Every finding on record at Starline Hospice, Inc.

Observed in Emergency Management Session. The Surveyor noted the organization’s hazard vulnerability analysis did not include emerging infections and this was observed and validated with the QAPI coordinator and the Administrator

Observed in Emergency Management Session. -The organization had not utilized After- Action reports to make updates or improvement in the Emergency Plan following a table top drill, this was observed and validated by the QAPT coordinator and the Administrator

Observed in Record Review. In 3 of 10 patient records reviewed, The organization failed to update the comprehensive assessment based on changes that have taken place since the initial assessment and includes information about the patient’s progress toward desired outcomes and a reassessment of the patient’s response to care as evidenced in RRNHV#5 Same goal since SOC: -Pt will have optimum level of oxygen as evidenced by reduced/absence of SOB, signs of respiratory distress by end of cert. RRNHV#6 & RRNHV#7: Since SOC Goal is : BP will be controlled with range of 90-140/60-90mmHg asymptomatic of hypo/hypertensive crisis by end of cert, this was observed and validated by the DON

Observed in Record Review. In 3 of 10 patient records reviewed, The organization failed to have written plan of care based on the patient’s goals and services required to meet those goals as evidenced in RRH#3 patient has intermittent vaginal bleeding no goals in POC identified. RRNHV#1 and RRHV#2, Braden score high risk @ SOC and no interventions or goals identified in POC this was observed and validated by the DoN

Observed in Record Review. In 6 of 10 patient records reviewed, The HCO failed to revise plans and goals for care, treatment, or services based on the patient’s needs as evidenced in RRHV#2: HHA plan not update from SOC 90 days later patient is up in a wheelchair dressed in street clothes and HHA care plan states bedbound, chairbound, no wheelchair mentioned and to be dressed in gown/pajamas and in POC and some goals are the same for the 12 weeks and going into the next cert period starting as evidenced by : BP will be controlled with range of 90-140/60-90mmHg asymptomatic of hypo/hypertensive crisis , BP in nursing notes were 112/60 and 120/88 . RRHV#3: .Pt will remain free from fall/injury and Pt/pcg will verbalize understanding of increased risk of fall, and safety precautions/interventions date mentioned which is end of cert. RRNHV#1: Pt will manifest regular bowel elimination status as evidenced by pt having regular BM every 1-2 days with reduced discomfort by end of cert. RRNHV#2: Pt will have increased comfort/satisfaction from pain /discomfort, less than 3/10 pain scale as exhibited by verbal and non-verbal communication by end of cert. RRNHV#3: Pt will have optimum level of oxygen as evidenced by reduced/absence of SOB, signs of respiratory distress by end of cert . RRNHV#7: In the last month the Nursing assessment and IDG note identified increased agitation in patient, the HHA care plan has not been updated with this informationthis was observed and validated by DON

Observed in Record Review. In 6 of 10 patient records reviewed, Some of the organizations plan of care did not includes all services needed for the palliation and management of the terminal illness and related conditions as evidenced in RRHV#1 and RRHV#2: Oxygen ordered 2-5 litres via N/C PRN without any indication. RRHV#3: Voltaren Arthritis 1% topical gel apply to affected areas as needed 3 times daily. RRNHV#2: Tylenol 325 mgs 2 tabs every 6 hours as needed for pain management, RRNHV#4 & RRNHV#5: O2 @ 2-5 litres via N/C PRN, this was observed and validated by the DON

Observed in Patient Home. In 3 of 3 home visits conducted, The RN, LVN and HHA did not follow Safe, Operable, Equipment policy No. 6-010.1 which states equipment will be wiped dry, or moisture will be permitted to evaporate before bagging as evidenced by staff cleaned equipment but bagged it directly while still wet, this was observed and validated by DON

Observed in HR File Review. The organization failed to evaluate HHA appropriate and safe techniques in personal hygiene and grooming that include bed, sponge, tub, or shower bath; sink, as evidenced in HR#7: HHA competency was for a bed bath only the last 3 years, this was observed and validated by the Administrator and DON

Observed in Record Review. In 1 of 10 patient records reviewed, The record did not have accurate documentation for care treatment and services related to oxygen as evidenced in RRNHV#3: The order was for 2 LPM via Nasal Cannula as needed for SOB or O2 sat<95% and RN documentation states O2 2-5 litres N/C PRN, this was observed and validated by DON

Observed in Record Review. In 2 of 5 patient records reviewed, the organization failed to ensure that the plan of care include all services needed for the palliation and management of the terminal illness to include a statement of the scope and frequency of the services necessary to meet the patient and family needs. For example: In review of RR#1 and RR#3 the frequency order for MSW and Spiritual Care were 1 time and PRN, however there was no specifications for the number or reason for the PRN visits. Further, in RR#1 the MSW and Spiritual care were seeing the patient each certification period more than the one time ordered. This observation was reviewed with the Administrator.

Observed in Record Review. In 2 of 5 patient records reviewed, the organization did not provide the patient with care, treatment, or services according to the patient's individualized plan of care. In RR #1 the MSW and Spiritual Care were ordered 1 time and PRN however the clinicians were visiting the patient every certification period. Example 2: In RR#3 the patient had a foley catheter and the aide documented that catheter care was provided, yet catheter care was not an assigned task on the aide's plan of care. These observations were reviewed with the Administrator.

Observed in Record Review. In 4 of 5 patient records reviewed, the organization failed to ensure that the RN provide the hospice aide with written patient care instructions. For example: in RR#1, RR#2, RR#3, and RR#4 the aide was assigned to take the patient's vital signs yet there was no parameters documented for when the aide was to report abnormal vital signs to the RN. In RR#3 the patient had a foley catheter and the aide assignment did not include catheter care. These observations were reviewed with the Administrator.

Observed in Record Review. In 2 of 5 patient records reviewed, The organization failed to ensure the clinical record reflect the patient care, treatment, and services. On review of RR#1 and RR#2 the RN comprehensive assessment documentation from 2/9/23 was left incomplete well beyond the organization policy for submission of 7 working days. This observation was reviewed with the Administrator and Director of Nursing.

Observed in Record Review. In 2 of 5 patient records reviewed, all entries in the clinical record were not appropriately completed and authenticated. In review of RR#1 and RR#2 the RN comprehensive assessments for 2/9/23 and 1/26/23 were noted to not be complete and not electronically signed by the clinician. This was reviewed with the administrator.

Observed in Individual Tracer. In 1 of 3 patient records reviewed, the hospice care plan (or updates to the care plan) did not reflect key components of the intervention required. RR#2 who resided in a nursing home had orders to insert a Foley however the balloon size and or the frequency of change of the catheter was not indicated. This observation was discussed with the director and the administrator.

Observed in Individual Tracer. In 1 of 3 patient records reviewed, the hospice care plan did not delineate who would provide care. RR#2 resided in a nursing home and had a wound requiring daily care and a Foley catheter. The care plan did not specify who would change the Foley and or provide the wound care. This observation was discussed with the director and the administrator.

Observed in Emergency Management Session. The Surveyor noted the Emergency Operation’s Plan was not reviewed and updated annually as evidenced by the organization was not able to produce documentation at the time of survey. This was confirmed by the administrator.

Observed in Emergency Management Session. The Surveyor noted the organization did not identify in writing the potential emergencies that could affect its ability to provide services as evidenced by the Administrator was only able to produce written documentation of earthquake as the identified potential emergency. A HVA was not provided. This was confirmed with the Administrator

Observed in Emergency Management Session. The organization did not evaluate the effectiveness of its Emergency Operations Plan. The Surveyor noted that there were no emergency response exercises and no activation during an actual emergency, therefore, the organization did not monitor its management of staff roles and responsibilities as evidenced by the organization was not able to produce this documentation at the time of survey. This was confirmed by the administrator.

Observed in Emergency Management Session. The Surveyor noted the evaluation of all emergency response exercises and all responses to actual emergencies did not include the identification of deficiencies and opportunities for improvement as evidenced by the organization was not able to produce this documentation at the time of survey. This was confirmed by the administrator. Observed in Emergency Management Session. The organization did not analyze the hospice response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the emergency plan. There was no evidence of review or revision to the emergency plan for the past three years. No drill was conducted since the last survey. This was confirmed by the administrator.

Observed in Individual Tracer. In 1 of 3 home visits conducted, the organization did not respect the patient's right to elect and revoke hospice care, in accordance with Medicare hospice regulations. For example, on HV 1, the facility chart contained a signed Revocation form dated on the same day as Hospice Election. This was discussed with the Administrator and the Director of Patient Care Services who explained all forms were emailed to the Patient Representative who signed every form. The organization placed all signed forms in the facility chart, failing to remove the Revocation form. Observed in Record Review. In 4 of 11 patient records reviewed, the organization did not respect the patient's right to elect and revoke hospice care.In RR #8, the surveyor noted the patient signed the revocation statement on admission. This was confirmed with the administrator and director of patient care services. Observed in Record Review. On RR 1, RR 2, RR 3, RR 4 the charts contained a signed Revocation form dated on the same day as Hospice Election. This was discussed with the Administrator and the Director of Patient Care Services who explained all forms were emailed to the Patient Representative who signed every form.

Observed in Individual Tracer. In 1 of 2 home visits conducted, with skilled nursing services, the organization did not perform a comprehensive pain assessment per agency policy Pain Assessment. Per the facility nurse translator, the patient expressed that she was in pain in her leg when the hospice nurse attempted to reposition her but the hospice nurse did not assess this during the visit per policy. This was discussed with the director of patient of patient care services.

Observed in Individual Tracer. In 2 of 2 home visits conducted, with skilled nursing services, the organization failed to conduct and document a patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services. The skilled nurse did not perform a complete assessment per agency policy Ongoing Comprehensive Assessment. For example, on HV 1 a skin assessment was not conducted. On HV 2 the patient had multiple wounds but the skilled nurse failed to complete a skin and wound assessment. This was reviewed and discussed with the Director of Patient Care Services. Observed in Record Review. In 1 of 11 patient records reviewed, the registered nurse did not reassess as part of the comprehensive reassessment all areas of hospice care related to palliation and the management of the terminal illness every 15 days. In RR #7, the surveyor noted the nurse did not reassess pain, lung sounds, bowel sounds, reassessment of constipation, and the wound every 15 days. In addition, there was no reassessment of the stage 2 pressure ulcer after admission in the first certification period. This was confirmed with the administrator and director of patient care services.

Observed in Record Review. In 1 of 11 patient records reviewed, the hospice’s interdisciplinary group did not update the comprehensive assessment in collaboration with the patient’s attending physician, if any, as frequently as the patient’s condition requires, but no less than every 15 days. In RR # 5, the RN did not reassess the patient for 26 days. This was reviewed and discussed with the Director of Patient Care Services.

Observed in Record Review. In 6 of 11 patient records reviewed, the patient record was not complete, promptly and accurately documented.n RR #6 and RR #8, the surveyor noted the oxygen safety assessment was inaccurately completed. The assessment indicated the presence of smoking materials in the home and the potential for open flames; however, in discussion with agency director of patient care services this was not accurate. This was confirmed with the administrator and director of patient care services. Observed in Individual Tracer. In HV #1, HV #2, HV #3 and RR #1 the oxygen safety assessment was inaccurately documented. The organization indicated that sources of open flames were present and identified. This was validated by the administrator and director of patient care services who stated they did not understand the form.

Observed in Record Review. In 3 of 11 patient records reviewed, In RR #8, the surveyor noted the patient was identified as having dysphagia and skin breakdown risk; however, the plan of care did not include interventions to address these identified needs. In addition, two weeks ago the patient was identified as having agitation; however, the plan of care was not updated to include interventions to address this identified need. This was confirmed with the administrator and the director of patient care services. In RR #7, the surveyor noted the patient was identified as having constipation; however, the plan of care only included assessments and did not include interventions to address this identified need. In RR #6, the surveyor noted the patient with UTI; however, there were no interventions on the plan of care only to assess/monitor. In addition, the patient was identified as having diarrhea, ascites, dysphagia and skin breakdown risk; however, there were no interventions identified on the plan of care. Also, at the second skilled nursing visit the nurse documented the patient sometimes had nausea and complained of itchiness; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the administrator and director of patient care services. Observed in Record Review. In 1 of 11 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: - Interventions to manage pain and symptoms. In RR# 4 the comprehensive assessment identified depression and constipation. There were no interventions to address these symptoms on the Plan of Care. This was reviewed and discussed with the Director of Patient Care Services.

Observed in Record Review. In 2 of 11 patient records reviewed, the plan of care did not include a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. In RR #7, the surveyor noted the visit frequency on the initial plan of care indicated MSW one time and then PRN for psychosocial issue; Chaplain one time and then PRN for spiritual issue. This was confirmed with the administrator and director of patient care services. In RR #6, the surveyor noted the visit frequency on the plan of care indicated MSW 11 PRN; however, there was no scheduled visit frequency and no indication given for the PRN visits. This was confirmed with the administrator and director of patient care services.

Observed in Record Review. In 1 of 11 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: Medications and treatment necessary to meet the patient’s needs. In the record review for HV #2, the wound care orders for Santyl were expired. The nurse obtained new wound care orders 5 days later during the visit with the surveyor. This was discussed and validated with the Director of Patient Care Services. Observed in Record Review. In 2 of 11 patient records reviewed, the plan of care did not include the drugs and treatment necessary to meet the needs of the patient. In RR #7, the surveyor noted the plan of care included a respiratory goal of Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects; however, there were no interventions to instruct on oxygen use and safety measures. This was confirmed with the administrator and director of patient care services. In RR #6, the surveyor noted the patient had a paracentesis site; however, the plan of care did not include interventions to address this identified need. This was confirmed with the administrator and director of patient care services.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization did not provide the patient with care, treatment, or services according to the patient's individualized plan of care. In RR #2, the ordered frequency for SN services was two times per week. The nurse made only one visit during the week with no evidence of notification to the physician or missed visit documentation. This was reviewed and discussed with the Director of Patient Care Services.

Observed in Data Session. The surveyor noted the organization did not have a quality assessment and improvement program in place for the past three years as evidenced by the organization was not able to produce this documentation at the time of survey. This was confirmed with the administrator and director of patient care services.

Observed in Data Session. The surveyor noted the organization did not use the data collected to monitor the effective and safety or services and the quality of care as evidenced by the organization did not aggregate and analyze data or utilize data collected to make improvement in processes. This was confirmed with the administrator and the director of patient care services.

Observed in Individual Tracer. In 2 of 2 home visits conducted, with use of vital sign equipment, the organization did not implement infection prevention and control activities when doing the following: Cleaning and performing disinfection of medical supplies and devices. For example, during HV #1 and HV #2 the RN did not follow organization policy Bag Technique for cleaning of equipment. The policy stated: stethoscope - clean with alcohol; thermometer - clean with soap and water. The nurse used a Natural Care wipe that contained benzalkonium chloride. This was confirmed by the director of patient care services. Observed in Individual Tracer. In 2 of 3 home visits conducted, the organization failed to use standard precautions, including the use of personal protective equipment, to reduce the risk of infection. For example, on HV 1 and HV 2 the nurse did not follow the organization policy Hand Hygiene requiring use of hand gel following removal of gloves. The nurse donned and doffed gloves multiple times during the visit without using hand gel between glove changes. This was reviewed and discussed with the Administrator and Director of Patient Care Services.

Observed in Data Session. The surveyor noted the organization's written infection prevention and control goals did not include improving compliance with hand hygiene guidelines as evidenced by the organization was not able to produce this documentation at the time of survey. This was confirmed with the administrator and director of patient care services. Observed in Data Session. The surveyor noted the organization's written infection prevention and control goals did not include addressing its prioritized risks as evidenced by the organization was not able to produce this documentation at the time of survey. This was confirmed with the administrator and director of patient care services. Observed in Data Session. The surveyor noted the organization's written infection prevention and control goals did not include limiting unprotected exposure to pathogens as evidenced by the organization was not able to produce this documentation at the time of survey. This was confirmed with the administrator and director of patient care services. Observed in Data Session. The surveyor noted the organization did not collect to evaluate hand hygiene compliance in the past three years as evidenced by the organization was not able to produce this documentation at the time of survey. This was confirmed with the administrator and director of patient care services. Observed in Data Session. The surveyor noted the organization's written infection prevention and control goals did not include limiting the spread of infections associated with procedures as evidenced by the organization was not able to produce this documentation at the time of survey. This was confirmed with the administrator and director of patient care services. Observed in Data Session. The surveyor noted the organization's written infection prevention and control goals did not include limiting the spread of infections associated with the use of medical equipment, devices and supplies as evidenced by the organization was not able to produce this documentation at the time of survey. This was confirmed with the administrator and director of patient care services.

Observed in Data Session. The surveyor noted the organization did not educate staff and licensed independent practitioners about at a minimum the influenza vaccine; non-vaccine control and prevention measures; and the diagnosis, transmission and impact of influenza as evidenced by the organization was not able to produce this documentation at the time of survey. This was confirmed with the administrator and the director of patient care services.

Observed in Document Review. The surveyor noted the hospice's core services were not routinely provided directly by hospice employees as evidenced by the administrator and director of patient care services indicated that some of the nurses, medical social worker and chaplain were contracted. This was confirmed with the administrator and the director of patient care services.

Observed in HR File Review. In 1 of 1 Hospice Aide HR files, reviewed, hospice aide did not successfully complete a competency evaluation before providing patient care. For example, in HR # 6 there was no evidence that the aide had been observed to assess competency prior to providing patient care. This was validated by the director of patient care services.

Observed in HR File Review. In 1 of 1 Hospice Aide HR files, reviewed, the hospice aide did not participate in at least 12 hours of in-service training during each 12-month period. In HR #6 there was no evidence of 12 hours of in-services training for the past three years. This was confirmed by the director of patient care services.

Observed in Record Review. In 1 of 7 patient records reviewed where the patient received aide services, a registered nurse did not prepare written patient care instructions for the hospice aide.In RR #7, the surveyor noted the aide plan of care indicated diet other; however, did not specify the diet type. The patient was NPO. Also, the aide plan of care did not include instructions specific to the g-tube site. This was confirmed with the administrator and director of patient care services.

Observed in Record Review. On RR #1, a supervisory visit was not conducted for 28 days. This was reviewed and discussed with the Administrator and Director of Patient Care Services. Observed in Record Review. In 2 of 7 patient records reviewed where the patient received aide services, a registered nurse did not perform an aide supervisor visit every 14 days.In RR #7, the surveyor noted the aide supervisory visit was performed 15 days apart in the second month of service. This was confirmed with the administrator and director of patient care services.

Observed in HR File Review. In 1 of 1 Hospice Aide HR files, reviewed, a Registered Nurse did not make an annual onsite visit to the location where a patient was receiving care in order to observe and assess the aide while performing care for the past three years. HR file #6 had no documentation of annual on site supervision. This was confirmed with the administrator and director of patient care services.

Observed in HR File Review. In 1 of 1 Volunteer HR files, reviewed, the hospice did not maintain, document and provide volunteer orientation and training that is consistent with industry standards. For example in HR # 7 the volunteer did not have a role specific job description. The job description was for a Volunteer Coordinator. Orientation to the specific duties of the volunteer was not done. This was confirmed by the Director of Patient Care Services.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: - §418.100 and 418.52, 418.60, 418.102, 418.116, 418.58, 418.104.

Observed in HR File Review. In 6 of 6 HR files reviewed, that had been working for at least one year, the hospice did not assess the skills and competency of all individuals furnishing care. The organization policy Competency Assessment stated competency would be assessed annually. There were no annual competency assessments in HR#1, HR #2, HR #3, HR #4, HR #5, or HR #6. This was validated by the Director of Patient Care Services.

Observed in HR File Review. The surveyor noted that the hospice did not have an alternative physician to serve as medical director according to the regulation requiring a physician designated by the hospice assumes the same responsibilities as the medical director when the medical director is not available. This was confirmed by the administrator. Observed in HR File Review. The surveyor noted that the hospice failed to designate a physician to serve as the medical director. The medical director named by the organization did not have a contract. This was confirmed by the administrator.

Observed in Record Review. In 2 of 11 patient records reviewed, the patient record did not contain all clinical information. In RR #7, the surveyor noted the skilled nurse documented on the recertification visit made three weeks ago RN completed the wound treatment as the PCP MD ordered; however, there was no documentation of an assessment of the wound or location of wound site, In addition, there was no documentation of the specific care provided. This was confirmed with the administrator and director of patient care services. In RR #8, the surveyor noted the visit frequency was twice per week; however, there was a missing visit the fifth week of service. In discussion with the director of patient care services, the visit was made; however, the documentation had not been completed. This visit occurred two weeks ago. This was confirmed with the administrator and director of patient care services. Observed in Individual Tracer. In 1 of 2 home visits conducted, with skilled nursing services, the patient record did not contain the following clinical information: - Any medications administered, including dose. The skilled nurse performed a medication reconciliation at the facility. Three medications listed on the hospice medication profile: Lisinopril, Atorvastin, and Donepezil were not present in the skilled nursing facility medication cart. No further follow up was conducted by the nurse. This was reviewed, discussed and validated with the director of patient care service.

Observed in Record Review. In 1 of 11 patient records reviewed, all entries in the clinical record were not appropriately authenticated. In RR #6, the surveyor noted the bereavement risk assessment was not electronically signed by the medical social worker. This was confirmed with the administrator and director of patient care services.

Observed in Record Review. In 1 of 1 patient records reviewed where the patient was transferred to the hospital, the hospice did not provide the receiving facility with a copy of the hospice discharge summary and, if requested a copy of the patient's clinical record. In RR #6, the surveyor noted the patient's services were revoked due to transfer to hospital; however, the hospice did not provide the receiving facility with a copy of the hospice discharge summary or a copy of the patient's clinical record. This was confirmed with the administrator and director of patient care services.

Observed in Record Review. In 5 of 5 contracts reviewed, the organization did not have a method for verifying that the contract requirements were met. In review of the DME contract and the pharmacy contract and 3 of the SNF contracts used for GIP level of care, there was no evidence of annual contract oversite or review. This was confirmed by the administrator.

Observed in Record Review. In 1 of 5 contracts, reviewed, the hospice did not have a signed agreement by authorized representatives of the hospice. The DME contract was not signed by the hospice. This was confirmed by the administrator

Observed in Record Review. In HV #1 the plan of care did not designate which provider would manage or change the foley catheter or monitor the blood glucose. In HV #2 the plan of care did not designate which provider would manage or change the foley catheter. In RR #3 the plan of care did not designate which provider would manage or perform the wound care. This was reviewed and discussed with the Director of Patient Care Services. Observed in Record Review. In 4 of 8 patient records reviewed where the patient resided in a nursing facility, the hospice plan of care did not specify which provider was responsible for performing the respective functions that were agreed upon.In RR #7, the surveyor noted the plan of care did not specify which provider was responsible for the g-tube site care or wound care. This was confirmed with the administrator and director of patient care services.

Observed in HR File Review. In 1 of 7 HR files reviewed, the hospice did not obtain a criminal background check on all hospice employees who have direct patient contact or access to patient records. For example, in HR #5 the Medical Director did not have a criminal background check. This was confirmed by the director of patient care services.

Observed in Record Review. The organization did not provide care, treatment, or services in accordance with licensure requirements, laws, and rules and regulations. In RR #1 and RR #2, the organization obtained a Hospice Election of Benefits Statement that was not completed. There were blanks on the form related to the patient requesting or declining the Addendum: Patient Notification for Non-Covered Items, Services and Drugs. This was reviewed and validated by the Administrator and Director of Patient Care Services. Observed in Data Session. The surveyor noted the organization, as required by Infection Control CoP 418.60(d)(3)(iv) did not have a process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC as evidenced by the organization was not able to produce this documentation at the time of survey. This was confirmed with the administrator and director of patient care services. Observed in Record Review. In 5 of 11 patient records reviewed, the organization did not provide care, treatment or services in accordance with licensure requirements.In RR #6 and RR #7, the surveyor noted the patient requested the election of benefit addendum; however, the patient signed a blank addendum form. This was confirmed with the administrator and director of patient care services.In RR #8, the surveyor noted the election of benefit section that indicated whether the patient was requesting an addendum on the non-covered hospice items was blank. In addition, the patient signed a blank addendum. This was confirmed with the administrator and director of patient care services. Observed in Data Session. The surveyor noted the organization, as required by Infection Control CoP di 418.60(d)(3)(iv) d not have contingency plans for staff who are not fully vaccinated for COVID-19 as evidenced by the organization was not able to produce this documentation at the time of survey. This was confirmed with the administrator and the director of patient care services. Observed in Data Session. The surveyor noted the organization, as required by Infection Control CoP 418.60(d)(3)(iv) did not have a process for ensuring t 418.60(d)(3)(iv) hat all documentation that confirms recognized clinical contraindications to COVID-19 vaccines and supports staff requests for medical exemptions from vaccination had 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 as evidenced by the organization was not able to produce this documentation at the time of survey. This was confirmed with the administrator and director of patient care services. Observed in Data Session. The surveyor noted the organization, as required by Infection Control CoP 418.60(d)(3)(iv) did not have a process for tracking and securely documenting information provided by those staff who have requested, and for whom the organization has granted, an exemption from the staff COVID-19 vaccination requirements based on recognized clinical contraindications or applicable federal laws as evidenced by the organization was not able to produce this documentation at the time of survey. This was confirmed with the administrator and director of patient care services. Observed in Data Session. The surveyor noted the organization did not have a process, as required by Infection Control CoP 418.60(d)(3)(iv) , for ensuring all eligible staff are fully vaccinated for COVID-19 as evidenced by the organization was not able to produce this documentation at the time of survey. This was confirmed with the administrator and the director of patient care services. Observed in Data Session. The surveyor noted the organization, as required by Infection Control CoP 418.60(d)(3)(iv)did not have a process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable federal law as evidenced by the organization was not able to produce this documentation at the time of survey. This was confirmed with the administrator and director of patient care services.