Vivie Hospice

“Based on interview and document review, the agency failed to ensure volunteer duties and services provided to patients and families were incorporated into the individualized plan of care and documented in the medical record for 2 of 2 patients (P9 and P13) reviewed who received volunteer services. Findings include: P9 P9’s plan of care (POC) identified a start of care (SOC) date 2/13/25. P9’s POC for certification period 6/8/26 through 8/6/26, identified services for skilled nursing, social worker, hospice health aide, chaplain, massage therapist and music therapist. All listed services included visit frequency and duration. The POC identified task, assessments and duties each discipline would provide to P9, as well as the goals each discipline planned to attain. Diagnoses included chronic obstructive pulmonary disease (COPD), and emphysema. P9’s POC did not identify volunteer services. P9’s coordination note dated 6/15/26, identified a request was made for ongoing volunteer services to provide respite care, food preparation, light housekeeping, errands, companionship and emotional support. P9’s coordination note dated 6/17/26, identified volunteer services were initiated one visit per week and would start on 6/17/27. P9’s Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of Care Update Report dated 6/10/26, under the heading of Volunteer Information was listed the agency was working on it and 6/24/26, under the heading of Volunteer Information was listed a volunteer had been started, however did not list frequency of visits or duration. P9’s medical record lacked documentation of physician orders for the add on of volunteer services. P13 P13’s POC 4/4/26 through 6/2/26, identified a SOC date 8/7/25. P13’s POC identified services for skilled nursing, social worker, hospice health aide, chaplain, massage therapist and music therapist. All listed services included visit frequency and duration. The POC identified task, assessments and duties each discipline would provide to P9, as well as the goals each discipline planned to attain. Diagnoses included chronic obstructive pulmonary disease (COPD), and emphysema. P9’s POC did not identify volunteer services. P13’s POC 6/3/26 through 8/1/26, identified services for skilled nursing, social worker, hospice health aide, chaplain, massage therapist and music therapist. All listed services included visit frequency and duration. The POC identified task, assessments and duties each discipline would provide to P9, as well as the goals each discipline planned to attain. Diagnoses included chronic obstructive pulmonary disease (COPD), and emphysema. P9’s POC did not identify volunteer services. P13’s coordination note dated 5/26/26, identified volunteer services were requested, and a volunteer was scheduled one time per week to start 5/28/26. P13’s Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of Care Update Report dated 5/27/26 and 6/11/26, lacked documentation volunteer services had been initiated with approaches and goals discussed. Under the heading of Volunteer Information was listed as not applicable (NA). P13’s Physician Order dated 5/29/26 for hospice recertification POC update identified services changes for skilled nurse, social worker, hospice aide, chaplain, music and massage visits with frequency and duration of visits. Volunteer services were not identified as an ordered service for P13, despite having been initiated on 5/26/26. P13’s medical record lacked documentation of physician orders for the add on of volunteer services. During interview on 6/24/26, at 2:16 p.m. the volunteer coordinator (VC)-A stated when she initiated volunteer services for a patient she documented it in the coordination notes of the patient’s chart. VC-A noted the volunteers name and start date in the home. VC-A did not do anything with the patient’s plan of care, just the coordination note when a volunteer was initiated. Volunteer services were not revisited again unless there were questions. VC-A was not sure why volunteer services were not included on a patient’s POC. When VC-A started a volunteer in a patient’s home, they were instructed on the importance that the volunteer saw the patient an hour a week and/or as scheduled. The volunteer was instructed to call VC-A if they were going to gone or unable to make the scheduled visits. If the volunteer not going to be able to make the scheduled visits for an extended period of time, she sent out a message to the team to let them know that, as well as spoke with the family and/or patient. It was not documented in the patient’s chart if a volunteer was not going as scheduled, or if the patient or agency discontinued the volunteer. The agency did not obtain an order to hold or discontinue visits. Volunteer services were communicated to the team via team notes but there was no official documentation in the patient’s charts. VC-A stated you would not be able to identify if a volunteer had missed visits or was no longer going by reviewing the patient’s medical record because it was not formally documented. The only documentation of volunteer services was the one coordination note she entered when she initiated the service. During joint interview with hospice director (HD)-A and HD-B via telephone, on 6/24/26, at 3:14 p.m. HD-A stated she thought there was a problem with the computer program the agency used, Volunteers did not have access to the agency’s computer program. The volunteer coordinator communicated to the team when a volunteer was initiated, visit changes or discontinuation of the volunteer. The volunteer program was a regulatory service, and the service did impact the patient’s care. Because it affected the care of the patient, when a patient utilized volunteer services, the service should be included in the patient’s medical record and on their POC. The agency’s policy Hospice Volunteer Process dated 11/13/26, identified active volunteer assignments would be reviewed during scheduled IDG meetings. Updates regarding volunteer involvement, patient needs, concerns or service changes would be discussed and documented as appropriate. The agency policy IDG Care Planning Process revised February 2024 identified the plan of care specified the care and services necessary to meet the patient and family specific needs as identified in the comprehensive assessment. All care and services furnished to patients and their families followed an individualized written plan of care established by the IDG in collaboration with the attending physician, the patient and primary caregiver in accordance with the patient’s needs. The POC would be written to include all services necessary for the palliation and management of the terminal illness and related conditions. The POC would include a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs with visit ranges for visit frequencies to ensure the most appropriate level of service was provided to the patient.”