Every finding on record at West Michigan Hospice, LLC

Based on record review and interview, the Hospice agency failed to develop and maintain a complete Emergency Preparedness communication plan, resulting in the agency's inability to ensure the coordination of patient care during an emergency/disaster and the potential to negatively affect the health and safety of all patients receiving services. Findings include: --- On 2/18/26, review of the agency's emergency preparedness documentation concerning its Communication Plan (CP) noted a failure to document how the agency would coordinate patient care within the facility and across other healthcare providers. The CP also failed to have documented evidence of how the agency would interact and coordinate with emergency management agencies and systems to protect patient health and safety in the event of a disaster. Further, the CP contained no language or process of how any staff member would communicate and coordinate the support of patient care needs within the agency and other healthcare providers during an emergency/disaster. The findings above were reviewed and acknowledged by the Administrator (Staff-A) and Clinical (Staff-B) during an interview on 2/18/26 at 3:20 PM.

Based on record review and interview, the agency failed to ensure emergency preparedness training was provided to staff every 2 years for 5 (Staff A, Staff B, Staff C, Staff F,  and Staff G) of 5 employees hired in 2023 or after, resulting in the potential for an unprepared staff response in the event of an emergency. Findings include: --- During review of personnel files on 2/18/26 at 1:30 PM, the director of clinical services (Staff B) was asked to provide evidence of ongoing emergency preparedness (EP) training (every 2 years) for 5 staff hired since 2023 (Staff A, Staff B, Staff C, Staff F, Staff G). Upon further review of the personnel files, it was determined there was no evidence of ongoing EP training for any employees.During an interview with the administrator (Staff A) on 2/18/26 at 1:39 PM, Staff A was asked about ongoing EP training. Staff A stated he did not think EP was included in their annual in-service list and acknowledged the findings at the time of interview.

Based on record review and interview, the Hospice agency failed to provide documentation that it had participated in the community-based, full-scale exercise required every two years, resulting in the potential for patients and staff not to be properly prepared in the event of an actual emergency. Findings include: --- On 2/18/26, review of the agency's emergency preparedness binder found no evidence that the Hospice agency had conducted the required full-scale community-based exercise every two years. No communication or effort was noted by the Agency in reaching out to the local incident command center to participate in the community-based exercise for the last 3 years. The above findings were reviewed with and acknowledged by the Administrator (Staff-A) and Clinical Director (Staff-B) during an interview on 2/18/26 at 3:22 PM.

Based on record review and interview, the agency failed to ensure the drug profile included all patient medications for 3 (P-2, P-3, P-10) of 16 records reviewed and review of all medications for significant drug interactions for 2 (P-15 and P-16) of 16 records reviewed, resulting in the potential for harmful drug interactions. Findings include: --- Patient #15’s (P-15) Start of Care (SOC) was dated 1/30/25. The Plan of Care (POC) identified a terminal diagnosis of Nonalcoholic Steatohepatitis. During record review on 2/17/26, it was noted that the “Medication Interaction” report within the EMR (Electronic Medical Record) noted 1 Drug-Drug interactions with “Severity: Major” interaction between Paroxetine and Tramadol. There was no documented evidence that a drug review was completed per the policy.         Patient #16’s (P-16) Start of Care (SOC) was dated 10/24/25. The Plan of Care (POC) identified a terminal diagnosis of Nasal Cancer. During record review on 2/18/26, it was noted that the “Medication Interaction” report within the EMR (Electronic Medical Record) noted 1 Drug-Drug interactions with “Severity: Major” interaction between Tramadol and Trazodone. There was no documented evidence that a drug review was completed per the policy.         A review of the agency policy occurred on 2/19/26 titled "Medication Monitoring" (Revised June 2019). The policy states, "Procedure: 2. A Registered nurse reviews all of the patient’s prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy on an ongoing basis. This review is done in collaboration with other IDG members which may include a physician, and/or pharmacist during the IDG meeting and whenever needed. This review includes, but is not limited to: Actual or potential drug interactions.”The Administrator (Staff-A) and Director of Clinical Services (Staff-B) reviewed and acknowledged the findings listed above in an interview on 2/19/26 at 2:00 pm. Patient #10 (P-10) was admitted to this hospice agency on 2/1/24 with the terminal diagnosis of senile degeneration of the brain. During a joint home visit on 2/17/26 at 1:00 PM, a medication list was requested from the medication passer at the assisted living facility where P-1 resided. Upon comparison of the medications listed on the plan of care and the medications listed from the facility, it was determined there were 2 medications (“anti-diarrheal 2 mg caplet” and “atropine 1% eye drops”) that were on the list from the assisted living facility but were not on the most recent plan of care. Additionally, the plan of care dated 1/21/26 indicated “*Added O2 at 2L” on 1/6/26. Upon further review of the medication profile, it was determined oxygen was not listed.A review of agency policy titled “Medication Reconciliation” (revised June 2019) revealed, “Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication.”The administrator (Staff A) and the director of clinical services (Staff B) reviewed and acknowledged the findings during an interview on 2/19/26 at 11:00 AM. Patient #2 (P-2) was admitted to this hospice facility 1/15/26 with the terminal diagnosis of malnutrition. Review of records on 2/18/26 concluded that the patient required oxygen therapy. Documentation to support the findings includes: Hospice Plan of Care and Certificate of Terminal Illness (CTI) for episode 1/14/26-4/13/26, included the narrative, “recent hospitalization and sub-acute rehab stay due to aspiration pneumonia in December…. required oxygen and been unable to wean…”HOPE (Hospice Outcomes and Patient Evaluation) Assessments dated 1/15/26 and 1/22/26 26 included documentations under the “O2” assessment O2: “Yes” Liters/Min: “2” … Via-NC/other: “NC”.Skilled Nursing (SN) visits (1/16/26, 1/29/26, 2/5/26, and 2/12/26) include documentation of “Oxygen 2 LPM” (liters per minute) and checked boxes for “continuous” and “Nasal Cannula” in the Respiratory/Pulmonary Status assessment. Review of the Hospice Plan of Care was void of an order for oxygen. Upon further review of the medication profile dated 1/15/26 it was determined that oxygen was not listed.   Patient #3 (P-3) was admitted to this hospice facility 12/29/26 with the terminal diagnosis of malnutrition. The review of records on 2/18/26 revealed documentation of "Oxygen marked “PRN” (as needed) and Oxygen Via: “Nasal Cannula”, in 5 of 5 SN visit notes reviewed (1/6/26,1/27/26, 2/3/26, 2/10/26, 2/17/26). Review of the plan of care was void of an order for oxygen. Upon further review of the medication profile dated 12/30/26 it was determined that oxygen was not listed.    The Agency Administrator (Staff-A) and Clinical Director (Staff-B) reviewed and acknowledged the findings during an interview on 2/19/26 at 13:00 PM.

Based on record review and interview, the hospice failed to ensure the Initial Bereavement Assessment (IBA) included the identification of the potential bereaved individuals, and the social, spiritual and cultural factors that may impact their ability to cope with the patient's death in 13 (P-1, P-2, P-3, P-4, P-5, P-7, P-9, P-11, P-12, P-13, P-14, P-15, and P-16) of 16 patients, resulting in the potential for ineffective grieving and lack of bereavement support for the family members, caregivers and others that may be affected upon the patient's death.  Findings include: --- Patient #9’s (P-9) Start of Care (SOC) was dated 1/9/26. The Plan of Care (POC) identified a terminal diagnosis of Prostate Cancer. During record review on 2/18/26, it was noted that a bereavement risk assessment was not completed. The agency failed to assess potential bereaved per policy. Patient #15’s (P-15) Start of Care (SOC) was dated 1/30/25. The Plan of Care (POC) identified a terminal diagnosis of Nonalcoholic Steatohepatitis. During record review on 2/17/26, it was noted that the bereavement risk assessment was completed by the Chaplain on 2/3/25 for the patient’s daughter. The MSW completed an assessment on 1/31/25 stating, “…P-15 currently lives in the ALF (Assisted Living Facility) portion of ALF with her husband…Daughter confirmed that P-15 has a medical DPOA (Durable Power of Attorney) and that is her and her 2 siblings…” The bereavement risk assessment failed to include the patient’s husband and other 2 siblings.         Patient #16’s (P-16) Start of Care (SOC) was dated 10/24/25. The Plan of Care (POC) identified a terminal diagnosis of Nasal Cancer. During record review on 2/18/26, it was noted that the bereavement risk assessment was completed by the Chaplain on 11/3/25. The bereavement assessment contained no documentation on who was assessed and was blank under the background information for relationship and emergency contact. The referral documented, “Emergency Contacts: Spouse, Daughter, Daughter.” The bereavement risk assessment failed to include the patient’s spouse and other 2 daughters.         The Administrator (Staff-A) and Director of Clinical Services (Staff-B) reviewed and acknowledged the findings listed above in an interview on 2/19/26 at 2:00 pm. Patient #11 (P-11) was admitted to this hospice facility on 1/30/26 with the terminal diagnosis of Parkinson’s disease. During record review on 2/18/26, it was noted the initial bereavement assessment only listed P-11’s spouse. Upon further review of the record, it was determined P-11 had a son and a daughter listed on the consent paperwork dated 1/30/26 as other individuals involved in his care.Patient #12 (P-12) was admitted to this hospice agency on 11/22/25 with the terminal diagnosis of pancreatic cancer. During record review on 2/18/26, it was noted the initial bereavement assessment only listed “Richard” (relationship to P-12 was not documented). Upon further review of the record, it was determined the social worker documented on the plan of care dated 11/22/25 that P-12 lived with one of his daughters and had another daughter who was active in his care.Patient #13 (P-13) was admitted to this hospice agency on 1/6/26 with the terminal diagnosis of senile dementia of the brain. During record review on 2/18/26, it was noted the initial bereavement assessment only listed P-13’s daughter. Upon further review of the record, it was determined another person was listed as her durable power of attorney (DPOA) and a son was listed as a back-up. Additionally, the social work evaluation dated 1/12/26 indicated P-13 had a niece who was present and involved in her care.Patient #14 (P-14) was admitted to this hospice agency on 10/22/25 with the terminal diagnosis of colon cancer. During record review on 2/18/26, it was noted the initial bereavement assessment only listed P-14’s daughter. Upon further review of the record, it was determined the social work evaluation dated 10/22/25 indicated P-14 lived with his son and his niece was his DPOA.The initial bereavement assessment failed to assess all individuals potentially affected by the death of the patient.The administrator (Staff A) and director of clinical services (Staff B) reviewed and acknowledged the findings during an interview on 2/19/26 at 11:00 AM. Patient #5 (P-5): The patient's hospice start of care (SOC) was on 11/25/25, with a terminal diagnosis of lung cancer with metastasis (spreading) to the brain. Record review on 2/17/26 noted the IBA was void of any names of family members or close friends qualifying for bereavement services and 14 of 17 assessment areas were left blank. Examples include: "Are there any conflicts between family members; Has there been previous experience dealing with loss; Is the bereaved individual being treated for anxiety, depression, or other mental illness?" In addition, during a joint home visit with skilled nursing services on 2/17/26, it was revealed during an interview at 12:23 PM that P-5's husband, son and daughter-in-law are very important to her as care givers and emotional support on a frequent basis. Patient #7 (P-7): This patient's hospice SOC date was 1/13/26, with a terminal diagnosis of protein calorie malnutrition, dementia, chronic kidney disease stage 4, and heart disease. Record review on 2/18/26 noted the IBA mentioned P-7's husband but was void of other family members or close friends qualifying for bereavement services and 14 of 17 assessment areas were left blank. Examples include: "Are there any health concerns affecting the family; Has there been previous experience dealing with loss; Is the bereaved individual being treated for anxiety, depression, or other mental illness?" Further record review noted the following documentation from Social Work services: "Their younger daughter visits approximately twice per week, often stopping by after work and on Saturdays and Sundays. Their older daughter is currently undergoing cancer treatment and medication. Social Work provided empathy and emotional support as (P-7's husband) shared about his daughter's illness." The IBA failed to comprehensively assess all individuals that would be significantly impacted by the death of the patient. The above findings were reviewed with and acknowledged by the Administrator (Staff-A) and Clinical Director (Staff-B) during an interview on 2/19/26 at 1:47 PM. Both further noted this did not meet agency expectations or its policy referenced below.Agency Policy: "Bereavement Services" 4.26.1 (Revised June 2019) stated, "An initial Bereavement Risk Assessment will be performed as a part of the Comprehensive Assessment. The services are available to assist the patient and family in minimizing stress and problems that arise from the terminal illness, related conditions and the dying process."   Patient #1 (P-1) was admitted to this hospice facility 1/29/26 with the terminal diagnosis of corticobasal degeneration (progressive brain cell death). During record review on 2/17/26, the initial bereavement assessment (IBA) only listed P-1’s spouse and was void of other family members or close friends qualifying for bereavement services. Additionally, 18 out of 31 assessment areas were left blank. For example, “List other family members requiring care; Time since diagnosis; Has there been previous experience dealing with loss; Is the bereaved individual being treated for anxiety, depression, or other mental illness?” Further review of the medical social worker evaluation dated 1/28/26 indicated that P-1 had six children (5 daughters and 1 son), a caregiver and a “lady who comes to read to her every Thursday.”  Patient #2 (P-2) was admitted to this hospice facility 1/15/26 with the terminal diagnosis of malnutrition. During the record review on 2/18/26, the IBA dated 1/20/26 was not completed and included the comment: “I had a brief text correspondence (only one brief reply from daughter) without additional follow up despite daughter's message indicating that she would follow up again by this week. Unable to perform bereavement assessment.” At the time of the review, the record was void of documentation of further attempts to complete the bereavement assessment.Patient #3 (P-3) was admitted to this hospice facility 12/29/25 with the terminal diagnosis of malnutrition. During record review on 2/18/26, the IBA only included P-3’s daughter-in-law and was void of other family members or close friends qualifying for bereavement services. Additionally, 18 out of 31 assessment areas were left blank. For example, “List other family members requiring care; Time since diagnosis; Has there been previous experience dealing with loss; Is the bereaved individual being treated for anxiety, depression, or other mental illness; Is the bereaved individual involved in the care of the patient?” Further review of the medical social worker evaluation dated 12/31/25 indicated that P-3 resides with her son, daughter-in-law, and spouse.Patient #4 (P-4) was admitted to this hospice facility 11/15/24 with the terminal diagnosis of Alzheimer’s. Review of the initial bereavement assessment dated 11/15/24 only included P-4’s daughter and commented that P-4’s “… son’s may have more complicated grief d/t (due to) their closer relationship and more chaotic social circumstances.” During the home visit 2/18/26 it was observed that P-4 resides with her spouse.The IBA failed to comprehensively assess all individuals that would be significantly impacted by the death of the patients.The above findings were reviewed with and acknowledged by the Administrator (Staff-A) and Clinical Director (Staff-B) during an interview on 2/19/26 at 12:47 PM.

Based on record review and interview, the agency failed to ensure a registered nurse was a member of the interdisciplinary group in 1 (P-9) of 16 records reviewed, resulting in uncoordinated care and the potential for unmet care needs.  Findings include: --- Patient #9’s (P-9) Start of Care (SOC) was dated 1/9/26. The Plan of Care (POC) identified a terminal diagnosis of Prostate Cancer. During record review on 2/18/26, it was noted that Registered Nurse failed to document within the “Hospice IDT Meeting Report” for the meeting dated 1/14/26. The registered nurse documented two completed visits: 1/9/26 and 1/13/26. The agency failed to incorporate a registered nurse as a member of the IDT.  The Administrator (Staff-A) and Director of Clinical Services (Staff-B) reviewed and acknowledged the findings listed above in an interview on 2/19/26 at 2:00 pm.

Based on record review and interview, the agency failed to ensure the patient/caregiver(s) received education and training as ordered in the plan of care (POC) in 1 (P-6) of 16 records reviewed, resulting in the potential for unrecognized hazards and patient suffering. Findings include: --- Patient #6 (P-6): was admitted to this hospice agency on 5/15/25, with a terminal diagnosis of lung cancer with metastasis (spreading) to the brain. Record review on 2/18/26 noted the following POC order: "Skilled nurse to teach and instruct: Signs and symptoms of UTI (urinary tract infection), ... Signs and symptoms to observe and report to nurse or MD, ... Fall Precautions/Transfer safety, ... Emergency Information." Further record review of the 7 skilled nursing (SN) visits dated 1/5/26 through 2/16/26, noted all 7 visits documented the following on: "Education Provided: Patient Education: none. Caregiver Education: none." No evidence was found within any of the 7 SN visit notes that any education or training had been provided as ordered.The above findings were reviewed with and acknowledged by the Administrator (Staff-A) and Clinical Director (Staff-B) during an interview on 2/19/26 at 1:37 PM.

Based on record review and interview, the agency failed to ensure the plan of care (POC) included all services to be provided to the patient in 1 (P-10) of 16 patients reviewed; and failed to include pertinent safety measures to protect all individuals against injury in 1 (P-5) of 16 patients reviewed, resulting in the potential for unapproved services being rendered and an unsafe patient environment. Findings include: --- Patient #10 (P-10) was admitted to this hospice agency on 2/1/24 with the terminal diagnosis of senile degeneration of the brain. During record review on 2/17/26, it was noted the patient received visits from a volunteer on 9/5/24, 10/4/24, 11/1/24, and 11/27/24. Upon review of the plans of care dated 7/30/24 and 9/28/24 (surrounding the volunteer visits), it was determined volunteer services were not listed on either.During an interview with the administrator (Staff A) and the director of clinical services (Staff B) on 2/19/26 at 11:00 AM, Staff A stated the volunteer services “should be on the plan of care.” Staff A and Staff B acknowledged the findings at the time of interview. Patient #5 (P-5): was admitted to this hospice agency on 11/25/25, with a terminal diagnosis of lung cancer with metastasis (spreading) to the brain. Record review on 2/17/26 found that the POC included an "oxygen concentrator with backup, oxygen tubing, and portable oxygen." However, under "Safety Measures" the only risk factor listed pertained to patient falls. No oxygen precautions were found under P-5's "Safety Measures".The above findings were reviewed with and acknowledged by the Administrator (Staff-A) and Clinical Director (Staff-B) during an interview on 2/19/26 at 1:27 PM.

Based on record review and interview, the Hospice agency failed to ensure that the Plan of Care (POC) included patient specific measurable goals as required in 4 (P-5, P-6, P-7 and P-8) of 16 records reviewed. Findings include: --- Patients #5 - #8 (P-5 through P-8): During record review from 2/17/26 through 2/19/26, it was noted that the POC's were generic and not measurable as required. Subsequently, progress made (or lack of) could not be tracked and trended to enable Hospice staff to accurately perform an objective evaluation of the patient's progress concerning the specified goal. The scope of non-measurable goals corresponded as follow: P-5 (21 of 21 goals); P-6 (19 of 19 goals); P-7 (19 of 19); and P-8 (27 of 27). These non-measurable goals concerned patient care related items such as spiritual needs, coping skills, pain control, skin integrity, medication safety, among others.The above findings were reviewed with and acknowledged by the Administrator (Staff-A) and Clinical Director (Staff-B) during an interview on 2/19/26 at 1:53 PM.

Based on observation, interview, and record review the Hospice agency failed to share information and coordinate patient needs between disciplines and the physician in 3 (P-2, P-4, P-6) of 16 records reviewed, resulting in the potential for unmet urgent care needs and poor clinical outcomes. Findings include: --- Patient #6 (P-6): was admitted to this hospice agency on 5/15/25, with a terminal diagnosis of lung cancer with metastasis (spreading) to the brain. Record review on 2/19/26 found a visit note dated 2/18/26 by home health aide (HHa) services. The HHa (Staff J) documented under "Comments" the following: "Patient stated she was very shaky and chest palpitations- called staff and had them evaluate her. She hadn't had breakfast yet that morning."This finding was reviewed with and acknowledged by the Administrator (Staff-A) and Clinical Director (Staff-B) during an interview on 2/19/26 at 1:35 PM. Both further acknowledged that the Hospice agency had no documented follow-up evaluation or physician notification concerning the above finding. Staff B was noted when asked that this did not meet agency expectations for coordinating care services. Patient #2 (P-2) was admitted to this hospice facility 1/15/26 with the terminal diagnosis of malnutrition. During the record review on 2/18/26 of the Hospice Plan of Care and Certificate of Terminal Illness (CTI) for episode 1/14/26-4/13/26, included the narrative, “…recent hospitalization and sub-acute rehab stay due to aspiration pneumonia… dietary requirements have changed, now only able to tolerate thickened liquids”. Further review concluded a lack of coordination of care of P-2's safety needs of aspiration precautions, evidenced by:The HOPE (Hospice Outcomes and Patient Evaluation) Assessment dated 1/15/26 marked aspiration precautions. However, the Plan of Care (POC) was void of documented safety measures of aspiration precautions.The aide care plan did not include the communication of P-2’s risk for aspiration or safety measures of aspiration precautions.POC ordered “1.) RN to monitor appetite, oral intake and signs of dysphagia or aspiration…” and ordered diet “general diet-as tolerated”.Skilled Nursing (SN) visits (1/16/26, 1/29/26, 2/5/26, and 2/12/26) assessment of appetite documented “poor”, and void of the assessments of oral intake and signs of dysphagia or aspiration.Further review of SN visits found no documentation that SN provided education to P-2/caregiver the signs of dysphagia or aspiration, with 5 of 5 documented caregiver education to include: “Medication application, Hospice goals, Patient goals, Comfort pack”.Patient #4 (P-4) was admitted to this hospice facility 1/9/26 with the terminal diagnosis of Alzheimer’s. Review of records on 2/18/26 noted a Patient Communication Log dated 2/1/26 that documented the agency received a text from the staff where P-4 resides, an assisted living facility (ALF). Communication noted that P-4 fell and stated “…texted RN that pt had a fall. No signs or symptoms of pain reported…”. Further review the aide POC dated 1/9/26 did not include safety measures of fall precautions. Whereas the Hospice Plan of Care included fall precautions. No documented updated aide POC or communication notifying the aide of the fall was found during the record review. The 2/11/26 interdisciplinary meeting had no documented mention of the reported fall 2/1/26.  Additional evidence supporting the lack of care coordination was observed during the home visit observation 2/18/26. It was observed that while the agency aide (Staff-D) transferred P-4 from the wheelchair to the shower chair, no gait belt or non-slip socks/shoes were utilized. During the transfer Staff-D lifted P-4 by the waist and underarms. P-4 required full assistance related to stiff/rigid upper and lower extremities Staff-D was queried if a gait belt is typically used for transfer. Response “Oh she does not have one in her room”.The Agency failed to ensure communication and care was coordinated among team members concerning significant safety needs of the patients.  The Agency Administrator (Staff-A) and Clinical Director (Staff-B) acknowledged the findings during an interview on 2/19/26 at 13:00 PM, which did not meet agency expectations or their policy referenced below.A review of agency policy titled Title “IDG Care Planning Process” (Revised June 2019), revealed, “4. A registered nurse that is a member of the IDG is designated to provide coordination of care and to ensure continuous assessment of each patient’s and family’s needs and implementation of the IDG plan of care".

Based on record review and interview, it was determined that the Hospice agency failed to ensure its Governing Body approved the frequency and detail of the data collection used for the Quality Assurance Performance Improvement (QAPI) program which is needed to monitor trends for measurable improvement in patient care quality indicators. Findings include: --- On 2/18/26, review of the Governing Body meeting minutes for 2025 noted that there was no evidence that the data collection plan for the QAPI program had been presented to and approved by the Governing Board as required. The above findings were reviewed with and acknowledged by the Administrator (Staff-A) and Clinical Director (Staff-B) during an interview on 2/19/26 at 1:13 PM.

Based on record review and interview, the agency failed to ensure skilled nursing provided follow-up in 1 (P-10) of 16 patients reviewed, resulting in the potential for poor patient outcomes. Findings include: --- Patient #10 (P-10) was admitted to this hospice agency on 2/1/24 with the terminal diagnosis of senile degeneration of the brain. During record review on 2/17/26, it was noted a hospice aide visit note dated 2/13/26 stated, “Skin concerns on bottom, hip, and leg reported to RN.” Upon review of the next skilled nursing note dated 2/16/26, it was determined the nurse failed to document assessment of the skin problems reported by the aide.The administrator (Staff A) and director of clinical services (Staff B) reviewed and acknowledged the findings during an interview on 2/19/26 at 11:00 AM.

Based on record review and interview, the agency failed to maintain documentation to demonstrate hospice aide training requirements were met for 1 (Staff H) of 3 hospice aides reviewed (see L614); and failed to ensure the hospice aide only provided services as ordered in the plan of care in 1 (P-10) of 16 patients reviewed (see L626). Findings include: --- .

Based on record review and interview, the agency failed to maintain documentation to demonstrate hospice aide training requirements were met for 1 (Staff H) of 3 hospice aides reviewed, resulting in the potential for delivery of untrained services. Findings include: --- During review of personnel files on 2/18/26 at 1:30 PM, the director of clinical services (Staff B) was asked to provide evidence of hospice aide training for Staff H. During review of the personnel file for Staff H, it was determined Staff H was not registered as an aide with the Michigan Department of Licensing and Regulatory Affairs (LARA). At 1:40 PM, the administrator (Staff A) was asked for evidence of the required aide training for Staff H. Staff A stated “she has done her competencies” with the agency upon hire, however, he did not have evidence of her initial 75 hours of training, including 16 hours of classroom time. At 3:45 PM, Staff B sent a text to Staff H to see if she was able to provide evidence of her completed aide training program.On 2/19/26 at 9:35 AM, Staff A and Staff B were asked if they had received anything from Staff H. Staff A stated that Staff H sent pictures of some completion certificates for review.  Upon review of the certificates, it was determined they did not provide evidence of her initial aide training program per the requirements of the regulation. At 10:05 AM, Staff A stated he talked to one of Staff H’s previous employers to see if she could provide the evidence, however, that person was out sick and would be gone for a while. At 11:30 AM, Staff A and B were asked again for an update. Staff A and Staff B stated they had no additional information at that time and that they would let surveyors know if they received anything else from Staff H.A review of agency policy titled “Hospice Aide Services and Training Program” (revised June 2019) revealed, The Hospice Aide training program must address each of the following subject areas through classroom and supervised practical training totaling at least 75 hours, with at least 16 hours devoted to supervise practical training. The individual being trained must complete at least 16 hours of classroom training before beginning the supervised practical training.” The policy also stated, “Documentation is maintained to demonstrate that the training requirements are met and includes:  A description of the training/competency evaluation program, including the qualifications of the instructions; A record that distinguishes between skills taught at a patient’s bedside with supervision, and those taught in a laboratory using a real person (not a mannequin) and indicators of which skills each aide was judged to be competent; How additional skills (beyond the basic skills listed in the regulation) are taught and tested...”No additional documentation was provided by Staff A or Staff B by the time of exit on 2/19/26 at 3:00 PM and Staff A and Staff B acknowledged the findings.

Based on record review and interview, the agency failed to ensure the hospice aide only provided services as ordered in the plan of care in 1 (P-10) of 16 patients reviewed, resulting in the potential for delivery of unapproved services. Findings include: --- Patient #10 (P-10) was admitted to this hospice agency on 2/1/24 with the terminal diagnosis of senile degeneration of the brain. During record review on 2/17/26, it was determined the aide care plan included the tasks of shampoo, skin care, mouth/denture care, foot care, range of motion (ROM) exercise (per PT/OT), and reposition in bed. Upon review of 7 hospice aide visit notes dated from 1/23/26 through 2/13/26, it was determined the notes included additional tasks that were completed in the narrative section including dressing, brief change, and cream to bottom. These tasks were not listed on the aide care plan.A review of agency policy titled “Hospice Aide Services and Training Program” (revised June 2019) revealed, “The duties of the Hospice Aide are to provide services that are ordered by the IDG, included in the plan of care and are permitted to be performed by applicable state(s) laws and are consistent with Hospice Aide training.”During an interview with the administrator (Staff A) and the director of clinical services (Staff B) on 2/19/26 at 11:00 AM, Staff A stated he wasn’t sure why the aide did that as it was not typical of her. Additionally, during the interview, Staff B was asked for evidence of physical or occupational therapy (PT/OT) instruction in the ROM exercises as noted on the aide care plan. Staff B stated there was no involvement of a PT or OT. Staff A and Staff B acknowledged the findings at the time of interview.

Based on interview and record review, the agency failed to provide a completed volunteer plan of care in 2 of 4 (P-21 and P-22) records reviewed in which the agency documented volunteer services were provided. --- Patient # 21 (P-21): A review of the clinical record revealed a Hospice Volunteer Note completed 7/1/24 by Staff-C the Volunteer Coordinator. The “Volunteer Hours Log” documented that P-21 received volunteer services on 7/1/24 by someone other than Staff-C. No defined plan of care for volunteer services was found in the clinical record.  Patient # 22 (P-22) was listed on the “Volunteer Hours Log” as receiving volunteer services on 7/22/24. A review of clinical record revealed a Hospice Volunteer Assessment dated 7/22/24 was performed. The assessment was found to be missing documentation under the General Patient Assessment Information section. Under this section of the assessment the following patient clinical information was not obtained: the patient’s activity status, safety precautions, communication needs, and the patient’s preferences.The documented service requested was “Companionship”, no frequency for this service was documented. No documentation of a defined plan of care for the volunteer services was found in the clinical record. During the interview with Staff-A on 2/19/26 at 12:05 PM, the findings above were reviewed. Staff-A reviewed P-21 and P-22's records and reported he could not locate volunteer services in the plan of care or a separate plan of care specifically for volunteer services. Staff-A acknowledged findings above, which did not meet agency expectations or its policy referenced below.  A review of agency policy titled Title “Volunteer Services” (Revised June 2019), revealed, “9. Volunteer duties may include, but are not limited to: Patient care activities, e.g., emotional support, companionship… Such duties must be evident in the patient’s pan of care. Each volunteer will document time spent and services provided.” [sic]

Based on interview and record review, it was determined the hospice failed to maintain documentation of ongoing efforts to recruit and retain volunteers, resulting in the potential for unfulfilled patient volunteer requests. --- On 2/18/26 at 12:48 PM the Volunteer Coordinator (Staff-C) was queried about the agency’s volunteer recruitment efforts. He explained that the agency receives inquiries from the community via phone or email. He provides follow-up for each inquiry to offer detailed information about the expectations for hospice volunteers and to evaluate whether the individual could be a suitable candidate for volunteering. Additionally, the agency website advertises volunteer services. Staff-C voiced he did not have documentation of recruitment efforts.A follow-up interview with the administrator (Staff-A) on 2/19/26 was conducted to ascertain the documentation of volunteer recruitment efforts. Staff-A could vocalize recruitment efforts, for example, during community events, the volunteer opportunities would be discussed, and an agency pamphlet would be handed out. Staff-A unable to provide documentation of recruitment efforts. Staff-A acknowledged on 2/19/26 at 12:15 PM the findings above, which did not meet agency expectations or their policy referenced below.A review of agency policy titled Title “Volunteer Services” (Revised June 2019), revealed, “1. Hospice will document active and ongoing efforts to recruit and retain volunteers.”

Based on interview and record review, the agency failed to ensure volunteers provided administrative and/or direct patient care services in an amount that equals at least 5% of the total patient care hours of all paid hospice employees and contract staff for 2 of 2 records reviewed (P-20, P-23), resulting in a lack of cost savings for the agency. --- An interview was conducted 2/18/26 at 12:48 PM with the Volunteer Coordinator (Staff-C). When asked to provide documentation of the volunteer hours for 2024 and 2025, Staff-C provided a document titled, “Volunteer Hours Log”. The review of the document noted it did not provide the direct patient care hours needed to determine the annual volunteer level of activity. Staff-C explained that direct patient care hours are tracked by the agency’s administrator (Staff-A).At 1:45 PM Staff-A was requested to provide documentation for the last 2 years of direct patient care hours, and the cost savings generated by the volunteer program. Staff-A provided printed documents, “2024 Volunteer Summary" and "2025 Volunteer Summary”. The review of these documents noted they did not include the annual direct patient care hours. Staff-A was queried about the missing hours. He then provided verbally, 2024 direct patient care hours- 19,981.61 and 2025 direct patient care hours- 26,773.50.On 2/19/26 two patient records (P-20 and P-23) were randomly selected from the “Volunteer Hours Log” for review of volunteer service documentation. The volunteer listed for P-20 and P-23 is employed by the agency (Staff-I) as a Nurse Practitioner.Patient #20 (P-20) was listed to have received volunteer services on 5/9/24. The review of records revealed no documentation that the patient received volunteer services on 5/9/24 by Staff-I. Further review of the record found that Staff-I documented a “Patient Communication Log” dated 6/13/24 with a visit “Type: Provider Note and Subject: NP Palliative Visit”. The record was void of documented volunteer services performed by Staff-I or an assigned alternate volunteer.Patient #23 (P-23) was listed to have received volunteer services on 9/20/24 and 9/25/24. The record review revealed that Staff-I documented a “Patient Communication Log” dated 9/25/24 with a visit “Type: Provider Note and Subject: NP Palliative Visit”. The record was void of documented volunteer services performed by Staff-I or an assigned alternate volunteer.On 2/19/26 at 12:15 PM the above findings were reviewed and acknowledged by Staff-A who explained that the patients listed as seen by Staff-I, on the "Volunteer Hours Log", (10.5 total hours), were in palliative care at that time, and volunteer services were not provided. The adjusted 2024 volunteer hours total is 338. The final review of all the documents concluded that the volunteer level of activity to be less than 5% for 2024 and 2025. See calculation below.                                                      2024                   2025Volunteer hours                           338                    150Direct care hours                        19,981                26,774Volunteer level of activity          1.69%                 0.56% Staff-A acknowledged the findings above, which did not meet agency expectations or their policy referenced below.A review of agency policy titled “Volunteer Services” (Revised June 2019), revealed, “Hospice will document the cost savings achieved through the use of volunteers and will include:… Hospice will document and maintain a volunteer staff sufficient to provide  administrative and/or direct patient care in an amount that, at a minimum, equals 5% of the total patient care hours of all paid hospice employees and contract staff… “

Based on record review and interview, the Hospice agency failed to provide MSW (Master of Social Work) services as required in 1 (P-8) of 16 records reviewed, resulting in the potential for poor patient outcomes due to a lack of MSW evaluations, assessments and interventions. Findings include: --- Patient #8 (P-8): was admitted to this hospice agency on 1/2/26, with a terminal diagnosis of sarcopenia (progressive loss of muscle, strength and function) and heart disease. Record review on 2/19/26 found no evidence that the Hospice agency had provided MSW services since admission (over 6 weeks). Further the plan of care for P-8 was void of any evidence of acknowledgement of MSW services. Subsequently no evaluations or interventions by MSW services were found in the medical record.This finding was reviewed with and acknowledged by the Administrator (Staff-A) and Clinical Director (Staff-B) during an interview on 2/19/26 at 1:35 PM. Both further acknowledged this did not meet agency expectations and was unacceptable.

Based on record review and interview, the hospice failed to ensure that each patient's record included appropriate clinical assessment notes to document the care provided in 1 (P-16) of 16 records reviewed, resulting in a lack of documented care. Findings include: --- Patient #16’s (P-16) Start of Care (SOC) was dated 10/24/25. The Plan of Care (POC) identified a terminal diagnosis of Nasal Cancer. During record review on 2/18/26, it was noted that the POC ordered Skilled Nursing (SN) at a frequency of weekly visits and 5 PRN (as needed). The SN visit completed on 12/30/25 stated, “Pain intensity: 5. Pain Duration: Blank. Patient’s acceptable pain level: 3. Medication last taken: Blank. Pain description: Blank.” The SN visit completed on 2/17/26, “Pain intensity: 5. Pain Duration: Blank. Patient’s acceptable pain level: Blank. Medication last taken: Blank. Pain description: Blank.” The agency failed to assess and document the pain assessment notes per policy.A review of the agency policy occurred on 2/19/26 titled "Patient Record Content" (Revised June 2019). The policy states, “Procedure: 1. Hospice will initiate and maintain an individual and accurate patient record containing past and current findings for each patient receiving care in compliance with all federal/state laws and regulations. The record must contain correct clinical information that is available to the patient’s attending physician and Hospice staff… 3. Each patient record will contain the following as applicable: Conclusions of patient medication monitoring.”The Administrator (Staff-A) and Director of Clinical Services (Staff-B) reviewed and acknowledged the findings listed above in an interview on 2/19/26 at 2:00 pm.

Based on record review and interview, the agency failed to ensure all clinical record entries were completed and properly authenticated in 1 (P-14) of 16 patients reviewed, resulting in an incomplete clinical record. Findings include: --- Patient #14 (P-14) was admitted to this hospice agency on 10/22/25 with the terminal diagnosis of colon cancer. During record review on 2/18/26, it was determined a social work noted dated 10/29/25 was void of most information and failed to include a signature of the clinician. It was also noted the note was listed as “In Use” and “Not Signed” instead of “Completed.”A review of agency policy titled “Patient Record Content” (revised June 2019) revealed “All entries must be legible, clear, complete and appropriately authenticated.”During an interview with the director of clinical services (Staff B) on 2/19/26 at 11:00 AM, Staff B was asked about the status of this note. Staff B stated it appeared that the social worker did not complete this note, however, he was unsure of why and acknowledged the findings. The administrator (Staff A) was also present during the interview and acknowledged the findings.

Based on record review and interview, the hospice failed to send a copy of the patient's discharge summary to the receiving hospice agency for 1 (P-15) of 1 record reviewed in which the patient transferred to another hospice agency, resulting in the potential lack of continuity of care for this patient. Findings include: --- Patient #15’s (P-15) Start of Care (SOC) was dated 1/30/25. The Plan of Care (POC) identified a terminal diagnosis of Nonalcoholic Steatohepatitis. During record review on 2/17/26, it was noted that the patient was transferred to another hospice agency on 2/18/25. There was no documented evidence that a discharge summary was sent to the receiving hospice agency. The agency failed to verify that the discharge summary was sent to the accepting hospice agency.  A review of the agency policy occurred on 2/19/26 titled "Discharge Summary" (Revised June 2019 2017). The policy states, "Procedure: 1. If the care of a patient is transferred to another Medicare/Medicaid-certified facility, Hospice will forward, to the receiving facility; a copy of: The Hospice discharge summary...”The Administrator (Staff-A) and Director of Clinical Services (Staff-B) reviewed and acknowledged the findings listed above in an interview on 2/19/26 at 2:00 pm.

Based on record review and interview, the agency failed to ensure a discharge summary was forwarded to the patient’s attending physician following a revocation of services for 1 (P-14) of 2 patients with live discharges reviewed, resulting in the potential for poor continuity of care. Findings include: --- Patient #14 (P-14) was admitted to this hospice agency on 10/22/25 with the terminal diagnosis of colon cancer. During record review on 2/18/26, it was determined P-14 revoked his hospice benefit on 11/18/25 due to being admitted to the hospital for treatment. Upon further review of the record, it was determined there was no discharge summary written for this patient.During an interview with the director of clinical services (Staff B) on 2/19/16 at 11:00 AM, Staff B was asked about the discharge summary for P-14. Staff B stated this was a was a strange case and that P-14 ended up being re-admitted a couple of days later. However, Staff B agreed there should have been a discharge summary written and sent to the physician following the revocation.A review of agency policy titled “Discharge Summary” (revised June 2019) revealed, “If a patient revokes the election of Hospice care, or is discharged from Hospice, Hospice will forward to the patient’s attending physician, a copy of: The Hospice discharge summary; The patient’s record, if requested.”Staff B and the administrator (Staff A) acknowledged the findings at the time of interview.

Based on record review and interview, the hospice failed to document a discharge summary that included a summary of the patient's course of care in 1 (P-15) of 2 discharge records, resulting in a lack of information provided to the receiving hospice agency. Findings include: --- Patient #15’s (P-15) Start of Care (SOC) was dated 1/30/25. The Plan of Care (POC) identified a terminal diagnosis of Nonalcoholic Steatohepatitis. During record review on 2/17/26, it was noted that the patient was transferred to another hospice agency on 2/18/25. The Skilled Nurse (SN) completed a Hospice Discharge on 2/18/25. There was no documented discharge summary. The hospice agency failed to ensure the discharge summary compiled the patient's course of care, including treatments, symptoms, and pain management.A review of the agency policy occurred on 2/19/26 titled "Discharge Summary" (Revised June 2019 2017). The policy states, "Procedure: 3. The Hospice discharge summary will include: A summary of the patient’s stay including treatments, symptoms and pain management...” The Administrator (Staff-A) and Director of Clinical Services (Staff-B) reviewed and acknowledged the findings listed above in an interview on 2/19/26 at 2:00 pm.

Based on record review and interview, the agency failed to ensure hospice aide met the required qualifications in 1 (Staff H) of 3 hospice aide reviewed, resulting in the potential for unqualified delivery of services. Findings include: --- During review of personnel files on 2/18/26 at 1:30 PM, the director of clinical services (Staff B) was asked to provide evidence of hospice aide training for Staff H. Upon review of the files, it was determined Staff H did not have a registration number through the Michigan Department of Licensing and Regulatory Affairs (LARA). At 1:40 PM, the administrator (Staff A) was asked for evidence of Staff H’s initial aide training and Staff A stated “she has done her competencies” with the agency upon hire, however, he did not have evidence of her initial 75 hours of training, including 16 hours of classroom time. During an interview on 2/19/26 at 10:05 AM, Staff A was asked how he verified she was qualified as an aide when Staff H applied to this agency. Staff A stated it was based on her previous work history and that she completed her competencies upon hire. Staff A was unable to provide evidence Staff H met the required personnel qualifications for a hospice aide. Staff A acknowledged the findings at the time of interview.

Based on record review and interview, the agency failed to ensure nursing services included physical assessments to monitor the patient and ensure the nursing needs were met in 2 (P-1 and P-3) of 3 records reviewed, resulting in the potential for unmet care needs. Findings include: --- Patient #3 (P-3) was admitted to this hospice agency on 6/23/25 with the terminal diagnosis of a malignant neoplasm of the ascending colon (colon cancer). P-3 had additional diagnoses of type II diabetes mellitus, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF).During record review on 9/12/25, it was determined the following sections of the comprehensive assessment were left blank by skilled nursing on 6/23/25: pain location, heart sounds, edema (swelling), weight, blood pressure, pulse, temperature, respirations, oxygen saturation, and lung sounds.A review of agency policy titled “Initial Assessment/Comprehensive Assessment” (revised June 2019) revealed, “The initial assessment includes the patient’s immediate physical, psychosocial, emotional and spiritual status related to the terminal illness and related conditions. The initial assessment gathers essential information necessary to begin the plan of care and provide the immediate necessary care and services.” Additionally, the policy indicated, “6. The comprehensive assessment will include data elements that allow for measurement of outcomes. Hospice will measure and document data in the same way for all patients. The data elements will take into consideration aspects of care related to Hospice and palliation.”The skilled nursing assessment failed to establish baseline measurements for multiple systems to effectively monitor changes in the patient’s status. During an interview with the Director of Clinical Services (DCS #1) on 9/12/25 at 12:01 PM, DCS #1 was asked about the agency expectation regarding these sections of the comprehensive assessment. DSC #1 stated these sections should be filled out by the skilled nurse to establish a baseline to monitor changes in the patient’s status. DCS #1 acknowledged the findings at the time of interview. (Patient #1) P-1's start of care was 6/19/25 with a terminal diagnosis of Stage 4 Lung Cancer.  The Plan of Care ordered Skilled Nursing (SN), Hospice Aide and Medical Social Work (MSW) services to be provided.  On 9/11/25 at 12:15 p.m., the clinical record review revealed the following: The section of the Initial Assessment, completed by the Registered Nurse, dated 6/19/25, titled Principal Diagnosis Criteria/Cancer diagnosis was left blank.  The questions, "When does usually pain starts? [sic] and how long does it last? were left blank. The Medication Status-Medication Regiment review was left blank.  The SN visit note dated 6/24/25 was void of an assessment of P-1's vital signs (blood pressure, temperature).The SN visit note dated 7/1/25 was void of an assessment of P-1's blood pressure and temperature.The SN visit note dated 7/8/25 was void of an assessment of P-1's blood pressure and temperature.  On 9/12/25 at 9:23 a.m., during an interview, the Registered Nurse (RN #1) was queried regarding her process of assessment of patients during home visits and reported, "I assess their pain and if it's at an acceptable level. If they are due for their pain medications, I administer it.  I assess lungs bowels, edema, anxiety, sleep and eating habits and I ask if they have any questions or concerns before I leave.  I also check on their supplies."  When asked if she assesses the patient's vital signs, RN #1 responded, "We don't always do blood pressure. I do pulse check, O2 and listen to the lungs."  When asked if the agency's policy was to only check the areas mentioned, RN #1 responded, "I don't know if there is a specific policy, but we check heart rate.  I only check their blood pressure if they complain of pounding."  RN #1 made no mention of the patient's temperature.  On 9/12/25 at 10:14 a.m., the Director of Clinical Services (DCS #1) was queried about the expectation to assess the patient's vital signs and reported, "I do the initial assessments. I ask families if they want a set of vitals. Most times I do. Most times they don't want that. Lung sounds, heart sounds, pain, head to toe assessment.  We only check the vitals if the patient wants them."  When asked if it is the expectation that the patient's vital signs are assessed in accordance with professional standards of practice, DCS #1 responded, "It is my expectation that all vital signs be assessed, unless the patient declines." The agency failed to ensure the Registered Nurse thoroughly assessed the patient's health status to determine the presence of a decline and to provide subsequent relief of the presented symptoms.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 5 (40%) records reviewed it was revealed that the agency did not ensure the drug profile contained the patient's current prescription and over the counter (OTC) drugs. Document 2: Policy 9 11.10.01 titled Medication Profile (revised June 2019) read, 3. "All prescribed medications, over the counter medications and home remedies will be documented on the medication profile as well as the date medication prescribed and dose frequency and route." Clinical Record 1: The Election of Benefits form was dated 08/14/2023. The drug profile documented 'MSO4 20mg/ml .25ml q4hr prn PO/SL, Haldol 2mg/ml 1ml q4hr prn PO/SL, Acetaminophen Ex Str 500mg 1 tablet PO q6hr prn.' there were no prn qualifiers. Clinical Record 5: The Election of Benefits form was dated 08/22/2023. The drug profile read 'Tums 500 mg oral chewable 1250mg 2tablets PO prn and Menthol external gel 4% apply to area q6hr prn,' with no prn qualifiers. During interview on 10/16/2023, the Administrator stated that the prn qualifiers were missing and had since been corrected.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) records reviewed it was revealed that the agency did not ensure that the comprehensive assessment included an initial bereavement assessment. Clinical Record 1: The Election of Benefits form was dated 08/14/2023. The initial bereavement assessment was documented as completed on 10/16/2023. Clinical Record 4: The Election of Benefits form was dated 09/14/2023. At the time of the review on 10/16/223 there was no documented evidence of a completed bereavement assessment. During interview on 10/16/2023, the Administrator reviewed the associated charts and stated that the initial bereavement assessments were not present.

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, and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 3 of 5 (60%) records reviewed it was revealed that the agency did not ensure visits were provided as ordered on the patient's plan of care. Clinical Record 1: The Election of Benefits form was dated 08/14/2023. The original plan of care dated 08/14/2023 and the updated plans of care dated 08/30/2023, and 09/13/2023 included a frequency of 1xweek for the social worker. There was no evidence of social work visits from the visit dated 08/23/2023 through the visit dated 10/04/2023 nor an explanation of why the services were not provided as ordered. Clinical Record 2: The Election of Benefits form was dated 09/21/2023. The 09/21/2023 plan of care included a frequency of 1xweek for the social worker. There was no evidence of a social work visit the week of 09/24/2023 nor an explanation of why the service was not provided as ordered. Clinical Record 4: The Election of Benefits form was dated 09/14/2023. The 09/14/2023 plan of care included a frequency of 1xweek for the social worker. There was no evidence of social work visits from the visit dated 09/14/2023 through the visit dated 10/09/2023 nor an explanation of why the service was not provided as ordered. During interview on 10/16/2023, the Administrator reviewed the associated records and stated the missed visit documentation had since been entered.

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 5 (80%) records reviewed it was revealed that the agency did not ensure that the hospice plan of care included interventions and goals for services provided. Document 3: Agency Policy 9.12.1 titled IDG Care Planning Process read 8. "An individualized plan of care is developed for each patient, The plan of care reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments. The plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions including interventions to manage pain and other symptoms, a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs, measurable outcomes anticipated from implementing and coordinating the plan of care." Clinical Record 1: The Election of Benefits form was dated 08/14/2023. The plan of care dated 08/14/2023 did not contain interventions and goals for the social worker or chaplain. The visit frequency read "MSW 1xweek for psychosocial and SC qoweek for spiritual support." Clinical Record 3: The Election of Benefits form was dated 09/23/2023. The plan of care dated 09/23/2023 did not contain interventions and goals for the social worker or chaplain. The visit frequency read 'MSW 1xweek for psychosocial and SC 1xweek, for spiritual support'. Clinical Record 4: The Election of Benefits form was dated 09/14/2023. The plan of care dated 09/14/2023 did not contain interventions and goals for the chaplain with a visit frequency that read 'SC 1xweek,' for spiritual support. Clinical Record 5: The Election of Benefits form was dated 08/22/2023. The plan of care dated 08/22/2023 did not contain interventions and goals for the aide or chaplain. The visit frequency read 'Aide 2xweek for ADL assistance and SC 1xweek, for spiritual support.' During interview on 10/16/2023, the Administrator reviewed the associated records and stated the interventions and goals had inadvertently been omitted and had since been corrected.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 5 (40%) records reviewed it was revealed that the agency did not ensure that the hospice plan of care included a detailed statement of the scope and frequency of services ordered. Document 3: Agency Policy 9.12.1 titled IDG Care Planning Process read, 8." An individualized plan of care is developed for each patient. The plan of care reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments. The plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions including interventions to manage pain and other symptoms, a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs, measurable outcomes anticipated from implementing and coordinating the plan of care." Clinical Record 2: The Election of Benefits form was dated 09/21/2023. The 09/21/2023 hospice plan of care read 'SC prn.' Clinical Record 5: The Election of Benefits form was dated 08/22/2023/2023. The 08/22/2023 hospice plan of care read 'SC prn.' During interview on 10/16/2023, the Administrator stated that the prn frequency had been entered in error and had since been corrected.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 5 of 5 (100%) records reviewed it was revealed that the agency did not ensure the hospice aide provided services as ordered. Clinical Record 1: The Election of Benefits form was dated 08/14/2023. The aide care plan created by the registered nurse on 08/14/2023 included a task frequency of every visit for shampoo and shower. The aide visit notes dated 09/21/2023, 09/26/2023, 09/28/2023, 10/03/2023 and 10/05/2023 did not document the completion of a shampoo and shower nor was an explanation of why the tasks were not completed documented. Clinical Record 2: The Election of Benefits form was dated 09/21/2023. The aide care plan created by the registered nurse on 09/21/2023 included a task frequency of every visit for hair care, shampoo, skin care, dressing, feeding assist and shower. The aide visit notes dated 10/02/2023 and 10/09/2023 did not document the completion of the tasks and did not document an explanation of why the tasks were not completed as ordered. Clinical Record 3: The Election of Benefits form was dated 09/23/2023. The aide care plan created by the registered nurse on 09/23/2023 included a task frequency of every visit for hair care, feeding assist and make bed. The aide visit note dated 10/09/2023 did not document the completion of the nor an explanation of why the tasks were not completed. Clinical Record 4: The Election of Benefits was dated 09/23/2023. The hospice plan of care dated 09/14/2023 included an aide frequency of 2xweek. There was no evidence of aide visits for the week of 09/14/2023 nor an explanation of why the services were not provided as ordered. Clinical Record 5: The Election of Benefits was dated 08/22/2023. The hospice plan of care dated 08/22/2023 included an aide visit frequency of 2xweek. There was evidence of one aide visit for the week of 08/22/2023 dated 08/24/2023 and no documented explanation of why the services were not provided as ordered. During interview on 10/16/2023, the Administrator reviewed the associated records and stated that staffing changes had been made and remedial education was needed and would be provided.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties. This standard was not met as evidenced by interview and personnel record review. In 1 of 5 (20%) records reviewed it was revealed that the agency did not ensure the completion of an initial orientation program for all newly hired employees. Personnel Record 5: This employee's date of hire was 8/14/2023. There was no documented evidence of a completed orientation program checklist at the time of the review on 10/16/2023. During interview on10/16/2023, the Administrator stated the checklist was missing and it would be added to the employee's file post review.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by document review, clinical record review and interview. In 5 of 5 (100%) records reviewed it was revealed that the agency did not ensure all entries in the patient record were appropriately authenticated and dated by the person performing the care/service. Document 4: Agency policy 3.2.2 2. read "Professional identification: a. In addition to a signature, all personnel are required to include their professional title and credentials when signing documents." Clinical Record 1: The Election of Benefits form was dated 08/14/2023. The social work visit documentation dated 08/14/2023 through 10/10/2023, the chaplain visit documentation dated 08/14/2023 through 10/09/2023 and the aide visit documentation dated 09/15/2023 through 10/12/2023 did not contain credentials with the associated signature and date. Clinical Record 2: The Election of Benefits form was dated 09/21/2023. The chaplain visit documentation dated 09/21/2023 and the aide visit documentation dated 10/02/2023 through 10/16/2023 did not contain credentials with the associated signature and date. Clinical Record 3: The Election of Benefits form was dated 09/23/2023. The social work visit documentation dated 09/23/2023 through 10/13/2023, the chaplain visit documentation dated 09/23/2023 through 10/02/2023 and the aide visit documentation dated 09/25/2023 through 10/09/2023 did not contain credentials with the associated signature and date. Clinical Record 4: The Election of Benefits form was dated 09/14/2023. The social work visit documentation dated 09/14/2023 through 10/09/2023, the chaplain visit documentation dated 09/14/2023 through 10/06/2023 and the aide visit documentation dated 09/18/2023 through 10/11/2023 did not contain credentials with the associated signature and date. Clinical Record 5: The Election of Benefits form was dated 08/22/2023. The chaplain visit documentation dated 08/22/2023 through 10/11/2023 and the aide visit documentation dated 08/24/2023 through 10/13/2023 did not contain credentials with the associated signature and date. During interview on 10/16/2023, the Administrator reviewed the associated records and stated signatures were incomplete and had since been corrected.

It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. The plan: Is based on and includes a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served. This standard was not met as evidenced by document review and interview. Review of the organization's Emergency Preparedness Program documents revealed the agency did not ensure that an annual and every 2-year review of the hazard vulnerability risk assessment was conducted, as described in agency policy. The agency policy stated the vulnerability risk assessment was to be completed annually, and the most recent hazard vulnerability risk assessment was documented as completed on 1/1/2020, with an update to the hazard vulnerability analysis made on 3/26/2020. Agency policy, "2.1.1 Emergency Operations Plan and Policies (revised June 2019)", stated in part: "The emergency preparedness program includes but is not limited to, the following elements. Hospice has developed and maintains an emergency preparedness plan and policies that are reviewed and updated at least annually. The plans based on and includes a documented, facility-based (Hospice), and community-based risk assessment, utilizing an all-hazards approach. Includes strategies for addressing emergency events identified by the risk assessment. Agency policy, "2.2.1 Hospice Facility-Based and Community-Based Risk Assessment Policy (revised June 2019)", stated in part: "(1). Hazard Vulnerability Analysis (HVA) will be conducted and evaluated annually. The HVA will include both facility-based and community-based risk assessments." In a joint document review and interview conducted with the Administrator on 2/24/2023, it was confirmed the agency did not follow their policy for updating the hazard vulnerability risk assessment as part of its emergency preparedness program. A documentation review of the Emergency Preparedness Program revealed the agency did not ensure a written comprehensive emergency preparedness program demonstrating compliance with its own policies and procedures. The agency did not provide an up-to-date annual hazard vulnerability risk assessment. The agency policy stated the vulnerability risk assessment is to be completed annually. The most recent hazard vulnerability risk assessment was completed on 1/1/2020. In addition, there was an update to the hazard vulnerability analysis dated 3/26/2020.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 3 (100%) home visits it was revealed that the agency did not ensure complete and accurate drug profiles were updated and completed per the agency's policy and procedure. Agency policy, "11.10.1, revised June 2019, Medication Profile", stated in part: "The initial assessment performed by the Registered Nurse (RN) includes a review of all medications that the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. The RN checks all medications a patient may be taking and documents on the medication profile. All prescribed medications, over-the-counter (OTC) medications, and home remedies will be documented on the medication profile as well as: date medication was prescribed, and the dose, frequency, and route. The nurse will add all new/changed medications to the medication profile. Discontinued (D/C) medications will also be documented and dated. The medication profile will be reviewed every home visit, updated as changes occur and reviewed by the IDG. The RN or LPN reviews the medications with the patient on an ongoing basis. The original medication record will be filed in the patient's record. A copy may be placed in the patient's home." Clinical Record 1: During a home visit (Home Visit 2), medication reconciliation was performed between the agency's medication list and the resident's assisted living facility medication list. The agency's medication list had one order for: "Docusate Sodium 100 mg. Take half (1/2) tab per day/hold with loose stool". The resident's assisted living facility medication list contained two physician orders for Docusate Sodium that did not match the hospice orders: "Docusate Sodium 100 mg. Give 50 mg by mouth as needed (PRN) for constipation, may give one half (1/2) tablet in the evening as needed; and Docusate Sodium 100 mg give 50 mg one time a day for constipation. Give one half (1/2) tab. Hold if loose stool". Clinical Record 2: During a home visit (Home Visit 1). The hospice's medication profile included "Acetaminophen 650 mg suppository take one (1) suppository every 6 hours as needed for mild pain or fever; and Biscolax rectal suppository 10 (ten) mg. Take one (1) suppository daily as needed (PRN) for no BM greater than three (3) days.” The resident's assisted living facility medication list did not contain any physician orders for Acetaminophen and Biscolax. The hospice medication profile included, “Clonazepam half (0.5) mg taken one (1) tablet once a day at bedtime”, and the assisted living facility medication list order stated, “Clonazepam (half) 0.5 mg take one (1) tablet by mouth nightly as needed (PRN) for anxiety”. The hospice agency order stated, “Haldol 2mg/1 ml 0.25 ml every 6 hours as needed for agitation”, and the resident assisted living facility medication list did not contain an order for the medication Haldol. The hospice agency order stated, “Hyoscyamine sulfate 0.125 mg oral disintegrating tablet. Take one (1) to two (2) tablets every four (4) hours as needed for secretions”. The resident facility medication list did not contain a physician's order for Hyoscyamine sulfate. The resident assisted living facility medication list contained a physician's order for “Albuterol 0.083%; inhale one (1) vial via NEB (nebulizer) every six (6) hours as needed (PRN) for wheezing or shortness of breath”. The hospice agency medication list did not contain a physician order for the medication Albuterol sulfate. Clinical Record 3: During the home visit (Home Visit 3), review of the agency’s medication list revealed it contained a physician order for “Milk of Magnesia thirty (30) ml. Take thirty (30) ml daily as needed (PRN) for constipation”. The resident assisted living facility medication list stated, “Milk of Magnesia suspension take thirty (30) ml by mouth twice daily as needed (PRN) for constipation”. The resident assisted living facility medication record list contained a physician order for Calcium 500 mg. Take one (1) tablet by mouth daily. The hospice agency medication list did not contain a physician's order for calcium. The resident assisted living facility medication list contained the medication, “Triamcinolone 0.5% cream 15 GM. Apply topically to the affected area twice (2X's) daily as needed (PRN)”. The hospice agency medication list did not contain a physician order for the medication Triamcinolone cream 0.5%. The resident assisted living facility medication list contained a physician's order for the medication, “Vitamin C 500-100MG tablet. Take one (1) tablet by mouth once daily”. The hospice agency medication list did not contain an order for Vitamin C. A joint record review and interview with the Director of Clinical Services on 2/23/2-22 confirmed the hospice agency medication lists did not match the resident facility medication lists and did not include a medication regimen review of all the medications the patients were receiving.

It is required that 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; and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 11 (9%) records reviewed the agency did not ensure visits were provided as ordered on the patient's plan of care. Clinical Record 8: The record for this patient with the hospice benefit election date of 2/11/2022 with a diagnosis of Unspecified Dementia with Behaviors, revealed a plan of care dated 5/26/2022, for the certification period of 5/26/2022 through 7/24/2022, contained orders for nursing visits to be provided as "one (1) time every fourteen (14) days". The RN completed the initial visit for assessment on 5/26/2022, and there was no documentation of another RN visit completed on 6/9/22, which would have been 14 days after the first visit. The next RN visit was documented as completed on 6/16/2022, which was 21 days after the first RN visit, and 7 days past due. There was no documentation in the clinical record to identify or explain the missed RN visit. In a joint record review and interview with the Nurse Practitioner on 2/24/2023, it was confirmed there was a missed RN visit the week of 6/5/2022 through 6/11/2022 without any documentation to identify or explain the missed visit. The Nurse Practitioner also confirmed there was no documentation of notification of the missed visit to the interdisciplinary group.

It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes: Education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by document review, interview and personnel record review. In 2 of 8 (25%) personnel records reviewed with a hire date after 4/19/2020 revealed the agency did not ensure all staff were provided education on infection prevention at the time of hire and annually, per agency policy. Agency policy, "4.14.1 (revised June 2019)", stated in part: "(1) The employee will be responsible for attending in-service programs and maintaining compliance with the requirements for his/her position. (2) Certain in-service programs are determined by Hospice to be mandatory initially and annually for all staff. These include but are not limited to: OSHA bloodborne pathogens (infection control), TB risk program, hazardous materials in the workplace (Right-to-Know Program). Agency policy, "5.2 (revised June 2019)", stated on page 2: "(3) The infection Control Plan establishes and implements policies and procedures for controlling employee exposure to fluids, tissues, and other potentially infectious material considered being sources of HIV or HBV infection or other bloodborne pathogens. These policies/procedures include: Establishes a training program upon employment which educates employees in the infection control program." Personnel Record 3: The record for this employee with a hire date of 8/10/2021 did not have documentation of completed annual infection prevention training for the year 2022. Personnel Record 7: The record for this employee with a hire date of 10/26/2020 did not have documentation of completed annual infection prevention training for the years 2021 and 2022. In an interview and joint record review with the Director of Clinical Services, it was confirmed the agency did not have documentation of completed infection prevention training.

It is required that licensed professionals participate in hospice sponsored in-service training. This standard was not met as evidenced by interview and personnel record review. In 2 of 6 (33%) records reviewed of licensed professional employees, it was revealed the agency did not ensure all staff participated in mandatory in-service training per agency policy. Agency policy, "4.14.1 (revised June 2019)", stated in part: "(1) The employee will be responsible for attending in-service programs and maintaining compliance with the requirements for his/her position. (2) Certain in-service programs are determined by Hospice to be mandatory initially and annually for all staff. These include but are not limited to OSHA bloodborne pathogens (infection control), TB risk program, hazardous materials in the workplace (Right-to-Know Program). Personnel Record 5: The record for this employee with a hire date of 11/18/2019 revealed there was no documented evidence of the completion of any annual in-service training, as described in agency policy, in 2021 and 2022. Personnel Record 6: The record for this employee with a hire date of 4/2/2020 revealed there was no documented evidence of the completion of any annual in-service training, as described in agency policy, in 2021 and 2022. In a joint record review and interview with the Director of Clinical Services on 2/23/2023, it was confirmed the agency did not have any evidence or documentation that the staff had completed annual in-service training since the date of hire.

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group; included in the plan of care; Permitted to be performed under state law and regulation; and consistent with the hospice aide training. This standard was not met as evidenced by document review and interview. In 4 of 8 (50%) records reviewed where hospice aide services were accepted, it was revealed the aide visits and services were not consistently provided in accordance with the documented plan of care. Clinical Record 1: The hospice aide visit frequency order for the eighth (8th) benefit period of 10/30/2022 through 12/28/2022 described hospice aide visits to be provided two times (2X's) weekly. During the week of 12/18/2022 through 12/24/2022 evidence revealed the patient received one hospice aide visit on 12/20/2022 and there was no additional evidence that the second visit was made that week, and no documentation that described the reason for a missed visit. During the ninth (9th) benefit period of 12/29/2022 through 2/26/2023, hospice aide visits were ordered as two times (2X's weekly). During the week of 1/1/2023 through 1/7/2023 evidence revealed the patient received one hospice aide visit on 1/03/2022 and there was no additional evidence that the second visit was made that week, and no documentation that described the reason for a missed visit. Clinical Record 2: The patient elected hospice on 1/16/2023 with a diagnosis of Huntington's Disease. The aide care plan dated 1/16/2023 listed two types of baths, a shower, per patient preference and a bed bath, per patient preference. The hospice aide documented both types of baths were completed during the visit on 1/16/2023. Clinical Record 4: The patient elected hospice on 10/21/2022 with a diagnosis of pancreatic disorder. The aide care plan dated 11/22/2022 listed two types of baths, a shower per patient's preference, and a sponge bath up in a chair per patient preference. The hospice aide documented that both types of baths were completed during the visit on 11/22/2022. Clinical Record 7: The patient elected hospice on 11/20/2022, with a hospice diagnosis of intrahepatic bile duct carcinoma, and was discharged on 11/12/2022. The aide care plan dated 11/20/2022 listed two types of baths, a partial bed bath per patient preference, and a complete bed bath per patient preference. The hospice aide documented that both types of baths were completed during the visit on 11/20/2022. In a joint record review and interview with the Director of Clinical Services on 2/23/2023, they confirmed the hospice aide visits were missed and documentation of bath types provided were not accordance with visits ordered and tasks assigned on the aide plans of care.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties. This standard was not met as evidenced by interview and personnel record review. In 2 of 8 (25%) records reviewed for employees with a hire date after 4/19/2020 it was revealed the agency did not provide or document the completion of an orientation program for all newly hired employees. Personnel Record 2: This employee was hired on 8/15/2022 and the record did not contain documented evidence of a completed orientation program checklist. Personnel Record 4: This employee was hired on 10/26/2022 and the record did not have documented evidence of a completed orientation program. The record did contain a copy of an orientation checklist dated 10/26/2022 however, the checklist was bland and did not reflect orientation topics completed. The document was missing signatures from the employee and the agency representative. In an interview and joint record review on 2/23/2023 with the Director of Clinical Services, it was confirmed the employees' records did not contain evidence of a completed orientation program.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: the most recent hospice plan of care; hospice election form and any advance directives; and names and contact information for hospice staff involved in the patient’s care. This standard was not met as evidenced by document review, interview and observation. In 3 of 3 (100%) home visits completed with patients who resided in a nursing facility, it was revealed the agency did not provide the facility with copies of all of the required hospice documents. Clinical Record 1: This patient with a hospice benefit election date of 7/7/2021 and a diagnosis of Dementia with Moderate Behaviors resided in an assisted living facility. Review of the facility record during a home visit observation revealed there was no documented evidence that the hospice provided the facility with a copy of the patient's hospice plan of care, including ordered medications, the hospice election form, and identification of the hospice attending physician. Clinical Record 2: This patient with a hospice benefit election date of 1/16/2023 and a diagnosis of Huntington's Disease resided in an assisted living facility. Review of the facility record during a home visit observation revealed there was no documented evidence that the hospice provided the facility with a copy of the patient's hospice plan of care, including ordered medications, the hospice election form, and identification of the hospice attending physician. Clinical Record 3: This patient with a hospice benefit election date of 1/11/2023 and a diagnosis of Senile Degeneration of the Brain resided in an assisted living facility. Review of the facility record during a home visit observation revealed there was no documented evidence that the hospice provided the facility with a copy of the patient's hospice plan of care, including ordered medications, the hospice election form, and identification of the hospice attending physician. In a joint record review and interview with the Director of Clinical Services on 2/23/2023, it was confirmed the agency did not provide the nursing facilities with the required hospice documentation. The Director of Clinical Services confirmed this was an issue the agency was aware of.

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 document review, interview and personnel record review. In 3 of 10 (30%) personnel records reviewed it revealed the agency did not adhere to their COVID-19 policy by ensuring documentation of the vaccination status of each employee. Agency policy, "5.20.1 Covid-19 Policy", stated in part: "Hospice will collect and review at least quarterly the results from non-vaccinated employees COVID tests. Hospice will collect and review at least annually the reasons given by employes licensed practitioners, students, trainees, volunteers, and individuals who provide care, treatment, or other services for the hospice and/or its patients under contract or by arrangement for declining the vaccine. All employees, regardless of clinical responsibility or patient contact, will be fully vaccinated within three (3) months of hire or have an approved exemption applicable by Federal Law. This includes both medical and religious exemptions. Those employees that have an approved exemption will test in the main office at a minimum of once a week. Testing forms will be kept in the main office and tracked quarterly with infection control data aggregation. Those employees that do not meet these criteria within three (3) months of hire will receive a written warning, and an action plan will be created for the employee to complete the vaccine series or exemption. If the employee fails to meet the action plan, the employee will be terminated for non-compliance". Personnel Record 1: The record for this employee with a hire date of 8/20/2019 did not contain documented evidence of the receipt of any COVID-19 vaccine. The personnel record contained a request letter for religious exemption however, the record contained no evidence of the agency approving or denying the employee's religious exemption request. There was no evidence of written warnings or action plans in the personnel record, and no documented evidence of the employee performing weekly COVID-19 tests filed in the record or the weekly COVID-19 test log. An interview and joint record review with the Administrator conducted on 2/23/2022 confirmed a religious exemption was requested but evidence was missing to confirm the religious exemption was approved or denied by the agency. The Administrator did confirm the agency did not have any record of the employee performing weekly COVID-19 testing and confirmed there was no evidence of a written warning or action plan. Personnel Record 5: The record for this employee with a hire date of 11/18/2019 did not contain documented evidence of the receipt of any COVID-19 vaccine. The personnel record did not contain evidence of a request for letter for a religious or other exemption, and there was no evidence of written warnings or action plans in the personnel record, and no documented evidence of the employee performing weekly COVID-19 tests filed in the record or the weekly COVID-19 test log. Personnel Record 6: The record for this employee with a hire date of 4/2/2020 did not contain documented evidence of the receipt of any COVID-19 vaccine. The personnel record did not contain evidence of a request for letter for a religious or other exemption, and there was no evidence of written warnings or action plans in the personnel record, and no documented evidence of the employee performing weekly COVID-19 tests filed in the record or the weekly COVID-19 test log. An interview and joint record review with the Director of Clinical Services on 2/23/2020 confirmed that Records 5 and 6 were missing proof of COVID-19 vaccine or exemption status. The interview also confirmed there were no written warnings or action plans in place the agency did not have evidence of weekly COVID-19 testing.