Every finding on record at Day-By-Day Staff Relief, LLC

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes the following: for all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles; demonstration of staff knowledge of emergency procedures; EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years; more frequent training occurs if there is a significant update of EP policies and procedures; a periodic review and rehearsal of the hospice’s EP plan with hospice employees (including non-employee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others; and documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy #E06, "Emergency Preparedness Plan," stated in part, "All staff, whether employees or contract, will be instructed on the Emergency Preparedness Plan during orientation and annually thereafter." In 1 of 10 (10%) personnel records reviewed, the hospice did not ensure that emergency preparedness training was provided annually. Personnel Record 3: The Hospice Medical Director was hired on 04/04/2021 as an independent contractor. There was no documented evidence of Emergency Preparedness training annually in 2023, 2024, or 2025 as of 03/06/2025. During a joint record review and interview on 03/06/2025, the Alternate Director of Operations agreed there was no documented evidence that emergency preparedness training was provided annually. During an interview on 03/06/2025, the Director of Operations agreed with the finding and did not have any additional information to provide.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 14 (7%) clinical records reviewed and home visits observed, the hospice did not ensure that the comprehensive assessment included a drug profile that contained the patient's medications and supplements. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 07/29/2024 with the diagnosis of cerebral infarction due to an unspecified occlusion or stenosis of the right middle cerebral artery. During the home visit with the Registered Nurse (RN) [Personnel Record 5] on 03/04/2025, a medication review was completed comparing the hospice medication profile, dated 03/04/2025, to the patient's medications. The patient's spouse presented a list of medications and multiple medication bottles that he reported giving to the patient every day. The spouse confirmed that the patient has been taking the following supplements for months: Fruits and Veggies probiotics capsule (two (2) capsules twice daily), turmeric ginger 1800mg capsules (one (1) capsule twice daily), nitric oxide blood flow #7 (two capsules twice daily), vitamin C 1000mg (once daily), vitamin D3 125mcg 5000IU (once daily), vitamin E 268mg (once daily), Prevagen (once daily), CoQsol 100mg (once daily), DreamWell Ultra (once daily), Relaxium Sleep (once daily). The spouse reported that the patient has been using a nebulizer treatment twice or more daily when needed. The spouse presented the medication dated 02/17/2025, "ipratropium bromide and albuterol sulfate inhalation solution 0.5mg/3ml per 3ml, empty one ampule into the nebulizer, inhale by mouth 4 times daily for shortness of breath." The supplements and ipratropium bromide inhalation solution were not listed on the hospice medication profile reviewed on 03/04/2025. There was no evidence the supplements and ipratropium bromide inhalation solution were reviewed with the patient's medication regimen. During the home visit, the RN [Personnel Record 5] stated, "I am not the regular nurse, so I don't know why these aren't on our medication list. The regular nurse should have added them. I will get them updated. The RN [Personnel Record 5] agreed there was no documented evidence that the hospice medication profile was updated with these supplements and medication. During a joint record review and interview on 03/05/2025, the Alternate Director of Operations agreed there was no documented evidence that the hospice medication profile included the supplements and Ipratropium Bromide Inhalation Solution. During an interview on 03/06/2025, the Director of Operations agreed with the finding and did not have any additional information to provide.

It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes Education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy #I13, "Infection Prevention & Control Plan," stated in part, "All staff will be educated upon hire, annually during Safety Month and at other times indicated in the diseases listed above, their transmission and use of universal precautions and other infection safety measures as needed." In 2 of 10 (20%) personnel records reviewed, the hospice did not ensure that infection control education was provided annually per the agency's policy. Personnel Record 3: The Hospice Medical Director was hired on 04/04/2021 as an independent contractor. Infection control education was last documented on 06/16/2022. There was no documented evidence of infection control education annually in 2023, 2024, or 2025 as of 03/06/2025. Personnel Record 4: The Hospice Medical Director was hired on 10/11/2018 as an independent contractor. Infection control education was last documented on 01/31/2023. There was no documented evidence of infection control education annually in 2024 or 2025 as of 03/06/2025. During a joint record review and interview on 03/06/2025, the Alternate Director of Operations agreed there was no documented evidence that the infection control education was provided annually. During an interview on 03/06/2025, the Director of Operations agreed with the finding and did not have any additional information to provide.

It is required that all hospice aide services must be provided by an individual who has successfully completed one (1) of the four (4) training and competency evaluation programs described below. The individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program also described below. The hospice maintains documentation that each hospice aide has met the requirements. A qualified hospice aide has successfully completed a competency evaluation program that evaluates the aide’s competency in the following subject areas by observation of the aide’s performance with a patient or pseudo-patient: communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; reading and recording temperature, pulse, and respiration; appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: bed bath; sponge, tub, and shower bath; hair shampoo (sink, tub, and bed); nail and skin care; oral hygiene; toileting and elimination; safe transfer techniques and ambulation; normal range of motion and positioning. Evaluates the aide’s competency in the following subject areas by written exam, oral examination, or after observation of a hospice aide with a patient or a pseudo-patient during a simulation: observation, reporting, and documentation of patient status and the care or service provided; basic infection control procedures; basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor; maintenance of a clean, safe, and healthy environment; recognizing emergencies and the knowledge of emergency procedures and their application; the physical, emotional, and developmental needs of—and ways to work with—the populations served by the hospice, including the need for respect for the patient, his or her privacy, and his or her property; adequate nutrition and fluid intake; any remaining task(s) that the hospice chooses to have an aide perform. The competency evaluation is performed by a registered nurse in consultation with other skilled professionals, as appropriate. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy #P02, "Home Health/Hospice Aide Competency & Supervision," stated in part, "The hospice aide must successfully complete a competency evaluation. The Agency confirms that the home health/hospice aides are competent and proficient to perform the assigned duties. The Agency maintains documentation of competency training. The Agency confirms skills learned and/or evaluated elsewhere transfer to the care during orientation as first visit competency evaluation prior to unsupervised patient care." In 1 of 1 (100%) personnel record reviewed of a Hospice Aide, the agency did not ensure to assess the competency of the Hospice Aide prior to unsupervised patient care. Personnel Record 6: The Hospice Aide was hired on 12/26/2023. A personnel record review revealed no evidence that the hospice agency assessed the competency of the Hospice Aide before unsupervised patient care. During a joint record review and interview on 03/05/2025, the Alternate Director of Operations agreed there was no documented evidence that the competency was completed. During an interview on 03/06/2025, the Director of Operations agreed with the finding. The Director of Operations stated, "One of our nurses is on vacation, and she told us that she has the competency on paper but not with her. "We are going to get the aide competency done this week."

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review and interview. In 3 of 12 (25%) clinical records reviewed of patients who accepted Hospice Aide services, the agency did not ensure the Hospice Aide (HA) provided services as ordered by the Interdisciplinary Group. Clinical Record 1: The patient elected the hospice benefit on 07/29/2024. The physician's order, effective 12/26/2024, ordered Hospice Aide (HA) services "1wk1, 2wk8." During the week of 01/26/2025 through 02/01/2025, one HA visit was documented on 01/31/2025. There was no documented evidence of a second visit or reason for the missed visit. During the week of 02/02/2025 through 02/08/2026, one hospice aide visit was documented on 02/02/2025. There was no documented evidence of a second visit or reason for the missed visit. Clinical Record 9: The patient elected the hospice benefit on 09/30/2024. The physician's order, effective 10/01/2024, ordered HA services "2wk9." During the week of 10/27/2024 through 11/02/2024, one HA visit was documented on 10/30/2024. There was no documented evidence of a second visit or reason for the missed visit. Clinical Record 12: The patient elected the hospice benefit on 09/30/2023. The physician's order, effective 11/12/2023, ordered HA services "1wk2, 2wk3." During the week of 12/10/2023 through 12/16/2023, one HA visit was documented on 12/15/2023. There was no documented evidence of a second visit or reason for the missed visit. During a joint record review and interview on 03/05/2025, the Alternate Director of Operations agreed there was no documented evidence that the HA visits were completed and no documented reason for the missed visits. During an interview on 03/06/2025, the Director of Operations agreed with the finding and stated that the aide who missed the visits was no longer with the agency.

It is required that a registered nurse makes an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy #P02, "Home Health/Hospice Aide Competency & Supervision," stated in part, "The Agency provides onsite supervision of skills and compliance to agency policies every 12 months during an onsite visit conducted by a registered nurse. The Licensed Professional documents findings on the Supervisory On-site Visit form or in the mobile device. Date/time of visit and name of aide being supervised. Services Provided. Individualized comments about the relationship between family/patient and aide. Observation of care delivery. Progress toward goals. Any instruction given. In-service training, noting the new skill or theory." In 1 of 1 (100%) personnel record reviewed of a Hospice Aide (HA), the hospice did not ensure that the Registered Nurse (RN) completed an annual on-site supervisory visit. Personnel Record 6: The Hospice Aide was hired on 12/26/2023. A personnel record review revealed no documented evidence that a Registered Nurse completed an annual onsite visit with the required elements and documented it on the Supervisory On-site Visit form. During a joint record review and interview on 03/06/2025, the Alternate Director of Operations agreed there was no documented evidence that annual onsite supervision of skills was completed and documented according to agency policy. The Alternate Director of Operations stated, "We can see they are doing joint visits with the aides, but we have no evidence that the annual onsite supervisory visits are being documented with all the required information." During an interview on 03/06/2025, the Director of Operations agreed with the finding and did not have any additional information to provide.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, interview, and personnel record review. Agency Policy #P01, "Personnel Competency & Supervision," stated in part, "Staff competencies are addressed, completed, and stored...Professional staff will not be assigned to any task until competency for that task is obtained. The Agency confirms that the professional personnel are competent and proficient to perform the assigned duties. " In 1 of 9 (11%) personnel records reviewed of professional staff, including the volunteer, the hospice did not ensure to assess the competency of the Registered Nurse (RN). Personnel Record 5: The Registered Nurse (RN) was hired on 09/16/2024. There was no documented evidence that the hospice assessed the competency of the Registered Nurse as of 03/05/2025. During a joint record review and interview on 03/05/2025, the Alternate Director of Operations agreed there was no documented evidence that the competency was completed. During an interview on 03/06/2025, the Director of Operations agreed with the finding and did not have any additional information to provide.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #S10, “Patient Reassessment & Recertification,” stated in part, “The Medical Director completes a written certification of terminal illness no more than 15 days prior to the start of any benefit period.” Agency policy #S01, “Scope of Services,” stated in part, “The Hospice Director is responsible for reviewing the clinical information for each hospice patient, providing written certification that it is anticipated that the patient’s life expectancy is 6 months or less if the illness runs its normal course.” In 2 of 11 (18%) clinical records reviewed of patients with more than one benefit period, the agency did not ensure that the Hospice Medical Director (HMD) completed a physician narrative based on a review of the patient’s medical record for recertification of the terminal illness per the agency's policy. Clinical Record 4: The patient elected the hospice benefit on 04/16/2021. The recertification of terminal illness for the benefit period dated 10/03/2023 through 12/01/2023, signed by the physician on 09/27/2023, did not include documented evidence that the HMD reviewed the clinical information and completed a physician’s narrative. The physician’s narrative was blank. The recertification of terminal illness for the benefit period 09/27/2024 through 11/25/2024, signed by the physician on 10/18/2024, did not include documented evidence that the HMD reviewed the clinical information and completed a physician’s narrative. The physician’s narrative was blank. Clinical Record 6: The patient elected the hospice benefit on 08/19/2024. The recertification of terminal illness for the benefit period dated 12/17/2024 through 02/14/2024, signed by the physician on 01/08/2025, did not include documented evidence that the HMD reviewed the clinical information and completed a physician’s narrative. The physician’s narrative was blank. During a joint record review and interview on 03/05/2025, the Alternate Director of Operations agreed there was no documented evidence that the Hospice Medical Director completed a physician narrative based on a review of the patient’s medical record for recertification of the terminal illness. The Alternate Director of Operations stated, “This is a problem we identified and are working on.” During an interview on 03/06/2025, the Director of Operations agreed with the finding. The Director of Operations stated, “The Branch Director left in November 2024, and we discovered the certification of terminal illness (CTI) and recertifications by the Medical Director were not being completed properly, timely, and to our standards. In January, our Associate MD took over as Hospice Medical Director.”

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients discharged due to moving out of the service area or being no longer terminally ill, the agency did not ensure that the discharge summary was forwarded to the patient's attending physician. Clinical Record 11: The patient elected the hospice benefit on 05/15/2024, was discharged, and moved to an out-of-the-service area hospital on 05/28/2024. There was no documented evidence that the discharge summary was forwarded to the attending physician. Clinical Record 12: The patient elected the hospice benefit on 09/30/2023 and was discharged, with an extended prognosis, on 03/13/2024. There was no documented evidence that the discharge summary was forwarded to the attending physician. During a joint record review and interview on 03/06/2025, the Alternate Director of Operations agreed there was no documented evidence that the discharge summary was provided to the attending physician. During an interview on 03/06/2025, the Director of Operations agreed with the finding and did not have any additional information to provide.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: the most recent hospice plan of care. THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by interview and observation. In 1 of 1 (100%) home visit observation of patient residing in a Skilled Nursing Facility (SNF), the hospice did not ensure the IDG provided the SNF with the most recent hospice plan of care. Home Visit 1: The patient elected the hospice benefit on 3/1/2023 with a primary hospice diagnosis of atherosclerosis heart disease of native coronary artery w/o angina pectoris. During observation of Home Visit #1 with the Registered Nurse (Staff #1) on 3/21/2023 at 2:00 pm, a joint review of the patient’s hospice binder in the SNF revealed no documented evidence the hospice plan of care was provided to the SNF. The Branch Director was interviewed on 3/21/2023 and agreed there was no documented evidence the hospice plan of care was provided to the SNF. The patient elected the hospice benefit on 3/1/2023 with a primary hospice diagnosis of athesclerosis heart disease of native coronary artery w/o angina pectoris. During observation of Home Visit #1 with the Registered Nurse (Staff #1) on 3/21/2023 at 2:00pm, a joint review of the patient’s hospice binder in the SNF revealed there was no documented evidence the hospice plan of care was provided to the SNF. The Branch Director was interviewed on 3/21/2023 and agreed, there was no documented evidence the hospice plan of care was provided to the SNF.

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, includes all services necessary for the palliation and management of the terminal illness including intervention to manage pain and symptoms and measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. 3 of 11 (27%) records reviewed revealed the hospice did not ensure plans of care included interventions based on problems identified in the assessments and outcomes that were measurable. Record #43385: Start of Care (SOC) 5/20/2021. Diagnosis Congestive Heart Failure. A comprehensive nursing assessment on 12/16/2021 was reviewed which revealed wound care was provided “St 1 PU apply barrier cream to coccyx bid and prn for moisture barrier.” The POC reviewed by IDG on 12/29/2021 did not include evidence identifying the wound as a problem or interventions to address it. Record #29418: SOC 3/30/2021. Diagnosis Chronic Obstructive Pulmonary Disease. The POC reviewed by IDG on 3/31/2021 identified: Problem: Need for o/a of respiratory status. Goal: Patients resp status is stabilized to comfort within constraints of disease. Record #47681: SOC 6/11/2021. Diagnosis Congestive Heart Failure. The POC on 6/11/2021 identified: Problem: Need for o/a of respiratory status. Goal: Patients resp status is stabilized to comfort within constraints of disease. The Administrator was interviewed on 5/5/2022 and stated, that the plan of care did not include interventions and measurable outcomes within the records identified.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by observation, interview, and document review. 1 of 3 (33%) observations during home visits revealed the hospice did not ensure adherence to agency infection prevention and control policies and procedures for hand hygiene. During observation of Patient #24855 on 5/4/2022 at 11:05 am, RN #93974 put gloves on, measured heel wound on left foot, picked up bedside remote to change the position of the bed, moved bedside table, pulled the curtains closed, opened briefs, used handheld tablet, measured open coccyx wound and applied cream to wound. Agency policy, “Infection surveillance, hand hygiene”, stated in part, “At a minimum, personnel will perform hand hygiene in the following instances: after any contact with patient excretions (feces, urine) or secretions (from wounds) or with articles/surfaces contaminated by secretions or excretions.” The Branch Director was interviewed on 5/4/2022. She agreed with the finding that the staff did not wash her hands before providing wound care to the coccyx. The Administrator confirmed this finding on 5/5/2022.

It is required that a hospice aide provides services as ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. 3 of 9 (33%) applicable records reviewed receiving hospice aide services revealed the hospice did not ensure that the hospice aide followed the plan of care as ordered. Record #19846: a hospice aide plan of care on 11/26/2021 assigned a shampoo every visit. For the hospice aide visit on 11/29/2021, the aide marked the task shampoo as not completed “patient refused today.” Record #56774: a hospice aide plan of care on 3/22/2022 assigned bathing (shower), assist to toilet, shampoo, hair care, skin care (lotion), and oral care every visit. For the hospice aide visit on 5/2/2022 the aide marked the following tasks not completed, “pt refused” bathing (shower), assist to toilet, shampoo, hair care, skin care (lotion), oral care. Record #47681: a hospice aide plan of care on 4/1/2022 assigned bathing (shower), assist to toilet, shampoo, hair care, skin care (lotion), and oral care every visit. For the hospice aide visit on 5/2/2022 the aide marked the following tasks not completed, “pt refused” bathing (shower), assist to toilet, shampoo, hair care, skin care (lotion), oral care. The Administrator was interviewed on 5/5/2022. He agreed with the finding that the aide did not follow the plan of care.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a Registered Nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. 3 of 9 (33%) applicable hospice patients receiving hospice aide services reviewed the agency did not ensure that the hospice aide reported changes in the patient’s condition to a registered nurse. Record #24855: a hospice aide plan of care on 4/15/2022 assigned bathing (shower), transfer client from bed/chair each visit. For the hospice aide visit on 5/3/2022 the aide marked the following tasks not completed, bathing (shower) “hitting”, transfer client from bed/chair “fighting.” There was no evidence the Registered Nurse was notified of the change in the patient’s condition. Record #43385: a hospice aide plan of care on 7/15/2021 assigned bathing (shower), assist to toilet, shampoo, dressing each visit. For the hospice aide visit on 7/21/2021, the aide marked the following tasks not completed: assist to toilet "pt was not stable", bathing (shower) “pt was not able to”, shampoo “pt was not able to”, dressing “pt was not able to”. There was no evidence the Registered Nurse was notified of the change in the patient’s condition. Record #64075: a hospice aide plan of care on 12/16/2021 assigned oral care each visit. For the hospice aide visit on 3/1/2022, the aide marked the following tasks not completed, oral care “patient refused hitting and would not open mouth.” There was no evidence the Registered Nurse was notified of the change in the patient’s condition. The Administrator was interviewed on 5/5/2022. He stated there was no documentation within the records identified that the aide notified the Registered Nurse of the change in condition.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care; documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review and interview. 3 of 11 (27%) records reviewed revealed the hospice did not ensure that volunteer services were provided to patients/families. Record #24855: SOC 3/2/21, Diagnosis Severe Protein-Calorie Malnutrition. The initial comprehensive nursing assessment on 3/2/2021 revealed the patient/family answered yes to “is patient open to receiving volunteer services to meet social/family support needs.” There was no evidence of follow up in the record. Record #56774: SOC 3/22/2022, Diagnosis Cerebral Infarction. The initial comprehensive nursing assessment on 3/22/2022 revealed the patient/family answered yes to “is patient open to receiving volunteer services to meet social/family support needs.” There was no evidence of follow up in the record. Record #29418: SOC 3/30/2021, Diagnosis Chronic Obstructive Pulmonary Disease. The initial comprehensive nursing assessment on 3/30/2021 revealed the patient/family answered yes to “is patient open to receiving volunteer services to meet social/family support needs.” There was no evidence of follow up in the record. The Branch Director was interviewed on 5/5/2022 and stated, that there was no documentation of follow up or volunteer visits within the records identified. The Administrator confirmed this finding on 5/5/2022.

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. The hospice documents the cost savings achieved through volunteers. Documentation includes the identification of each position that is occupied by a volunteer; the work time spent by volunteers occupying those positions; estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1 and for the duration noted in Item 2. This standard was not met as evidenced by the interview and document review. A review of the 2019 cost savings report revealed the hospice did not ensure the volunteer's hours equaled at least 5% of the total patient care hours by paid hospice staff. A review of the 2019 volunteer cost savings report revealed a total cost savings of 2.11% The Branch Director was interviewed on 5/5/2022 and stated, that the 5% was not met in 2019 and there was no additional information to provide. The Administrator confirmed this finding on 5/5/2022.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: the most recent hospice plan of care, hospice election form, physician certification, and recertification of the terminal illness. This standard was not met as evidenced by observation, record review, and interview. 1 of 1 (100%) applicable record reviewed for a patient living in a Skilled Nursing Facility (SNF) revealed the hospice did not ensure the physician certification and recertification of the terminal illness were provided to the SNF by the designated IDG member. During a joint visit with the Registered Nurse #93974 to Patient #24855, on 5/4/2022 at 10:55 am, observation and review of the facility records revealed there was no evidence the physician certification and recertification of the terminal illness were provided to the SNF. The Administrator was interviewed on 5/5/2022 and confirmed this finding.

It is required that the hospice demonstrates the vaccination status of each individual eligible to be fully vaccinated for COVID-19. At a minimum, the hospice has evidence of an individual having received a single-dose of COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to providing any care, treatment, or other services for the hospice and/or its patients/families. Or there is evidence of an individual having a pending request for, or having been granted a medical or spiritual vaccination exemption, or a job responsibility exception, or a temporary COVID-19 vaccination delay due to clinical precautions and considerations per policy and procedure. This standard was not met as evidenced by personnel record review, interview, and document review. 5 of 11 (45%) records reviewed revealed the hospice did not ensure staff were fully vaccinated or had an approved medical or spiritual exemption completed by March 15, 2022. Record #63355 (Aide): hire date 1/10/2022. A review of the Worker HR Log Report revealed an approved medical exemption was completed on 5/4/2022. Record #23825 (HMD): contract hire date 4/4/2021. A review of the Worker HR Log Report revealed an approved spiritual vaccination exemption was completed on 4/8/2022. Record #84414 (RN): hire date 10/14/2019. A review of the Worker HR Log Report revealed an approved spiritual vaccination exemption was completed on 5/4/2022. Record #60339 (CH): hire date 8/31/2020. A review of the Worker HR Log Report revealed an approved spiritual vaccination exemption was completed on 3/23/2022. Record #78455 (MSW): hire date 12/27/2021. A review of the Worker HR Log Report revealed a single dose (Janssen) vaccination was completed on 4/15/2022. The agency's policy "CMS vaccine mandate policy P31” stated, in part: “By March 15, 2022, covered staff is required to: Receive all necessary doses to complete the COVID-19 vaccine series (one dose of the Johnson and Johnson vaccine or both doses of the Pfizer and Moderna vaccines) OR have an approved religious or medical exemption.” The Branch Director was interviewed on 5/5/2022 and stated, there were email complications. The Human Resources Director was interviewed on 5/5/2022 and stated the exemptions were approved on the completed dates, which was after the March 15, 2022 deadline. The Administrator confirmed this finding on 5/5/2022.