Every finding on record at Infinite Life, Inc

Upon home visit review, 1 of 3 (Patient 2) did not have evidence the medications on the medication profile are consistent with the medications on the plan of care and what the patient/caregiver states they are taking. Patient 2 medication profile included "Benicar 40 mg tab 1 tab by mouth once daily". Benicar was in the home but not kept with the daily medications. Patient was able to locate the med in a drawer in the home after Surveyor review of current meds. Patient stated to Nurse, "I don't take this medication daily for a while now." Medication profile included "Gabapentin 100mg 1 tab by mouth 3 x daily" as of 3/21/24. Medication was not in the home and patient stated to Surveyor and Nurse, "I don't take this med anymore and has not in a while."

Upon patient client record review, 3 of 14 (Patient 2, 3 and 8) 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 2 IDG’s on 7/4/24 and 7/18/24 were attended by all required attendees evidenced by discipline documentation but only signed by RN and MD. SC and MSW did not sign and date their entries. Patient 3 IDG on 7/18/24 was attended by all required attendees evidenced by discipline documentation but only signed by RN, MSW and MD. SC did not sign and date their entry. Patient 8 IDG on 7/4/24 was attended by all required attendees evidenced by discipline documentation but only signed by RN and MD. SC and MSW did not sign and date their entries.