Every finding on record at Suncrest Hospice Cleveland, LLC

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. The agency did not ensure that hospice volunteers provided administrative or direct patient care services in an amount equivalent to at least five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The "2024 Annual Volunteer Hours and 2025 Annual Volunteer Hours" reports were reviewed with the Administrator on 04/17/2025. The Administrator confirmed that 0.0047% of volunteers provided day-to-day administrative and/or direct patient care services from 01/01/2024 through 12/31/2024, and 0.10% of volunteers provided day-to-day administrative and/or direct patient care services from 01/01/2025 through 03/31/2025, less than the required 5%. During an interview on 04/17/2025, the Administrator confirmed that volunteer utilization was below the 5% requirement for the periods from 01/01/2024 through 12/31/2024 and 01/01/2025 through 03/31/2025. The Administrator stated, "We have had three volunteer coordinators in the last three years. Our current volunteer coordinator started in March 2025 and is focusing on recruitment. He has onboarded a volunteer and increased our percentage from 0% in January and February to 0.10% in March." The hospice agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.

It is required that medical supplies and appliances related to the palliation and management of the patient’s terminal illness and related conditions are checked for expiration dates. This standard was not met as evidenced by observation of the supply room with inspection of patient related items and interview. A tour on 6/30/2022 of the supply room containing various patient related items revealed one (1) protective ointment tube expired in June 2021. The senior Compliance Educator was present and a witness during the supply room inspection and confirmed the ointment was expired. Item was removed from the supply room.