Every finding on record at Saint Maria Hospice Care, Inc

Upon patient record review, 10 of 14 (Patient #1,2,3,8,9,10,11,12,13,14) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #1,2,3,8,9,10,11,12,13,14 Missing documentation of election of attending physician.

Upon client record review, 1 of 14 (Patient #8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #8, MSW frequency 1x/month, no visit made the month of Feb 2023. LVN visit 1x/week, visits made 1/20/23/, 1/23/23.

Upon patient record review 2 of 14 (Patient #1,8) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1, Aide documented street clothes completed but was not on care plan, 3/25/23, 4/15/23, 5/20/23, 6/3/23, 6/10/23. Patient #8, Aide documented no BM on 1/20/23, which was not a direction on care plan. Aide documented on 12/10/22 patient was bed bound, bed low position, turn and reposition, this was not a direction on the care plan.

Upon patient client record review, 10 of 14 (Patient #1,2,3,8,9,10,11,12,13,14) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #1,2,3,8,9,10,11,12,13,14 Missing documentation of election of attending physician.

Upon patient client record review, 5 of 14 (Patient #1,2,8,10,11) 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 #1, SC frequency ordered as 1x/month, SC visit note on 3/11/23 documents within visit note patient declined, no missed visit documentation instead looks as a visit was completed and wasn't. Patient #2, LVN did not sign note on 6/12/23. Note closed out by admin. Patient #8, SC frequency 1x/month, visits on 11/13/22, 12/11/22, 2/10/23, 5/7/23 all declined. SC visits completed on 1/11/23 and 4/10/23. No missed visit documentation instead looks as visits were completed and they were not. Patient #10, SC frequency 1x/month, 3/11/23, 4/12/23, 5/11/23, 6/11/23, 7/10/23, 8/10/23 all documented as declined within visit note, no missed visit documentation instead looks as visits were completed and they were not. IDG notes, MD signature missing on 3/10/22, 4/26/22, 8/2/22, 8/30/22, 9/13/22. Patient #11, SC frequency 1x/month, SC visits on 4/2/23, 5/1/23, 6/2/23, 7/2/23, 8/1/23 all documented as declined visits within visit note, no missed visit documentation instead looks as visits were completed and they were not.