Compassus - Indianapolis

“It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient’s attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by clinical record reviews, document reviews, observations, and interviews with the Administrator, Management and Clinical teams, and the Regional Quality Director, which revealed the hospice: Failed to ensure that the Registered Nurse (RN) provided coordination of patient care, continuous assessment of the patient and family’s needs, and implementation of the interdisciplinary plan of care in 6 of 19 (32%) clinical records reviewed [HCPC.19.I/L540]; Failed to ensure that the plan of care included the scope and frequency of services necessary to meet specific patient and family needs in 1 of 19 (5%) clinical records reviewed [HCPC.21.I/L547]; Failed to ensure all drugs and treatments necessary to meet the patient’s needs were included in the plan of care in 2 of 19 (11%) clinical records reviewed [HCPC.21.I/L549]; and Failed to ensure that the patient’s plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments in 6 of 19 (32%) clinical records reviewed [HCPC.21.I/L545]. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.56: Interdisciplinary group, care planning, and coordination of service. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the hospice agency.”

“It is required that a hospice aide provides services: ordered by the Interdisciplinary Group; included in the plan of care; permitted to be performed under state law and regulation; [and] consistent with the hospice aide training. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by clinical record reviews, observation, and interviews with the Administrator and Regional Quality Director, which revealed the following: Failure of the agency to ensure that the Hospice Aide received written patient care instructions prepared by a Registered Nurse (RN) responsible for the supervision of the Hospice Aide In 3 of 13 (23%) clinical records reviewed [HCDT.15.I/L625]; Failure of the agency to ensure that the Hospice Aide provided services as instructed in the Hospice Aide care plan in 1 of 13 (8%) clinical records reviewed [HCDT.16.I/L626]; and Failure of the agency to ensure that the Hospice Aide reported changes in the patient’s needs to the RN in 2 of 13 (15%) clinical records reviewed [HCDT.16.I/L628]. The cumulative effect of these deficiencies has resulted in the hospice agency’s ability to ensure the provision of quality hospice care for the condition of participation CFR 418.76: Hospice Aide and Homemaker Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice aide services from the agency.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive [sic] measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review, observation, and interview. Agency policy #PC-15 “Medication Reconciliation” stated in part, “Document a complete medication inventory, noting prescriptions, over-the-counter medications, and herbal preparations the patient is currently taking or has on hand. Review all ordered medications for effectiveness, side effects, drug/drug interactions, duplicative therapies, and potential laboratory monitoring needed.” In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that comprehensive assessment included a review of the patient’s current medications. Clinical Record 3/Home Visit 3: The patient elected hospice care on 08/15/2024. The updated nursing assessment dated 09/12/2024 documented instructions for the patient to use “Bio Freeze” for neck and back pain. During the home visit with the Chaplain (CH) [Personnel Record 3] on 09/17/2024, the patient was observed using “Bio Freeze” on their neck and higher back. The patient stated that they had a lot of pain and that it helped. The medication profile was not updated as of 09/18/2024 to include the “Bio Freeze.” There was no evidence that “Bio Freeze” was reviewed with the patient’s medication regimen. Clinical Record 13: The patient elected hospice care on 12/21/2023. The initial nursing comprehensive assessment dated 12/21/2023 documented the patient’s allergy to Seroquel (Quetiapine- antipsychotic medication). The patient had a current order for Quetiapine 150mg every night for sleep. Evidence showed that the physician and pharmacy were aware of the patient’s allergy. There was no documentation that this was reviewed with the patient as potentially causing side effects due to the patient’s allergy. Clinical Record 17: The patient elected hospice care on 10/17/2023. A clinical record review of the certification period dated 01/15/2024 to 04/02/2024 revealed the skilled nursing note dated 02/16/2024, documenting the skilled nurse’s recommendation that the patient use “Bio freeze” cream or Tylenol for knee pain. The medication profile did not document these medications. There was no evidence that the Bio Freeze and Tylenol were reviewed with the patient’s medication regimen. During an interview and joint record review, the Administrator stated that the medication profiles were not updated.”

“It is required that the hospice designates a registered nurse member of the IDG to: provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; [and] ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care. This standard was not met as evidenced by clinical record review, document review, interview, and observation. Agency policy #PC-15 “Nursing Services” stated in part, “Nursing services include the following: Initial and ongoing assessment of the patient and family with respect to the impact of their terminal diagnosis and disease process on their physical, emotional social, spiritual and functional capabilities. Implementation of the plan of care and recommendations for revision to the plan of care based on assessment data. Collaboration with the interdisciplinary team and coordination of all patient care/support activities.” In 6 of 19 (32%) clinical records reviewed, the agency did not ensure that the Registered Nurse (RN) member of the IDG provided care coordination and ensured the implementation of the interdisciplinary plan of care. Clinical Record 1: The patient elected hospice care on 03/26/2024 with a diagnosis of Alzheimer’s Disease. Volunteer services were requested and assessed on 03/29/2024 with an ordered visit frequency of four (4) times a month for companionship. Volunteer visit notes were documented on 04/24/2024 and 04/26/2024, two (2) times a month. On 05/15/2024, the ordered visit frequency was decreased to two (2) times a month. On 06/07/2024, a coordination note stated the volunteer needed a break and would resume in late June. There was evidence documenting the family’s notification, but the family’s response was not documentedocumented. A clinical record review revealed no volunteer visit notes documented from 05/15/2024 through 08/2024 and no evidence that the RN member of the IDG coordinated care to ensure all disciplines provided the visits ordered by the IDG (Interdisciplinary Group). Clinical Record 4: The patient elected hospice care services on 04/14/2024. The Plan of Care (POC) for the certification period dated 04/14/2024 to 07/12/2024 ordered a Medical Social Worker (MSW) evaluation. The clinical record did not include documentation of the MSW evaluation. The RN member of the IDG did not coordinate care to ensure all disciplines provided the visits ordered by the IDG. Clinical Record 7: The patient elected hospice care services on 08/30/2023 with a diagnosis of multi-system degeneration of the autonomic nervous system. On 12/12/2023, the physician ordered Speech Therapy (ST), a frequency of three (3) visits for the patient with increased swallowing difficulty and choking. A clinical record review revealed no evidence that the three (3) ST visits were completed and no evidence that the RN member of the IDG coordinated care to ensure all disciplines provided the visits ordered by the IDG. Clinical Record 8: The hospice elected hospice care on 05/24/2024 with the diagnoses of senile degeneration and stage 3 and 4 pressure ulcers. On 05/21/2024, the physician ordered wound care for all wounds, with daily measurements of all three wounds. Wound care measurements were documented on 05/23/2024, 05/30/2024, 06/03/2024, 06/10/2024, 06/13/2024, 06/17/2024, and 06/22/2024. There was no evidence of wound measurements or communication with the physician to change the wound measurement frequency for July 2024. The RN did not coordinate the daily measurements ordered or care follow-up for the wounds dressed weekly and twice a week for the patient. The patient’s wounds did improve during this time. Clinical Record 17: The patient elected hospice care on 10/17/2023. For the certification period dated 10/17/2023 through 01/14/2024, the Hospice Aide (CNA) documented the observation of a new wound on the patient’s left elbow on 01/16/2024. The CNA documented that this observation was reported to the RN/Case Manager (CM). A clinical record review revealed no evidence of follow-up coordination of care by the RN/CM or communication with the CNA. During an interview with the CNA and RN/CM, the nurse agreed the CNA had called with the concern, but this was not documented in the clinical record. Clinical Record 18: The patient elected hospice services on 05/11/2023 with an order for a Medical Social Worker (MSW) to evaluate the patient who demonstrated poor coping and concerning behaviors. The patient resided in a facility. The coordination note dated 05/15/2023 documented that the MSW attempted a phone evaluation, but there was no answer. On 05/19/2023, the MSW documented a missed visit as the patient could not be reached. On 06/22/2023, the MSW entered a coordination note documenting an attempt to call the patient’s sister to obtain the patient’s phone number, but there was no answer. In the same coordination note, the MSW documented they were awaiting a return call after leaving a message for the facility’s Social Worker on 06/21/2023 and 06/22/2023 for collaboration and assistance with the patient’s Medicaid application. Other hospice team members documented visiting the patient. The RN member of the IDG did not coordinate care to ensure all disciplines provided the visits ordered by the IDG. During an interview, the management team confirmed the findings, stating they started a process improvement in May 2024 for documentation as a review of records identified the need for documentation consistency.”

“It is required that each patient’s individualized written plan of care: reflects patient and family goals; [and] identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 6 of 19 (32%) clinical records reviewed, the agency did not ensure that the patient’s plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected hospice care on 03/26/2024 with a diagnosis of Alzheimer’s Disease. The updated nursing comprehensive assessment dated 07/16/2024 documented a stage 2 pressure area on the patient’s right back and a stage 1 pressure area on the patient’s neck. The plan of care was not updated to include planned interventions to address the patient’s problems with skin integrity. The updated comprehensive assessment dated 08/17/2024 documented that a nutritional supplement was started for weight loss. The POC was not updated with an intervention to address the patient’s identified problem with weight loss. Clinical Record 10: The patient elected hospice care on 06/18/2024 with a primary diagnosis of lung cancer with metastasis to the brain. The initial comprehensive assessment documented that the patient had pain, and morphine was ordered. The POC for the certification period dated 06/18/2024 to 09/15/2024 did not include interventions to address the patient’s identified problem with pain and the use of morphine. Clinical Record 11: The patient elected hospice care on 03/01/2024 with the diagnoses of senile degeneration of the brain, unspecified mental disorder, anxiety, and hypertension ( HTN). The initial comprehensive nursing assessment dated 03/01/2024 documented a fall risk assessment that indicated the patient was at high risk for falls. The patient was incontinent of urine and required a cane for ambulating. The plans of care for the certification periods of 03/01/2024 to 05/29/2024 and 05/30/2024 to 08/27/2024 did not include documentation of interventions to address the patient’s identified problems with falls and incontinence. Clinical Record 12: The patient elected hospice care on 04/24/2024 with the diagnoses of senile degeneration of the brain, unspecified dementia, complete atrioventricular (AV) block, atrial fibrillation (A-Fib), and atherosclerosis of the heart. The initial nursing comprehensive assessment dated 04/24/2024 documented that the patient was incontinent of bowel and bladder and ambulatory with the assistance of another person. The plans of care for the certification period dated 04/24/2024 to 07/22/2024 did not include documentation of interventions to address the patient’s identified problems with incontinence and mobility. Clinical Record 13: The patient elected hospice care on 12/21/2023 with the diagnoses of centrilobular emphysema, pulmonary HTN, coronary artery disease (CAD), and chronic respiratory failure. The initial nursing comprehensive assessment dated 12/21/2023 documented that the patient was furniture walking, had shortness of breath, was oxygen dependent, complained of pain, and was incontinent of urine at times. The plans of care dated 12/21/2023 and updated every two weeks did not document planned interventions for the patient’s fall risk and pain. The initial comprehensive assessment documented the patient’s anxiety and the anti-anxiety medications ordered. The POC did not include documentation of interventions to address the identified problems with anxiety. The initial comprehensive nursing assessment documented that the patient was using oxygen and was an active smoker. The plan of care did not document oxygen safety interventions specific to this patient. The nursing visit notes documented education for the patient and safety measures related to oxygen safety. Clinical Record 14: The patient elected hospice care on 04/26/2024 with the diagnoses of acute ischemia of large intestines, cerebral infarct, atrial fibrillation, and HTN. The initial nursing comprehensive assessment dated 4/26/2024 documented the patient’s active complaints of pain, incontinence of bowel and bladder habits, and high-risk medications that included Eliquis (anticoagulant), aspirin (antiplatelet), and Tramadol (opioid). The initial POC dated 04/26/2023 and the updated plans of care did not document interventions for the patient’s identified problems with incontinence, high-risk medications, and pain. During an interview, the Management Team confirmed the findings. They presented their quality process improvement projects effective May of 2024.”

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met, as evidenced by clinical record review, document review, and interview. Agency policy #C9, “Written Interdisciplinary Plan of Care,” stated in part, “The content of the plan includes at a minimum: Detail and scope and frequency of services necessary to meet the assessed needs, including the level of care.” In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the plan of care included the scope and frequency of services necessary to meet specific patient and family needs. Clinical Record 16: The patient elected hospice care on 04/06/2023 with a primary diagnosis of Alzheimer’s Disease. The initial nursing comprehensive assessment identified the patient’s need for volunteer services. There were documented volunteer visit notes dated 05/03/2023, 05/20/2023, and 05/27/2023. A missed visit note was documented for the week of 05/07/2023 through 05/13/2023. A volunteer assignment in the coordination notes dated 06/01/2024 documented that a volunteer would visit weekly for companionship. The updated plans of care dated 05/10/2023 through 01/16/2024 did not document that the volunteer frequency was weekly. However, volunteer visits were being provided. During an interview, the management team confirmed the finding, stating that a full evaluation of clinical documentation was conducted, and process improvement for accurate documentation started in May 2024 and continues.”

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the plan of care (POC) included drugs and treatments necessary to meet the patient’s needs. Clinical Record 3/Home Visit 3: The patient elected hospice care on 08/15/2024. The updated nursing assessment dated 09/12/2024 documented instructions for the patient to use “Bio Freeze” for neck and back pain. During the home visit with the Chaplain (CH) [Personnel Record 3] on 09/17/2024, the patient was observed using “Bio Freeze” on their neck and higher back. The patient stated that they had a lot of pain and that it helped. The plan of care did not document “Bio Freeze.” Clinical Record 17: The patient elected hospice care on 10/17/2023. A clinical record review of the certification period dated 01/15/2024 to 04/02/2024 revealed the skilled nursing note dated 02/16/2024, documenting the skilled nurse’s recommendation that the patient use “Bio freeze” cream or Tylenol for knee pain. The plan of care did not document “Bio Freeze” and Tylenol. During an interview, the Management Team confirmed the findings and stated that following audits, a process improvement project was in place to ensure accurate and complete documentation.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions, such as: safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids; safe handling of soiled items in the patient’s care environment; Other requirements of applicable state and federal law and regulation. This standard was not met, as evidenced by document review, interview, and observation. The Sani wipe label read, “Contact Time: Use a second germicidal cloth to thoroughly wet the surface. Allow to remain wet for three (3) minutes; let air dry.” In 1 of 4 (25%) home visits observed, the agency did not ensure that the clinician followed all recommended cleaning of equipment per manufacturer requirements. Home Visit 1/Clinical Record 1: During the home visit with the Registered Nurse (RN) [Personnel Record 1] on 09/17/2024, the RN completed the patient assessment and cleaned their equipment with the Sani wipe. The tape measure used during the assessment was retractable. It was cleaned and immediately retracted, not allowing wet time for decontamination. The thermometer, stethoscope, pulse oximeter, and blood pressure cuff were also cleaned and allowed to be wet and dry. The case where the RN kept the equipment was cleaned and returned to the bag. The case was not allowed to dry. During an interview, the Clinical Team stated that education would be provided to ensure this process is followed.”

“It is required that Medical social services are provided by a qualified social worker: medical social services are provided by a qualified social worker: based on a psychosocial assessment; according to the patient’s and family’s needs and acceptance of these services; per the plan of care; under the direction of a physician. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that medical social services were provided per the plan of care (POC). Clinical Record 4: The patient elected hospice care on 04/14/2024. The POC for the certification period dated 04/14/2024 to 07/12/2024 ordered a Medical Social Worker (MSW) evaluation. A clinical record review revealed no evidence of the MSW evaluation. Clinical Record 12: The patient elected hospice care on 04/24/2024. The Plan of Care (POC) for the certification period dated 04/24/2024 to 07/22/2024 ordered a Medical Social Worker (MSW) evaluation. A clinical record review revealed no evidence of the MSW evaluation. During an interview, the Administrator confirmed the finding, stating that a comprehensive documentation review was conducted, and a process improvement project was initiated in May.”

“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 an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, observation, and interview. In 3 of 13 (23%) clinical records reviewed in which Hospice Aide services were accepted, the agency did not ensure that the Hospice Aide received written patient care instructions, which contained clear and specific instructions from the Registered Nurse (RN). Clinical Record 1/Home Visit 1: The patient elected hospice care on 03/26/2024 with a diagnosis of Alzheimer’s Disease. The initial nursing comprehensive assessment dated 03/26/2024 documented the patient’s skin integrity problem. The HA care plan dated 03/26/2024 assigned the HA the relevant task of a partial sponge bath every visit. The updated HA care plans dated 06/24/2024 and 07/01/2024 assigned the HA the relevant task of a bed bath. During the home visit with the Registered Nurse (RN) [Personnel Record 1] on 09/17/2024, the patient was observed wearing arm sleeves for protection. The HA visit note dated 06/21/2024 documented that the patient had no arm sleeves on for skin protection. The HA care plans did not assign the task of applying the arm sleeves after bathing. Clinical Record 5: The patient elected hospice care on 09/21/2023 with a diagnosis of cerebral vascular disease (CVA). The initial nursing comprehensive assessment completed on 09/21/2023 documented the patient’s use of oxygen at 2-4 (liters per minute) LPM as needed for shortness of breath. The HA care plans dated 09/21/2023 to 12/19/2023, 12/20/2023 to 03/18/2024, and 03/9/2024 to 05/17/2024 did not document oxygen precautions. Oxygen precautions were added to the HA care plan dated 06/21/2024. Clinical Record 7: The patient elected hospice care on 08/30/2023 with a diagnosis of multi-system degeneration of the autonomic nervous system. The updated nursing clinical assessment dated 04/02/2024 documented that the patient had a stage 2 wound with wound care and a foam dressing on the left shoulder. This wound care with the dressing continued through 07/15/2024. The HA care plan dated 08/30/2023 and updated on 06/28/2024 and 07/07/2024 assigned the HA the relevant task of a bed bath. The HA care plan updated on 06/28/2024 and 07/07/2024 did not document instructions for the HA on what to do if the dressing was saturated or had fallen off. During the interview, the Administrator confirmed the findings and stated that one of the identified process improvements for May 2024 was the corrections and updates to the HA care plans.”

“It is required that a hospice aide provides services: included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed of patients that accepted Hospice Aide (HA) services, the agency did not ensure that the HA provided services included in the plan of care. Clinical Record 1: The patient elected hospice care on 03/26/2024 with a diagnosis of Alzheimer’s Disease. The HA care plan was documented on 03/26/2024 and updated on 06/24/2024 and 07/01/2024. The HA care plan dated 03/26/2024 assigned the HA the relevant task of a partial sponge bath every visit. The updated HA care plans dated 06/24/2024 and 07/01/2024 assigned the HA the relevant task of a bed bath. The HA visit note dated 06/04/2024 documented that a shower was provided. The HA care plan did not assign a shower. There was no documented communication with the Registered Nurse (RN) for a change in the bath assignment for the day. During an interview, the Administrator and Regional Quality Director confirmed the finding. They stated that a process improvement project for documentation of aide care plans, aide following the care plan, and reporting to nurses was initiated in May 2024.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 2 of 13 (15%) clinical records reviewed in which Hospice Aide services were accepted, the agency did not ensure that the Hospice Aide reported changes related to the patient’s plan of care and needs to the Registered Nurse (RN). Clinical Record 1: The patient elected hospice care on 03/26/2024 with a diagnosis of Alzheimer’s Disease. The HA care plan was documented on 03/26/2024 and updated on 06/24/2024 and 07/01/2024. The HA care plan dated 03/26/2024 assigned the HA the relevant task of a partial sponge bath every visit. The updated HA care plans dated 06/24/2024 and 07/01/2024 assigned the HA the relevant task of a bed bath. The HA visit note dated 06/04/2024 documented that a shower was provided. There was no evidence that the HA notified the Registered Nurse (RN) that the bath provided was not what was assigned. Additionally, the HA visit note dated 06/14/2024 documented that the HA reported to the facility nurse that the patient still had red eyes. There was no evidence the HA notified the RN of the patient’s red eyes. Clinical Record 19: The patient elected hospice care on 04/28/2023. The HA visit note dated 03/01/2024 documented that the patient had leg pain and a rash on his back. A clinical record review revealed no documentation that the HA notified the RN case manager of the change in skin integrity. During an interview, the Administrator and Regional Quality Director confirmed the finding. They stated that a process improvement project for documenting aide care plans, ensuring aides follow the care plan, and reporting to nurses was initiated in May 2024.”

“It is required that volunteers services are: noted in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (50%) clinical records reviewed in which volunteer services were accepted, the agency did not ensure that the volunteer services were provided as noted in the plan of care. Clinical Record 1: The patient elected hospice care on 03/26/2024 with a diagnosis of Alzheimer’s Disease. Volunteer services were requested and assessed on 03/29/2024 with an ordered visit frequency of four (4) times a month for companionship. Volunteer visit notes were documented on 04/24/2024 and 04/26/2024, two (2) times a month. On 05/15/2024, the ordered visit frequency was decreased to two (2) times a month. On 06/07/2024, a coordination note stated the volunteer needed a break and would resume in late June. There was evidence documenting notification of the family but no response from the family was documented. A clinical record review revealed no volunteer visit notes documented from 05/15/2024 through 08/2024. There was no evidence of a change in visit frequency or reason why the visits were not made. Clinical Record 2: The patient elected hospice care on 08/09/2024 with the diagnoses of cerebral vascular accident and dementia. The initial comprehensive assessment documented a need for volunteers for socialization. There was no volunteer assessment documented as of review 09/18/2024. A clinical record review revealed no evidence of a volunteer visit, assessment, or communication with the patient or family. During an interview, the Administrator and Regional Quality Director confirmed the findings. The agency implemented a process improvement project in May of 2024 for volunteer recruitment, retention, and documentation of volunteer care and coordination.”