Every finding on record at Springfield Hospice Services Inc.

Upon personnel record review, 1 of 1 applicable (Personnel #8) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) Personnel #8: The HHA performed toileting and elimination tasks with a patient. This HHA did not have evidence in their employee file that competency was completed/observed prior to performing this task.

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 by agency. However, there is no evidence of cost savings report.

Upon patient client record review, 2 of 5 (Patients #2 and #4) 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 #2: The 1st-ninety-day benefit period did not have correct dates on CTI. The start of care is listed as 09/14/22. The agency benefit period reads 09/14/22 to 12/13/22. The 1st benefit should read 09/14/22 to 12/12/22 (90 days). Patient #4: The 1st-ninety-day benefit period did not have correct dates on CTI. The start of care is listed as 04/17/22. The agency benefit period reads 04/17/22 to 07/16/22. The 1st benefit should read 04/17/22 to 07/15/22 (90 days).