Every finding on record at Starlyte Health and Palliative Care LLC

Upon patient record review, 1 of 15 (Patient #1) 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 #1: The Initial Bereavement Risk Assessment had not been completed by the Bereavement Coordinator or other staff.

Upon personnel record review, 1 of 13 (Personnel #10) 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 #10: The Aide did not have Normal Range of Motion and Positioning checked-off on the Initial/Annual Skills Competency.

Upon patient record review 5 of 15 (Patients #2, #7, #8, #13, #14) 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 Patient #2: The POC listed Aide visit frequency of, 2 X's per week (3/18/23). For first Benefit Week there was only 1 visit on 3/18/23. Patient #7: The POC listed Aide visit frequency of, 2 X's per week (3/25/23). For first Benefit Week there was only 1 visit on 3/25/23. Patient #8: The POC listed Aide visit frequency of, 2 X's per week (3/24/23). For first Benefit Week there were no visits the first benefit week. Patient #13: The POC listed Aide visit frequency of, 2 X's per week (10/21/23). For first Benefit Week there were no visits the first benefit week. Patient #14: The POC listed Aide visit frequency of, 2 X's per week (3/17/23). For first Benefit Week there was only 1 visit on 3/18/23.

Upon observation, there was no evidence the hospice governing body annual report and meeting minutes 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

Upon observation, there was no evidence the annual report documented the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The volunteer hours were not calculated.

Upon patient client record review, 2 of 15 (Patients #1, #12) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #1: The Election of Benefit (EOB) form does not match hospice start of care date. The EOB indicated effective date of 3/17/23. The hospice started services per patient record on 3/16/24. Patient #12: The Hospice Medicare Election statement does not provide BFCC-QIO contact information.

Upon patient client record review, 1 of 15 (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. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1: There was no evidence the Physician signature had been digitally signed on the form.

Upon observation, there was no evidence the hospice is in compliance with patient record retention from 2021 (initial survey). The alternate administrator was unable to locate patient records from 2021 initial survey.