Every finding on record at Infinity Hospice and Palliative Care Inc

Upon patient record review 3 of 14 (Patient #1, 4, 9) 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 #1: Admitted/SOC 5/10/23. RN identified psychosocial distress rating as mild, and indicated visit needed. MSW initial assessment 6/21/23. Psychosocial components lacking from initial RN comprehensive assessment include: ability and style of expressing emotions, thoughts and needs; and feelings regarding loss and grief, response to previous loss, issues related to life closure as appropriate Patient #4 Admitted/SOC 8/30/23. Initial SC visit made 9/6/23. MSW visits declined. RN did not document spiritual distress rating. (blank). The missing spiritual assessment components include: Ÿ Ÿ Loneliness Despair Guilt Forgiveness Reconciliation, Inner strengths or weaknesses, as appropriate. MSW discipline declined. Psychosocial components lacking from initial RN comprehensive assessment include: ability and style of expressing emotions, thoughts and needs; and feelings regarding loss and grief, response to previous loss, issues related to life closure as appropriate Patient #9 Admitted/SOC 12/7/23. Initial SC visit declined. Missing spiritual components to initial comprehensive assessment include: Ÿ Ÿ Loneliness Despair Guilt Forgiveness Reconciliation Inner strengths or weaknesses, as appropriate. MSW initial visit made 12/15/23. Psychosocial components lacking from initial RN comprehensive assessment include: ability and style of expressing emotions, thoughts and needs; and feelings regarding loss and grief, response to previous loss, issues related to life closure as appropriate

Upon patient record review, 3 of 14 (Patient #1, 4, 9) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #1: No evidence of complete bereavement assessment. SOC 5/10/23. Initial Bereavement assessment not performed by MSW until 6/21/23. SN identifies "no" bereavement concerns, but did not answer if bereavement visit is or is not needed (blank). Patient #4: No evidence of complete bereavement assessment. SOC 8/30/23. MSW typically accountable for initial bereavement assessment, but MSW declined. SN identifies that patient has hx of grieving wife's 2021 death. But did not answer if bereavement visit is or is not needed. (blank). Patient #9: No evidence of complete bereavement assessment. SOC 12/7/23. Initial Bereavement assessment not performed by MSW until 12/15/23. SN identifies "no" bereavement concerns, but did not answer if bereavement visit is or is not needed (blank).

Upon patient record review, 2 of 14 (Patient #2,4) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #2: SOC 6/21/23. Initial IDG POC 6/21/23 and subsequent frequency of visit updates: MSW 1 time and then PRN. Patient #4: SOC 8/30/23. Initial IDG POC 8/30/23 and subsequent frequency of visit updates: SC 1 time and then prn.

Upon client record review, 4 of 14 (Patient #2, 3, 7, 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: SOC 6/21/23. There is initial MD order for MSW initial frequency of visits is MSW 1x and then PRN. Beginning in June, patient was seen monthly (June 21, July 24, Aug 16) until Sept. 15, 2023 note that daughter refused additional visits. Change reported in IDG, but documented frequency of visits continued to be MSW 1x/month and 1 prn per q2wk IDG POC updates (signed by physician). No MSW visits Oct, Nov, Dec. 2023. Patient #3: SOC 7/27/23. Initial MD order frequency for MSW and SC to be eval, monthly and 1 PRN. IDG POC updates (signed by MD) 8/9/23-12/27/23 Frequency of visits did not include freq for MSW and SC. MSW and SC disciplines both visited monthly July-Dec, 2023. Patient #7: SOC 10/27/23. Initial MD order frequency for MSW and SC to be eval, monthly and 1 PRN. IDG POC updates (signed by MD) thru 12/27/23 Visit frequencies did not include frequency for MSW or SC. MSW and SC disciplines both visited monthly Oct-Dec 2023. Patient #10: SOC 12/7/23. IDG POC frequency of visits 12/13/27, 12/27/23 (signed by MD): LVN 2/wk and 3 prn. RN 1/wk and 3 prn. SN Visits were provided 2/wk for December 2023, (while order SN frequency totals 3/wk).

Upon personnel record review, 1 of 15 (Personnel #6 ) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·(C) Shampoo, sink, tub, and bed ·The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #6: HA competency checklist utilized by agency generalized "shampoo" and does not specify requirement to validate competency in specific tasks of sink, tub, bed bah.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #1: The initial attending MD certification is not signed by the attending physician of choice, but by the Medical Director only.

Upon patient client record review, 2 of 14 (Patient #1, 2) 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 #1: SOC 5/10/23. Initial IDG 5/10/23 psychosocial comment "Patient was calm and MSW will provide support." 5/17/23 IDG psychosocial comment was "Patient has no changes at this time" and 5/31/23 "Patient has no changes at this time." 6/14/23 IDG psychosocial comment was "MSW will continue to provide support". Initial MSW visit was not until 6/21/23. Verified with leadership that comments documented in IDG psychosocial section are expected to be by social worker. Patient #2: SOC 6/21/23. Initial IDG note by SC 6/21 and 6/28/23 "No spiritual issues during this period. SC remains available as needed SC will continue to monitor spiritual needs. The patient and family feel well supported with current interventions." SC did not make initial visit until 7/3/23, as was initially declined.