Every finding on record at Tri-County Home and Hospice Care, 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 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. A joint review of the agency report titled "Hospice Volunteer Requirement Report" with the Volunteer Coordinator on 12/01/2025 revealed that volunteer utilization was 0.3% for the period 01/01/2024 through 12/31/2024. The annual volunteer report for calendar year 2025, 01.01/2025 through the review date 12/01/2025, revealed volunteer utilization was 1.56%. During an interview on 12/01/2025, the Volunteer Coordinator stated, "We have not had a Volunteer Coordinator. We have had challenges recruiting volunteers, and we were not able to recruit volunteers. Since last year, we have not been able to recruit enough volunteers, and we have not met the 5% requirement. We are currently in the process of recruiting more volunteers." The Volunteer Coordinator provided documentation of the active volunteer recruitment and retention program, as well as the 2025 Volunteer Manual. They implemented an improvement plan that was started on 08/06/2025. This is an agency improvement plan that is in progress. No further information was provided. The agency did not ensure that volunteer hours met the Medicare requirement of at least 5% of total patient-care hours as required under 42CFR 418.78 (e)

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 16 (12%) clinical records reviewed, the comprehensive assessment was not completed within five calendar days after the election of hospice care. Clinical Record 5: The patient was admitted on 11/15/22. The initial bereavement assessment was done on 12/6/22 when the Social Worker documented a low-risk bereavement assessment. The nurse or the chaplain did not address the bereavement status on admission. The Administrator agreed during the Interview that it should have been addressed before 12/6/22. Clinical Record 6: The patient was admitted on 10/27/22. The initial bereavement assessment was done on 11/8/22 and documented by the Spiritual Counselor, which was 12 days after the election of hospice care.