Every finding on record at Evergreen Hospice Care, Inc.

Observed in HR File Review. In 1 of 10 HR files reviewed, it was noted that not all staff were trained on their emergency management roles, as volunteers were not included. For example, the documentation in the human resource records included emergency management annually in all the records, but the volunteers. This was confirmed with the DON and Volunteer Coordinator present.

Observed in Record Review. In 4 of 16 patient records reviewed, it was noted that the comprehensive assessment had not been completed no later than five calendar days after the election of hospice care. For example, in RR#5 the psychosocial and bereavement assessments were completed by the MSW on day 6 after election of hospice care. For example, in RR#7 the psychosocial and bereavement assessments were completed by the MSW on day 10 after election of hospice care. For example, in RR#9 the psychosocial and bereavement assessments were completed by the MSW on day 12 after election of hospice care. For example, in RR#10 the spiritual assessment was documented 117 days after the election of hospice care. This was discussed with the DON.

Observed in Record Review. In 16 of 16 patient records reviewed, it was noted that the plan of care was not individualized for each patient. For example, in the 16 records each of the goals documented had a time frame of 2 weeks. This was confirmed with the DON.

Observed in Record Review. During record review it was noted that the aide documentation did not show that the tasks in the plan of care assigned were completed. For example, in record HV#2, the aide did not document anything on 2 visits in the past 2 months, the notes were signed by the patient and aide, but no care was documented. Also in the past 2 months 15 of 17 aide notes stated no that the patient had not received the shower and shampoo the nurse had included on the POC. The documentation stated that if no, then an explanation was required, no explanations were documented and there was no documentation of the aide contacting the nurse. This was confirmed with the DON.

Observed in Record Review. In 2 of 2 patient records reviewed, of patient's discharged while still living, it was noted that at the time of discharge or transfer the organization did not communicate with other service providers. For example, in record DC#1 the discharge summary indicated that the patient moved out of the area for aggressive treatment, but there was no summary of the care, treatment and services provided to the patient. For example, record DC#2 the discharge summary only indicated the patient revoked and went to the hospital to seek aggressive treatment. There was no summary of the care, treatment and services provided to the patient. Neither discharge summary included a summary of the patient’s stay, including treatments, symptoms, and pain management, the patient’s current plan of care and the patient’s latest physician orders. This was confirmed with the Director of Nursing.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation (COP) in Infection Control was met as follows: a. The hospice agency failed to follow the standards of practice to prevent spread of COVID-19 (Coronavirus 19 disease, a highly, contagious respiratory illness caused by virus that spread from person to person) by failing to: 1. Have procedures for symptoms screening for COVID-19 for the staff and visitor who enter in the hospice agency as indicated in the Centers for Disease Control and Prevention (CDC). (Refer to L 579) 2. Have procedures for fit-testing for N95 masks (a respiratory protective device designed to achieve a very close facial fit to form a seal around the nose and mouth to efficiently filter airborne particles) the agency staff, composed of 18 licensed nurses and 12 certified home health aide (CHHA). (Refer to L 579) These deficient practices placed the patients, staff, and/or visitors at risk for COVID-19 and further spread of infection that could lead to severe respiratory illness, hospitalization and/or death. b. The hospice agency failed to develop and implement its policy and procedures on vaccination for COVID-19 (Coronavirus 19 disease, a highly, contagious respiratory illness caused by virus that spread from person to person) for 38 staff and 116 patients by failing to: 1. Have a process for ensuring all required staff (who provide any care, treatment or other services for hospice patients) have received, at a minimum, the first dose of a multi-dose COVID-19 vaccine, or a one-dose COVID-19 vaccine, before staff provide any care, treatment, or other services for the hospice and/or its patients; 2. Have a process for ensuring that all required staff are fully vaccinated; 3. Have a process for ensuring that the hospice continues to follow all standards of infection prevention and control practice, for reducing the transmission and spread of COVID-19 in the hospice, especially by those staff who are unvaccinated or who are not yet fully vaccinated; 4. Have a process for tracking and securely documenting the COVID-19 vaccination status for all required staff; 5. Have a process for ensuring all staff obtain any recommended booster doses, and any recommended additional doses for individuals who are immunocompromised, in accordance with the recommended timing of such doses; 6. Have a process by which staff may request a vaccine exemption from the COVID-19 vaccination requirements based on recognized clinical contraindications or applicable Federal laws, such as religious beliefs or other accommodations; 7. Have a process for tracking and securely documenting information confirming recognized clinical contraindications to COVID-19 vaccines provided by those staff who have requested and have been granted a medical exemption to vaccination; 8. Have a process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination: 9. Have a process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; 10. Have contingency plans for staff that are not yet vaccinated for COVID-19 (and without an exemption for medical contraindications or without a temporary delay in vaccination due to clinical considerations). (Refer to L 900) The cumulative effect of these systemic problems resulted in the agency's inability to ensure the provision of quality health care in a safe environment.

Based on observation, interview, and record review, the hospice agency failed to follow the standards of practice to prevent spread of COVID-19 (Coronavirus 19 disease, a highly, contagious respiratory illness caused by virus that spread from person to person) by failing to: 1. Have procedures for symptoms screening for COVID-19 for the staff and visitor who enter in the hospice agency as indicated in the Centers for Disease Control and Prevention (CDC). 2. Have procedures for fit-testing for N95 masks (a respiratory protective device designed to achieve a very close facial fit to form a seal around the nose and mouth to efficiently filter airborne particles) for the agency staff, composed of 18 licensed nurses and 12 certified home health aide (CHHA). These deficient practices placed the patients, staff, and/or visitors at risk for COVID-19 and further spread of infection that could lead to severe respiratory illness, hospitalization and/or death. Findings: 1. During an observation on 3/16/22 at 10 a.m., upon entrance to the hospice agency, there was no procedures to screen for COVID-19 symptoms. An interview was conducted with the Director of Patient Care Services (DPCS) on 3/16/22 at 11:30 a.m., she stated that there was no screening done for the visitors and staff, but she would start to implement the screening of the visitors for COVID-19 symptoms. 2. During an interview with the DPCS on 3/18/22, at 12 p.m., she stated she did not know if all staff were fitted for N 95 masks and did not have documented evidence of fit testing. In an interview on 3/16/22 at 12:30 p.m., the DPCS stated the agency has 12 Registered Nurses, 6 licensed vocational nurses, and 18 CHHA. In another interview on 3/17/22 at 2 p.m., the DPCS stated that there was one staff member (CHHA) who was positive for COVID-19 on 12/27/21. DPCS stated the staff member (CHHA) did not work and was quarantined at home. DPCS stated there was no COVID-19 positive patient. A review of the agency's policy and procedure titled, "Infection Control Plan" dated April 2019 indicated the organization will address surveillance, prevention, identification, control and reporting of infections, utilizing current scientific methods and epidemiologic principles. The policy and procedure did not include procedures for COVID-19 symptoms screening for the staff and visitors. A review of the agency's policy and procedures titled, Pandemic Infectious Disease revised April 2019 indicated the purpose was to reduce the risk of further spreading the COVID-19 virus. COVID-19 is transmitted mostly through airborne droplets (sneezing or coughing). Symptoms of COVID-19 ranges from mild disease to non-specific signs and symptoms of acute respiratory illness to severe pneumonia with respiratory failure and septic shock. The policy and procedure did not address procedures for symptoms screening for COVID-19 for the staff and visitor who enter the workplace. The policy and procedure also did not address fit testing for N-95 respirator. A review of the Centers for Disease Control and Prevention (CDC)'s Interim Infection Control Recommendation for Healthcare Personnel during COVID-19 Pandemic updated 2/2/22 indicated to establish a process to identify and manage individuals with suspected or confirmed COVID-19 regardless of vaccination status including options that could include individual screening on arrival at the facility or implementing electronic monitoring system in which the individual can self-report before entering the facility. A review of the CDC's Interim Infection Control Recommendation for Healthcare Personnel during COVID-19 Pandemic updated 2/2/22 indicated to implement Source Control Measures that addressed the use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. NIOSH-approved N95 or equivalent or higher-level respirators should be used for aerosol-generating procedures or by healthcare personnel (HCP) working in other situations where risk factors for transmission are present such as the patient is not up to date with all recommended COVID-19 vaccine doses or may also be considered if healthcare-associated COVID-19 transmission is identified and universal respirator use by HCP working in affected areas is not already in place. A review of the Centers for Disease Control and Prevention (CDC) regarding the need of Fit Testing during emerging infectious disease outbreaks indicated proper respirator use is essential for healthcare worker who are expected to interact with patients with infectious respiratory disease. Fit testing confirms the fit of any respirator that creates a tight seal on the user's face before it used in the workplace.

Based on interview and record review, the hospice agency failed to develop and implement its policy and procedures on vaccination for COVID-19 (Coronavirus 19 disease, a highly, contagious respiratory illness caused by virus that spread from person to person) for 38 staff and 116 patients and by failing to: 1. Have a process for ensuring all required staff (who provide any care, treatment or other services for hospice patients) have received, at a minimum, the first dose of a multi-dose COVID-19 vaccine, or a one-dose COVID-19 vaccine, before staff provide any care, treatment, or other services for the hospice and/or its patients; 2. Have a process for ensuring that all required staff are fully vaccinated; 3. Have a process for ensuring that the hospice continues to follow all standards of infection prevention and control practice, for reducing the transmission and spread of COVID-19 in the hospice, especially by those staff who are unvaccinated or who are not yet fully vaccinated; 4. Have a process for tracking and securely documenting the COVID-19 vaccination status for all required staff; 5. Have a process for ensuring all staff obtain any recommended booster doses, and any recommended additional doses for individuals who are immunocompromised, in accordance with the recommended timing of such doses; 6. Have a process by which staff may request a vaccine exemption from the COVID-19 vaccination requirements based on recognized clinical contraindications or applicable Federal laws, such as religious beliefs or other accommodations; 7. Have a process for tracking and securely documenting information confirming recognized clinical contraindications to COVID-19 vaccines provided by those staff who have requested and have been granted a medical exemption to vaccination; 8. Have a process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination: 9. Have a process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; 10. Have contingency plans for staff that are not yet vaccinated for COVID-19 (and without an exemption for medical contraindications or without a temporary delay in vaccination due to clinical considerations); These failures placed the patients and staff at risk for getting and spreading COVID-19 which cause severe illness or death. Findings: On 3/16/2022, at 2:30 a.m., during the complaint validation survey, an interview was conducted with the Director of Patient Care Services (DPCS). The DPCS stated that the hospice agency had 116 active patients, 12 active Registered Nurses, 6 Licensed Vocational Nurses, and 18 Certified Home Health Aides (CHHA) that provides direct patient care for their patients. The DPCS further stated that the hospice agency did not keep track if all hired staff were vaccinated because they had no written policy addressing COVID-19 vaccination. When the DPCS was asked regarding weekly testing for unvaccinated staff, she stated the field nurses were not required to do weekly COVID test. The DPCS stated that the only time the field nurses would take their COVID-19 test was when they visited the hospice patients in the skilled nursing facility, where they would be asked for COVID-19 symptom screening. On 3/17/2022, at 1 p.m., during an interview with the Administrator, she stated that they did not ask or screen their employees if they were vaccinated, because it was unethical and COVID- 19 vaccines were all authorized for emergency use and for human experimental use only. A review of the agency's policy and procedures titled, Pandemic Infectious Disease revised April 2019 indicated the purpose was to reduce the risk of further spreading the COVID-19 virus. COVID-19 is transmitted mostly through airborne droplets (sneezing or coughing). Symptoms of COVID-19 ranges from mild disease to non-specific signs and symptoms of acute respiratory illness to severe pneumonia (lung infection) with respiratory failure and septic shock. The agency would coordinate with state Division of Epidemiology in the event o pandemic for reporting protocols and secure testing and medical supplies including vaccine. A review of the agency's policy and procedures titled, Pandemic Infectious Disease revised April 2019 indicated the purpose was to reduce the risk of further spreading the COVID-19 virus. COVID-19 is transmitted mostly through airborne droplets (sneezing or coughing). Symptoms of COVID-19 ranges from mild disease to non-specific signs and symptoms of acute respiratory illness to severe pneumonia with respiratory failure and septic shock. The policy and procedure did not address procedures for COVID-19 vaccination of the staff, vaccination exemption, tracking and documenting vaccination status, ensuring all staff obtain any recommended booster doses, and any recommended additional doses for individuals who are immunocompromised, tracking and securely documenting information confirming recognized clinical contraindications to COVID-19 vaccines, and contingency plan for unvaccinated staff. A review of Centers for Disease Control and Prevention on COVID-19 vaccines indicated COVID-19 vaccines are effective at protecting people from getting seriously ill, being hospitalization, and dying. COVID-19 vaccination lowers the risk of severe illness, hospitalization, and death. Unvaccinated people are more likely to get COVID-19, much more likely to be hospitalized with COVID-19, and much more likely to die from COVID-19.