Every finding on record at Infinite Hope Hospice Corp

Observed in Emergency Management Session. During the Emergency management session and plan review, the Hospice surveyor noted that there was no plan that included how they will inform state and local officials of any on-duty staff or patients that they are unable to contact. This was validated in a discussion with and observation by the Administrator and DCPS.

Observed in Individual Tracer. In 1 of 3 home visits conducted, During one of three home visits, the Hospice surveyor noted that the organization did not involve the family in developing the plan of care around medications. In HV1 the daughter stated that they had no comfort kit in the home and she had requested one multiple times during 10 months of services provided. There had been no explanation as to why a comfort kit had not been provided or whether it was needed. This was validated in a discussion with and observation by the Administrator and DCPS designee.

Observed in Individual Tracer. In 1 of 3 patient records reviewed, During the Competency session, in 1 of 3 home visit records, the Hospice surveyor noted that the organization did not complete an initial bereavement assessment as required. In HV2, a bereavement screening was done by the RN, however a scored bereavement assessment was not completed by the chaplain when he performed his spiritual assessment. This was validated in a discussion with and observation by the Administrator and DCPS designee.

Observed in Record Review. In 3 of 3 patient records reviewed, During the record review, in 3 of 3 home visits, the Hospice surveyor noted that the organization did not have measurable goals. For example, maintain optimal peripheral circulation; :maintain comfort during bowel incontinence; adequate food and fluids; patient will remain comfortable;optimum level of oxygen. In addition, the time frames specified were at the end of the certification period instead of the next IDT. This was validated in a discussion with and observation by the Administrator and DCPS.

Observed in Data Session. During the QAPI session, the Hospice surveyor observed that while the hospice had a quality plan in place, since it had not collected or analyzed significant data, it could not demonstrate an ongoing effective quality program. This was validated in a discussion with and observation by the Administrator and DCPS. Observed in Data Session. During the QAPI session, the Hospice surveyor observed that while the hospice had a quality plan and indicated data would be collected quarterly, no data had been collected. For example, for 4 quarters chart audit data was not collected or analyzed, pain in 48 hours audit data was not collected or analyzed, no patient satisfaction data had been collected or analyzed, personnel chart audit data was not collected or analyzed and monitoring of HIS data submission was not collected or analyzed. This was validated in a discussion with and observation by the Administrator and DCPS.

Observed in Individual Tracer. In 2 of 3 home visits conducted, In 2 of 3 home visits conducted, the Hospice surveyor noted that the organization did not follow it's policy on bag technique and equipment cleaning. During HV1, the nurse used a barrier but failed to have a clean and dirty section for his equipment and did not clean the equipment before placing it back in his bag. In HV 3, the nurse did not use a barrier and cleaned did not have an area of clean and dirty for his equipment. This was validated in a discussion with and observation by the Administrator and DCPS designee.

Observed in Infection Control System Tracer. During the Infection control session and plan review, the Hospice surveyor noted that there was no goal set for improving hand hygiene in the QAPI plan. This was validated in a discussion with and observation by the Administrator and DCPS. Observed in Infection Control System Tracer. During the Infection control session and plan review, the Hospice surveyor noted that there had been no ongoing surveillance of hand hygeine and no data collected. This was validated in a discussion with and observation by the Administrator and DCPS.

Observed in Leadership Session. During the QAPI session and plan review, the Hospice surveyor noted that the governing body failed to provide for the continuous quality assessment and performance improvement as evidenced by condition levels at 418.58 and 418.60. This was validated in a discussion with and observation by the Administrator and DPCS..

Observed in Individual Tracer. In 3 of 3 home visits conducted, In 3 of 3 home visits conducted, in HV1, 2 and 3, the Hospice surveyor noted that the organization did not have a documented emergency preparedness plan for each patient that is based on the patient’s priority level, is individualized to the patient’s needs, and is reviewed and confirmed with patients and family or caregivers. The emergency plan of care in the home only listed the triage level and had no other information. This was validated in a discussion with and observation by the Administrator.

Observed in HR File Review. In 5 of 8 licensed personnel files, During the Competency session, in 5 of 8 files, the Hospice surveyor noted that the organization did not validate licenses or certifications through the primary source on hire. For example, in the medical director file there was no license validation on the hire date of hire. The license was verified yesterday. In HR3, HR4, HR5, HR6 there was no verification on hire. All were validated yesterday. This was validated in a discussion with and observation by the Administrator and DCPS. Observed in HR File Review. In 2 of 2 MD files, During the Competency session, in 2 of 2 MD files, the Hospice surveyor noted that the organization did not not validate possession of a current DEA license. For example, in the medical director an alternate medical directors file, file there was no current DEA license on file. This was validated in a discussion with and observation by the Administrator and DCPS.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not assess and reassess its patients by conducting and documenting a patient-specific assessment that identifies the needs related to the management of the patient's condition and the severity of symptoms. During HV#1, the patient presented with three new wounds of the lower extremities. Upon assessment, no wound measurements were obtained by the RN. The organization's Wound Assessment & Documentation policy indicated wound measurements were to be completed/documented as part of the skilled nursing assessment of wounds. This was reviewed with the Leadership Team.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not provide patient education and training based on each patient's needs and caregiver's assigned responsibilities. During HV#1, it was noted the patient's caregivers did not receive training/information on the use, care, and management of the patient's bed side rails. Per organizational policy and procedure, the use of side rails was considered a restraint, with the need for patient/caregiver education. This was reviewed with the Leadership Team.

Observed in Record Review. In 3 of 3 live patient discharge records, the organization did not give information about the care, treatment, or services provided to other service providers. In RR#1, RR#2, and RR#3, the organization did not inform the attending physician of the availability of a discharge summary. This was reviewed with the Leadership Team. Observed in Record Review. In 1 of 3 live patient discharge records reviewed, the organization did not give information to other service providers upon discharge or transfer regarding care, treatment, or services provided to the patient. The hospice did not provide the receiving Medicare/Medicaid-certified facility with a copy of the hospice discharge summary. In RR#1, the patient's family requested revocation of hospice, as patient was hospitalized for treatment. A discharge summary was completed, but there was no documentation to support a copy of the discharge summary was provided to the receiving hospital. This was reviewed with the Leadership Team.