Every finding on record at Superior Hospice, LLC

Based on record review and interview the agency failed to ensure volunteer service hours were documented for 2 of 2 years (2022–2023) for which records were reviewed. This failure caused an inability of the agency to track and monitor effective utilization of its volunteer staff to assist with allowed administrative tasks as well as direct client support. --- Findings Include: Record review of Volunteer Hours/Cost Saving Calculation for the years 2022-2023 revealed zero volunteer hours were documented. The reports were not signed or dated. 11/14/2024 at 3:10 PM- Interview with AA. Volunteer Cost Savings Reports for 2022-2023 were reviewed. AA stated the total volunteer service hours for 2022-2023 were not documented accurately and volunteers were utilized during that time. AA stated she was not responsible for the report and was not able to provide the actual number of volunteer service hours during that period. During an interview on 11/14/2024 at 4:00 PM with TIC, TIC stated she was an LVN and had been employed by the agency for approximately 3 years. TIC stated she previously held the position of agency Compliance Officer. Surveyor asked if she was aware no volunteer service hours were documented for the years 2022–2023. TIC stated she was not aware of that but was sure volunteers were utilized during that time. Surveyor asked if she knew who the Volunteer Coordinator was during 2022-2023. TIC stated she oversaw volunteer activities during that time. During a telephone interview on 11/15/2024 at 11:17 AM with the Chaplain, he confirmed he is also the Bereavement Coordinator, Volunteer Coordinator, and the only volunteer at this time. Chaplain stated he became the Volunteer Coordinator on 08/03/2024 but has always been a volunteer. Surveyor asked what services he provided as a volunteer. Chaplain stated as a volunteer he delivered supplies to patients, visited with patients, and provided free funeral services. Surveyor discussed the annual volunteer cost savings requirements. Chaplain stated he was not aware of the requirement but would review the procedure with the Administrator. Surveyor asked if there was a plan for recruitment of volunteers. Chaplain stated he planned s to reach out to senior citizens, church members, retired veterans, college students and high school students. Review of the agencys policy titled ";VOLUNTEERS, HR.19. Rvd. 050120", which read ";The hospice will maintain records on the use of volunteers for patient care and administrative services, including the type of services and time worked. The agency will document the cost savings achieved through the use of volunteers. Documentation will include the following: The identification of each position that is occupied by a volunteer. The work time spent by volunteers occupying these positions. A continuing level of volunteer activity."