Every finding on record at Healthstar Home Health & Hospice

Upon patient record review, 1 of 2 applicable records (Patient #5) did not have evidence the hospice offers bereavement counseling that includes: • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #5: There was not evidence of a bereavement plan of care.

Upon patient client record review, 1 of 6 records (Patient #6) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #6: The record indicated that the patient/representative wished to receive the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs.” There was not evidence that this document was provided.

Upon policy and procedure review, the COVID-19 vaccination policy did not include the provisions of • A process for ensuring the implementation of additional precautions, intended to mitigate the transmission, and spread of COVID-19, for all personnel who are not fully vaccinated for COVID-19. • A process for tracking and securely documenting the COVID-19 vaccination status of all personnel specified in 42 CFR 418.60(d)(1). • A process for tracking and securely documenting the COVID-19 vaccination status of any personnel who have obtained any booster doses as recommended by CDC. • A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines, and which supports personnel requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable state and local laws, and for further ensuring that such documentation contains: • All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the personnel member to receive and the recognized clinical reasons for the contraindications; and • A statement by the authenticating practitioner recommending that the personnel member be exempted from the Hospice's COVID-19 vaccination requirements for personnel based on the recognized clinical contraindications • Contingency plans for personnel who are not fully vaccinated for COVID-19. All provisions were corrected on site