Every finding on record at Inspire Hospice-W, LLC

It is required that each patient’s individualized written plan of care, includes all services necessary for the palliation and management of the terminal illness, including the following: Measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed it was revealed that the agency did not ensure the patient's plan of care included measurable outcomes from implementing and coordinating the plan of care. Clinical Record 7: The patient elected the hospice benefit on 03/08/2023. The skilled nurse follow-up assessment dated 08/28/2024 revealed the patient had obtained two skin tears to the left forearm. The plan of care dated 09/04/2024 did not include measurable outcomes for wound/integumentary problems. In an interview on 09/19/2024, the Director of Quality stated, "Oh no, we will work on it."

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. A review of the volunteer percentage form revealed that the agency did not ensure that the volunteers provided administrative or direct patient care services equal to a minimum of 5% of the total patient care hours. Document 1: A review of the volunteer percentage form for January 2024 to current revealed an average volunteer percentage of 2% for 2024. The Volunteer Coordinator in an interview on 09/19/2024 stated a performance improvement plan (PIP), developed in August 2024, was in place to address the volunteer percentage. A review of the volunteer percentage form revealed that the agency did not ensure that the volunteers provided administrative or direct patient care services equal to a minimum of 5% of the total patient care hours.