Every finding on record at Hope Star Hospice Care Inc.

Upon patient record review 1 of 14 (Patient #2) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #2, Aide frequency 2x/week, first aide visit completed on 8/28/24, no evidence of RN supervisory visit completed until 11/19/24.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78 Volunteer hours are tracked. However, there is no evidence of cost savings report.

Upon patient client record review, 1 of 5 (Patient #3) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #3: The CTI benefit period does not have correct dates for 1st -90 days benefit. The start of care is 09-14-22. The agency benefit period reads 09-14-22 to 12-11-22. The 1st benefit should read 09-14-22 to 12-12-22. (90 days).