Every finding on record at Interim Healthcare of Wichita Inc (Hospice)

Based on document review, policy review and interview, the hospice failed to ensure that the required percentage of patient hours provided through use of volunteers was achieved. This deficient practice has the potential to affect availability and provision of services for patients who request volunteer services. --- Findings Include:Review of the Hospice Policy titled, "IV. Volunteer Services," dated 04/25/18, showed Volunteers must provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equaled 5 percent of the total patient care hours of all paid hospice employees and contract staff.The surveyor requested and reviewed Volunteer program documentation to support provision of volunteer services to hospice patients and that included percentage of total patient care hours. Documentation provided titled, "Hospice Volunteer Program 2024," showed percentages (%) by month and the year-end monthly average percentage at 0.94%.During an interview on 05/30/25 at 12:45 PM, Staff H, Volunteer Coordinator confirmed the percentage of volunteer hours fell short of the required 5% minimum for the hospice.