Every finding on record at Infinite Heart Hospice LLC

Upon patient record review 1 of 14 (Patient #3) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 3: The patient was admitted to hospice on 10/19/23. The spiritual care assessment was completed on 11/1/23.

Upon patient record review, 3 of 14 (Patient #4,#6,#10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 4:The medical record includes an entry on the medication profile upon admission of MiraLAX 17 grams po daily PRN. There is no evidence that the profile includes a type and amount of diluent for administration. The medical record includes an entry on the medication profile for oxygen with a strength of 5LPM and a dose of 2LPM. There is no evidence of the specific liter flow for oxygen delivery. COS Patient 6:The medical record includes an entry on the medication profile for oxygen with a strength of 5LPM and a dose of 2LPM. There is no evidence of the specific liter flow for oxygen delivery. COS Patient 10:The medical record includes an entry on the medication profile for oxygen to be delivered at 2-5 LPM via NC. There is no evidence of instructions for titration of oxygen. COS

Upon patient record review, 3 of 14 (Patient #4,#9,11) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 4:The medical record contains documentation on admission of a primary diagnosis of Cirrhosis of the Liver. There is no evidence of problems, goals and interventions on the plan of care for management of the primary diagnosis. COS Patient 9:The medical record contains documentation that the patient sustained a fall prior to admission on 2/1/24 resulting in fracture of patella. Upon admission, patient is bedbound with brace to immobilize patella. There is no evidence of problems, goals and interventions on the plan of care for mobility/musculoskeletal issues. COS Patient 11:Upon admission, medical record contains documentation on of imminence and transitioning. There is no evidence of an update to the plan of care with problems, goals and interventions related to the imminently dying patient. COS

Upon patient record review, 1 of 14 (Patient #4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 4:The medical record includes an order on the plan of care upon admission for MiraLAX 17 grams po daily PRN. There is no evidence that the order includes a type and amount of diluent for administration. COS

Upon patient record review, 1 of 14 (Patient #6) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 6: The medical record includes documentation that the patient has a history of seizures and a diagnosis of unknown seizure disorder. The aide plan of care did not include seizure precautions. COS