Every finding on record at Infinite Care Hospice Inc

Upon patient record review, 3 of 14 (Patient #6, 7, 8) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death.

Upon patient record review, 2 of 14 (Patient #7, 11) 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 #7 - No initial Bereavement assessment completed. (corrected on site) Patient #11 - Patient admitted 04/04/24, initial Bereavement assessment completed 04/30/24.

Upon patient record review, 1 of 14 (Patient #14) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #14 - RN completed assessment on 03/19/24 then again on 04/04/24 - 16 days between assessments.

Upon patient record review, 1 of 14 (Patient #5) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #5 - SN visit note on 04/22/24 documented "Foley catheter patent" but no assessment of urine or output. "wound care 2 x week" but no assessment of wounds or care. Facility changes suprapubic catheter monthly but not documentation when it was changed in April. SN visit note on 05/06/24 documented "Foley catheter patent" but no assessment of urine or output. "routine wound care" but no assessment of wounds.

Upon patient record review, 3 of 14 (Patient #9, 10, 11) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #9 - POC 04/29/24 MSW and SC visit frequency PRN. Patient #10 - POC dated 04/15/24 MSW and SC visit frequency PRN. Patient #11 - POC dated 04/04/24 MSW and SC visit frequency PRN.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #7 - IDG on 05/01/24 and 05/15/24 did not contain the nurses input or coordination.

Upon patient record review, 3 of 14 (Patient #7, 8, 12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #7 - POC dated 03/13/24 MSW made visit in April and May but no order for visits. Patient #8 - POC dated 04/05/24 MSW and SC visit frequency 1 x month but no visits documented in April or May. Patient #12 - POC dated 03/01/24 SC made visit on 05/14/24 but no order for visit.

Upon personnel record review, 1 of 17 (Personnel #7) 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.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #7 - initial competency did not have the task bed bath, shampoo in bed or oral hygiene performed by the aide with a patient prior to making visits independently.

Upon patient record review 3 of 14 (Patient #6, 7, 12) 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #6 - Aide visit frequency effective 03/17/24 - 3 x week - only 2 visits made week 7 without documentation reason visit was missed. Patient #7 - Aide visit frequency effective 03/17/24 - 3 x week - only 2 visits made week 6 and 10 without documentation reason visit was missed. Patient #12 - Aide visit frequency effective 03/06/24 - 3 x week - only 2 visits made week 1 without documentation reason visit was missed.

Upon patient record review 2 of 14 (Patient #6, 9) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #6 - Aide supervisory visit completed on 03/19/24 - next aide supervisory visit documented on 04/04/24 RN - 16 days. Patient #9 - Aide supervisory visit completed on 05/09/24 - next RN visit note 05/21/24 without documentation of Aide supervisory visit.

Upon patient record review, 1 of 14 (Patient #5) 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 #5 - SN visit note on 04/22/24 documented "Foley catheter patent" but no assessment of urine or output. "wound care 2 x week" but no assessment of wounds or care. Facility changes suprapubic catheter monthly but not documentation when it was changed in April. SN visit note on 05/06/24 documented "Foley catheter patent" but no assessment of urine or output. "routine wound care" but no assessment of wounds or documentation of wound care provided.

Upon patient record review, 1 of 14 (Patient #5) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #5 - POC dated 03/30/24 - Suprapubic catheter to be changed 1 x month did not have documented who is responsible for performing.