Every finding on record at Infinite Hospice Care, Inc.

Observed in Individual Tracer. In 1 of 1 home visits conducted, HV1, the aide was observed to use the patients hand soap, rather than soap or hand sanitizer provided by the organization. This was not compliant with the organization's hand hygiene policy and validated by the Owner. Observed in Individual Tracer. In 1 of 1 home visits conducted, HV1, the aide placed the clinical bag directly on a plastic child's chair and then moved it to the bathroom and placed it directly on the toilet lid. The aide failed to place a barrier or clean either surface prior to placing the bag down. This was not compliant with the organization's Bag Technique Policy and validated by the Owner.

Observed in Record Review. In 1 of 11 patient records reviewed, the initial comprehensive assessment was not completed within five calendar days of the patient electing the hospice benefit. In RR#8, the surveyor noted that the spiritual assessment and initial bereavement assessment was completed on Day 6. This was confirmed by the Administrator/DPCS Designee.

Observed in Record Review. In 1 of 3 home visits conducted, the organization did not plan the patient's care. In HV#1 record review, the plan of care was not updated to meet the patient's needs. Patient declined aide services; however, the plan of care continued to reflect a visit frequency of 2 x week. This was confirmed by the Administrator/DPCS Designee.

Observed in Patient Home. In 1 of 3 home visits conducted, the surveyor noted that the patient was admitted on a prescription of 2-3 liters of 02 via nasal cannula continuously. As per the order, 2 LPM via nasal cannula for mild dyspnea with a respiration rate of 21-22 bpm to maintain O2 saturation above 90%. If not effective, may titrate up to 3 LPM based on the following parameters: 1) RR 21-25 cpm, give 2 LPM, 2) RR 26-25 cpm, give 3 LPM. During HV#1, the surveyor observed that patient was on 3.5 LPM. LVN did not check the rate. This was confirmed by the Administrator/DPCS Designee. Observed in Record Review. In 1 of 10 patient records reviewed, care was not provided according to the plan of care. In RR#9, the surveyor noted that the patient received one aide visit during the first week of December, even though the visit frequency is 2 x week. This was confirmed by the Administrator/DPCS Designee.

Observed in Patient Home. In 1 of 3 home visits conducted, all disciplines that provide care, treatment or services to patient did not collaborate in the care of the patient. In HV#1, the aide did not notify the registered nurse that the patient had declined aide services. This was confirmed by the Administrator/DPCS Designee.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not provide care, treatment, or services in accordance with orders or prescriptions, as required by law and regulation. In HV#1 record review, the aide failed to follow the aide care plan by not making visits as ordered. This was confirmed by the Administrator/DPCS Designee.

Observed in Record Review. In 1 of 10 patient records reviewed, the surveyor noted that staff were not supervised effectively. In RR#7, the aide was not supervised at least every 14 days. This was confirmed by the Administrator/DPCS Designee.

Observed in Record Review. In 1 of 10 patient records reviewed, the surveyor noted that staff were not supervised effectively. In RR#7, the aide was not supervised at least every 14 days. This was confirmed by the Administrator/DPCS Designee. Observed in Patient Home. In 1 of 3 home visits conducted, staff was not supervised effectively. Although the frequency of supervisory visits met the Standards, in HV#1 record review, the registered nurse did not identify that the aide was not providing services. This was confirmed by the Administrator/DPCS Designee.

Observed in Tracer Activities. Leaders did not review, approve, and manage the implementation of policies and procedures that guide and support patient care, treatment, or services: 418.76, 418.56, and 418.104. This was confirmed by the Administrator/DPCS Designee.

Observed in Record Review. In 1 of 11 patient records reviewed, Medical Director did not review clinical information or sign the initial certificate of terminal illness. In HV#3 record review, the surveyor noted that the Initial CTI from November 2022 and the subsequent CTI from January 2023 had not been signed and did not consider all of the required elements until survey. Both CTIs were completed and signed during survey. This was confirmed by the Administrator/DPCS Designee.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not maintain complete and accurate patient records. In HV#1 record review, the aide entered inaccurate documentation in the record as evidenced by aide continued to document care was provided even though aide services were declined. This was confirmed by the Administrator/DPCS Designee.

Observed in Patient Home. In 1 of 3 home visits conducted, the medication list was discovered to be inaccurate. In HV#2, the surveyor noted that the patient had Acetaminophen 325 mg tablets listed on the medication list; however, according to the caregiver the patient never received the medication. Surveyor also noted that the medication list had Tylenol PM listed in liquid form; however, the patient is taking tablets. This was validated with the clinician.

Observed in Record Review. In 1 of 11 patient records reviewed, entries in the patient record were not authenticated. In HV#3 record review, the surveyor noted that the initial Certification of Terminal Illness (CTI) revealed it had not been signed. CTI was incorrectly signed during survey because the EMR automatically prepopulates to the start of benefit period date. This was confirmed by the Administrator/DPCS Designee. Observed in Record Review. In 5 of 11 patient records reviewed, the surveyor observed that the IDG/POC had not been electronically signed by one or more of the IDG members. In HV#1, HV#2, and HV#3 records review, the surveyor noted that the medical social worker and the spiritual counselor had attended March 2023 team meeting, but had not signed IDG/updated POC electronically, nor on paper. In RR#9 and RR#10, the surveyor noted that the medical social worker had attended the meeting, but had not signed any of the IDG/updated POC electronically, nor on paper. This was confirmed by the Administrator/DPCS Designee. Observed in Record Review. In 1 of 11 patient records reviewed, entries in the patient record not authenticated. In RR#9, the surveyor noted that the discharge summary did not include a signature and title, or a secured computer entry by a unique identifier of a primary author who has reviewed and approved entry. This was confirmed by the Administrator/DPCS Designee.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to maintain the security and integrity of health information. In HV#3 record review, the Medical Director completed the CTI during survey. EMR system automatically defaulted the date to the beginning of the benefit period. In addition, the Medical Director did not follow the organization's Entries Into the Clinical Record- Policy No. 5-006.1, which states ...clinical notes dictated or written will be incorporated into the patient's heath record. This was confirmed by the Administrator/DPCS Designee.

Observed in Patient Home. In 1 of 3 patient records reviewed, the organization did not provide care, treatment, or services in accordance with orders or prescriptions, as required by law and regulation. In HV#1 record review, the surveyor noted that the aide failed to follow the aide care plan since November 2022 until March 2023. This was confirmed by the Administrator/DPCS Designee.