Every finding on record at Meridian Palliative & Hospice Care Services LLC

Upon patient record review 2 of 14 (Patient #8,10) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #8 - Patient was admitted on 12/12/25. The psychosocial comprehensive assessment was not completed until 12/19/25. Patient #10 - Patient was admitted on 12/23/25. The psychosocial comprehensive assessment was not completed until 12/29/25. There was no evidence of an attempt to complete prior to that assessment. The spiritual comprehensive assessment was not completed until 12/30/25.

Upon patient record review 1 of 14 (Patient #2) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #2 - The patient was admitted on 12/04/25. The MSW documented a note dated for 12/08/25, "LCSW made several attempts and LVM to schedule initial psychosocial visit within 5 days of admission and no response. LCSW will continue to monitor and be available to address psychosocial needs. IDG aware." There was no evidence that the psychosocial or emotional needs have been assessed.

Upon patient record review, 7 of 14 (Patient #1,3,4,6,7,8,10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1 - The medication profile contained MiraLAX 17 gm daily. There was no evidence of a diluent added. Patient has Bisacodyl 5 mg po daily prn and bisacodyl 10 mg suppository daily prn with no indication of which prn medication to use first. Patient #3 - The medication profile contained Tylenol 500 mg tabs take 2 tabs every 4 hours prn. The profile also contained Tylenol 650 mg suppository q 4 hrs prn. There was no evidence of a maximum daily dose of acetaminophen listed. Patient #4 - The medication profile contained MiraLAX 17 gm daily. There was no evidence of a diluent added. Patient #6 - The medication profile contained MiraLAX 17 gm daily. There was no evidence of a diluent added. The profile also contained Tylenol 500 mg take 2 tabs three times daily and Tylenol suppository 650 mg every 4 hrs prn. There was no evidence of a maximum daily dose of acetaminophen listed. Patient #7 - The medication profile contained MiraLAX 17 gm daily. There was no evidence of a diluent added. Patient #8 - The medication profile contained MiraLAX 17 gm daily. There was no evidence of a diluent added. Patient #10 - The medication profile contained MiraLAX 17 gm daily. There was no evidence of a diluent added.

Upon patient record review, 6 of 14 (Patient #3,4,5,7,8,10) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #3 - The medical record contained a missed visit note dated 09/26/25 for the bereavement risk assessment. There was no evidence that a risk assessment was completed Patient #4 - Patient was admitted on 12/24/25. There was no evidence that an initial bereavement risk assessment was completed. Patient #5 - Patient was admitted on 01/16/25. There was no evidence that an initial bereavement risk assessment was completed. Patient #7 - Patient was admitted on 11/12/25. There was no evidence that an initial bereavement risk assessment was completed. Patient #8 - Patient was admitted on 12/12/25. There was no evidence that an initial bereavement risk assessment was completed. Patient #10 - Patient was admitted on 12/23/25. There was no evidence that an initial bereavement risk assessment was completed.

Upon patient record review, 9 of 14 (Patient #1,2,3,4,5,6,8,10,13) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1 - The recertification nursing assessment and subsequent assessments, documented patient was on a mechanical soft diet. There was no evidence of problems, goals or interventions for that diet listed. Patient #2 - The medication profile contained coumadin and ASA daily as blood thinners. There was no evidence of problems, goals, or interventions related to bleeding risk. Patient #3 - The medication profile contained Eliquis and ASA daily as blood thinners. There was no evidence of problems, goals, or interventions related to bleeding risk. Patient #4 - The medical record contained advanced directives which outlined patient wishes to remain a full code. There was no evidence of problems, goals, or interventions related to that full code status. Patient #5 - The medication profile contained Eliquis as a blood thinner. There was no evidence of problems, goals, or interventions related to bleeding risk. The medical record also contained advanced directives which outlined patient wishes to remain a full code. There was no evidence of problems, goals, or interventions related to that full code status. Patient #6 - The medication profile contained several bowel medications to include MiraLAX daily, bisacodyl suppository prn, and Colace twice a day. There was no evidence of problems, goals, or interventions related to constipation listed. Patient #8 - The medical record contained advanced directives which outlined patient wishes to remain a full code. There was no evidence of problems, goals, or interventions related to that full code status. Patient #10 - The medical record contained advanced directives which outlined patient wishes to remain a full code. There was no evidence of problems, goals, or interventions related to that full code status. The initial plan of care contained an order for a mechanical soft diet. There were no problems, goals or interventions related to that diet. The medication profile contained several bowel medications to include MiraLAX daily, bisacodyl suppository prn, and Senna Plus twice a day. There was no evidence of problems, goals, or interventions related to constipation listed. Patient #13 - The medication profile contained the medication Jardiance for diabetes management. There was no evidence of problems, goals, or interventions related to the endocrine system.

Upon patient record review, 8 of 14 (Patient #1,2,3,4,6,7,8,10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1 - The plan of care contained an order MiraLAX 17 gm daily. There was no evidence of a diluent added to the order. Patient has Bisacodyl 5 mg po ordered daily prn and bisacodyl 10 mg suppository daily prn with no indication of which prn medication to use first in the order. Patient #2 - The nursing comprehensive assessment dated 12/04/25, noted patient had an indwelling catheter. There was no evidence of an order for the maintenance of that catheter. Patient #3 - The plan of care contained Tylenol 500 mg tabs take 2 tabs every 4 hours prn. The order also contained Tylenol 650 mg suppository q 4 hrs prn. There was no evidence of a maximum daily dose of acetaminophen listed. Patient #4 - The plan of care contained an order for MiraLAX 17 gm daily. There was no evidence of a diluent added to that order. Patient #6 - The plan of care contained an order for MiraLAX 17 gm daily. There was no evidence of a diluent added to that order. The record also contained an order for Tylenol 500 mg take 2 tabs three times daily and Tylenol suppository 650 mg every 4 hrs prn. There was no evidence of a maximum daily dose of acetaminophen listed. Patient #7 - The plan of care contained an order for MiraLAX 17 gm daily. There was no evidence of a diluent added to that order. Patient #8 - The plan of care contained MiraLAX 17 gm daily. There was no evidence of a diluent added to that order. Patient #10 - The plan of care contained MiraLAX 17 gm daily. There was no evidence of a diluent added to that order.

Upon patient record review, 2 of 14 (Patient #9,10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #9 - The medication profile contained the medication DuoNeb nebulized every 6 hours prn. The plan of care did not contain a nebulizer machine on the DME list. Patient #10 - The nursing comprehensive dated 12/23/25 and subsequent nursing assessments, documented that patient is incontinent of bowel and bladder. The plan of care orders did not include incontinent supplies.

Upon observation, there was no evidence the program shows measurable improvement in indicators related to improved palliative outcomes and hospice services. The agency QAPI program only contains data collected related to infections, incidents, wounds, revocations, HIS submission tracking, live discharges, ADC, and ALOS and a review of this data by the QAPI committee quarterly for 2024 and 2025. There is no evidence of the committees assessment, identification, and or review of any opportunities for improvement in these areas. There was no evidence of any process improvement projects listed.

Upon observation, there was no evidence the QAPI program uses quality indicator data, including patient care and other relevant data in the design of its program. The hospice must use the data collected to: • Monitor the effectiveness and safety of services and quality of care • Identify opportunities and priorities for improvement The agency QAPI program only contains data collected related to infections, incidents, wounds, revocations, HIS submission tracking, live discharges, ADC, and ALOS and a review of this data by the QAPI committee quarterly for 2024 and 2025. There is no evidence of the committees assessment, identification, and or review of any opportunities for improvement in these areas. There was no evidence of any process improvement projects listed.

Upon observation, there was no evidence the hospice's governing body is responsible for ensuring that the hospice-wide Quality Assessment and Performance Improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness. The governing body meeting minutes from 04/02/25, 06/25/25, 09/17/25, and 12/17/25, showed evidence that the QAPI program meeting minutes were reviewed, however there was no evidence that the governing body addressed priorities for improved quality of care or any other areas needing improvement.

Upon observation during home visits 1 of 3, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Visit with the aide and note clinician placed backpack which contained gloves and other items, directly on the patients floor and did not utilize a clean barrier between the floor and the backpack. Agency policy on bag technique was reviewed and stated that bags cannot be placed on a floor.

Upon observation, there was no evidence in the QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. The agency QAPI program only contains data collected related to infections, incidents, wounds, revocations, HIS submission tracking, live discharges, ADC, and ALOS and a review of this data by the QAPI committee quarterly for 2024 and 2025. There is no evidence of the committees assessment, identification, and or review of any opportunities for improvement in these areas. There was no evidence of any process improvement projects listed.

Upon patient record review, 2 of 14 (Patient #11,12) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • 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 #11 and #12 did not have evidence that a bereavement plan of care was initiated.

Upon patient record review 6 of 14 (Patient #2,3,4,5,6,7) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #2 - The plan of care dated 12/04/25 noted aide frequency for 2 visits per week. The medical record showed for the weeks of 01/13/26, 01/20/26 and 01/27/26, there was only 1 visit completed with no documentation of a missed or refused visit. There is also no evidence of aide visits since 01/27/26. Patient #3 - The plan of care dated 09/23/25, noted aide frequency for 2 visits per week. There is no evidence of any visits completed since 01/20/26. Patient #4 - The plan of care dated 12/24/25, noted aide frequency for 2 visits per week. There is no evidence of any visits completed since 01/29/26. Patient #5 - The plan of care dated 01/16/26, noted aide frequency for 2 visits per week. There is no evidence of any visits competed since 01/30/26. Patient #6 - The plan of care dated 07/22/25, noted aide frequency for 2 visits per week. There is evidence that only 1 visit was completed the week of 01/12/26 and no evidence of any aide visits the week of 02/02/26-02/06/26. Patient #7 - The recertification plan of care dated 12/29/25, noted aide frequency for 2 visits per week. The week of 01/12/26 had only 1 visit dated 01/16/26 and no evidence of missed visit or patient refusal documentation.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Agency volunteer percentage rolling 12 month average is at 1.03%.

Upon patient client record review, 1 of 14 (Patient #4) did not evidence that each patient record contains physician orders. Patient #4 - Patient was admitted to hospice on 12/24/25. The initial plan of care and physician certification has not been signed by the Medical Director. DME orders dated 12/29/25 and 12/31/25 do not contain physician signature.

Upon client record review, 2 of 14 (Patient #13,14) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #13 - Patient decided to revoke hospice service effective 04/21/25. There was no evidence that a discharge summary was forwarded to attending physician. Patient #14 - Patient transferred hospice service to another agency. There was no evidence that a discharge summary was forwarded to attending physician.

Upon client record review, 2 of 14 (Patient #13,14) did not have evidence that the discharge summary includes all required information. Patient #13 - Patient decided to revoke hospice service effective 04/21/25. There was no evidence that a discharge summary was completed. Patient #14 - Patient transferred hospice service to another agency. There was no evidence that a discharge summary was completed.

Upon patient record review, 6 of 11 (Patients #1,#2,#7,#8,#9,#10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient 1, 2, 9, 10: The plan of care identified patient has oxygen equipment. There was no evidence of oxygen listed on the medication profile. Corrected on site. Patient 7: The medical record contained nursing documentation upon recertification visit 12/6/22 identifying patient use of oxygen equipment. There was no evidence of the oxygen listed on the medication profile. Corrected on site. Patient 8: The medical record contained nursing documentation upon recertification visit 11/2/22 identifying patient use of oxygen equipment. There was no evidence of the oxygen listed on the medication profile. Corrected on site.

Upon patient record review, 5 of 11 (Patients #1,#2,#6,#8,#10) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 1: The initial bereavement assessment was completed 12/14/22 with start of care date 12/3/22. Patient 2: The initial bereavement assessment was completed 1/4/23 with start of care date 12/23/22. Patient 6: The initial bereavement assessment was completed 11/7/22 with start of care date 9/8/22. Patient 8: The initial bereavement assessment was completed 8/31/22 with start of care date of 8/24/22. Patient 10: There was no evidence of an initial bereavement assessment included as part of the comprehensive assessment upon admission.

Upon patient record review, 2 of 11 (Patient #1,#2) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 1: There was no evidence of wound assessments to coccyx since admission 12/3/22. Agency wound care management policy also stated wound assessments to occur weekly at minimum. Patient 2: There was no evidence of wound assessments to sacrum since admission 12/23/22. Agency wound care management policy also stated wound assessments to occur weekly at minimum.

Upon patient record review, 2 of 11 (Patients #6,#8) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 6: The medical record contained nursing documentation upon recertification assessment 11/28/22 identifying patient shortness of breath with minimal exertion. There was no evidence of problems, goals, and interventions related to respiratory dysfunction included on the plan of care. Corrected on site. Patient 8: The medical record contained wound care orders. There was no evidence of problems, goals, and interventions related to skin impairment included on the plan of care. Corrected on site.

Upon patient record review, 8 of 11 (Patients #1,#2,#7,#8,#9,#10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1, 2, 9, 10: The plan of care identified patient has oxygen equipment. There was no evidence of an order for oxygen dose, frequency and delivery method. Corrected on site. Patient 7: The medical record contained nursing documentation upon recertification visit 12/6/22 identifying patient use of oxygen equipment. There was no evidence of an order for oxygen dose, frequency and delivery method. Corrected on site. Patient 8: The medical record contained nursing documentation upon recertification visit 11/2/22 identifying patient use of oxygen equipment. There was no evidence of an order for oxygen dose, frequency and delivery method. The medical record contains two incomplete wound care orders dated 11/7/22. One states barrier cream to be applied and foam dressing to cover but does not identify location or frequency of wound care. The second states foam dressing to be applied for coccyx but does not identify frequency of wound care. Corrected on site.

Upon patient record review, 8 of 11 (Patients #1,#2,#3,#4,#5,#6,#7,#8) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 1: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair and air mattress. There was no evidence of the wheelchair and mattress included as DME on the plan of care. Corrected on site. Patient 2: The medical record contained nursing documentation upon admission identifying patient need for suction machine and oxygen equipment. There was no evidence of suction and oxygen included as DME on the plan of care. Corrected on site. Patient 3: The medical record contained nursing documentation upon admission identifying patient use of commode. There was no evidence of the commode included as DME on the plan of care. Corrected on site. Patient 4: The medical record contained nursing documentation 12/20/22 identifying patient ambulation with a walker. There was no evidence of the walker included as DME on the plan of care. Corrected on site. Patient 5: The medical record contained nursing documentation upon admission identifying patient use of a walker and shower chair. There was no evidence of the walker and shower chair included as DME on the plan of care. Corrected on site. Patient 6: The medical record contains nursing documentation upon recertification assessment 11/28/22 identifying patient use of cane, air mattress, and shower chair. There was no evidence of the cane, mattress and shower chair included as DME on the plan of care. Corrected on site. Patient 7: The medical record contains nursing documentation upon recertification assessment 12/6/22 identifying patient use of wheelchair, bed, over-bed-table, shower chair, hoyer lift, suction machine, and oxygen equipment. There was no evidence of the wheelchair, bed, table , shower chair, lift, suction and oxygen included as DME on the plan of care. Corrected on site. Patient 8: The medical record contains nursing documentation upon recertification assessment 11/2/22 identifying patient use of bed, wheelchair, over-bed-table, shower chair, and oxygen equipment. There was no evidence of the bed, wheelchair, table, shower chair, and oxygen included as DME on the plan of care. Corrected on site.

Upon client record review, 4 of 11 (Patients #1,#3,#5,#6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: The medical record contained ordered RN frequency of twice monthly and LVN frequency of twice monthly. In December, 3 RN visits and 1 LVN visit was completed. Corrected on site. Patient 3: The medical record contained an ordered nursing frequency of once weekly. Two scheduled visits were completed the week of 11/20/22. Patient 5: The medical record contained an ordered social work frequency of twice monthly. There was no evidence of a second visit completed in December. The medical record contained an ordered nursing frequency of twice weekly. There was no evidence of a second visit completed the week of 1/1/23. Patient 6: The medical record contained an ordered nursing frequency for LVN once weekly. There was no evidence of an LVN visit completed the week of 1/1/22.

Upon observation, there was no evidence in QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the hospice's Quality Assessment and Performance Improvement program. There was evidence of infection surveillance and investigation quarterly but there was no evidence it was incorporated into the QAPI program. No evidence of infection reports in QAPI.

Upon patient record review, 1 of 11 (Patient #10) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • 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 10: There was no evidence of a post-mortem bereavement assessment, care plan, or bereavement support/declination.

Upon patient record review, 2 of 11 (Patients #5,#6) did not have evidence in the patient record that hospice aide assignments and duties are written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 Patient 5 and 6: The aide care plan contains task to obtain vital signs. There is no evidence of parameters for when the aide is to notify the RN. Corrected on site.

Upon patient record review 2 of 11 (Patients #3,#6) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient 3: The medical record contained an ordered aide frequency of twice weekly. There was evidence of 3 visits the week of 11/20/22. Patient 6: The medical record contained an ordered aide frequency of twice weekly. There was no evidence of second visit completed the week of 11/27/22.

Upon patient record review, 3 of 11 (Patients #3,#7,#9) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient 3: The medical record contained a signed CTI by the medical director 11/19/22 with start of care date 11/9/22. There was no evidence that a verbal certification was received by a qualified clinician timely. Patient 7: There was no evidence of a CTI completed for benefit period with start of care 9/6/22. Patient had 5 previous hospice benefit periods and admitted to agency in the 6th period. Patient 9: There was no evidence of a CTI with a composed physician narrative signed by the medical director.

Upon patient record review, 1 of 11 (Patient #7) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient 7 The attending physician from the facility documented round/progress notes for the 7th and 8th benefit period, no narrative or note documented from a hospice physician of eligibility to meet face to face or certification requirements.

Upon patient client record review, 11 of 11 (Patients #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 1 3 and 7: The election of benefits form is empty regarding patient representative's relationship to the beneficiary for explanation of legal authority. Patient 2, 3, 4, 5, 6, 7, 8, 9, 10, 11: The patient/representative elected to receive the Notice of Hospice Non-Covered Items. There was no evidence the patient/representative received the notification.

Upon client record review, 1 of 11 (Patient #11) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient 11: There was no evidence of a discharge summary.

Upon personnel record review, 1 of 13 (Personnel #9) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel 9: There was no evidence of a criminal background check included in the personnel file.

Upon policy and procedure review, there is no evidence the Hospice has developed written policies and procedures to ensure that all personnel are fully vaccinated for COVID19. The policies and procedures include, at a minimum, the following components: • A process for ensuring all personnel specified in 42 CFR 418.600(d)(1) (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of 42 CFR 418.600(d)(1), or those personnel for whom COVID-19 vaccination must be temporarily delayed, as recommended by CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to personnel providing any care, treatment, or other services for the Hospice and/or its patients; • A process for ensuring that all personnel specified in 42 CFR 418.600(d)(1) are fully vaccinated, except for those personnel who have been granted exemptions to the vaccination requirements of 42 CFR 418.600(d)(1) or those personnel for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations. • 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 418.600(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 by which personnel may request an exemption from the personnel COVID-19 vaccination requirements based on an applicable federal law. • A process for tracking and securely documenting information provided by those personnel who have requested, and for whom the Hospice has granted, an exemption from the personnel COVID-19 vaccination requirements. • 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. • A process for ensuring the tracking and secure documentation of the vaccination status of personnel for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and • Contingency plans for personnel who are not fully vaccinated for COVID-19.