been implemented, as evidenced by no documentation of how the agency planned to accomplish this requirement. In an interview with the Administrator on 2/22/2023, it was confirmed that the agency had no process documented for how the agency planned to communicate their or their patients' needs to emergency management officials or how the hospice could integrate with local emergency efforts to assist with a surge in patient needs in the area. The administrator was unable to produce this documentation or describe ways that the agency planned to meet this requirement.

It is required that the hospice maintains an emergency preparedness communication plan that complies with federal, state, and local laws. The communication plan includes contact information for the federal, state, tribal, regional, and local emergency preparedness staff and other sources of assistance. This standard was not met as evidenced by document review and interview. A review of the agency's "Emergency Policies and Procedures" dated 8/16/2022 and the EP plan template revealed the plan did not contain documented evidence of contact information for federal, state, tribal, regional, or local emergency management agencies or officials. During an interview with the administrator on 2/22/2022, it was confirmed that the agency had no contact information for any emergency officials or resources in their emergency plan. A review of the Emergency Policies and Procedures effective from 8/16/2022 through 2/20/2023 revealed that while the agency did have an Emergency Policy, the policy had not been implemented, as evidenced by the agency's emergency plan missing contact information for federal, state, tribal, regional, or local emergency management agencies or officials. Review of policy EC.40 effective from 8/16/2022 through 2/20/2023 on page 10 under the heading "Response and Recovery Phase" the policy stated that the hospice would have means of providing information about the hospice's needs to the authorities having jurisdiction during a disaster. There was no contact information for any emergency management offices or official nor any resources for emergencies like the Red Cross, FEMA, etc. In an interview with the administrator on 2/22/2022, it was confirmed that the agency has no contact information for any emergency officials or resources in their emergency plan. The Administrator could not produce this documentation during the site visit or verbalize how the hospice would fulfill this requirement.

It is required that the hospice maintains an emergency preparedness communication plan that complies with federal, state and local laws. The communication plan includes primary and alternate means for communicating with hospice staff, and federal, state, tribal, regional, and local emergency management agencies. This standard was not met as evidenced by document review and interview. A review of the agency's "Emergency Policies and Procedures" dated 8/16/2022 and the EP plan template revealed that the agency did not develop and maintain a communication plan to include the primary contact information for employees, federal, state, tribal, regional, or local emergency management agencies or an alternate means of communicating in the event of a disaster. During an interview with the Administrator on 2/22/2023, the finding was confirmed. A review of the Emergency Policies and Procedures effective from 8/16/202 through 2/20/2023 revealed that the agency did have an Emergency Policy, but the policy had not been implemented as evidenced by the agency-specific emergency plan did not include any alternate contact information for federal, state, tribal, regional, or local emergency management agencies or alternate means of communicating in the event of a disaster. Review of the EC.40 policy effective 8/16/2022 through 2/20/2023 on page 10 under the heading of "Response," the policy stated that if communication methods at a hospice site are disrupted, mobile communication systems, email, short-wave radios, walkie-talkies, social media, local TV, or radio are designated as alternate methods to communicate with the patient population or staff if necessary. Additionally, on page 10, under the heading of "Response and Recovery Phase," the policy stated that the agency's emergency preparedness and response plan would describe a means of providing information to the authority having jurisdiction .... about the hospice's needs and its ability to provide assistance. There is no contact information documented in the agency emergency plan for any emergency management officials. The agency's specific emergency plan had no documentation of an alternate backup communication method designated nor did their plan include how the agency planned to provide information to any emergency or other authorities about the hospice's potential needs in a disaster or the hospice's ability to provide assistance. In an interview with the Administrator on 2/22/2023, it was confirmed that there was no documentation in the agency's emergency plan of a designated alternate method of communication in the event the hospice's primary means of communication failed and no alternate contact information for emergency officials. The Administrator was unable to produce any agency information or plan for another means of communication, nor was the Adminstrator able to verbalize how the agency would handle a disruption in communication.

It is required that the hospice maintains an emergency preparedness communication plan that complies with federal, state, and local laws. The communication plan includes how information and medical documentation for patients under the hospice’s care is shared, as necessary, with other healthcare providers to maintain the continuity of care and a means to share information in the event of an evacuation concerning how to release patient information, including their general condition and location, as permitted by the Health Insurance Portability and Accountability Act (HIPAA). This standard was not met as evidenced by document review and interview. A review of the agency's "Emergency Policies and Procedures" dated 8/16/202 and the EP plan template revealed that the agency did not include a documented process to release patients' medical information during a disaster that complied with HIPAA laws and ensured continuity of care with other healthcare providers or assisted local emergency management officials with patient evacuation or location as required. During an interview with the Administrator on 2/22/2023, it was confirmed that the hospice had no defined process documented in the emergency plan as to how the agency would share patient information as needed during a disaster situation, and could not produce such documentation nor describe verbally how the agency would fulfill this requirement. A review of the Emergency Policies and Procedures effective from 8/16/202 through 2/20/2023 revealed that the agency did have an Emergency Policy, but the policy had not been implemented as evidenced by the agency-specific emergency plan that did not include a documented process to release patients' medical information during a disaster that complies with HIPAA laws and ensures continuity of care with other healthcare providers or assists local emergency management officials with patient evacuation or location as required. Review of the EC.40 policy effective 8/16/2022 through 2/20/2023 page 11 under the heading "Response" the policy stated that the agency would include in their agency's emergency plan a process to release patient information in a HIPAA compliant way in the event of a disaster to include other healthcare porviders and a means to release information to non-healthcare providers (like realtives, neighbors, friends) with authorization. The policy also states the agency's plan should include a process on sharing patient information as necessary to identify, locate, notify family members, guardians, or the patient's POA about the patient's location, general condition or death. And a process to share patient information with those necessary to prevent or lessen a serious and imminent threat to the health and safety of persons or the public consistent with applicable law and ethical conduct. The agency's emergency plan contained no process for how the agency would ensure that patient information could be provided as needed and spelled out by HIPAA and the emergency policy. In an interview with the Administrator on 2/22/2023, it was confirmed that the hospice has no defined process documented in the emergency plan as to how the agency would share patient information as needed during a disaster situation. Furthermore, the Administrator could not produce such documentation nor describe verbally how the agency would fulfill this requirement.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. The agency did not ensure that ongoing recruitment and retention of volunteers were documented. A review of the Hospice Volunteer Binder revealed no documented evidence of a viable and ongoing effort to recruit and retain volunteers. During an interview on 2/22/2023 and 2/23/2023, the Volunteer Coordinator confirmed that the agency had no documented volunteer recruitment efforts. A review of the Volunteer Department information and documentation effective 8/16/2022 through 2/20/2023, there was no documentation for ways in which the agency planned to recruit volunteers. Furthermore, there was no documentation that any recruitment efforts had occurred. Review of the Hospice Volunteer Binder and "Hospice Volunteer Recruitment" policy (no policy number and no effective date), on page 2 the policy stated ways in which the hospice could pursue recruitment efforts. This policy was not implemented as evidenced by no documentation that any interventions by the hospice had been performed to bring more volunteers into the agency. In an interview with the Volunteer Coordinator on both 2/22/2023 and 2/23/2023, it was confirmed that the agency had no documented volunteer recruitment efforts. During the site visit, neither the Volunteer Coordinator nor the Administrator were able to produce any volunteer recruitment documentation. Additionally, the Volunteer Coordinator could not verbalize any actions that they agency had taken to recruit volunteer.