Every finding on record at Star Hospice Care, Inc.

Upon client record review, 1 of 5 (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4: The IDG Care Plan identifies SN frequency as 1/month. SN services were provided 1/week.

Upon personnel record review, 1 of 12 (Personnel #5) 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.) (C) Shampoo, sink, tub, and bed Personnel #5: The hospice aide competency form utilized by the agency does not specify types of shampoo demonstrated, but only "shampoo"; therefore, the aide's competency for the various types of shampoos cannot be verified as documented.

Upon patient client record review, 2 of 5 (Patient #2, 5) 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 #2,5: On the Election Statement form, the effective date is left blank. The patient representative signature is consistent with SOC date. (The agency's NOMNC has the effective date identified properly, but not the Election Statement.)

Upon patient client record review, 1 of 5 (Patient # 1) 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. Patient #1: IDG Meeting notes/POC Update for 8/22 and 9/5/23 include documentation that: "During past 15 days, has patient experienced any changes in physical needs: yes. assistance with ADLs by hospice aide." In fact, the HA service was declined 8/20/23. In speaking with RN, she states this was typo.