Every finding on record at Msa Home Health & Hospice of the Piedmont Inc

Based on agency policy, clinical record review, and staff interviews, the Plan of Care did not include individualized interventions for 2 of 19 records [#3 and 7]. The findings included: --- The policy, Plan of Care [3/25], was provided by the agency administrator on 10/15/25 at 4:50 pm. The policy stated, "...The plan of care includes interventions, goals, and services tailored to the patient and family's needs..."1. Patient # 3 had a Start of Care date of 8/30/25 with a terminal diagnosis of interstitial pulmonary disease [a group of chronic lung conditions that cause inflammation and scarring of the lung tissue]. Review of the Plan of Care [POC] for the certification period 8/30/25-11/27/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 13 weeks. Further review of the POC revealed the following intervention related to respiratory function “Tracheostomy [surgical procedure that creates an opening in the trachea (windpipe) to provide an airway and facilitate breathing]: Patient/caregiver demonstrate proper management and aseptic technique in trach care”.  Review of the updated POC dated 9/4/25 revealed the same intervention. A review of the clinical record revealed the patient did not have a tracheostomy. During an interview with the agency administrator on 10/16/25 at approximately 10:30 am, the administrator confirmed the POC was not individualized for Patient # 3.  2. Patient # 7 had a Start of Care date of 8/10/25 with a terminal diagnosis of idiopathic pulmonary fibrosis [a progressive disease characterized by a progressive and irreversible decline in lung function]. Review of the Plan of Care [POC] for the certification period 8/10/25-11/7/25 included orders for SN [skilled nursing [3 times a week for 1 week, 2 times a week for 12 weeks. Further review of the POC revealed the following interventions related to shortness of breath -“Perform/assess/educate on proper trach [tracheostomy - [surgical procedure that creates an opening in the trachea (windpipe) to provide an airway and facilitate breathing] care and suctioning techniques” and “Provide/assess/educate on respiratory management devices, including pleural catheter [ thin, flexible tube inserted into the pleural space to drain excess fluid] care”. The patient did not have a tracheostomy or a pleural catheter. During an interview with the agency administrator on 10/16/25 at approximately 10:30 am, the administrator confirmed the POC was not individualized for Patient # 7.

Based on agency policy, clinical record review, and staff interviews, the agency failed to update the plan of care with planned visit frequencies for the next 15 days for 18 of 18 patients [#1, 2, 3, 4, 6, 7, 9, 11, 12, 15, 16, 18, 8, 10, 6, 13, 19] receiving MSW [medical social worker] visits; and failed to enter IDG [interdisciplinary group-team of healthcare professionals who collaboratively create and manage a patient's plan of care for holistic support] notes for 11 of 18 [#1, 6, 7, 9, 11, 15, 16, 18, 10, 13, 19] patients with MSW services. The findings included: --- 13. Patient #8 had a Start of Care (SOC) date of 9/19/2025 and a terminal diagnosis of Hypertensive Heart and Chronic Kidney Disease (High blood pressure leading to kidney disease). The Plan of Care (POC) for the certification period of 9/19/2025 - 12/17/2025 included orders for Skilled nursing (SN) 1 time a week for 1 week, 2 times a week for 13 weeks; hospice aide 2 times a week for 13 weeks; Medical Social worker (MSW) 1 time a month for 4 months; Chaplain 1 time a month for 4 months. Review of the clinical record revealed that the IDG meeting conducted on 10/2/2025 had no MSW visit projections for the next 15 days. During an interview with the administrator on 10/16/2025 at approximately 10:10 am, the administrator confirmed the POC for MSW was not updated with visit projections for the next 15 days during the 10/2/2025 IDG meeting.14. Patient #10 had a Start of Care (SOC) date of 8/23/2025 and a terminal diagnosis of other symptoms and signs involving cognitive functions following cerebral infarction (cognitive impairment related to having a disruption of blood supply to a part of the brain causing tissue death). The Plan of Care (POC) for the certification period of 8/23/2025-11/20/2025 included orders for Skilled nursing (SN) 2 times a week for 13 weeks; hospice aide 2 times a week for 1 week, 1 time a week for 12 weeks; Medical Social worker (MSW) 1 time a month for 4 months; Chaplain 1 time a month for 4 months. Review of the clinical record revealed that IDG meetings were conducted on 9/4/2025, 9/19/2025, and 10/2/2025. Review of the 9/4/25 and 10/2/25 IDG meeting minutes revealed no visit projections for the next 15 days by the MSW. Review of the 9/19/25 IDG meeting minutes revealed no IDG note by the MSW.  During an interview with the administrator on 10/16/2025 at approximately 10:10 am, the administrator confirmed the POCs for the MSW were not updated with visit projections for the next 15 days during the 9/4/2025 or 10/2/25 IDG meetings. The administrator also confirmed there was no IDG note entered by the MSW for the 9/19/25 meeting. 15. Patient #13 had a Start of Care (SOC) date of 8/9/2025 and a terminal diagnosis of Hemiplegia (paralysis or unable to move) and hemiparesis (weakness) affecting one side of the body. The Plan of Care (POC) for the certification period of 8/9/2025-10/13/2025 included orders for Skilled nursing (SN) 2 times a week for 3 weeks, 1 time a week for 6 weeks, 1 time a week for 9 weeks; Hospice aide 3 times a week for 8 weeks; Medical Social worker (MSW) 1 time a month for 2 months. Review of the clinical record revealed that IDG meetings were conducted on 8/21/2025, 9/4/2025, 9/19/2025, and 10/2/2025. Review of the 8/21/2025 and 9/19/2025 IDG meeting minutes revealed no visit projections for the next 15 days by the MSW. Review of the 9/4/2025 and 10/2/2025 IDG meeting minutes revealed no IDG note by the MSW. During an interview with the administrator on 10/16/2025 at approximately 10:10 am, the administrator confirmed the POCs for the MSW were not updated with visit projections for the next 15 days during the 8/21/2025 and 9/19/2025 IDG meetings. The administrator also confirmed there was no IDG note entered by the MSW for the 9/4/2025 and 10/2/2025 meetings.16. Patient #19 had a Start of Care (SOC) date of 7/18/2025 and a terminal diagnosis of senile degeneration of the brain (age related decline in memory, behavior, and cognitive ability). The Plan of Care (POC) for the certification period of 7/18/2025-10/15/2025 included orders for Skilled nursing (SN) 1 time a week for 12 weeks; hospice aide 1 time a week for 12 weeks; Medical Social worker (MSW) 1 time a month for 3 months; Chaplain 1 time a month for 3 months.  Review of the clinical record revealed that IDG meetings were conducted on 7/24/2025, 8/7/2025, 8/21/2025, 9/4/2025, 9/19/2025, and 10/2/2025. Review of the 7/24/2025, 9/4/2025, and 9/19/2025 IDG meeting minutes revealed no visit projections for the next 15 days by the MSW. Review of the 8/7/2025, 8/21/2025, and 10/2/2025 IDG meeting minutes revealed no IDG note by the MSW.During an interview with the administrator on 10/16/2025 at approximately 10:10 am, the administrator confirmed the POCs for MSW were not updated with visit projections for the next 15 days during the 7/24/2025, 9/4/2025, and 9/19/2025 IDG meetings. The administrator also confirmed there was no IDG note entered by the MSW for the 8/7/2025, 8/21/2025, and 10/2/2025 meetings.   The policy, Plan of Care [revised 3/25], was provided by the agency administrator on 10/15/25 at 4:50 pm. The policy stated, “...The plan of care will be reviewed, revised and documented in the patient’s clinical record by the interdisciplinary team at least every 15 days...”The policy, Interdisciplinary Group [revised 6/2025], was provided by the agency administrator on 10/14/25 at 2:03 pm. The policy stated, “...The IDG [interdisciplinary group-team of healthcare professionals who collaboratively create and manage a patient's plan of care for holistic support] meets at least every 15 days to...review and revise plans of care...”1. Patient # 1 had a Start of Care date of 11/6/24 with a terminal diagnosis of severe protein-calorie malnutrition [condition where a person does not consume enough protein and calories to meet their body's needs]. Review of the Plan of Care for the certification period 11/6/24-2/3/25 included orders for SN [skilled nursing] 2 times a week for 3 weeks, 1 time a week for 9 weeks; hospice aide 1 time a week for 9 weeks; MSW [medical social worker] 1 time a month for 3 months. Review of the IDG [interdisciplinary group- team of healthcare professionals who collaboratively create and manage a patient's plan of care for holistic support] minutes revealed IDG meetings were conducted on 11/14/24, 11/28/24, and 12/12/24. Further review of the minutes revealed no visit projections for the next 15 days from the MSW for the 11/14/24 or 12/12/24 meetings, and no narrative note from the MSW for the 11/28/24 IDG meeting.2. Patient # 2 had a Start of Care date of 8/19/25 with a terminal diagnosis of malignant neoplasm of upper lobe, left bronchus or lung [lung cancer]. Review of the Plan of Care for the certification period 8/19/25-10/17/25 included orders for SN [skilled nursing] 1 time a week for 9 weeks; hospice aide 2 times a week for 9 weeks; MSW [medical social worker] 1 time a month for 3 months; chaplain 1 time a month for 2 months. Review of the IDG [interdisciplinary group- team of healthcare professionals who collaboratively create and manage a patient's plan of care for holistic support] minutes revealed a meeting was conducted on 8/21/25. Review of the 8/25/25 IDG minutes revealed no visit projections for the next 15 days by the MSW. The patient revoked hospice on 9/3/25.3. Patient # 3 had a Start of Care date of 8/30/25 with a terminal diagnosis of interstitial pulmonary disease [a group of chronic lung conditions that cause inflammation and scarring of the lung tissue]. Review of the Plan of Care for the certification period 8/30/25-11/27/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 13 weeks; hospice aide 2 times a week for 13 weeks; MSW [medical social worker] 1 time a week for 1 week; chaplain 1 time a week for 1 week. A supplemental order for MSW visits was noted for 9/3/25 with a frequency of 1 time a month for 3 months. Review of the IDG [interdisciplinary group-team of healthcare professionals who collaboratively create and manage a patient's plan of care for holistic support] minutes revealed a meeting on 9/4/25.  Review of the 9/4/25 IDT minutes revealed no visit projection for the next 15 days by the MSW. The patient passed away on 9/12/25.4. Patient # 4 had a Start of Care date of 12/19/24 with a terminal diagnosis of Alzheimer’s Disease [a progressive neurodegenerative disorder that affects memory, thinking, and behavior]. Review of the Plan of Care for the certification period 12/19/24-3/18/25 included orders for SN [skilled nursing] 2 times a week for 13 weeks; hospice aide 2 times a week for 11 weeks; MSW [medial social worker] 1 time a month for 4 months. Review of the IDG [interdisciplinary group-team of healthcare professionals who collaboratively create and manage a patient's plan of care for holistic support] minutes revealed meetings were conducted on 12/26/24 and 1/9/25. Further review of the IDG minutes revealed no MSW visit projections for the next 15 days for either meeting. The patient passed away on 1/16/25.5. Patient # 6 had a Start of Care date of 8/22/25 with a terminal diagnosis of central nervous system lymphoma [cancer that affects the brain and spinal cord]. Review of the Plan of Care for the certification period 8/22/25-11/19/25 included orders for SN [skilled nursing] 1 time a week for 13 weeks; hospice aide 1 time a week for 13 weeks; MSW [medical social worker] 1 time a month for 3 months; chaplain 1 time a month for 4 months. Review of the IDG [interdisciplinary group-team of healthcare professionals who collaboratively create and manage a patient's plan of care for holistic support] minutes revealed IDG meetings were conducted on 9/4/25, 9/19/25, and 10/2/25. Further review of the IDG minutes revealed no MSW visit projections for the next 15 days for the 9/19/25 or the 10/2/25 meetings. Review of the minutes for the 9/4/25 meeting revealed no entry by the MSW.6. Patient # 7 had a Start of Care date of 8/10/25 with a terminal diagnosis of idiopathic pulmonary fibrosis [a progressive disease characterized by a progressive and irreversible decline in lung function]. Review of the Plan of Care for the certification period 8/10/25-11/7/25 included orders for SN [skilled nursing [3 times a week for 1 week, 2 times a week for 12 weeks; MSW [medical social worker] 1 time a month for 3 months. Review of the IDG [interdisciplinary group-team of healthcare professionals who collaboratively create and manage a patient's plan of care for holistic support] minutes revealed meetings were conducted on 8/21/25, 9/4/25, 9/19/25, and 10/2/25. Further review of the IDG minutes revealed no visit projections for the next 15 days by the MSW for the 8/21/25 or the 9/19/25 meetings. The IDG minutes revealed no MSW entry in the minutes for the 9/4/25 or the 10/2/25 meetings.7. Patient # 9 had a Start of Care date of 9/11/25 with a terminal diagnosis of heredity spastic paraplegia [large group of inherited neurologic disorders that share the primary symptom of difficulty walking]. Review of the Plan of Care for the certification period 9/11/25-11/9/25 included orders for SN [skilled nursing] 1 time a week for 9 weeks; hospice aide 2 times a week for 8 weeks, 1 time a week for 1 week; MSW [medical social worker] 1 time a month for 2 months. Review of the IDG [interdisciplinary group-team of healthcare professionals who collaboratively create and manage a patient's plan of care for holistic support] minutes revealed meetings were conducted on 9/19/25 and 10/2/25. Further review of the IDG minutes revealed no visit projections for the next visit days by the MSW for the 9/19/25 meeting. The 10/2/25 minutes revealed no entry by the MSW.8. Patient # 11 had a Start of Care date of 8/30/25 with a terminal diagnosis of Pompe Disease [disorder that affects muscles and other organs]. Review of the Plan of Care for the certification period 9/30/25-11/28/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 8 weeks; hospice aide 1 time a week for 1 week, 2 times a week for 8 weeks; MSW [medical social worker] 1 time a month for 2 months. Review of the IDG [interdisciplinary group-team of healthcare professionals who collaboratively create and manage a patient's plan of care for holistic support] minutes revealed an IDG meeting was conducted on 10/2/25. Further review of the IDG minutes for that date revealed no entry from the MSW.9. Patient # 12 had a Start of Care date of 9/15/25 with a terminal diagnosis of senile degeneration of the brain [a progressive decline in cognitive abilities that occurs with aging]. Review of the Plan of Care for the certification period 9/15/25-11/13/25 included orders for SN [skilled nursing] 2 times a week for 1 week, 1 time a week for 9 weeks; hospice aide 1 time a week for 9 weeks; MSW [medical social worker] 1 time a week for 1 week then 1 time a month for 3 months; chaplain 1 time a week for 1 week then 1 time a month for 3 months. Review of the IDG [interdisciplinary group-team of healthcare professionals who collaboratively create and manage a patient's plan of care for holistic support] minutes revealed IDG meetings were conducted on 9/19/25 and 10/2/25. Review of the IDG minutes for those dates revealed no visit projections for the next 15 days by the MSW.10. Patient # 15 had a Start of Care date of 8/20/25 with a terminal diagnosis of severe protein-calorie malnutrition [condition where a person does not consume enough protein and calories to meet their body's needs]. Review of the Plan of Care for the certification period 8/20/25-11/17/25 included orders for SN [skilled nursing] 3 times a week for 2 weeks, 2 times a week for 11 weeks; hospice aide 2 times a week for 11 weeks; MSW [medical social worker] 1 time a month for 4 months; chaplain 1 times a month for 4 months. Review of the IDG [interdisciplinary group-team of healthcare professionals who collaboratively create and manage a patient's plan of care for holistic support] minutes revealed IDG meetings were conducted on 9/4/25, 9/19/25, and 10/2/25. Further review of the IDG minutes revealed the MSW failed to project visit frequencies for the next 15 days during the 9/4/25 and 10/2/25 meetings. The minutes for the 9/19/25 revealed no MSW entry for that meeting date.11. Patient # 16 had a Start of Care date of 8/14/25 with a terminal diagnosis of severe protein-calorie malnutrition [condition where a person does not consume enough protein and calories to meet their body's needs]. Review of the Plan of Care for the certification period 8/14/25-10/12/25 included orders for SN [skilled nursing] 1 time a week for 8 weeks; hospice aide 1 time a week for 8 weeks; MSW [medical social worker] 1 time a month for 3 months; chaplain 1 time a month for 2 months. Review of the IDG [interdisciplinary group-team of healthcare professionals who collaboratively create and manage a patient's plan of care for holistic support] minutes revealed meetings were conducted on 8/21/25, 9/4/25, 9/19/25, and 10/2/25. Further review of the IDG minutes revealed no entry by the MSW for the IDG meetings on 8/21/25, 9/4/25, or 10/2/25. The minutes for the meeting conducted on 9/19/25 revealed no visit projections for the next 15 days by the MSW.12. Patient # 18 had a Start of Care date of 11/29/24 with a terminal diagnosis of chronic kidney disease, stage 4 [severe kidney damage, where the kidneys function at 15-29% of their normal capacity]. Review of the Plan of Care for the certification period 9/25/25-11/23/25 included orders for SN [skilled nursing] 1 time a week for 8 weeks; MSW [medical social worker] [effective 10/1/25] 1 time a month for 2 months; chaplain [effective 10/1/25] 1 time a month of 2 months. Review of the IDG [interdisciplinary group-team of healthcare professionals who collaboratively create and manage a patient's plan of care for holistic support] minutes revealed an IDG meeting was conducted 10/2/25. Review of the IDG minutes revealed no narrative note related to plan for next 15 days for the MSW.During an interview with the agency administrator and employee # 27 on 10/16/25 at approximately 10:15 am, it was confirmed that the MSW failed to update the the Plan of Care with projected visit frequencies.

Based on agency policy, clinical record review, and staff interviews, the agency failed to provide wound care  in accordance with the plan of care for 3 of 7 patients with a wound [#1, 15, and 10]; failed to follow the plan of care related to visit frequency of 1 of 17 [#4] patients receiving aide services. The findings included: --- 4. Patient #10 had a Start of Care (SOC) date of 8/23/2025 and a terminal diagnosis of other symptoms and signs of cerebral infarction (cognitive impairment related to having a disruption of blood supply to a part of the brain causing tissue death). The Plan of Care (POC) for the certification period of 8/23/2025-11/20/2025 included orders for Skilled nursing (SN) 2 times a week for 13 weeks and “Skilled nurse to provide wound care twice a week. Remove old dressing, cleanse with soap and water or wound cleanser, pat dry, cover wound bed with xeroform and secure with bordered foam dressing.” Review of the clinical record revealed that on 8/26/25, RN (registered nurse) #14 documented wound dressing change as “cleansed with wound wash, pat dry, Vaseline impregnated gauze applied over wound bed, skin prep applied to peri-wound skin, covered with adhesive foam dressing.” Further review of the clinical record revealed that on 8/28, RN #14 documented wound dressing change as “cleansed with hygiene wipes, zinc paste applied, covered with adhesive foam dressing.”  E-mail correspondence with the director on 10/16/2025 at 11:47 am confirmed that wound care orders had not been followed on the 8/26/25 and 8/28/25 SN visits.  The policy, Plan of Care [3/25], was provided by the agency administrator on 10/15/25 at approximately 4:50 pm. The policy stated, “...the patient’s plan of care reflect [sic]  the patient’s current health status, care needs...”The policy, Patient Visits-Scheduling [9/25], was provided by the agency administrator on 10/15/25 at 4:50 pm. The policy stated, “______ [agency name] shall insure all patient visits are scheduled and provided in accordance with the individualized plan of care, physician orders...Missed visits must be documented with the reason, and the physician notified...”1. Patient # 1 had a Start of Care date of 11/6/24 with a terminal diagnosis of severe protein-calorie malnutrition [condition where a person does not consume enough protein and calories to meet their body's needs]. Review of the Plan of Care for the certification period 11/6/24-2/3/25 included orders for SN [skilled nursing] 2 times a week for 3 weeks, 1 time a week for 9 weeks, 3 PRN [as needed] for symptom management.  Review of the clinical record revealed the following documentation by RN # 5 on 11/8/25, “PRN visit made tonight following a call from daughter...2 new skin tears to left arm...Wound care performed...” Further review of the clinical record revealed no orders for wound care. During an interview with RN # 3 on 10/17/25 at approximately 11 am, RN # 3 stated, “Sometimes the nurses will pull orders from the standing orders without writing them. I believe the correct method would be to write any specific order pulled from the standing orders.”2. Patient # 15 had a Start of Care date of 8/20/25 with a terminal diagnosis of severe protein-calorie malnutrition [condition where a person does not consume enough protein and calories to meet their body's needs]. Review of the Plan of Care for the certification period 8/20/25-11/17/25 included orders for SN [skilled nursing] 3 times a week for 2 weeks, 2 times a week for 11 weeks and “Pressure Ulcer Stage 4 [a severe, deep open wound that extends through the skin and fat into the underlying muscle, tendon, ligament, or bone] sacrum [a triangular bone in the lower; situated between the two hipbones of the pelvis]: Cleanse with soap and water, apply Baza cream thick over area, leave open due to risk for soiling and infection. SN to assess at each visit”. Review of the clinical record revealed LPN # 10 conducted a visit on 8/27/25 and documented the following information,” ...Location: Sacral Pressure...Treatment: Cleanse with wound cleanser and gauze, dress with zero form [sic], covered with bordered gauze...” During an interview with the agency administrator on 10/16/25 at approximately 10 am, the director confirmed the area to the sacrum should not have had a dressing applied.  3A. Patient # 4 had a Start of Care date of 12/19/24 with a terminal diagnosis of Alzheimer’s Disease [a progressive neurodegenerative disorder that affects memory, thinking, and behavior]. Review of the Plan of Care [POC] for the certification period 12/19/24-3/18/25 included orders for SN [skilled nursing] 2 times a week for 13 weeks; hospice aide 2 times a week for 11 weeks. Review of the clinical record revealed the patient received 3 hospice aide visits the week of 12/29/24. During an interview with employee # 27 on 11/16/25 at approximately 10 am, it was confirmed the patient received 3 hospice aide visits instead of 2 as ordered on the POC.3B. Patient # 4 had a Start of Care date of 12/19/24 with a terminal diagnosis of Alzheimer’s Disease [a progressive neurodegenerative disorder that affects memory, thinking, and behavior]. Review of the Plan of Care [POC] for the certification period 12/19/24-3/18/25 included orders for SN [skilled nursing] 2 times a week for 13 weeks; hospice aide 2 times a week for 11 weeks. Review of the clinical record revealed the hospice aide documented a missed visit on 12/26/24. There was no evidence the physician was notified of the missed visit. During an interview with the agency administrator on 10/16/25 at approximately 10 am, the administrator confirmed the patient did not receive aide services in accordance with the POC.

Based on agency policy, clinical record review, and e-mail correspondence the Hospice Aide care plan failed to include correct advanced directives for 1 out of 17 patients with hospice aide services (#8). The findings included: --- The policy, Hospice Aide Services, Assignments and Supervision HC. 19 (Revised 01/2025), was provided by the agency director on 10/16/25 at 12:10 pm. The policy stated, “Hospice Aide services are provided under the supervision of a registered nurse (RN)…The RN provides written or electronic patient care instructions before the hospice aide begins providing services…A hospice aide care plan is developed and updated by the RN based on the patient’s evolving needs.”Patient #8 had a Start of Care (SOC) date of 9/19/2025 and a terminal diagnosis of Hypertensive Heart and Chronic Kidney Disease (High blood pressure leading to kidney disease). The Plan of Care (POC) for the certification period of 9/19/2025 - 12/17/2025 included orders for Skilled nursing (SN) 1 time a week for 1 week, 2 times a week for 13 weeks; hospice aide 2 times a week for 13 weeks; Medical Social worker (MSW) 1 time a month for 4 months; Chaplain 1 time a month for 4 months. Review of the clinical record revealed a signed DNR (do not resuscitate-a medical order instructing healthcare providers not to perform life-saving measures if a person’s heart or breathing stops) dated 9/19/2025. Review of the Hospice Aide care plan dated 9/19/2025 indicated that the patient did not have a DNR in place. E-mail correspondence with the director on 10/16/2025 at 11:47 am confirmed the hospice aide care plan failed to include the patient’s DNR status.

Based on agency policy, clinical record review and staff interviews the agency failed to use volunteers in accordance with the Medicare Conditions of Participation. --- The policy, Volunteer Services [9/25], was provided by the agency administrator on 10/16/25 at approximately 11 am. The policy stated, "..._______ [name of agency] ensures the use of trained, supervised, and qualified volunteers to support patients, caregivers, and administrative operations..." During an interview with the agency director on 10/15/25 at approximately 3 pm, the director stated, “We haven’t had any volunteers since the end of 2023. We were able to retain volunteers before the pandemic but since then we haven’t been able to recruit any volunteers. We have a brochure that is in the admission packet. People just don’t want to go into patient's home anymore.”

Based on agency policy, clinical record review, and e-mail correspondence, the clinical record failed to include wound measurements for 1 out of 7 patients with a wound (#8). Findings include: --- The policy, Wound Care (revised 12/2024) was provided by the agency director on 10/14/2025 at 11:00 am. The policy stated, “…after the initial visit, skin integrity will be assessed at every subsequent visit…any open area will have the sites measured and documented weekly.”Patient #8 had a Start of Care (SOC) date of 9/19/2025 and a terminal diagnosis of Hypertensive Heart and Chronic Kidney Disease (High blood pressure leading to kidney disease). The Plan of Care (POC) for the certification period of 9/19/2025 - 12/17/2025 included orders for Skilled nursing (SN) 1 time a week for 1 week, 2 times a week for 13 weeks and “LLE (left lower extremity) wound…Cleanse wound with wound cleanser. Pat dry. Apply xeroform to wound bed. Cover with non-adherent gauze. Secure with rolled gauze and tape. Dressing to be changed twice a week”. Review of the clinical record revealed no wound measurements for the left lower leg wound on 9/25/2025.E-mail correspondence with the director on 10/16/2025 at 11:47 am confirmed the clinical record failed to include wound measurements on 9/25/25.

Based on the Emergency Preparedness Program review, the agency failed to conduct required emergency preparedness training for staff. Findings included: --- The Emergency Operations Plan (EOP) (last revised 8/24/22), was provided by the Clinical Manager on 12/6/22 at approximately 11:30 a.m. The plan stated, ";All new staff will be trained on the EOP in orientation...Emergency Preparedness training will be conducted annually...Documentation of the training on the EOP and annual emergency preparedness training will be maintained by the Human Resource Dept [Department]..." Five active personnel records were reviewed. Four of five personnel records reviewed did not have evidence of emergency preparedness training. During an interview with the Clinical Manager on 12/8/22 at 11:00 a.m. it confirmed only one of the five employee records reviewed had completed the emergency preparedness training.

Based on Emergency Preparedness Program review, the agency failed to conduct required testing of the Emergency Preparedness Program. Findings included: --- The Emergency Operations Plan (EOP) (last revised 8/24/22) was provided by the Clinical Manager on 12/6/22 at approximately 11:30 a.m. The plan stated, ";The Agency will participate in a full scale exercise that is community-based or when a community based exercise is not available, an individual, facility based exercise annually...In the event that the Agency experiences an actual natural or man-made emergencies [sic] that requires activation of the EOP, the Agency is exempt from engaging in an individualized full scale exercise for 1 year following the onset of the actual event...The agency must conduct a second exercise every year. The second exercise can be another full scale exercise of tabletop exercise...After full scale exercises, tabletops or actual events, the Agency should analyze the response, identify areas for improvement and updated [sic] the EOP, if required." A review of drill/actual event documents dated 8/24/22 revealed a fire drill was conducted. There was no evidence of any further exercises or activation of the emergency preparedness plan. In in with the Clinical Manager on 12/7/22 at 2:20 p.m., it was confirmed at there was no evidence of a drill or activation of the emergency preparedness plan since 2019.

Based on clinical record review and staff interview the Plan of Care was not individualized related to symptom management (nausea/pain) medications for 2 of 13 patients reviewed (#2 and 1). Findings included: --- 2. Patient #1 had a Start of Care 10/7/22 with diagnosis of Neurocognitive disorder with Lewy Bodies [a progressive decline in mental abilities]. The Plan of Care [POC] for the certification period 10/7/22 to 1/4/23 included orders for skilled nurse [SN] visits 2 times per week for 12 weeks with 3 PRN [as needed] for symptom management needs and end of life issues. Patient #1 was a resident at an assisted living facility. A review of patient #1 POC medication profile had documented two orders each for Morphine sulfate [pain medication] solution 20mg [milligram]/ milliliter [ml] and two orders for Lorazepam tablets. Orders were as follows: Morphine sulfate solution, give 0.25 ml by mouth or under the tongue every 2 hours as needed for pain or air hunger; and Morphine sulfate solution, give 0.5 ml by mouth or under the tongue every 2 hours as needed for pain or air hunger. Lorazepam tablet 1 mg every 4 hours as needed for anxiety or agitation; and Lorazepam tablet 0.5mg take one half tablet by 2 times daily as needed for anxiety or agitation. An interview with clinical manager #1 on 12/7/22 at approximately 3:45 p.m. verified there was no instruction on when to take which dose. 1. Patient #2 was admitted on 4/1/22 with a diagnosis of malignant neoplasm right breast (breast cancer). The Plan of Care (POC) for 9/28/22-11/26/22 included orders for skilled nursing weekly for nine weeks. The POC included Zofran 8 mg orally every eight hours as needed for nausea. The visit note on 10/4/22 stated, the facility ";Staff administered Phenergan [anti-nausea medication] prior to arrival." Phenergan was not included on the POC. An interview with the Clinical Manager on 12/8/22 at 9:18 a.m. revealed that Phenergan was in the comfort kit for symptom management. The interview confirmed that there was no indication of when to administer Zofran versus Phenergan (both medications were for nausea).

Based on policy review, clinical record review, and staff interviews, the plan of care did not include all medication for 4 of 13 patients reviewed (#2, 9, 12, and 11). Findings included: --- 4. Patient #11 had a Start of Care of 11/22/22 which included diagnoses of malignant neoplasm [cancerous tumor] of right female breast with metastasis [secondary malignant growths]. The Plan of Care [POC] for certification period 11/22/22 to 2/19/23 included orders for Skilled nursing [SN] for 2 times per week for 13 weeks with 3 PRN [as needed] for symptom management, falls and end of life issues. A virtual home visit was conducted on 12/6/22 at 9:35 a.m. with SN #3. The POC medication profile reviewed had the following discrepancies: 1. Femara oral tablet 2.5 mg [milligram] 1 tablet by mouth daily, for breast cancer, per report from the caregiver this medication had been discontinued approximately 11/23/22. 2. Zyprex [treatment of mental/mood conditions] 15 mg at night which had been started 6/2022 3. Senna S [laxative/stool softener] 8.6-50 mg take 2 tablets twice a day, caregiver reported he/she had been giving 1 tablet twice daily for approximately 2 weeks due to loose stools. An interview with SN #3 on 12/6/22 at approximately 9:45 a.m. verified the POC medication profile did not include all current medications. 1. Patient #2 was admitted on 4/1/22 with a diagnosis of malignant neoplasm right breast (breast cancer). The Plans of Care (POC) for 9/28/22-11/26/22 and 11/27/22-1/25/23 included orders for skilled nursing weekly for nine weeks; and an intervention to ";administer supplemental oxygen as ordered." The POC did not have the route of administration, flow rate, or frequency for oxygen. Between 9/28/22 and 11/28/22 oxygen was documented on 7 of 8 nursing visits. An interview with the Clinical Manager was conducted on 12/8/22 at 9:18 a.m. The interview confirmed that the POC did not include a complete oxygen order. 2. Patient #9 was admitted on 10/19/22 with diagnoses of chronic respiratory failure with hypercapnia (elevated carbon dioxide in the blood), chronic obstructive pulmonary disease (COPD—lung disease), obstructive sleep apnea, and dependence on supplemental oxygen. The Plan of Care (POC) for 10/19/22-1/16/23 included skilled nursing two times per week for one week, then weekly for 13 weeks; medical equipment of oxygen concentration and portable oxygen tank; and an intervention to instruct on safe oxygen use. The POC did not have the route of administration, flow rate, or frequency for oxygen. An interview with the Clinical Manager was conducted on 12/8/22 at 10:00 a.m. The interview confirmed that the POC did not include a complete oxygen order, and the patient used oxygen upon admission. 2B. Patient #5 received a skilled nursing visit on 11/2/22. The note stated, ";Verbalized taking PRN [as needed] Morphine more that 5 times and it wears off very fast. Started on Oxycontin [pain medication] 10 mg BID [twice daily]." Oxycontin was not included in the POC. An interview with RN #3 revealed an order was received but not written in the patient record. An interview with the clinical director on 12/8/22 at 10:00 a.m. confirmed oxycontin was not included on the POC. 3. Patient #12 was admitted on 5/6/22 with a diagnosis of malignant neoplasm to bronchus or lung (lung cancer). The Plan of Care (POC) for 11/2/22-12/31/22 included skilled nursing (SN) visits weekly for eight weeks; an oxygen concentrator and portable oxygen tank as supplies the patient had in the home; and an intervention to ";administer supplemental oxygen as ordered." The POC did not have the route of administration, flow rate, or frequency for oxygen. A nurse note from 11/8/22 revealed the patient used oxygen 4 liters per minute (lpm ) via nasal cannula continuously. An interview with the clinical director on 12/8/22 at 10:25 a.m. confirmed the patient was on oxygen at the time of admission. The interview also confirmed oxygen was no on the POC.

Based on policy review, clinical record review, and staff interview, the interdisciplinary team failed to update the Plan of Care every 15 days with the planned visit frequency for 10 of 12 patients that had orders for medical social services (#2, 5, 6, 9, 12, 1, 7, 8, 11, and 13); and for 8 of 10 patients that received chaplain services (#2, 6, 12, 1, 7, 8, 11, and 13). Findings included: --- 6. Patient #1 had a Start of Care 10/7/22 with diagnosis of Neurocognitive disorder with Lewy Bodies [a progressive decline in mental abilities]. The Plan of Care [POC] for the certification period 10/7/22 to 1/4/23 included orders for Medical Social Worker [MSW] 1 time per month for 1 month with 3 PRN [as needed] visits for unanticipated needs and concerns; Chaplain [CH] for 1 time per month for 2 months with 3 PRN visits for unplanned spiritual support, prayer, and pastoral support. A clinical review of IDG [interdisciplinary group] meetings for 10/20/22 and 11/16/22, showed no evidence of the MSW or CH individualized planned visit frequency for the upcoming 15 days for 2 of 2 meetings. 7. Patient #7 had a Start of Care 11/18/22 with diagnosis of Chronic obstructive pulmonary disease (lung disease). The Plan of Care for certification period 11/18/22 to 2/15/23 included orders for Medical Social Worker [MSW] 2 times per month for 3 months with 3 as needed visits for unanticipated needs of concerns; Chaplain [CH] visits 1 time per month for 3 months with 3 as needed for unplanned spiritual support, prayer, and pastoral care support. A clinical review of IDG [interdisciplinary group] meeting on 12/1/22, showed no evidence of the MSW or CH individualized- planned visit frequency for the upcoming 15 days for 1 of 1 meeting. 8. Patient #8 had a Start of Care 8/10/22 with a diagnosis of Anoxic brain damage [ caused by a complete lack of oxygen to the brain]. The Plan of Care for the certification period 11/8/22 to 2/5/23 included orders for Medical Social Worker [MSW] visits 1 time per month for 3 months with 2 as needed visits for unanticipated psychosocial support and needs; Chaplain [CH] visits for 1 time per month for 3 months with 3 as needed visits for unplanned spiritual support, prayer, and pastoral care support. A clinical review of IDG [interdisciplinary group] meetings held on 11/16/22 and 12/1/22, showed no evidence of the MSW and CH individualized-planned visit frequency for the upcoming 15 days for 2 of 2 meetings. 9. Patient #11 had a Start of Care 11/22/22 with a diagnosis of Malignant neoplasm [cancerous lesion] of right breast with metastasis [ secondary malignant growths]. The Plan of Care for the certification period 11/22/22 to 2/19/23 had orders for Medical Social worker [MSW] visits 2 times per month for 3 months with 3 as needed visits for unplanned needs and concerns; Chaplain visits [CH] 1 time per month for 3 months with 3 as needed for unplanned spiritual support, prayer, and pastoral care support. A clinical review of IDG [interdisciplinary group] meetings held on 12/1/22 showed no evidence of the MSW or CH individualized- planned visit frequency for the upcoming 15 days for 1 of 1 meeting. 10. Patient #13 had a Start of care 9/29/22 with a diagnosis of severe protein- calorie malnutrition [ the stated of the inadequate intake of food]. The Plan of Care for certification period 9/29/22 to 12/27/22 had orders for Medication Social work visits for 1 time per month for 3 months with 3 as needed for unanticipated needs or concerns; Chaplain [CH] visits 1 time per month for 2 months with 3 as needed for unplanned spiritual support, prayer, and pastoral care support. A clinical review of the IDG [interdisciplinary group] meeting on 11/4/22 showed no evidence of the MSW or CH individualized- planned visit frequency for the upcoming 15 days for 1 of 1 meeting. An interview with the Clinical Manager on 12/8/22 at approximately 9:30 a.m. revealed there was no evidence of MSW or chaplain planned visit frequency. A policy, Interdisciplinary Group HC.61 (revised 6/22), was provided by the clinical manager on 12/7/22 at approximately 2:00 p.m. The policy stated, ";...Interdisciplinary group (IDG) meets at least every fifteen (15) days to discuss patient and family changes, updates to the plan of care, deaths, changes in patient condition, referrals and admission/certification and recertification of patients to the hospice program...The interdisciplinary group (IDG) includes...social worker...pastoral or other counselor..." 1. Patient #2 was admitted on 4/1/22 with a diagnosis of malignant neoplasm right breast (breast cancer). The Plan of Care (POC) for 11/27/22-1/25/23 included orders for medical social worker (MSW) monthly for two months; and chaplain monthly for two months. Between 9/28/22 and 12/5/22, the MSW and Chaplain did not have planned visit frequencies for the next 15 days for 5 of 5 interdisciplinary team meetings. 2. Patient #5 was admitted on 8/17/22 with a diagnosis of senile degeneration of the brain. The Plan of Care for 11/16/22-2/12/23 included orders for medical social work (MSW) monthly for three months. Between 11/16/22-12/5/22, there was no evidence of the MSW planned visit frequency for the next 15 days for 2 of 2 interdisciplinary team meetings. 3. Patient #6 was admitted on 7/16/22 with a diagnosis of acute on chronic diastolic (congestive) heart failure. The Plan of Care for 11/13/22-1/11/23 included orders for medical social work (MSW) monthly for two months; and chaplain monthly for two months. Between 11/13/22-12/6/22, there was no evidence of the MSW or chaplain planned visit frequency for the next 15 days for 2 of 2 interdisciplinary team meetings. 4. Patient #9 was admitted on 10/19/22 with diagnoses of chronic respiratory failure with hypercapnia (elevated carbon dioxide levels in the blood, chronic obstructive pulmonary disease (COPD—lung disease), obstructive sleep apnea, and dependence on supplemental oxygen. The Plan of Care (POC) for 10/19/22-1/16/23 included skilled nursing two times per week for one week, then weekly for 13 weeks; medical social work services one time for one week, then monthly for three months. Between 10/19/22 and 11/16/22, there was no evidence of MSW planned visit frequency for the next 15 days for 3 of 3 interdisciplinary team meetings. 5. Patient #12 was admitted on 5/6/22 with a diagnosis of malignant neoplasm to bronchus or lung (lung cancer). The Plan of Care (POC) for 11/2/22-12/31/22 included orders for medical social work (MSW) monthly for two months; and chaplain services monthly for two months. Between 11/2/22 and 12/6/22, there was no evidence of MSW or chaplain planned visit frequency for the next 15 days for 3 of 3 interdisciplinary team meetings.

Based on clinical record review and staff interviews the agency failed to follow physician orders to obtain a urinalysis by an in and out catheterization for 1 of 1 [#1] patients with an order for a urinalysis. The findings included: --- Patient #1 had a Start of Care 10/7/22 with diagnosis of Neurocognitive disorder with Lewy Bodies [a progressive decline in mental abilities]. The Plan of Care [POC] for the certification period 10/7/22 to 1/4/23 included orders for skilled nurse [SN] visits 2 times per week for 12 weeks with 3 PRN [as needed] for symptom management needs and end of life issues. A supplemental order on 12/1/22 stated ";SN to obtain UA (urinalysis) with culture on 12/1/22 via in and out catheterization due to increased agitation." LPN # 6 (licensed practical nurse) 12/1/22 visit documentation stated, ";PRN visit made to collect urine specimen for possible UTI [urinary tract infection] SN attempted in and out [catheterization] 35 minutes without success...asked staff if they had a white hat [specimen collector that fits over the toilet] ... SN collected urine specimen via clean catch [a way of collecting urine] ..." The urinalysis confirmed the patient had a UTI. An interview with the clinical manager on 12/7/22 at 3:58 pm verified that the LPN reported he/she obtained the urine via clean catch due to patient #1s agitation to the clinical manager.

Based on clinical record review and staff interview, the medical social worked failed to report a fall to the nurse for 1 of 2 patients with a fall (#4); and the nurse failed to report an abnormal blood pressure for 2 of 13 patients reviewed (#1 and 13). Findings include: --- 2. Patient #1 had a Start of Care 10/7/22 with diagnosis of Neurocognitive disorder with Lewy Bodies [a progressive decline in mental abilities]; atherosclerotic heart disease [buildup of plaque in the walls of arteries causing obstruction of blood flow]; essential hypertension [ high blood pressure]. The Plan of Care [POC] for the certification period 10/7/22 to 1/4/23 included orders for skilled nurse [SN] visits 2 times per week for 12 weeks with 3 PRN [as needed] for symptom management needs and end of life issues. SN # 1 made a visit on 10/27/22 and obtained a blood pressure of 74/55. Patient #1 was on medication for high blood pressure. There is no evidence the SN notified the physician of low blood pressure. SN #1 verified in an interview on 12/7/22 at 3:42 pm, that the physician was not contacted regarding the low blood pressure. Patient #13 had a Start of care 9/29/22 with a diagnosis of severe protein- calorie malnutrition [ the stated of the inadequate intake of food]; essential hypertension [ high blood pressure]. The Plan of Care for the certification period of 9/29/22 to 12/27/22 had orders for skilled nursing [SN] 2 times per week for 12 weeks with 3 PRN [as needed] visits for symptom management and end of life education. SN #2 made an initial assessment visit on 9/29/22 and obtained a blood pressure of 153/108. Patient #13 was on medication for high blood pressure. There is no evidence the SN notified the physician of the elevated blood pressure. SN #2 was not available for an interview. SN #1 on 12/7/22 at 4:23 pm verified there was no documentation the physician had been notified. Patient #13 had a Start of care 9/29/22 with a diagnosis of severe protein- calorie malnutrition [ the stated of the inadequate intake of food]; essential hypertension [ high blood pressure]. The Plan of Care for the certification period of 9/29/22 to 12/27/22 had orders for skilled nursing [SN] 2 times per week for 12 weeks with 3 PRN [as needed] visits for symptom management and end of life education. SN #1 visit documentation from visit on 10/27/22 stated, ";patient had a fall yesterday [10/26/22] ...small skin tears to left shoulder blade and elbow... bruising noted to left hip... patient was taking Tylenol which has not been helping, MD suggest Ibuprofen..." SN#1 narrative does not show evidence the physician had been made aware of the fall. SN #1 verified in an interview on 12/7/22 at 4:30 pm there is no evidence of notifying the physician about the fall. Patient #4 was admitted on 10/5/22 with end stage renal (kidney) disease. The Plan of Care for 10/5/22-1/2/23 included orders for skilled nursing twice weekly for 13 weeks; and medical social worker (MSW) monthly for three months. The MSW conducted a visit on 11/7/22. The note stated, ";The daughter states that the patient had a fall from the chair last week, with no injuries and several other in in the weeks prior but never reported any as there were no injuries incurred [sic]." There was no evidence the MSW notified the nurse about the falls. An interview with Clinical Manager on 12/8/22 at 9:48 p.m. confirmed there was no evidence of the nurse was notified of the falls. The interview confirmed the MSW should have notified the nurse of the falls.

Based on policy review, documentation review, and staff interview, the agency did not document performance improvement projects. Findings included: --- A policy, Quality Assessment Performance Improvement, HC.59 (revised 6/22), was provided by the clinical manager on 12/7/22 at 11:08 a.m. The policy stated, ";...develop, implement, and evaluate performance improvement projects based on the needs of the hospice population and organizational needs and reflect the scope, complexity and past performance of services and operations...Performance improvement projects are documented with measurable progress achieved...Each Quality Assessment and Performance Improvement activity includes...a description of indicators to be monitored and activities to be conducted...frequency of activities...designation of the person responsible for conducting the activities...methods of data collection...acceptable limits for findings...programs to re-evaluate if findings fail to meet acceptable limits..." The Quality Assurance & Performance Improvement (QAPI) Program Toolkit (no date), was provided by the clinical manager on 12/7/22 at 11:08 a.m. The toolkit stated, ";The site manager will hold QAPI multidisciplinary meetings quarterly and as needed. The multi-disciplinary team will review quantitative and qualitative data and identify areas where improvement is indicated. The local QAPI Committee will develop action plans and monitor those action plans at subsequent meetings. The multidisciplinary team is responsible to set time tables and goals for improvement based on findings from data or otherwise. The QAPI Committee works together to determine goals, interventions and outcome measures and decides how and when goals and implementation should change." A review of the Quality Assessment Performance Improvement program had no evidence of Performance Improvement Projects. An interview with the clinical director on 12/8/22 at 9:00 a.m. revealed no evidence of documented performance improvement projects.

Based on policy review, personnel record review and staff interview, the agency failed to provide orientation to the hospice philosophy for 2 of 5 personnel files reviewed (#2 and 5). Findings included: --- 1. LPN #2 had an organizational hire date of 11/4/19. The exact date that LPN #1 transitioned to hospice was unknown. There was no evidence of orientation to the hospice philosophy. 2. Hospice Aide #5 had a hire date of 6/1/21. There was no evidence of orientation to the hospice philosophy. An interview with the human resources representative on 12/7/22 at 4:00 p.m. revealed there was no documentation that employees #2 and 5 received orientation to the hospice philosophy.

Based on policy review, personnel file review and staff interviews, the agency failed to assess skills competence for 3 of 5 employees (#1, 2, and 5). Findings included: --- A policy, Competency Based Orientation HC.57 (approved 6/22), was provided by human resources on 12/7/22 at 12:07 p.m. The policy stated, ";Prior to providing patient care or assuming responsibilities all new hospice employees and volunteers participate in an orientation program and demonstrate knowledge and proficiency of skills appropriate to their assigned responsibilities...Competency evaluation are provided during orientation, as a component of the performance evaluation and as needed, when adverse patient outcomes are directly related to an employee's performance. Successful completion of the 1. Medical Social Worker #1 had a hire date of 7/13/22. There was no evidence that competency was assessed. 2. LPN #2 had an organizational hire date of 11/4/19. The exact date that LPN #1 transitioned to hospice was unknown. There was no evidence that competency was assessed. 3. Hospice Aide #5 had a hire date of 6/1/21. There was no evidence that competency was assessed. An interview with human resources on 12/7/22 at 4:00 p.m. revealed there was no documentation that employees #1, 2, and 5 had competency assessments.

Based on North Carolina Licensing of Home Care Agencies Rules, policy review, personnel record review and staff interview, the agency failed to complete annual airborne and bloodborne pathogen training for 4 of 5 employees (#2, 3, 4, and 5); and to conduct performance evaluations annually for 3 of 5 employees (#2, 4, and 5). Finding included: --- North Carolina Home Care Licensing Rule 10A NCAC 13.J .1003(f)(6) stated that personnel records shall include, ";airborne and bloodborne pathogen training for hands on care employees, including annual updates, in compliance with 29 CFR 1910 and in accordance with the agency's exposure control plan." North Carolina Home Care Licensing Rule 10A NCAC 13.J .1003(f)(7) stated that personnel records shall include, ";performance evaluations according to agency policy and at least annually." A policy, Performance Appraisals HR504 (approved 6/22), was provided by the human resources representative on 12/7/22at 12:07 p.m. The policy stated, ";Supervisors should conduct an employee performance appraisal...annually...A completed and signed Performance Appraisal should be forwarded to the Corporate HR [human resources] department. A copy of the appraisal should also remain in the employees location file..." 1A. LPN #2 had an organizational hire date of 11/4/19. The exact date that LPN #1 transitioned to hospice was unknown. There was no evidence of airborne and bloodborne pathogen training. 1B. There was no evidence of an annual performance review for LPN #2. 2. Chaplain #3 had a hire date of 2/8/21. The chaplain completed the initial training on 2/8/21. There was no evidence of airborne or bloodborne pathogen training since 2/8/21. 3A. RN #4 had a hire date of 1/21/21. The RN completed the initial training on 1/21/21. There was no evidence of airborne or bloodborne pathogen training since 1/21/21. 3B. There was no evidence of an annual performance review for RN #4. 4A. Hospice Aide #5 had a hire date of 6/1/21. The hospice aide completed the initial training on 6/21/21. There was no evidence of airborne or bloodborne pathogen training since 6/21/21. 4B. There was no evidence of an annual performance review for Hospice Aide #5. An interview with human resources on 12/7/22 at 4:00 p.m. revealed there was no documentation of annual airborne and bloodborne pathogen training for employees #2, 3, 4, and 5. An interview with human resources on 12/7/22 at 4:00 p.m. revealed there was no documentation of annual performance reviews for employees #2, 4, and 5.

Based on the Covid-19 Vaccination policy, revised 4/22, the policy and procedure failed to include all required processes. Findings included: --- A policy, Covid-19 Vaccination (revised 4/22), was provided by the clinical manager on 12/6/22 at approximately 11:30 a.m. The policy did not include a process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any boosters as recommended by the Centers for Disease Control and Prevention (CDC); or a process for ensuring the tracking and secure documentation of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and consideration. An interview with the Clinical Manager on 12/8/22 at 9:30 a.m. confirmed the policy and procedure did not include all required elements.