Every finding on record at Oncare Hospice, LLC

Based on record review, policy and procedure review, and staff interview, the agency failed to provide volunteer services at least equal to 5 percent of the total of all patient care hours by paid employees and contracted staff for the periods of 2/2024 through 3/2024, and 5/2024 through 4/2025. The sample size was 19. The census was 64. --- Findings are: A. Review of the agency policy and procedure titled Volunteer Services, Policy No. 4-007, last reviewed 3/2025, revealed:1. The purpose of volunteer services is to support the hospice's mission and meet regulatory requirements, enhance the quality of care provided to patients and families, and reflect the hospice philosophy of community-based support and holistic care.2. The Volunteer Coordinator was to ensure that the cumulative hours contributed by volunteers equals or exceeds 5 percent of the total patient care hours provided by paid and contracted staff.  B. Review of the agency's Volunteer Cost Report for the period of 1/2024 through 4/2025 revealed the agency's cumulative hours contributed by volunteers were less than 5 percent of the total patient care hours provided by paid and contracted staff for each of the months from 2/2024 through 3/2024, and 5/2024 through 4/2025.  C. During an interview on 5/13/25 at 9:25 AM, the agency's Volunteer Coordinator confirmed the agency did not maintain cumulative hours contributed by volunteers of at least 5 percent of the total patient care hours provided by paid and contracted staff for each of the months from 2/2024 through 3/2024, and 5/2024 through 4/2025.

It is required that hospice aides are assigned to a specific patient by a Registered Nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by joint clinical record review and interview. 1 of 10 (10%) applicable records in which an aide was accepted, revealed the agency RN failed to update the aide care plan to include the specific instructions to meet the needs of the patient. Record #97571: (Date of election: 11/18/21): Hospice aide care plan, effective 11/19/21, revealed instructions for the aide to provide a "chair bath" and "assist patient to the toilet." On 11/26/21 the RN clinical note stated that the patient was “transitioning to actively dying” and because of the decline in the condition, a Foley catheter was ordered and was inserted that same day. The hospice aide documented a visit on 11/27/21 and checked the following tasks as being completed “chair bath” and “assist to the toilet.” An RN clinical note on 11/27/21 stated, “the aide was here earlier and gave the patient a bed bath.” The aide care plan did not provide the aide instructions to perform a bed bath or catheter care. The date of death was 11/29/21; the only hospice aide visit that was impacted by the non-updated aide care plan was on 11/27/21. During an interview, conducted on 3/2/22 at 1600, with the Clinical Manager and Administrator, they agreed that the aide care plan was not updated appropriately and that it should have included catheter care and bed bath.