Every finding on record at Beacon Hospice, LLC

Based on records reviewed, interviews, and observations, the Facility failed to ensure that their COVID-19 Vaccination Policy was consistently implemented and followed by staff, when during the survey, two staff members whose status was determined to be exempt from COVID-19 vaccines, were observed wearing surgical masks instead of N95 masks (as required per Agency policy) for added precaution for COVID-19 vaccination exempt staff. Findings Include: The Agency Policy titled COVID-19 Vaccination Policy, dated as revised on 02/21/22, indicated that all staff, regardless of clinical responsibility or patient contact, must report to work wearing a surgical mask and practice social distancing. The Policy indicated, as an additional precaution to mitigate the transmission and spread of COVID-19, staff who are not fully vaccinated for COVID-19 were required to wear a NIOSH-approved N95 or equivalent or higher-level respirator. During an interview on 03/09/22 at 3:10 P.M., Clinical Manager #1 said she received an exemption from receiving the COVID-19 vaccine and said as an additional precaution she had to wear a surgical mask at all times, but said on the rare occasions when she needs to go out to see a client, she must wear an N95 mask and full personal protective equipment (PPE). During the interview with Clinical Manager #1, the Surveyor observed that Clinical Manager #1 was not wearing an N95 mask, and was wearing a surgical mask. During an interview on 03/09/22 at 4:14 P.M., the Office Manager said she received an exemption from receiving the COVID-19 vaccinations and said she had to wear a mask just like everyone else in the office. The Office Manager said there were no special precautions she needed to take that she was informed about. During the interview with the Office Manager, the Surveyor observed that the Office Manager was not wearing an N95 mask, and was wearing a surgical mask. During an interview on 03/09/22 at 4:27 P.M., the Area Vice President of Operations (VP Ops) said the Agency Policy indicated that COVID-19 vaccine exempt staff, including office staff, were required to wear N95 masks as an additional precaution and said that Clinical Manager #1 and the Office Manager should have been wearing N95 masks.

Based on review of five employee personnel record files and interview with the Vice President of Clinical Operations, the Hospice Agency failed to contact the Nurse Aide Registry prior to hire, as required, for two (#1 and #2) of five employees. Findings include: 1. For Employee #1, the Agency did not request a Nurse Aide Registry check until after the date of hire. Employee #1 was hired on 1/4/21 as a Nurse Practitioner. A review of the employee's personnel file indicated the Agency did not request a Nurse Aide Registry check until 1/15/21. 2. For Employee #2, the Agency did not request a Nurse Aide Registry check until after the date of hire. Employee #2 was hired on 8/24/21 as a Registered Nurse. A review of the employee's personnel file indicated the Agency did not request a Nurse Aide Registry check until 9/23/21. During an interview on 11/16/21 at 2:00 P.M., the Vice President of Clinical Operations said the Nurse Aide Registry checks for Employee #1 and #2 were not completed prior to employment, as required.