Suncrest Hospice

“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 established by: the hospice IDG in collaboration with the attending physician (if any); the patient or patient representative if any of them so desire; [and] the primary caregiver in accordance with the patient’s needs if any of them so desire. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #1-027 “Missed Visits” (dated June 2022) read in part, “Missed visits will be communicated to the Interdisciplinary Group (IDG) at the IDG Meeting. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record...If a visit is missed and not rescheduled, the clinician will notify the IDG and clinical supervisor of the missed visit and reason for the missed visit; Document in the patient’s clinical record...date and type of visit that was missed, reason for the missed visit...persons notified of the missed visit...The clinical supervisor will track the number and reasons for missed visits to assess patterns and to assure the plans of care contain the correct number of planned visits...” In 8 of 19 (42%) clinical records reviewed, the agency did not ensure that hospice care and services provided to patients and families followed the individualized plan of care established by the hospice IDG. Clinical Record 1: The patient elected the hospice benefit on 10/30/2024. For the hospice benefit period dated 04/28/2025 to 06/26/2025, the plan of care ordered Chaplain (SC) services once or twice a month, with visits starting from 05/01/2025. A SC visit was documented on 06/10/2025. A clinical record review revealed no documented visit in May. There was no evidence of changes in the planned frequency, missed visits, or issues noted in the interdisciplinary documentation for meetings dated 05/07/2025, 05/21/2025, or 06/04/2025. The clinical record review did not reveal any unmet spiritual needs in May. Clinical Record 2: The patient elected the hospice benefit on 03/18/2025. For the hospice benefit period dated 03/18/2025 to 06/15/2025, the plan of care ordered SC services once or twice a month, with visits starting from 04/01/2025. SC visits were documented on 04/172025 and 06/10/2025. A clinical record review revealed no documented visit in May. There was no evidence of changes in the planned frequency, missed visits, or issues noted in the interdisciplinary documentation for meetings dated 05/07/2025, 05/21/2025, or 06/04/2025. The clinical record review did not reveal any unmet spiritual needs in May. Clinical Record 3: The patient elected the hospice benefit on 10/29/2024. For the hospice benefit period dated 04/27/2025 to 06/25/2025, the plan of care ordered SC services once or twice a month, with visits starting from 05/01/2025. A clinical record review revealed no documented visit in May. There was no evidence of changes in the planned frequency, missed visits, or issues noted in the interdisciplinary documentation for meetings dated 05/07/2025, 05/21/2025, or 06/04/2025. The clinical record review did not reveal any unmet spiritual needs in May. Clinical Record 4: The patient elected the hospice benefit on 04/02/2025. For the hospice benefit period dated 04/02/2025 to 06/30/2025, the plan of care ordered SC services once or twice a month, with visits starting from 04/09/2025. A SC visit was documented on 04/09/2025. A clinical record review revealed no documented visit in May. There was no evidence of changes in the planned frequency, missed visits, or issues noted in the interdisciplinary documentation for meetings dated 05/07/2025, 05/21/2025, or 06/04/2025. The clinical record review did not reveal any unmet spiritual needs in May. Clinical Record 9: The patient elected the hospice benefit on 04/26/2025. For the hospice benefit period dated 04/26/2025 to 07/24/2025, the plan of care ordered SC services once or twice a month, with visits starting from 04/28/2025. A SC visit was documented on 04/28/2025. A clinical record review revealed no documented visit in May. There was no evidence of changes in the planned frequency, missed visits, or issues noted in the interdisciplinary documentation for meetings dated 05/07/2025, 05/21/2025, or 06/04/2025. The clinical record review did not reveal any unmet spiritual needs in May. Clinical Record 12: The patient elected the hospice benefit on 12/27/2023. For the hospice benefit period dated 04/20/2025 to 06/18/2025, the plan of care ordered SC services once or twice a month, with visits starting from 04/20/2025. A SC visit was documented on 04/29/2025. A clinical record review revealed no documented visit in May. There was no evidence of changes in the planned frequency, missed visits, or issues noted in the interdisciplinary documentation for meetings dated 05/07/2025, 05/21/2025, or 06/04/2025. The clinical record review did not reveal any unmet spiritual needs in May. Clinical Record 13: The patient elected the hospice benefit on 11/23/2024. For the hospice benefit period dated 02/21/2025 to 05/21/2025, the plan of care ordered SC services once or twice a month, with visits starting from 03/04/2025. SC visits were documented on 03/04/2025 and 03/21/2025. A clinical record review revealed no documented visit in April or May. There was no evidence of changes in the planned frequency, missed visits, or issues noted in the interdisciplinary documentation for meetings dated 04/09/2025, 04/23/2025, 05/07/2025, 05/21/2025, or 06/04/2025. The clinical record review did not reveal any unmet spiritual needs in April or May. Clinical Record 14: The patient elected the hospice benefit on 10/11/2024. For the hospice benefit period dated 04/12/2025 to 06/10/2025, the plan of care ordered SC services once or twice a month, with visits starting from 04/12/2025. A SC visit was documented on 04/24/2025. A clinical record review revealed no documented visit in May. There was no evidence of changes in the planned frequency, missed visits, or issues noted in the interdisciplinary documentation for meetings dated 05/07/2025, 05/21/2025, or 06/04/2025. The clinical record review did not reveal any unmet spiritual needs in May. During an interview on 06/12/2025, the SC acknowledged missing some visits in May. The SC explained that the previous SC left unexpectedly in May, resulting in his taking on their caseload in addition to his own. Consequently, as needed, he was responsible for all the initial admission assessments, end-of-life visits, and other tasks. He emphasized that his priorities included completing initial assessments, attending to patients near the end of life, and responding to requests from nurses or social workers for additional needed patient support. During an interview on 06/12/2025, the Administrator confirmed the transfer of the other Chaplain effective 05/05/2025, leaving only one chaplain to cover all chaplain needs. A new Chaplain was hired on 05/30/2025, with their first patient assigned as of 06/12/2025.”

“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. An interview and document review on 06/13/2025 with the Volunteer Coordinator [Personnel Record 4], Administrator [Personnel Record 2], and the Senior Director of Clinical Quality [Personnel Record 9] revealed and confirmed that the Volunteer hour percentage for the calendar year 2024 was 0.49%. A Volunteer QAPI Performance Improvement Project (PIP) was identified and initiated on 05/03/2023 for a less than 5% Volunteer percentage. The last documented review was on 01/29/2025. The QAPI PIP was active with monthly documented initiatives to recruit new volunteers through Volunteer Match, flyers, health fairs at facilities and senior centers, a National Night Out event where the agency set up a table to speak to people about volunteering, and there were three new volunteers currently beginning their onboarding from a local college. Additionally, the retention activities were recorded monthly to show how the Volunteer Coordinator worked to keep the current volunteers engaged in the program. The Volunteer Coordinator was hired in June of 2024. The agency’s growth from 80 patients in June 2024 to the June census of 101 increased the struggle to improve the volunteer hour percentage. An interview and document review on 06/13/2025 with the Volunteer Coordinator (Personnel Record 4), Administrator (Personnel Record 2), and the Senior Director of Clinical Quality (Personnel Record 9) revealed and confirmed that the Volunteer hour percentage from 2024 was 0.49%. A Volunteer QAPI Performance Improvement Project (PIP) was identified and initiated on 05/03/2023 for a less than 5% Volunteer percentage. The last documented review was on 01/29/2025. The QAPI PIP was active with monthly documented initiatives to recruit new volunteers through Volunteer Match, flyers, health fairs at facilities and senior centers, a National Night Out event where the agency set up a table to speak to people about volunteering, and there were three new volunteers currently beginning their onboarding from a local college. Additionally, the retention activities were recorded monthly to show how the Volunteer Coordinator worked to keep the current volunteers engaged in the program. The Volunteer Coordinator was hired in June of 2024. The agency’s growth from 80 patients in June 2024 to the June census of 101 increased the struggle to improve the volunteer hour percentage.”