Every finding on record at Trusted Angels Hospice Inc

Upon patient record review, 1 of 14 (Patient #12) 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. #12-Pain level discrepancy. SN records pain as 3/10 in Pain section of clinical note date 04/30/24. SN narrative documents pain at 4/10.

Upon client record review, 1 of 5 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 The POC dated 12-13-21 listed Spiritual Counseling (SC) visit frequency of 1 x per month. The SC did not visit patient in February as ordered.

Upon patient client record review, 1 of 5 (Patient #1) did not have evidence that each patient record contains a signed election statement in accordance with 418.24. Patient #1 The "Patient Notification of Hospice Non-Covered Items, Services and Drugs" does not have the initials in space provided on the form (only the date is filled in next to this area). The bottom of the form does have full and complete signatures identified.