Every finding on record at St. Mary's Hospice & Palliative Care, Inc.

Upon patient record review, 1 of 14 (Patient #13) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes 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. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #13, Patient Initial bereavement assessment was not completed.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1, Documentation on nursing note patient ambulates with walker. Walker was not documented on plan of care under DME.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1, LVN went in and out nursing bag without sanitizing hands prior to entering nursing bag. Patient #2, #3, LVN went into nursing bag and set up equipment prior to washing her hands.

Upon patient client record review, 6 of 14 (Patient #2,5,11,12,13,14) 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, 5, RN assessment was not signed by the RN that completed assessment instead signed by a different staff member. Patient #11, IDG note missing MD and MSW signature on 11/14/22,11/24/22, 12/8/22. Patient #12, Missing RN signature on Discharge summary. Patient #13, IDG note missing MD signature on 11/10/22, 11/24/22. Patient #14, IDG note on 6/9/22 missing RN and MSW signature.