Every finding on record at Great Trinity Hospice LLC

It is required that for those individuals eligible to be fully vaccinated for COVID-19, Organization policy and procedure define: 1) The process for tracking and documenting each individual’s receipt, at a minimum, of a single dose COVID-19 vaccine, or the first dose of a COVID-19 primary vaccination series of a multi-dose vaccine prior to providing any care, treatment or other services for the hospice and/or its patients; 2) The process for tracking and documenting an individual’s completion of a COVID-19 primary vaccination series; 3) The process for tracking and documenting an individual’s receipt of COVID-19 booster doses, per CDC guidelines; 4) What vaccination documentation is accepted; 5) Who receives the vaccination documentation, reviews it, and accepts or rejects it; and 6) How each individual’s vaccination information is securely maintained. This standard was not met as evidenced by document review, record review, and interview. Review of the agency's policies revealed the agency did not ensure that their COVID policies contained the required verbiage to meet COVID vaccination requirements that were to be implemented by all states by April 20, 2022. Review of the policies, "Infections Disease Pandemic/Coronavirus (last revised 080121)" and "Emergency Temporary Standards: COVID-19 plan (last revised 080121)" revealed the policies did not contain verbiage that described the process the organization would use for tracking and documenting employees' receipt of COVID vaccines, per CDC guidelines, and how individuals' vaccination information would be securely maintained. Review of personnel records revealed that 1 of 1 (100%) record of an employee who was not actively working with patients was missing documentation of receipt of the COVID-19 vaccine. The remaining 8 of 8 (100%) personnel records of employees who were currently working with hospice patients [Records: 1 (Medical Director); 2 (Administrator/Vol Coord); 3 (Director of Nursing/Alt Administrator); 4 (RN/Asst Dir of Nursing); 5 (Aide); 6 (LMSW); 7 (Chaplain/Bereavement Coordinator); and 8 (Volunteer)] revealed documented evidence of the employees' vaccines received in compliance with CDC guidelines. Personnel Record 9: Review of the documentation provided for the Alternate Medical Director, hired on 12/15/22, revealed that the agency did not collect COVID-19 vaccine documentation or receive and grant a vaccine exemption request for this provider. During review of the record, it was reported that the Alternate Medical Director had not had any direct contact with any hospice patients, to date. The Administrator confirmed during an interview on 5/22/23 that these were the only COVID policies the agency had in place and that they did not contain the required verbiage to meet the COVID vaccination requirements. They also confirmed that the Alternate Medical Director had not yet had any direct contact with the organization’s hospice patients. An opportunity was provided for the hospice to obtain evidence of the Alternate Medical Director's vaccine status, however no additional evidence was provided for review prior to the end of the site visit. This standard is not met as evidenced by a review of the documents "Infections Disease Pandemic/Coronavirus (last revised 080121)" and "Emergency Temporary Standards: COVID-19 plan (last revised 080121)" which revealed the agency did not ensure the COVID policies contained the required verbiage to meet the COVID vaccination requirements required to be implemented by all states by April 20, 2022. However, the agency did obtain documentation for 8 of 9 personnel. (89%)