Every finding on record at Servant's Heart Hospice, LLC

Based on record review and interview, the agency failed to ensure volunteers provided 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 employees and contract staff.   Findings: --- Review of the provider’s current Volunteer Services Policy and Procedure, revised 07/2017, revealed the following, in part:Purpose: To ensure that qualified volunteers provide appropriate services in accordance with the plan of care and hospice program needs. Procedure: 7. The Volunteer Coordinator will track the use of volunteers, the cost savings achieved, and that the hours of volunteer services will meet or exceed 5% of the total patient care hours of paid and contracted hospice personnel.A review of the provider’s Volunteer Hour Report sheets dated 11/01/2024 – 10/31/2025 revealed the provider did not consistently 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 employees and contract staff. The provider failed to meet the 5 percent requirement for the months of November 2024, December 2024, January 2025, March 2025, April 2025, July 2025, September 2025, and October 2025. On 11/05/2025 at 10:15a.m., an interview was conducted with S2Director of Nursing (DON).  S2DON confirmed volunteers did not provide administrative and/or direct patient care services to meet the minimum 5 percent of total patient care hours for the months of November 2024, December 2024, January 2025, March 2025, April 2025, July 2025, September 2025, and October 2025.

Based on personnel record review and interview the provider failed to ensure the Hospice Certified Nurses Aide received 12 hours of in-service training during a 12 month period for 4 of 4 Hospice Certified Nurses Aides (S3CNA, S4CNA,S7CNA, S8CNA) reviewed for In-service training. --- Findings: Review of the personnel record revealed S3HCNA had a hire date of 07/28/21. Further review revealed the employee did not complete 12 hours of in-services for the 12 month period of 2022. Review of the personnel record revealed S4HCNA had a hire date of 07/15/21. Further review revealed the employee did not complete 12 hours of in-services for the 12 month period of 2022. Review of the personnel record revealed S7HCNA had a hire date of 12/30/19. Further review revealed the employee did not complete 12 hours of in-services for the 12 month period of 2022 .Review of the personnel record revealed S8HCNA had a hire date of 10/12/17. Further review revealed the employee did not complete 12 hours of in-services for the 12 month period of 2022. Interview on 02/08/23 at 2:10pm, with S1Interim Administrator confirmed the Hospice Certified Nursing Assistances did not complete 12 hours of in-service training in the year 2022.

Based on record review and staff interview the provider failed to ensure all employees were provided orientation upon hire to the employee's specific job duties for 2 of 6 (. S2RN, S5RN) staff personnel records reviewed. --- Findings: Review of S2RN (Registered Nurse) personnel record revealed a hire date of 01/03/22. Further review revealed no documentation of an initial orientation to hospice was completed upon hire or since for the employee. Review of S5RN (Registered Nurse) personnel record revealed a hire date of 09/01/22. Further review revealed no documentation of an initial orientation to hospice was completed upon hire or since for the employee. Interview on 02/08/23 at 3:15pm, S1Interim Administrator confirmed after reviewing S1RN and S5RN's personnel records that orientation was not completed for these two Registered Nurses upon hire.