Every finding on record at Tender Hospice Care Inc.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by a review of clinical records and interviews. 9 of 11 (82%) clinical records reviewed revealed the hospice did not ensure the initial spiritual assessments were completed. . Record 1: This patient was admitted to hospice on 7/28/2022 and the patient/caregiver accepted Chaplain visits. There was no documented evidence of an initial spiritual assessment. Record 2: This patient was admitted to hospice on 7/22/2022 and the patient/caregiver accepted Chaplain visits. The Chaplain documentation revealed a paper clinical note dated 7/26/2022 that stated, “Will visit again on Saturday morning.” There was no documented evidence of an initial spiritual assessment between 7/22/2022-9/6/2022. Record 3: This patient was admitted to hospice on 7/21/2022 and the patient/caregiver accepted Chaplain visits. There was no documented evidence of an initial spiritual assessment. Record 4: This patient was admitted to hospice on 2/23/2022 and the patient/caregiver declined Chaplain visits. There was no documented evidence of an initial spiritual assessment. Record 5: This patient was admitted to hospice on 4/29/2022 and the patient/caregiver declined Chaplain visits. There was no documented evidence of an initial spiritual assessment. Record 6: This patient was admitted to hospice on 11/12/2021 and the patient/caregiver declined Chaplain visits. There was no documented evidence of an initial spiritual assessment. Record 7: This patient was admitted to hospice on 4/21/2022 and the patient/caregiver declined Chaplain visits. There was no documented evidence of an initial spiritual assessment. Record 8: This patient was admitted to hospice on 10/29/2021 and the patient/caregiver declined Chaplain visits. There was no documented evidence of an initial spiritual assessment. Record 11: This patient was admitted to hospice on 10/29/2021 and the patient/caregiver declined Chaplain visits. There was no documented evidence of an initial spiritual assessment. The Chaplain was interviewed on 9/7/2022 and stated, “I work another job on weekdays until 4pm. Sometimes the timing doesn’t work for patients or caregivers.” The President was interviewed on 9/7/2022 and confirmed that there was no documented evidence the initial spiritual assessments were completed. The President stated, “We thought if they declined Chaplain, nothing else was required.” Record 1: This patient was admitted to hospice on 7/28/2022 and revealed the patient/caregiver accepted Chaplain visits. There was no documented evidence of an initial spiritual assessment. Record 2: This patient was admitted to hospice on 7/22/2022 and revealed the patient/caregiver accepted Chaplain visits. The Chaplain documentation revealed a clinical note documented on paper 7/26/2022, “will visit again on Saturday morning.” There was no documented evidence of an initial spiritual assessment between 7/22/2022-9/6/2022. Record 3: This patient was admitted to hospice on 7/21/2022 and revealed the patient/caregiver accepted Chaplain visits. There was no documented evidence of an initial spiritual assessment. Record 4: This patient was admitted to hospice on 2/23/2022 and revealed the patient/caregiver declined Chaplain visits. There was no documented evidence of an initial spiritual assessment. Record 5: This patient was admitted to hospice on 4/29/2022 and revealed the patient/caregiver declined Chaplain visits. There was no documented evidence of an initial spiritual assessment. Record 6: This patient was admitted to hospice on 11/12/2021 and revealed the patient/caregiver declined Chaplain visits. There was no documented evidence of an initial spiritual assessment. Record 7: This patient was admitted to hospice on 4/21/2022 and revealed the patient/caregiver declined Chaplain visits. There was no documented evidence of an initial spiritual assessment. Record 8: This patient was admitted to hospice on 10/29/2021 and revealed the patient/caregiver declined Chaplain visits. There was no documented evidence of an initial spiritual assessment. Record 11: This patient was admitted to hospice on 10/29/2021 and revealed the patient/caregiver declined Chaplain visits. There was no documented evidence of an initial spiritual assessment. The Chaplain was interviewed on 9/7/2022 and stated, “I work another job on weekdays until 4pm, sometimes the timing doesn’t work for patients or caregivers.” The President was interviewed on 9/7/2022 and agreed, there was no documented evidence the initial spiritual assessments were completed. The President stated, “we thought if they declined Chaplain, nothing else was required.”

It is required that the hospice designates a registered nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any); the patient or patient representative; the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by a review of clinical records and interviews. 3 of 3 (100%) records reviewed revealed the hospice did not ensure the social worker followed the plan of care as ordered. . Record 1: This patient was admitted to hospice on 7/28/2022. The plan of care dated 7/28/2022 ordered MSW (Medical Social Worker) 1 x month. There was a MSW initial visit on 7/30/2022. There was no documented evidence of a MSW visit or documented reason for a missed visit 8/1/2022-9/8/2022. Record 2: This patient was admitted to hospice on 7/22/2022. The plan of care dated 7/22/2022 ordered MSW (Medical Social Worker) 1 x month. There was a MSW initial visit on 7/23/2022. There was no documented evidence of a MSW visit or documented reason for a missed visit 8/1/2022-9/8/2022. Record 3: This patient was admitted to hospice on 7/21/2022. The plan of care dated 7/21/2022 ordered MSW (Medical Social Worker) 1 x month. There was a MSW initial visit on 7/23/2022. There was no documented evidence of a MSW visit or documented reason for a missed visit 8/1/2022-9/8/2022. The President was interviewed on 9/8/2022 and confirmed that there was no documented evidence the MSW followed the plan of care as ordered, or documented reasons for the missed visits. Record 1: This patient was admitted to hospice on 7/28/2022. The plan of care dated 7/28/2022 ordered MSW (Medical Social Worker) 1 x month. There was a MSW initial visit on 7/30/2022. There was no documented evidence of a MSW visit or documented reason for a missed visit 8/1/2022-9/8/2022. Record 2: This patient was admitted to hospice on 7/22/2022. The plan of care dated 7/22/2022 ordered MSW (Medical Social Worker) 1 x month. There was a MSW initial visit on 7/23/2022. There was no documented evidence of a MSW visit or documented reason for a missed visit 8/1/2022-9/8/2022. Record 3: This patient was admitted to hospice on 7/21/2022. The plan of care dated 7/21/2022 ordered MSW (Medical Social Worker) 1 x month. There was a MSW initial visit on 7/23/2022. There was no documented evidence of a MSW visit or documented reason for a missed visit 8/1/2022-9/8/2022. The President was interviewed on 9/8/2022 and agreed, there was no documented evidence the MSW followed the plan of care as ordered or documented reasons for the missed visits in August.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires; but no less frequently than every 15 calendar days. A revised plan of care includes information from the patient’s updated comprehensive assessment; record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 3 of 3 (100%) records reviewed revealed the hospice did not ensure the social worker reviewed, revised or updated the plan of care no less frequently than every 21 calendar days.. Record 1: This patient was admitted to hospice on 7/28/2022 and revealed the patient/caregiver accepted social worker visits. There was no documented evidence the social worker reviewed, revised or updated the plan of care 8/16/2022-9/8/2022. The Interdisciplinary Team meeting on 8/29/2022 did not include documented evidence of a social worker signature confirming the plan of care was reviewed. There was no documented evidence the social worker reviewed, revised or updated the plan of care no less frequently than every 21 calendar days. Record 2: This patient was admitted to hospice on 7/22/2022 and revealed the patient/caregiver accepted social worker visits. There was no documented evidence the social worker reviewed, revised or updated the plan of care 8/16/2022-9/8/2022. The Interdisciplinary Team meeting on 8/29/2022 did not include documented evidence of a social worker signature confirming the plan of care was reviewed. There was no documented evidence the social worker reviewed, revised or updated the plan of care no less frequently than every 21 calendar days. Record 3: This patient was admitted to hospice on 7/21/2022 and revealed the patient/caregiver accepted social worker visits. There was no documented evidence the social worker reviewed, revised or updated the plan of care 8/16/2022-9/8/2022. The Interdisciplinary Team meeting on 8/29/2022 did not include documented evidence of a social worker signature confirming the plan of care was reviewed. There was no documented evidence the social worker reviewed, revised or updated the plan of care no less frequently than every 21 calendar days. The President was interviewed on 9/7/2022 and confirmed that there was no documented evidence the social worker reviewed, revised or updated the plan of care 8/16/2022-9/8/2022. Record 1: This patient was admitted to hospice on 7/28/2022 and revealed the patient/caregiver accepted social worker visits. There was no documented evidence the social worker reviewed, revised or updated the plan of care 8/16/2022-9/8/2022. The Interdisciplinary Team meeting on 8/29/2022 did not include documented evidence of a social worker signature confirming the plan of care was reviewed. There was no documented evidence the social worker reviewed, revised or updated the plan of care no less frequently than every 21 calendar days. Record 2: This patient was admitted to hospice on 7/22/2022 and revealed the patient/caregiver accepted social worker visits. There was no documented evidence the social worker reviewed, revised or updated the plan of care 8/16/2022-9/8/2022. The Interdisciplinary Team meeting on 8/29/2022 did not include documented evidence of a social worker signature confirming the plan of care was reviewed. There was no documented evidence the social worker reviewed, revised or updated the plan of care no less frequently than every 21 calendar days. Record 3: This patient was admitted to hospice on 7/21/2022 and revealed the patient/caregiver accepted social worker visits. There was no documented evidence the social worker reviewed, revised or updated the plan of care 8/16/2022-9/8/2022. The Interdisciplinary Team meeting on 8/29/2022 did not include documented evidence of a social worker signature confirming the plan of care was reviewed. There was no documented evidence the social worker reviewed, revised or updated the plan of care no less frequently than every 21 calendar days. The President was interviewed on 9/7/2022 and agreed, there was no documented evidence the social worker reviewed, revised or updated the plan of care 8/16/2022-9/8/2022.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by a review of clinical records and interview. In 2 of 9 (22%) clinical records reviewed, it was revealed that the agency did not ensure the hospice aide reported a change in condition to the registered nurse. Clinical Record 2: This patient was admitted to hospice on 7/22/2022. Diagnosis Dysphagia following cerebral infarction. The hospice aide documentation on 7/25/2022 revealed oxygen saturation 89%, temperature 98.9, blood pressure 98/62, respiration 23. There was no documented evidence that the hospice aide notified the registered nurse with the change in condition. The hospice aide documentation on 8/29/2022 revealed temperature 98.9, small wound in the left armpit, blister noted in the left upper leg, and ants all over the bed. There was no documented evidence that the hospice aide notified the registered nurse with the change in condition. Clinical Record 6: This patient was admitted to hospice on 11/12/2021. Diagnosis Alzheimer's disease with late onset. The hospice aide documentation on 5/3/2022 revealed blood pressure 39/33, pulse 136. The patient died four days later. There was no documented evidence that the hospice aide notified the registered nurse with the change in condition. The President was interviewed on 9/8/2022 and confirmed that there was no documented evidence the hospice aide notified the registered nurse with the changes in condition. Record 2: This patient was admitted to hospice on 7/22/2022. Diagnosis Dysphagia following cerebral infarction. The hospice aide documentation on 7/25/2022 revealed oxygen saturation 89%, temperature 98.9, blood pressure 98/62, respiration 23. There was no documented evidence that the hospice aide notified the registered nurse with the change in condition. The hospice aide documentation on 8/29/2022 revealed temperature 98.9, small wound in the left armpit blister noted in the left upper leg, ants all over the bed. There was no documented evidence that the hospice aide notified the registered nurse with the change in condition. Record 6: This patient was admitted to hospice on 11/12/2021. Diagnosis Alzheimer's disease with late onset. The hospice aide documentation on 5/3/2022 revealed blood pressure 39/33, pulse 136. The patient died four days later. There was no documented evidence that the hospice aide notified the registered nurse with the change in condition. The President was interviewed on 9/8/2022 and agreed, there was no documented evidence the hospice aide notified the registered nurse with the changes in condition.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by a review of clinical records and interviews. 11 of 11 (100%) clinical records reviewed revealed the hospice did not ensure the election statement included the patient or representative’s right to request an addendum that includes hospice non-covered items upon admission. . Record 1: This patient was admitted to hospice on 7/28/2022. There was no documented evidence the hospice election statement included a section for the patient or representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 2: This patient was admitted to hospice on 7/22/2022. There was no documented evidence the hospice election statement included a section for the patient or representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 3: This patient was admitted to hospice on 7/21/2022. There was no documented evidence the hospice election statement included a section for the patient or representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 4: This patient was admitted to hospice on 2/23/2022. There was no documented evidence the hospice election statement included a section for the patient or representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 5: This patient was admitted to hospice on 4/29/2022. There was no documented evidence the hospice election statement included a section for the patient or representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 6: This patient was admitted to hospice on 11/12/2021. There was no documented evidence the hospice election statement included a section for the patient or representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 7: This patient was admitted to hospice on 4/21/2022. There was no documented evidence the hospice election statement included a section for the patient or representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 8: This patient was admitted to hospice on 10/29/2021. There was no documented evidence the hospice election statement included a section for the patient or representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 9: This patient was admitted to hospice on 4/5/2022. There was no documented evidence the hospice election statement included a section for the patient or representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 10: This patient was admitted to hospice on 8/10/2022. There was no documented evidence the hospice election statement included a section for the patient or representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 11: This patient was admitted to hospice on 10/29/2021. There was no documented evidence the hospice election statement included a section for the patient or representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." The President was interviewed on 9/7/2022 and confirmed that there was no documented evidence the notification of hospice non-covered items was discussed and offered upon admission. The President stated, “We didn’t know about that form.” Record 1: This patient was admitted to hospice on 7/28/2022. There was no documented evidence the hospice election statement included a section for the patient or representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 2: This patient was admitted to hospice on 7/22/2022. There was no documented evidence the hospice election statement included a section for the patient or representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 3: This patient was admitted to hospice on 7/21/2022. There was no documented evidence the hospice election statement included a section for the patient or representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 4: This patient was admitted to hospice on 2/23/2022. There was no documented evidence the hospice election statement included a section for the patient or representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 5: This patient was admitted to hospice on 4/29/2022. There was no documented evidence the hospice election statement included a section for the patient or representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 6: This patient was admitted to hospice on 11/12/2021. There was no documented evidence the hospice election statement included a section for the patient or representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 7: This patient was admitted to hospice on 4/21/2022. There was no documented evidence the hospice election statement included a section for the patient or representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 8: This patient was admitted to hospice on 10/29/2021. There was no documented evidence the hospice election statement included a section for the patient or representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 9: This patient was admitted to hospice on 4/5/2022. There was no documented evidence the hospice election statement included a section for the patient or representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 10: This patient was admitted to hospice on 8/10/2022. There was no documented evidence the hospice election statement included a section for the patient or representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." Record 11: This patient was admitted to hospice on 10/29/2021 There was no documented evidence the hospice election statement included a section for the patient or representative to request or decline the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." The President was interviewed on 9/7/2022 and agreed, there was no documented evidence the notification of hospice non-covered items was discussed and offered upon admission. The President stated, “we didn’t know about that form and haven’t been doing this.”

It is required that drugs and biologicals related to the palliation and management of the terminal illness and related conditions are Identified in the plan of care; Provided to a patient while under the care of the hospice. This standard was not met as evidenced by a review of clinical records, observations, and interview. 2 of 11 (18%) clinical records reviewed revealed the hospice did not ensure medications were provided by the hospice while the patient was under hospice care.. Record 1: This patient was admitted to hospice on 7/28/2022. Diagnosis was other specified diseases of spinal cord. During a home visit on 9/7/22, the caregiver was interviewed about current medications. The caregiver confirmed the patient was taking Tylenol 500mg every 4-6 hours, as needed for pain in the neck and back, and open wounds. This was listed as covered by the hospice agency on the medication profile. The caregiver stated, "No pain medications were provided by hospice since the admission date. Hospice was supposed to get back to us on his Gabapentin but never did. We give him Tylenol because we ran out of the gabapentin weeks ago, but the Tylenol doesn’t always work.” There was no documented evidence the hospice provided medications related to the palliation and management of the terminal illness and related conditions. Record 4: This patient was admitted to hospice on 2/23/2022. Diagnosis was malignant neoplasm of bladder. During a home visit on 9/7/2022, the caregiver was interviewed about current medications. The caregiver confirmed the patient was taking Hydrocodone-Acetaminophen 5/325, Docusate Sodium, Escitalopram, and Prednisone. These were listed as effective 2/23/2022, and covered by the patient on the medication profile. The caregiver stated, "None of these medications have been provided by hospice since the admit date. The nurse brings out wound supplies, but no other medications have been provided. No one told me hospice would cover some of his medications.” There was no documented evidence the hospice provided medications related to the palliation and management of the terminal illness and related conditions. The President was interviewed on 9/8/2022 and stated, “These medications should be covered by hospice.” The President confirmed that there was no documented evidence the hospice agency provided medications related to the palliation and management of the terminal illness and related conditions. Record 1: This patient was admitted to hospice on 7/28/2022. Diagnosis Other specified diseases of spinal cord. During a home visit on 9/7/2022, the caregiver was interviewed about current medications. The caregiver confirmed the patient was taking Tylenol 500mg every 4-6 hours as needed for pain in the neck, back and open wounds which was listed as covered by the hospice agency on the medication profile. The caregiver was interviewed and stated, no pain medications have been provided by the hospice since the admit date. The caregiver stated, “hospice was supposed to get back to us on his Gabapentin he takes but never did.” The caregiver stated, “we give him Tylenol because we ran out of the gabapentin weeks ago, but the Tylenol doesn’t always work.” There was no documented evidence the hospice provided medications related to the palliation and management of the terminal illness and related conditions. Record 4: This patient was admitted to hospice on 2/23/2022. Diagnosis Malignant neoplasm of bladder. During a home visit on 9/7/2022, the caregiver was interviewed about current medications. The caregiver confirmed the patient was taking Hydrocodone-Acetaminophen 5/325, Docusate Sodium, Escitalopram, and Prednisone which were listed as effective date 2/23/2022, covered by the patient on the medication profile. The caregiver was interviewed and stated, none of these medications have been provided by the hospice since the admit date. The caregiver stated, “the nurse brings out wound supplies, but no other medications have been provided.” The caregiver stated, “no one told me hospice would cover some of his medications.” There was no documented evidence the hospice provided medications related to the palliation and management of the terminal illness and related conditions. The President was interviewed on 9/8/2022 and stated, “these should be covered by hospice.” The President agreed, there was no documented evidence the hospice agency provided medications related to the palliation and management of the terminal illness and related conditions. The President stated, “sometimes we have their pharmacy bill us,” but confirmed there was no documented evidence hospice covered the medications.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. Criminal background checks are obtained in accordance with state requirements. a) In the absence of state requirements, criminal background checks are obtained within three (3) months of the date of employment for all states in which the individual has lived or worked during the past three (3) years. This standard was not met as evidenced by a review of documents and interviews. 2 of 6 (33%) contracts reviewed revealed the hospice did not ensure hospice contracts require all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. . Contract 2: Review of the General In Patient/Respite contract signed 2/27/17 revealed there was no evidence that the contracted entity was required to obtain a criminal background check on contracted employees who have direct patient contact or access to patient records. Contract 4: Review of the Pharmacy contract signed 4/22/14 revealed there was no evidence that the contracted entity was required to obtain a criminal background check on contracted employees who have direct patient contact or access to patient records. The President was interviewed on 9/7/2022 and confirmed that there was no documented evidence the contracted entities identified were required to obtain a criminal background check on contracted employees who have direct patient contact or access to patient records. Contract 2: (GIP Respite): signed date 2/27/2017. Review of the contract revealed there was no evidence that the contracted entity was required to obtain a criminal background check on contracted employees who have direct patient contact or access to patient records. Contract 4: (Pharmacy): signed date 4/22/2014. Review of the contract revealed there was no evidence that the contracted entity was required to obtain a criminal background check on contracted employees who have direct patient contact or access to patient records. The President was interviewed on 9/7/2022 and agreed, there was no documented evidence the contracted entities identified were required to obtain a criminal background check on contracted employees who have direct patient contact or access to patient records.

It is required that the hospice demonstrates the vaccination status of each individual eligible to be fully vaccinated for COVID-19. At a minimum, the hospice has evidence of an individual having received a single-dose of COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to providing any care, treatment, or other services for the hospice and/or its patients/families. Or there is evidence of an individual having a pending request for, or having been granted a medical or spiritual vaccination exemption, or a job responsibility exception, or a temporary COVID-19 vaccination delay due to clinical precautions and considerations per policy and procedure. This standard was not met as evidenced by a review of personnel records, documents, and interviews. 1 of 10 (10%) personnel records reviewed revealed the hospice did not ensure that employees, including contracted staff, were fully vaccinated or had an approved medical or spiritual exemption prior to providing care to patients/families or other services for the hospice. . Agency policy, “Operations and Provision of Care” “COVID-19 ETS,” revised September 2022, stated in part, “The organization shall require employees to be fully vaccinated. The organization shall require all vaccinated employees to provide an acceptable proof of vaccination status, including those employees who are partially or fully vaccinated. Acceptable proof of vaccination status includes evidence of dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to providing any care, treatment, or other services for the hospice and/or its patients/families; a copy of evidence of an individual having a pending request for or having been granted a medical or spiritual exemption, or a job responsibility exception. The following individuals are eligible to be fully vaccinated for COVID-19 regardless of their clinical responsibility or patient/family contact: those who provide care, treatment, or other services for the hospice and/or its patients/families, under contract or by other arrangement. If an employee cannot provide a copy of one of the acceptable forms for proof of vaccination status, that employee shall be treated as not fully vaccinated.” Staff 3: Chaplain with date of hire 6/11/2022. Review of the personnel file revealed there was no documented evidence of COVID vaccination or an approved or pending exemption. The Chaplain was interviewed on 9/7/2022 and stated, “I am not vaccinated, do I need to be?” The Chaplain confirmed the hospice had not requested vaccination documentation and she had not requested an exemption. The Chaplain confirmed she attended the Interdisciplinary team meetings in person on 8/1/2022, 8/15/2022, 8/29/2022. She also completed in-person patient visits on 7/15/2022, 7/26/2022. The President was interviewed on 9/7/2022 and confirmed that there was no documented evidence of the Chaplain’s vaccination status, pending exemption request or approved exemption. Agency policy, “Operations and Provision of Care” “COVID-19 ETS,” revised September 2022, stated in part, “The organization shall require employees to be fully vaccinated. The organization shall require all vaccinated employees to provide an acceptable proof of vaccination status, including those employees who are partially or fully vaccinated. Acceptable proof of vaccination status includes evidence of dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to providing any care, treatment, or other services for the hospice and/or its patients/families; a copy of evidence of an individual having a pending request for or having been granted a medical or spiritual exemption, or a job responsibility exception. The following individuals are eligible to be fully vaccinated for COVID-19 regardless of their clinical responsibility or patient/family contact: those who provide care, treatment, or other services for the hospice and/or its patients/families, under contract or by other arrangement. If an employee cannot provide a copy of one of the acceptable forms for proof of vaccination status, that employee shall be treated as not fully vaccinated.” Staff 3: (Chaplain): hire date 6/11/2022. Review of the personnel file revealed there was no documented evidence of COVID vaccination or an approved or pending exemption. The Chaplain was interviewed on 9/7/2022 and stated, “I am not vaccinated, do I need to be?” The Chaplain confirmed the hospice had not requested vaccination documentation and she had not requested an exemption. The Chaplain confirmed she attended the Interdisciplinary Team meetings in person on 8/1/2022, 8/15/2022, 8/29/2022 and in person patient visits on 7/15/2022, 7/26/2022. The President was interviewed on 9/7/2022 and agreed, there was no documented evidence of the Chaplain’s vaccination status, pending exemption request or approved exemption.