Every finding on record at Pruitthealth Hospice Inc.

Based on record reviews and interview, the Volunteer Coordinator (VC) failed to provide documentation of training for two of four volunteers for Emergency Preparedness. (Volunteer #2 and Volunteer #3) The findings are: On 3/23/2022 at 2:43 PM, review of the hospice's volunteer personnel files revealed Volunteer # 2 and Volunteer #3 had no documentation of Emergency Preparedness training. The finding was verified by the Administrator on 3/24/2022 at 2:23 PM.

Based on record reviews and interview, the Skilled Nurse (SN) failed to document an adverse event (fall). This failure to report a fall negatively impacted the hospice's Quality Assurance Performance Improvement (QAPI) data for one of one patient chart reviewed that revealed a patient fall. (Patient #3) The findings are: Patient #3 On 3/22/2022 at 11:31 AM, review of Patient #3's chart revealed the SN documented a "Client Coordination Note" dated 3/6/2022 that showed "Patient had slipped off the side of bed to the floor." On 3/24/2022 at 12:06 PM, the Administrator verified the documentation and stated, "There was no incident report done."

Based on record reviews and interview, the Volunteer Coordinator (VC) failed to provide documentation of training for COVID-19 for two of four volunteers (Volunteer #2 and Volunteer #3) and had no documentation of a volunteer job description for Volunteer #4. The findings are: On 3/23/2022 at 2:43 PM, review of the hospice's volunteer personnel files revealed Volunteer #2 and Volunteer #3 had no documentation of COVID-19 training. The finding was verified by the Administrator on 3/24/2022 at 2:23 PM. On 3/23/2022 at 2:43 PM, review of the hospice's volunteer personnel files revealed the hospice had no documentation that Volunteer #4's reviewed his/her volunteer job description. The finding was verified by the Administrator on 3/24/2022 at 2:23 PM.

Based on record reviews and interview, the hospice failed to designate one Medical Director for the hospice to assume the responsibility for the hospice's patient care program. The findings are: On 3/24/2022 at 11:01 AM, review of the hospice's Medical Director contracts revealed the hospice had appointed two Medical Directors (Medical Director #1 and Medical Director #2) for the hospice's patient care program. The finding was verified by the Administrator at 11:01 AM on 3/24/2022.

Based on record reviews and interview, the hospice failed to ensure documentation of status of COVID Vaccination, or documented the exemption status, and failed to ensure the hospice's policies and procedures had a process for ensuring the implementation of additional precautions to mitigate the transmission and spread of COVID-19 for all staff who are not vaccinated or fully vaccinated for 1 of 2 Licensed Practitioners (Medical Director #1) and 3 of 4 Volunteers (Volunteer #1, #3, and #4). Review of vaccination rates showed an 87% compliance rate for vaccination and a 13% compliance rate for staff who had no documentation of a COVID-19 vaccination data or exemption data. The findings are: On 3/24/2022 at 2:35 PM, review of the hospice policy, titled, "Mandatory COVID-19 and Influenza Vaccination Policy" received from the Administrator, revealed the hospice's policy had no process for ensuring the implementation of additional precautions to mitigate the transmission and spread of COVID-19 for all staff who are not vaccinated or not fully vaccinated. On 3/23/2022 at 2:43 PM, review of the hospice's volunteer personnel files revealed Volunteer #1, #3, and #4 had no documentation of receiving the COVID-19 vaccination or an exemption. The Administrator stated, "The volunteers are not offered the exemption option." Review of Medical Director #1's file revealed Medical Director #1 had no documentation of receiving the COVID-19 vaccination or documented exemption data. The Administrator stated, "We do not have it (Vaccine data)." The findings were verified by the Administrator at 2:25 PM on 3/24/2022.