Are you Ready for a Survey? Volunteer Managers Deis Consulting Mark Deis, RN

Objectives Review the Conditions of Participation- Volunteer Services 418.52-Patient’s Right 418.56- IDG, Care Planning & Coordination of Services 418.78-Volunteers 418.100-Organization & Administration of Services 418.114-Personnel Qualifications for Licensed Professionals

Objectives State Operation Manual-Volunteers L641-L642-Defined Roles & Supervised L643- Training L644- Roles L645-Recruiting & Retaining L646-Cost Saving L647- Level of Activity

418.52 Patient’s Rights All Written & Verbal patient information must include Volunteer Services. Volunteer Services are introduced to the patient and the patient decides whether or not they want the services Admission documents must demonstrate that Volunteer Services were discussed.

418.56 Interdisciplinary Group Volunteer Manager, coordinator or volunteers must be present at the IDG Meeting Ensure Coordination of Care Documentation of Meeting must demonstrate Volunteer Services participation

418.56 Care Planning “ a detailed statement of the scope and frequency of services to meet the patient’s & family’s needs, and that the plan of care must be reviewed as frequently as the patient’s condition requires, but no less frequently than every 15 days” Volunteer Services are part of patient care planning IDG documentation must demonstrate that Volunteer Services are planned.

418.56 Coordination of Care On-going Reporting of Volunteer Activity, observation and concerns must be given to Case Manager. Documentation Trail-Volunteer visit report to Volunteer Coordinator to Case Manager

418.78 Volunteers “Day to Day” Volunteer Services into daily patient care and operations Direct Patient Care Administrative Services Non-administrative or non- direct patient care can’t be counted to 5%. example- sewing or quilting)

418.100 Organization & Administration Services Volunteers are considered employees Training & Orientation must be aligned with employees Job Descriptions- specific roles On-going In-services Competency Demonstration HR files must look similar to Employee’s HR file

418.114 Personnel Qualification for Licensed Professionals Criminal Background check must be done on all volunteers prior to any services provided. Follow State Requirements Minor Volunteers can’t have criminal background checks.

L641-L642 Volunteer must have defined roles Example- Massage Therapist Supervision of Volunteer to Role Example-Massage Therapist supervisor Physical Therapist Volunteer Manager will be inter viewed by the Surveyor concerning defined role.

L643-Training Orientation/Training that is consistent with hospice industry Standards. Training should be consistent with the specific tasks that volunteers are to performed. Documentation of General & Specific Training Volunteers are aware of Duties & Responsibilities Person to whom they report

L643-Training Volunteers need to be able to articulate: How to get assistance & instructions Hospice Goals, Services & Philosophy HIPAA & Patient’s Rights Family dynamics, coping, psychological issue of terminal illness, death & bereavement Emergency Procedures Guidance

L644 Roles Professional Volunteers must meet all requirements of the specialty area Direct patient care-household chores, shopping, transportation, & companionship Administrative Support- Office support Non-direct patient care & administrative volunteer services can be provided and count in 5% calculation. Must be evidence that IDG conducts an assessment of patient need for volunteer services.

L645-Recruiting & Retention Viable Recruiting & Retention Plan Be able to document Recruitment Efforts for past 12 months Be able to document Retention Activities Be aware that limited Volunteer availability will be questioned Volunteer Services are a requirement of all Medicare Certified Agencies

L646 Cost Saving Identification of Volunteer Roles vs. cost for that role if provided by paid employee Use your payroll cost Discuss with the Administrator/ Executive Director Must provide documentation of cost savings

L647- Level of Activity Calculation Total volunteer hours compared to the total patient care hours. Minimum of 5%

References Center for Medicare & Medicaid Services- Hospice Program Interpretive Guidance Version (Rev. 149 10/09/2015) National Hospice & Palliative Care Organization –New COP Tip Sheets

Questions???