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

2. Objectives Review the Conditions of Participation- Volunteer Services
Patient’s Right
IDG, Care Planning & Coordination of Services
Volunteers
Organization & Administration of Services
Personnel Qualifications for Licensed Professionals

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

4. 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.

5. 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

6. 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.

7. 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

8. 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)

9. 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

10. 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.

11. 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.

12. 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

13. 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

14. 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.

15. 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

16. 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

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

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

19. Questions???