Every finding on record at Mercyhealth Visiting Nurses Association, Inc.

Based on document review and staff interview, the Hospice failed to ensure that volunteers provided a minimum of 5% total patient care hours of hospice paid employees. --- Findings include:1. The Hospice volunteer program was reviewed on 09/10/25 and 09/11/25.  The Volunteer Hours reports, indicated cost savings for use of direct patient care volunteers of 2% for 2024. The amount indicated was less than required 5% of total patient care hours.2. During an interview with the Director and Hospice and Palliative Care Manager on 09/12/25 at 9:45 AM, the above findings were confirmed

A. Based on a review of the Hospice Emergency Preparedness Plan and staff interview, it was determined that the Hospice failed to present documentation indicating the Hospice activated or conducted testing of the Emergency Preparedness since 2019. Findings Include: 1. The Hospice Emergency Preparedness Plan was reviewed on 09/14/2022 at 1:00 PM. The Emergency Preparedness Plan failed to include documentation indicating that the Hospice activated or conducted any testing exercise since 2019. 2. During an interview with the Administrator and Hospice Director on 09/15/2022 at 10:00 AM, it was stated that the Quality Assurance Coordinator has the documentation. 3. During an interview with the Quality Assurance Coordinator on 09/15/2022 at 11:30 AM. The Quality Assurance Coordinator presented an incomplete Emergency Preparedness report for 2021. The report for 2021 only contained a report titled "After Action / Improvement Plan Questionnaire." The Emergency Preparedness Plan lacked the narrative clinical relevant emergency activation process. No other reports were presented. 4. During an interview with the Quality Assurance Coordinator on 09/15/2022 at 11:45 AM, finding of the incomplete Emergency Preparedness testing requirement was confirmed.

A. Based on the review /observations of vaccination records, policy review and Staff interviews, it was determined the Hospice failed to ensure the COVID -19 vaccination requirements for tracking, monitoring and documenting the Exempted Staff. This was found in 1 of 6 (Staff # 3) with a religious exemption. Findings include: 1. On 09/15/22 at 8:45 AM, the Hospice vaccination records were reviewed. It was observed that Staff #3 was approved for the religious exemption (01/29/22). Staff #3 failed to document weekly COVID-19 testing results after 05/05/22 and continued to visit patients for 4 months (untested). 2. On 09/15/22 at 9:00 AM, the Hospice policy titled "COVID-19 Vaccination of Employees and Other Healthcare Workers" was reviewed and required " ...II EXEMPTIONS ... b. Religious Exemption ...will be required to wear adequate PPE following current CDC requirements and obtain weekly testing ... III CORRECTIVE ACTION PROCEDURE A HCW that is not in compliance with this policy will be removed from work ...will be placed on unpaid leave status until the requirements are met ..." 3. On 09/15/22 at 9:00 AM, during the onsite interview with the Hospice Director, it was stated that Staff #3, a part- time Registered Nurse, stopped testing after 05/05/22, because he thought the testing requirement was discontinued. A schedule was presented for Staff #3, that included 24 hospice patients visited by Staff #3 from the week of 05/05/22 through the week of 09/13/22. 4. On 09/15/22 at 9:30 AM, during the onsite interview with the Registered Nurse (Staff #3), it was stated that he provided care to some of the Hospice patients, 1 - 2 times a week, since 05/05/22. Staff #3 was observed wearing a N95 mask and adhering to social distancing but lacked the weekly COVID-19 testing for May, June, July and September 2022. 5. On 09/15/22 at 9:45 AM, during the interview with the Hospice Director and Hospice Administrator, it was confirmed the above non-compliance for the requirements for tracking, monitoring and documenting the weekly COVID-19 testing was not met.