Every finding on record at Infinite Love Hospice Care LLC

Upon patient record review 7 of 11 (Patient #2, 3, 5, 7, 8, 9, 10) 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 #2 SOC 10/1/22 psychosocial performed 1/25/23 outside 5 day window. Patient #3 SOC 1/28/22 psychosocial performed 3/17/22 outside 5 day window. Patient #5 SOC 10/29/22 psychosocial performed 3/24/22 outside 5 day window. Patient #7 SOC 7/7/22 psychosocial performed 1/11/23 outside 5 day window. Patient #8 SOC 8/31/22 psychosocial performed 1/23/23 outside 5 day window. Patient #9 SOC 12/8/22 psychosocial performed 1/23/23 outside 5 day window. Patient #10 SOC 11/15/22 psychosocial performed 1/11/23 outside 5 day window.

Upon patient record review 1 of 11 (Patient #4) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #4 SOC 5/17/22 no evidence of spiritual or psychosocial assessment.

Upon client record review, 7 of 11 (Patient #2, 3, 4, 5, 6, 9, 10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2 POC dated1/3/23 ordered SN 1xwk, no notes completed from 1/4-present, no communication of missed visits, SW ordered 1xmo, no notes or visits present for January 2023, SC ordered 1x month, no notes or visits for January of 2023. Patient #3 POC dated 1/3/23 SN ordered 1xwk, no notes prepared from 1/3 to present, no communication of missed visits, MSW not ordered on the plan of care but visit performed 1/12/23. Patient #4 POC effective 5/14/22 SN ordered 3x week. No visits completed from 5/18 to 5/31/22 no communication for missed visits. Patient #5 POC effective 12/6/22 SN ordered 1xwk no visits completed from 12/6/22 to 12/22/22, no communication for missed visits. Patient #6 POC effective 1/21/23 SN ordered daily, no visits completed from 1/22/23 to present no communication for missed visits. Patient #9 POC effective 1/3/23 SN ordered 1x wk. No visits completed from 1/3/23 to present, no communication for missed visits. Patient #10 POC effective 1/3/23 SC ordered 1x mo, SC visited 1/4/23 and 1/23/23 with no order for additional visit.

Condition of Participation: Quality Assessment and Performance Improvement.

Upon observation, there was no evidence the program must use quality indicator data, including patient care, and other relevant data, in the design of the program.

Upon observation, there was no evidence the QAPI program uses quality indicator data, including patient care and other relevant data in the design of its program. The hospice must use the data collected to: • Monitor the effectiveness and safety of services and quality of care • Identify opportunities and priorities for improvement

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection.

Upon observation, there was no evidence the number and scope of distinct QAPI projects conducted annually is based on the needs of the hospice's population and internal organizational needs and must reflect the scope, complexity, and past performance of the hospice's services and operations.

Upon observation, there was no evidence the hospice documents what QAPI projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program.

Upon observation, there was no evidence the hospice's governing body is responsible for ensuring that the hospice-wide Quality Assessment and Performance Improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness.

Upon observation, there was no evidence licensed professionals participate in the hospice's QAPI program.

Upon observation, there was no evidence volunteers are used in day to day administrative and/or direct patient care roles. The agency has just started recruiting for volunteers in the last few months per their admission. They have not had more than one volunteer since 2019.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. The agency has just started recruiting for volunteers in the last few months per their admission. They have not had more than one volunteer since 2019.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78 There is no evidence of documentation of any volunteer data since 2019.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. There has been no documented activity of the governing body since 2020 particularly in regards to QAPI, annual review of policies and procedures and fiscal affairs of the hospice. No oversight of the hospice agency documented since 2020.