Every finding on record at Life Choice Hospice of Alabama, LLC

It is required that 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; [and] the frequency of service delivery. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #C19 "Bereavement Services" stated in part, “Bereavement services are documented according to the bereavement plan of care." In 1 of 4 (25%) clinical records reviewed with bereavement services, the agency did not ensure that bereavement services were provided according to the bereavement plan of care. Clinical Record 18: The patient elected hospice care on 11/13/2023 and died on 12/07/2023. The bereavement plan of care was reviewed for 11/13/2023 through 06/13/2024. The bereavement assessment on 11/14/2023 identified the bereaved as a low risk. The plan of care dated 11/14/2023 revealed the services and frequency to be provided to the bereaved including support mailings and education materials at one (1), three (3), and six (6) months. There was no documented evidence that the one (1), three (3), and six (6) months mailings were sent to the bereaved. There was no documented evidence the bereaved declined bereavement services. During an interview on 06/13/2024, the Bereavement Coordinator stated, "If you don't see anything, that probably means they didn't want bereavement." During a joint review of the record and interview on 06/13/2024, the Director of Clinical Services stated, "I only see the two-week letter sent." The Director of Clinical Services agreed there was no documented evidence that bereavement services were provided according to the bereavement plan of care.

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. Agency policy #C20 "Volunteer Services" stated in part, “Volunteers, under the supervision of the volunteer coordinator, provide both patient support and administrative support in a manner and amount consistent with the program's identified needs while ensuring a minimum cost savings of 5%." A review of the Hospice Volunteer Requirement Report revealed the agency did not ensure that hospice volunteers provided 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. The Hospice Volunteer Requirement Report reviewed for January through June 13, 2024, revealed a volunteer cost savings of 3.42% for the parent and alternate delivery site combined. During a joint review of the Hospice Volunteer Requirement Report and interview on 06/13/2024, the Director of Clinical Services agreed the hospice agency did not meet the minimum five percent cost savings requirement.. During a joint review of the Hospice Volunteer Requirement Report and interview on 06/13/2024, the Area Executive of Clinical Operations agreed with the finding.