Every finding on record at Infinite Hospice, Inc

Based on a review of medical records, policy and procedure, and staff interview, the Department determined the administrator failed to ensure a patient or their representative is informed of the facility's policy on health care directives for (5) of (5) patients reviewed. This deficient practice poses the potential risk that a patient or their representative will not fully understand their rights before consenting to treatment (Patients #1, #2, #3, #4 and #5). --- A review of medical records on October 27, 2023 through October 30, 2023, revealed no documentation of the acknowledgment of the facility's policy on health care directives for Patients #1, #2, #3, #4, and #5. A request was made for this documentation but none was provided. A copy of the facility's policy on advance directives was requested. None was provided. Employee #1 confirmed during an interview conducted on October 30, 2023, that written information on the facility's policy for advance directed was not available and documentation that (5) of (5) patients received information on the facility's advance directive policy could not be provided.

Based on record review, observation and interview, it was determined that the hospice failed to meet the Condition of Participation for Initial and Comprehensive assessment of the patient as evidenced by the following references to standard level deficiencies: (L523) The hospice failed to ensure the hospice interdisciplinary group complete a comprehensive assessment no later than 5 calendar days after the election of hospice care. (L530) The hospice failed to review of all of the patient's prescription and over the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy as part of the the initial assessment. (L533) The hospice failed to update the comprehensive assessment by the interdisciplinary group in consideration with changes that had taken place since the initial assessment a patient. (L534) The hospice failed to ensure the comprehensive assessment included data elements that allow for measurement of outcomes. --- The cumulative effect of these systematic deficient practices resulted in the facility's failure to meet the requirement for Condition of Participation for Initial and Comprehensive Assessment of the Patient which can lead to the increased potential for care and services that do not meet the needs or the patient and undesired patient outcomes.

Based on record review and interviews, it was determined the hospice failed to ensure that hospice interdisciplinary group completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. The deficient practice poses a threat to the health and safety of patients when a patient's plan of care is delayed and all components of patient needs are not assessed appropriately and timely. --- A review of Infinite Hospice Policy No. 4-033.1, titled, " Physician Responsibility In Managing Hospice Patients", revealed, "... 2. Physician Responsibilities The physician has a responsibility to: ...C. Be available to respond to questions regarding patients. When the attending physician is not available, another physician who is familiar with the patient will be designated as the alternate coverage...". Review of Patient #1's medical record failed to reveal evidence that a comprehensive assessment was completed within 5 day following start of hospice care. Interview with Employee #1 confirmed that the medical director was out of the country from October 4, 2023 to October 26, 2023 and there was not an alternate medical director to complete the comprehensive assessment of newly admitted patients during this time.

Based on record review and interviews, it was determined the hospice failed to ensure that a patient's prescription and over the-counter drugs, herbal remedies and other alternative treatments were review at the time of the initial assessment. The deficient practice poses a threat to the health and safety of patients when established therapy does not promote the patients comfort level and sense of well-being based on the assessment of patient needs and desires. --- A copy of the facility policy on drug profile review and reconciliation was requested. None was provided. Review of Patient #1 medical record failed to contain evidence that prescription and over the-counter drugs, herbal remedies and other alternative treatments were review at the time of the initial assessment. Interview with Employee #1 confirmed that the medical director was out of the country from October 4, 2023 to October 26, 2023 and there was not an alternate medical director to review drug reconciliation of newly admitted patients during this time.

Based on record review and interviews, it was determined the hospice failed to ensure that the comprehensive assessment was updated based on changes in the condition of the patient since the initial assessment. The deficient practice poses a threat to the health and safety of patients when a change in condition is not assessed and documented preventing proper care to patients. --- Findings include: Review of Facility Policy No. 4-042.4 Procedure 5 revealed: "The comprehensive assessment is updated by the interdisciplinary group as frequently as the patient's condition requires but at a minimum every 15 days... The comprehensive assessment is updated by the interdisciplinary group as frequently as the patient's condition requires... C. If there has a been change in the patient's condition/status, then the comprehensive assessment must be updated..." A review of Patient # 6's medical record revealed progress noted dated October 5, 2023 which documented Patient #6 as "actively dying" and no doctor orders or plan of care updates were documented. In an interview conducted on 10/27/2023, with Employee #1, s/he confirmed that Patient #6's medical record did not contain evidence of an updated care plan. S/he further confirmed that the hospice medical director was out of the country during the expiration of Patient #6 and no alternate medical director was appointed or available to report changes in Patient #6's condition.

Based on record review and interviews, it was determined the hospice failed to ensure that the comprehensive assessment included data elements that allow for measurement of patient outcomes. The deficient practice poses a threat to the health and safety of patients when a patient outcomes are not measured and assessed to ensure continuous quality improvement. --- A review of INFINITE HOSPICE, INC Policy No. 4-079.1 titled Provision of Care and Record Management failed to reveal evidence that data elements for measuring patient outcomes were being collected and measured. Review of five (5) of five patient medical records failed to reveal documentation of data elements collected to measure patient outcomes. Interview with Employee #1 confirmed that patients outcomes were not being collected and measured.

Based on record review, observation and interviews, it was determined that the hospice failed to meet the requirement of the Conditions of Participation for IDG, Care Planning, Coordination of Services as evidenced by the following references to standard level deficiencies: L-0541 The hospice failed to ensure the interdisciplinary group included an individual who was qualified and competent to practice as a doctor of medicine or osteopathy. L-0545 The hospice failed to develop an individualized written plan of care for each patient. L-0554 The hospice failed to ensure that the interdisciplinary group maintains responsibility for directing, coordinating, and supervising the care and services provided including including medication orders for patients. --- The cumulative effect of these systematic deficient practices resulted in the facility's failure to meet the requirement for Condition of Participation for IDG, Care Planning, Coordination of Services, which poses a potential risk to the health and safety of patients when the hospice fails to assess and update patient care plans and coordinate services to meet the needs of patients.

Based on record review and interview, the Department determined the hospice failed to ensure the interdisciplinary group included an individual who was qualified and competent to practice as a doctor of medicine or osteopathy. This deficient practice poses a potential risk to health and safety of patients when patients admitted on to hospice do not receive the medical services under the direction of a qualified individual. --- Findings include: A review of hospice Policy No. 4-011.1 titled "Physician Services-Medical Director" revealed: "The hospice Medical Director will have overall responsibility for the medical component of the hospice program...The hospice Medical Director/hospice Team Physician (physician designee) will be either a part- or full-time employee of the hospice, or have a contract with the hospice outlining his/her responsibilities. The hospice Team Physician (physician designee) will be available whenever the hospice Medical Director is unable to perform his/her duties to illness or vacation, or upon request...Role and Responsibilities...The duties and responsibilities of the Medical Director will include...Acting as medical resource to the interdisciplinary group...Attending interdisciplinary group meetings...In conjunction with the attending physician and interdisciplinary group, reviewing and updating the plan of care every 15 days, or more frequently as needed." A review of hospice Policy No. 4-001.1 titled "Interdisciplinary Group Membership and Responsibilities" revealed: "The interdisciplinary group responsibilities include but are not limited to: A. Establishment of the plan of care for each patient... B. Participation in the periodic review and updating of the plan of care... C. Taking a proactive approach to develop/revising the plan of care." Review of facility record revealed Job Title/Position: Hospice Medical Director signed by Employee #4 on August 24, 2023. Further review of facility record revealed that Employee #4 was out of the country and unavailable to perform the duties of Hospice Medical Director from October 4, 2023 to October 26, 2023. The record failed to contain evidence that a hospice Team Physician (physician designee) was employed or contracted when Employee #4 was unavailable. Interview with Employee #1 confirmed that Employee #4 was unavailable from October 4, 2023 to October 26, 2023 and there was no alternate qualified individual to act as the medical resource for the interdisciplinary group to review and update plans of care between October 4, 2023 and October 26, 2023. Interview with Employee #2 confirmed that the hospice interdisciplinary group did not meet October 04, 2023 trough October 26, 2023 when Employee #4 was unavailable.

Based on record review and interview, it was determined the hospice failed to ensure a written plan of care was developed based an updated comprehensive assessment for a patient who was actively dying. This deficient practice poses a potential risk to the patient's health and safety when the plan of care is not updated to provide the necessary services for palliation and management of the patient's condition at the end of life. --- Findings include: Review of Infinite Hospice policy No. 4-001.1, titled "Interdisciplinary Group Membership and Responsibilities" revealed: "The interdisciplinary group responsibilities include...Participation in the periodic review and updating of the plan of care for each patient receiving hospice services...Taking a proactive approach to developing/revising the plan of care (POC) by planning ahead for anticipated patient changes and needs..." Review of Infinite Hospice policy No. 4-042.1, titled " Comprehensive Assessment" revealed: "...Procedure 5. The comprehensive assessment is updated by the interdisciplinary group as frequently as the patient's condition requires... C. If there has a been change in the patient's condition/status, then the comprehensive assessment must be updated...". Review of Patient #6's medical record revealed the assessment of patient by registered nurse on October 3, 2023 was described as "actively dying" and no updates were documented to the patient's plan of care. In an interview conducted on 10/27/2023, with Employee #1, s/he confirmed that Patient #6's medical record did not contain evidence of an updated plan of care as a result of the Medical Director being unavailable during the expiration of Patient #6 and no alternate qualified individual was available to update the plan of care.

Based on record review and interview, the hospice failed to ensure the interdisciplinary group directed and coordinated the the ordering of medications related to the hospice patient's terminal diagnosis. The deficient practice poses a threat to the health and safety of patients when medications ordered fail to promote the patients comfort level and sense of well-being based on the assessment of patient needs and desires. --- Findings include: A review of hospice Policy No. 4-001.1 titled "Interdisciplinary Group Membership and Responsibilities" revealed: "The interdisciplinary group responsibilities include but are not limited to: A. Establishment of the plan of care for each patient... B. Participation in the periodic review and updating of the plan of care...D. Provision or supervision of hospice care and services" A request for Infinite Hospice Medication Services policy was requested. Not received. A review of patient #1's medical record revealed no documentation that medication had been ordered. A review of patient #2's medical record revealed no documentation that medication had been ordered. A review of patient #3's medical record revealed no documentation that medication had been ordered. A review of patient #4's medical record revealed no documentation that medication had been ordered. A review of patient #5's medical record revealed no documentation that medication had been ordered. A review of patient #6's medical record revealed no documentation that medication had been ordered. In an interview conducted on October 27, 2023, with Employee #1, he/she confirmed that the medical records for patients #1, 2, 3, 4, 5, and 6 had no documentation of medication orders. No additional documentation could be provided.

Based on record review and interview, it was determined the hospice failed to have a quality assessment and performance improvement (QAPI) program that reflected the complexity of its organization and services involving all hospice services and focuses on indicators related to improved palliative outcomes as evidenced by: L-0561 The hospice failed to measure, analyze, and track quality indicators and other aspects of performance. L-0563 The hospice failed to use quality indicator data, including patient care, and other relevant data, in the design of its (QAPI) program. L-0576 The hospice failed to designated an individual(s) to operate the QAPI program. --- The cumulative effect of these systemic deficient practices resulted in the facility's failure to meet the requirement for Condition of Participation for Quality Assessment and Performance Improvement to ensure the provision of quality care and improve hospice performance.

Based on record review and interview, it was determined that the hospice has failed to implement a quality assessment and performance improvement program that is capable of showing measurable improvement in indicators related to improved palliative outcomes and hospice services. This deficiency poses a negative impact clinical performance and to patient health and safety. --- Findings include: A copy of the facility's policy on quality assessment and improvement (QAPI) program was requested. None was provided. Interview with Employee #1 on October 27, 2023 confirmed that there was no QAPI program at the facility and no QAPI coordinator or designee who had been assigned to operate a QAPI program for thehospice.

Based on record review and interview, it was determined that the hospice has failed to implement a quality assessment and performance improvement program that used quality indicator data, including patient care in the design of its program. This deficiency poses a negative impact clinical performance and to patient health and safety. --- Review of INFINITE HOSPICE, INC Policy No. 4-079.1 titled "Provision of Care and Record Management Clinical Record Review" revealed: "Each clinical record will be reviewed on an ongoing basis by the Clinical supervisor, Quality Assessment Performance Improvement (QAPI) Coordinator, Clinical Director, or designee for:...Procedure B. The established plan of care...Procedure C. Compliance with the established plan of care." Record review of Patient's #1-6 medical record confirmed that no clinical documentation was being notated in the QAPI section available A copy of the of the facility's quality indicator data was requested. No was provided. Interview with Employee #1 on October 27, 2023 confirmed that there was no QAPI program at the facility and no QAPI coordinator or designee who had been assigned to operate a QAPI program for the hospice. Interview with Employee #2 and 3 on October 30, 2023 confirmed that there was no QAPI program at the facility at the present time.

Based on facility policy, record review and interviews, it was determined that the facility has failed to designate a responsible party to ensure that there is a continuous and periodic collection and assessment of data for the improvement of the delivery of care and services provided by the hospice. --- Request made for the individuals designated to operate the quality assessment and performance improvement (QAPI) program. None were provided. Interview with Employee #1 on October 27, 2023 confirmed that there was no QAPI program at the facility and no QAPI coordinator or designee who had been assigned to operate a QAPI program for the hospice.

Based on document review, personnel records and interviews, it was determined that the hospice failed hospice infection control program must identify risks for the acquisition and transmission of infectious agents in all settings where patients reside. L-0579 The hospice failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases. L-0580 The hospice failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. L-0581 The hospice has failed to implement a plan to prevent infectious disease problems for the personnel and patients including the screening for infectious tuberculosis (TB). --- The cumulative effect of this systemic practice resulted in the failure of the hospice to meet the Condition of Participation for Infection Control.

Based on record review and interview, it was determined that the hospice failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases. This deficient practice poses the potential risk to health and safety of patients when infections and communicable diseases are spread amongst patients and staff of the hospice. --- A copy of the facility's policy regarding infection control was requested. Interview with Employee #1 confirmed that the hospice facility was using TB testing as the infection control program to measure, monitor and track infection control among employees. Review of personnel files revealed that TB testing was only documented in two (2) out of nine (9) employees in the personnel files. Interview with Employee #2 confirmed that there was no documentation of tracking the infection control.

Based on record review and interview, it was determined that the hospice failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. This deficiency poses a risk to the patients and families health and safety, as well as the staff that are not preventing the spread of infections and communicable diseases. --- A review of Infinite Hospice Policy No. 1-020.1, titled, "Personnel Record Contents", revealed, "...Procedure 2. The content of a separate file, which includes health information will contain: ... C. TB test documentation...". A review of employee files for Employee #4, #6, and #7 revealed no evidence of TB testing documentation. Review of all personnel records revealed only 2 of the 9 files contained proof of negative TB tests. Request for the QAPI monitoring of the facility's Infection Control Program was requested. Not received. In an interview conducted on 10/30/2023, with Employee #1, and Employee #2 confirmed that Employee files #4, 6, and 7 did not have evidence of TB testing documentation. No further documentation could be provided. In an interview with Employees #1 it was revealed that TB had been used as the QAPI infection control program, no documentation of measurements, documentation or tracking had been implemented.

Based on facility policy, document review, personnel records and interview, it was determined that the hospice has failed to implement a plan to prevent infectious disease problems for the personnel and patients. This deficient practice poses a risk the spread of infectious disease amongst the staff, family and patients of the hospice facility. --- A review of Infinite Hospice Policy No. 1-006.1, titled, " Selection/Hiring of Personnel", revealed, "... Hiring 1. A...9. A current physical and TB/chest X-Ray must be received prior to the first day ofemployment...". A review of Infinite Hospice Policy No. 1-020.1, titled, "Personnel Record Contents", revealed, "...Procedure 2. The content of a separate file, which includes health information will contain: ... C. TB test documentation...".A review of employee file #4 had no evidence of TB testing documentation.A review of employee file #6 had no evidence of TB testing documentation.A review of employee file #7 had no evidence of TB testing documentation.In an interview conducted on 10/30/2023, with Employee #1, he/she confirmed that Employee files #4, 6, and 7 did not have evidence of TB testing documentation. No further documentation could be provided.In an interview conducted on 10/30/2023, with Employee #2, he/she confirmed that Employee files #4, 6, and 7 did not have evidence of TB testing documentation. No further documentation could be provided. 1) In an interview with Employees #1 and 2 on 10/30/2023 it was revealed that an infection control program has not been implemented. Employee #2 confirmed the determination upon hiring was to require all employees having patient contact to have proof of a negative TB Mantoux test or chest x-ray. Review of all personnel records revealed only 2 of the 9 files contained proof of negative TB tests

Based on record review and interviews, it has been determined that the hospice failed to ensure qualified licensed professionals, whoprovide services to hospice patients participated in coordinating all aspects of the patients hospice care as evidenced by the failure to be in compliance with the standards found in this Condition of Participation. L585 The hospice failed to ensure licensed professionals actively participated in the coordination of all aspects of the patient's hospice care, in accordance with current professional standards and practice, including participating in ongoing interdisciplinary comprehensive assessments. L586 The hospice failed to ensure licensed professionals participated in the hospice's quality assessment and performance improvement program and hospice sponsored in-service training. --- The cumulative effect of these systematic deficient practices resulted in the facility's failure to meet the requirement for Condition of Participation for Licensed Professional Services, which poses a potential risk to the health and safety of patients when hospice care provided fails to meet the needs of the patient.

Based on facility policy, record review, and interview it was determined that the hospice failed to provide supervised assessment and competency based orientation. This deficiency poses a risk to the patients and the staff of injury and has a negative impact on healthcare outcome. --- Findings include: A review of Infinite Hospice Policy No. 3-002.1, titled, ";Competency Based Orientation", revealed, ";... Policy Hospice ensures that the competency of all personnel is assessed on hire, prior to providing care to hospice patients... A review of Employees files #4, #5, #6, #7, #8, and #9 revealed that no skills verification had been performed or documented. Interview with Employee #1 confirmed that s/he had done a verbal skills assessment only by signing the forms. Employee #1 confirmed in interview on October 30, 2023 that s/he has no clinical experience.

Based on facility policies and procedures, documents and interviews during the on-site survey of October 27, 2023 and October 30, 2023 it has been determined that the facility has failed to provide licensed professionals to participate in quality assessment and performance improvement programs and hospice in-service training. This deficiency in training and assessment poses a challenge in providing competent patient care and risks patient health and safety. --- Findings Include: A review of Infinite Hospice Policy No.1-026.1, titled, " Competency Assessment", revealed, "... The competence of all organization clinical personnel (employed, contract, or volunteer) will be assessed during orientation, during the probationary period, periodically throughout the course... Orientation and Probationary Period 1. As part of the orientation process, a preceptor/clinical supervisor will be assigned to each new person... 2. Using a Competency Skills Performance Checklist, and the Orientation Checklist, the preceptor/Clinical Supervisor will observe the new personnel performing the required skills and activities...". Training and in-service logs for training and evaluation purposes were asked for and not received. Preceptor assignment logs asked for, not received. Personnel record review revealed that Infection control and skills assessments were being evaluated by Employee #1 who has no healthcare or clinical training. Interview with Employee #1 and 2 on October 30, 2023 confirmed that Employee #1 has no clinical training and was doing the skills assessments for all employees.

Based on patient records review and interview, it was determined that the hospice failed to meet the requirement of the Conditions of Participation for Cores Services as evidenced by the following references to standard level deficiency: L-0590 The hospice failed to ensure the medical director and physician employees were responsible for the palliation and management of the terminal illness and conditions related to the terminal illness. --- The cumulative effect of this systematic deficient practices resulted in the facility's failure to meet the requirement for Condition of Participation for Core Services, which poses a potential risk to the health and safety of patient if patient do receive medical services as needed.

Based on facility policy, record review and interview during the on-site survey of October 27, 2023 and October 30, 2023 it has been determined that the facility has failed to provide physician services to the patients under hospice care for the facility. This deficient practice poses a risk to the patients and families health and safety. --- Findings include: A review of Infinite Hospice Policy No. 4-033.1, titled, " Physician Responsibility In Managing Hospice Patients", revealed, "... 2. Physician Responsibilities The physician has a responsibility to: ...C. Be available to respond to questions regarding patients. When the attending physician is not available, another physician who is familiar with the patient will be designated as the alternate coverage...". A review of Patient #3's medical record revealed no physician was available at the time of admission. A review of Patient #6's medical record revealed no physician was available at the time of admission. In an interview conducted on 10/27/2023, with Employee #1, s/he confirmed that the hospice's medical director was out of the country from 10/4/2023 to 10/22/2023. It was also confirmed that no Alternate Medical Director was designated/appointed during the aforementioned period Interview with Employee #1, 2 and 3 on October 30, 2023 confirmed that the facility had no Medical Director or Alternate Medical Director for the period of time from October 04, 2023 to October 26, 2023.

Based on the facility policies and procedures, patient records and interviews it was determined that the facility has failed to provide preceptors, document in-service training and supervisory visits for Hospice aides. This deficient practice poses a risk to the health and safety of patients and families receiving hospice care. --- A review of Infinite Hospice Policy No. 1-025.1, titled, "Competency Program", revealed, "... Procedure... 5. A preceptor will be assigned to each new staff member as part of the orientation process. The preceptor/supervisor will observe and deem proficient the indicated skills and core competencies...".5 Competency is reviewed by the Preceptor and Clinical Director and additional training and education... In an interview conducted on 10/27/2023, with Employee #1, s/he confirmed that Employee files # 6, 7 and 9 did not have evidence of in-service training documentation. No further documentation could be provided. In an interview conducted on 10/30/2023, with Employee #2, s/he confirmed that Employee files #6, 7 and 9 did not have evidence of in-service training documentation. No further documentation could be provided. Training and in-service logs for training and evaluation purposes were requested. Not received.

Based on patient medical records, and interviews, it has been determined that the facility has failed to meet the Condition of Participation for Medical Director as evidenced by the following standard level deficiency: L-0665 The hospice failed to ensure a physician designated by the hospice assumes the same responsibilities and obligations as the medical director when the medical director is not available. --- The cumulative effect of these systematic deficient practices resulted in the facility's failure to meet the requirement for Condition of Participation for Medical Director, which poses a potential risk to the health and safety of patients when the medical services provided by the hospice are not overseen by the medical director.

Based on facility policy, medical record review and interview, it was determined that the hospice failed to ensure that the needs of the patients and families were consistently met by the Medical Director. This deficient practice posed a risk to the health and safety when the medical component of the hospice services failed to meet the needs and desired outcomes of the patients and families. --- Findings include: A review of Infinite Hospice Policy No. 4-033.1, titled, " Physician Responsibility In Managing Hospice Patients", revealed, "... 2. Physician Responsibilities The physician has a responsibility to: ...C. Be available to respond to questions regarding patients. When the attending physician is not available, another physician who is familiar with the patient will be designated as the alternate coverage...". A review of Patient #3's medical record revealed no physician was available at the time of admission. A review of Patient #6's medical record revealed no physician was available at the time of admission. In an interview conducted on 10/27/2023, with Employee #1, s/he confirmed that the hospice's medical director was out of the country from 10/4/2023 to 10/22/2023. It was also confirmed that no Alternate Medical Director was designated/appointed during the aforementioned period Interview with Employee #1, #2 and #3 on October 30, 2023 confirmed that the facility had no Medical Director or Alternate Medical Director for the period of time from October 04, 2023 to October 26, 2023.

Based on record review and interview, it was determined that the hospice has failed retain patient medical records. This deficiency poses a risk compromising access to record for future patient care and undermines the patient privacy practice. --- Findings include: A review of Infinite Hospice Provision of Care and Record Management No. 4-096.1 titled "RECORD RETENTION" revealed the process and timeframes of retention of clinical, administrative, financial and personnel records. INFINITE HOSPICE INC.'s policy is that the clinical record shall be retained for six (6) years... Procedure 4. Closed (discharged records will be stored on premises for two(2) years. After two (2) years, the records will be properly labeled, boxed and stored off site in a secure storage facility. Request for five (5) of 5 patient medical records for discharged patients was requested. None were provided. Interview on October 30, 2023 with Employee #2 and 3 confirmed that the five (5) of 5 of patient files were missing and could not be located at the facility.

Based on the review of personnel files, payroll for the time period of October 03, 2023 to October 18, 2023 and onsite interviews it has been determined that the facility has failed to meet the personnel qualification requirements set forth to maintain a safeguard for patient safety. This deficiency poses a risk to patient care and to general public health interests. --- Findings include: A review of Policy No.1-006.2 titled INFINITE HOSPICE Personnel Administration "Selecting/Hiring Personnel" revealed that the organization will use a consistent, nondiscriminatory process for the selection of all personnel...Procedure 7 Other information obtained during the application process will include, but not limited to, social security number and driver's license, as applicable to job position... Procedure 14 New hires will complete the appropriate documentation forms such as withholding, Form I-9, etc. Personnel record review on October 30, 2023 revealed that Employee #2 did not use Federally required I-9, Social Security number, E-Verify Citizenship, and Immigration system to ensure the eligibility of Employee #5. Employee #5 did not have an application for employment or references. Interview with Employee #2 and #3 confirmed the missing tax and identification documentation in the personnel file. Employee #1 confirmed that Employee #5 called her own references for her job