Every finding on record at Infinity Care Services, Inc.

Observed in Record Review. In 1 of 9 active patient records reviewed, it was noted the organization failed to ensure that the written plan of care was based on measurable patient-centered goals with defined time frames. For example, in the record for HOSRRHV#3, the set goal oral intake within 1 month was not measurable. This finding was discussed and validated by the Administrator and DPCS.

Observed in Record Review. In 3 of 9 active patient records reviewed, it was noted the organization had failed to ensure that the plan of care includes all services needed for the palliation and management of the terminal illness and related conditions, including the drugs necessary to meet the needs of the patient. For example in HOSRRHV#1, it was noted in the patient's record, there were 2 PRN pain medications ordered, such as : Acetaminophen Suppository 650 mg rectally every 4-6 hours PRN for pain/fever and Morphine Sulfate oral Suspension 20 mg/ml0.25 ml every hour as needed for pain or sob, however, the order was incomplete as it did not include a clear parameters specifying which medication to administer according to the patient's reported pain scale. Additionally, during the home visit of HOSRRHV#2, staff at the boarding home reported that the patient's pain typically ranged from 7-8 on the pain scale and that Acetaminophen 650 mg (1 tablet) was being administered. Review of the medication profile again revealed that the PRN orders for Tylenol and Morphine did not include clear parameters to guide staff on which medication to administer according to the patient's reported pain level. Also noted in HOSRRNHV#5, multiple PRN pain medications, such as Acetaminophen 500 mg 2 tabs every 6 hrs. PRN for mild pain; Morphine Sulfate 0.25 ml every hour as needed for mild pain and Hydrocodone, Acetaminophen 10-300 mg every 6 hrs. for pain, and Lidocaine External patch up to 12 hours PRN for pain did not include clear parameters to guide staff on which medication to administer according to the patient's reported pain level. This finding was discussed and validated by the Administrator and DPCS.

Observed in Patient Home. In 1 of 9 active patient records reviewed, it was noted the organization failed to ensure that the care and services are provided in accordance with the plan of care. For example, during home visit of HOSRRHV#2, it was noted the patient's oxygen was set at 3 LPM, which differed from the 2 LPM flow rate specified in the plan of care. Staff at the boarding home reported that they typically turn on the oxygen but do not adjust the flow rate, as this is set by the hospice staff. This finding was discussed and validated by the Administrator and DPCS.

Observed in Record Review. In 1 of 7 active patient records reviewed with hospice Aide services, it was noted the organization failed to ensure that the hospice aide supervision is conducted no less frequently than every 14 days in order to assess the quality of care and services provided by the hospice aide. For example in record of HOSRRNHV#2 reviewed, the hospice nurse surveyor noted that the Hospice Aide supervision was 16 days late since the last sup visit conducted on 07/28/25. This finding was discussed with and validated by the Administrator and DPCS.

Observed in Patient Home. In 1 of 3 home visits conducted, it was noted the organization failed to ensure that the patient and the primary caregiver receive education provided as appropriate to their responsibilities for the care and services identified in the plan of care. For example in HOSRRHV#, during an interview with the patient's daughter, she stated that she had not received education on how to properly dispose of expired narcotics and other medications from the comfort kit. She further confirmed to the hospice surveyor that she had discarded them in the trash. This finding was discussed with the Administrator and DPCS.

Observed in Record Review. In 2 of 2 patient records reviewed, the organization did not honor the patient's right to revoke the hospice benefit. In the records of RR#5 and RR#6 the surveyor did not see revocation statements signed by patients prior to discharge as required by the Revocation of Hospice Benefit Election Policy. In addition, there was no documentation of attempts to get the statements signed. This was reviewed with the Administrator and Director of Patient Care Services.

Observed in Record Review. In 7 of 11 patient records reviewed, the organization failed to complete bereavement assessments as part of the initial comprehensive assessment in the hospice records of HV#1, HV#2, RR#1, RR#2, RR#3, RR#6, RR#8. This was reviewed with the Administrator and Director of Patient Care Services.

Observed in Record Review. In 5 of 6 patient records reviewed, the interdisciplinary group did not update the hospice comprehensive assessment every 15 days or less in the records of HV#2, RR#1, RR#2, and RR#3 because an RN did not visit patients that often, as required, even with the 1135 waiver allowing up to 21 days between visits. This was reviewed with the Administrator and Director of Patient Care Services.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization did not ensure that goals established in patients’ plans of care evaluated progress. In all hospice records reviewed it was found that while most goals were clear and concise, they did not include measurements to indicate progress or decline and were not revised when targeted completion dates were not met. This was reviewed with the Administrator and Director of Patient Care Services.

Observed in Record Review. In 11 of 11 patient records reviewed, the interdisciplinary group did not document its review and revision of patients’ plans of care during meetings because there was no template in the hospice EMR available for this purpose. This was reviewed with the Administrator and Director of Patient Care Services.

Observed in Patient Home. The organization did not implement the infection prevention and control activities it had planned. During HO HV#1 the surveyor observed that the CHHA donned gloves without performing hand hygiene. Later, she applied hand sanitizer gel but did not continue to rub her hands until dry. Rather, she waved her hands in the air to accelerate drying. Neither of these actions complied with the Hand Hygiene policy and accepted standards of practice. This was reviewed with the Administrator and Director of Patient Care Services.

Observed in Patient Home. In 1 of 3 home visits conducted, information regarding medications was not current. During the second hospice home visit, there were discrepancies found between the medications present in the home and the medication list. For example, Clonidine 0.1 mg tablet every 8 hours was not included on the medication list even though the prescription was filled a year ago. This was reviewed with the Administrator and Director of Patient Care Services.