Every finding on record at St. Teresa Hospice and Palliative Care, Inc.

Upon client record review, 1 of 14 (Patient #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: SC initial assessment conducted via telephone 2/15/24. No evidence found to indicate this was by pt/cg request nor is the performance of telephone visits allowed present on POC.

Upon patient client record review, 1 of 14 (Patient #1) 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: The patient elected to receive the addendum for Non-covered items on 12/27/23 at the time of admission. There is no evidence of this being furnished to the pt/cg.

Upon patient client record review, 4 of 14 (Patient #1, 3, 6, & 8) 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: There are no CHHA visits ordered per POC or visits made prior to 3/5/24. CHHA services were effective per POC 3/5/24. The RN conducted supervisory visits and specifically addresses CHHA services to include CHHA name on 1/10/24, 1/24/24, 2/7/24, 2/21/24, 3/6/24, and 4/3/24. Patient 3: RN initial assessment narrative states, "CHHA requested for bathing assistance." but "declined" is documented in the initial assessment under the frequency orders section of RN note. No CHHA services found on POC and services were not initiated. It is unclear whether the patient requested or declined services. Patient 6: Initial RN assessment (3/12/24) documents CHHA services declined. No CHHA services ordered on IPOC. 3/26/24 RN supervisory visit completed on CHHA specifically addressing CHHA services, utilizing CHHA name, and placing in narrative that CHHA provides punctual care. Patient 8: RN initial assessment (4/2/24) narrative states CHHA services to be twice weekly but "declined" is documented in the initial assessment under the frequency orders section of RN note. No CHHA services found on POC and services were not initiated. It is unclear whether the patient requested or declined services.