Deis Consulting
Mark Deis, RN
 Review
the Conditions of ParticipationVolunteer 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
 State
Operation Manual-Volunteers
L641-L642-Defined Roles & Supervised
L643- Training
L644- Roles
L645-Recruiting & Retaining
L646-Cost Saving
L647- Level of Activity



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.
 Volunteer
Manager,
coordinator or
volunteers must be
present at the IDG
Meeting
 Ensure Coordination
of Care
 Documentation of
Meeting must
demonstrate
Volunteer Services
participation
“
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.
 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
“Day to Day” Volunteer
Services into daily patient
care and operations
 Direct Patient Care
 Administrative Services
 Non-administrative or nondirect patient care can’t
be counted to 5%.
example- sewing or
quilting)

 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
 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.
 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.
 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
 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
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.

 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
 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
 Calculation
Total volunteer
hours compared to
the total patient
care hours.
Minimum of 5%
 Center
for Medicare
& Medicaid ServicesHospice Program
Interpretive
Guidance Version
(Rev. 149
10/09/2015)
 National Hospice &
Palliative Care
Organization –New
COP Tip Sheets