Munson Hospice and Palliative Care

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are: noted in the plan of care. THIS IS A CMS CONDITION-LEVEL DEFICIENCY This CONDITION was not met as evidenced by document review, clinical record review, and interview which revealed the agency: Failed to ensure volunteer services were provided as ordered and noted in the plan of care {HCDT.21.I/L644/418.78(b)}. The cumulative effect of these deficiencies indicates a lack of effective oversight and implementation of an effective volunteer program and could result in the hospice agency’s inability to ensure the provision of quality health care, in a safe environment, in order to meet all patients’ needs for the Condition of Participation CFR 418.78 Volunteer Program. The deficient practice demonstrates systemic process failures that have the potential to affect all patients cared for by the hospice agency.”

“It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The hospice emergency preparedness (EP) training program includes the following: For all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles. This standard was not met as evidenced by document review, interview, and personnel record review. In 2 of 18 (11%) personnel records reviewed, the agency did not ensure that all employees received emergency preparedness training per agency policy. POLICY AND PROCEDURES: The agency Emergency Operations Plan FY26 (fiscal year) stated, in part, “Staff Training - Train new staff upon hire”. VOLUNTEER ORIENTATION: The agency syllabus for Volunteer Orientation, reviewed on 06/26/2026, did not include emergency preparedness training as a topic that was provided to new volunteers. PERSONNEL RECORD 17: A review on 06/26/2026 of the personnel record for this volunteer, who started with the agency on 02/17/2025, showed completion of the volunteer orientation training. The syllabus for that training showed that the training did not contain emergency preparedness coverage. There was no additional documented evidence of emergency preparedness training. PERSONNEL RECORD 18: A review on 06/26/2026 of the personnel record for this volunteer, who started with the agency on 06/15/2025, showed completion of the volunteer orientation training. The syllabus for that training showed that the training did not contain emergency preparedness coverage. There was no additional documented evidence of emergency preparedness training. During interviews on 06/25/2026 and 06/26/2026 with the Volunteer Coordinator (Personnel Record 10), she confirmed that no emergency preparedness training was provided to volunteers either at hire or on an ongoing basis.”

“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; Other alternative treatments that could affect drug therapy. 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, interview, and observation. In 2 of 6 (33%) home visits it was revealed that the hospice did not ensure the medication profile was updated when medication was added or changes were made to existing medications. HOME VISIT 4: During the home visit on 06/25/2026 with the Hospice Aide (Personnel Record 4), the hospice medication profile printed on 06/24/2026 was compared to the Skilled Nursing Facility (SNF) medication profile. The hospice medication profile included Lorazepam 0.5mg tablet, take 0.5mg tablet every 4 hours as needed for anxiety, starting 03/11/2026. The SNF medication profile included Lorazepam 0.5mg tablet starting 03/10/2026 with a discontinuation date of 03/24/2026. There was no documented evidence that the hospice medication profile was updated with the discontinuation of the Lorazepam. HOME VISIT 6: During the home visit on 06/26/2026 with the Registered Nurse (Personnel Record 6), the hospice medication profile printed on 06/24/2026 was compared to the SNF medication profile. The hospice medication profile included Colace 100mg at bedtime as an active medication. The SNF discontinued the Colace on 02/03/2026. A physician’s order dated 02/27/2026 signed by the RNCM ordered Magnesium Citrate Solution, take 150ml every day by mouth for constipation. The hospice medication profile did not include the Magnesium Citrate Solution. The RNCM (Personnel Record 6) was interviewed during the visit and stated, “These were overlooked. I missed updating these.” During a joint record review and interview on 06/26/2026, the Director of Home Care and Hospice agreed that the medication profiles were not updated with the changes.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care, and documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 1 (100%) clinical record reviewed of a patient receiving volunteer services, it was revealed that the hospice did not ensure the volunteer provided services as ordered. DOCUMENT 5: Agency Policy titled, Hospice Volunteers, stated in part, “While on patient care assignment, volunteers will not administer medication to patients unless licensed by the state of [state name], to do so and competency tested by a qualified registered nurse. CLINICAL RECORD 15: The patient elected the hospice benefit on 12/19/2025 with a terminal diagnosis Alzheimer’s disease with a comorbidity of dysphagia. The volunteer plan of care dated 03/03/2026 ordered volunteer services 1 x week for companionship. Additionally, the plan of care documented, “Volunteer not to offer food or beverage, Personal Care NO”. The Volunteer visit note (Personnel Record 18) on 03/19/2026 documented, “brushed her teeth, washed her face and hands, lotioned her face and hands, cleaned sore on her head”. The Volunteer visit note dated 03/25/2026 documented, “Applied some triple a ointment to sores on her head, put refresh tear drops in her eyes, cleaned hands and face and applied lotion to both, brushed teeth, cleaned ears”. During a review of the volunteer documentation and interview on 06/26/2026, the Volunteer Coordinator stated, “He shouldn’t be doing personal care and he clearly is. He shouldn’t be doing that stuff but that is what they want. I don’t know what to do. I do not have any competencies for the volunteer. I didn’t know I needed to do them.””

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services. This standard was not met as evidenced by document review, interview, and personnel record review. In 3 of 17 (18%) personnel records reviewed, the agency did not ensure that the skills and competencies were assessed as per agency policy POLICY AND PROCEDURES: The agency’s Home Care Competency Assessment policy, last revised on 11/04/2025, stated in part, “All [agency] personnel (employed, contract, and volunteers) will be assessed prior to hire, during orientation, throughout the introductory period, periodically throughout the course of a year and during the annual performance evaluation”. In addition, this policy also states, “At time of hire and annually home care and hospice aides must demonstrate all skills described in the Medicare Conditions of Participation to a qualified registered nurse (RN) to be deemed competent to independently provide care”. JOB DESCRIPTION: The agency’s Full Job Description for the Volunteer Coordinator states, in part, that the Volunteer Coordinator “Facilitates and organizes competency evaluations for volunteer orientation and annually.” This job description was signed on 06/07/2025 by the agency’s current Volunteer Coordinator (Personnel Record 10; started employment on 06/23/2025). PERSONNEL RECORD 4: A review on 06/26/2026 of the personnel record for this home health aide, who was hired on 10/05/2009, revealed competency assessments completed on 10/13/2023 and 2/20/2026. There was no documented evidence of additional competency assessments completed for this home health aide during the review period. During an interview on 06/26/2026 with the Director of Home Care, Hospice, Private Duty Nursing Services, and Medical Alert Systems (Personnel Record 16), she confirmed that no documented evidence for additional completed competency assessments for this home health aide was available for the review period. PERSONNEL RECORD 17: A review on 06/26/2026 for this volunteer, who started on 02/17/2025, revealed no documented evidence of any completed competency assessments. PERSONNEL RECORD 18: A review on 06/26/2026 for this volunteer, who started on 06/15/2025, revealed no documented evidence of any completed competency assessments. During an interview on 06/26/2026 with the Volunteer Coordinator (Personnel Record 10), she stated that she had not completed any competency assessments and was not aware that it was her responsibility to complete competency assessments for the volunteers at any time.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: The initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided; Signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed of a patient discharged as no longer terminally ill revealed that the hospice did not ensure the patient was provided a Notice of Medicare Non-Coverage (NOMNC) when their Medicare covered service(s) were ending. CLINICAL RECORD 21: The patient elected the hospice benefit on 09/12/2025 and discharged, no longer terminally ill, on 05/01/2026. There was no documented evidence that the hospice provided the patient with a Notice of Medicare Non-Coverage (NOMNC) when their Medicare covered service(s) were ending. During a joint record review and interview on 06/26/2026, the Director of Home Care and Hospice agreed there was no documented evidence that the NOMNC was provided to the patient.”

“It is required that all hospice professionals who provide services directly, under an individualized contract, or under arrangements with a hospice are legally authorized (licensed, certified, or registered) in accordance with local, state, and federal law and regulation; Act only within the scope of their state license or state certification or registration; Keep their qualifications current at all times. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) personnel record reviewed of the nurse practitioner it was revealed that the hospice did not ensure the nurse practitioner kept their nurse practitioner license current at all times. PERSONNEL RECORD 13: The Nurse Practitioner was hired on 02/01/2015. The Nurse Practitioner (NP) national certification expired on 10/26/2025. The NP license was reinstated on 01/24/2026. During an interview on 06/26/2026, the Director of Home Care and Hospice confirmed that the NP notified the hospice of the expiration on 01/24/2026. The Director of Home Care and Hospice stated that she went to renew her RN license and found out her NP expired on 10/26/2025. Additionally, the Director of Home Care and Hospice stated, she had been completing face to face evaluations during that time and that has been corrected.”