Every finding on record at Innovision Hospice Care, Inc.

Upon patient record review, 1 of 5 (Patient #2) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #2: The patient's hospice diagnosis was Senile Degeneration of the Brain, but there was no plan of care for Neuro Sensory issues.

Upon patient record review, 3 of 5 (Patient #3,4,5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #3: The medication profile indicated the patient was taking Scopolamine, Lorazepam, Olanzapine, Sertraline, Eliquis and Promethazine, but there were no signed orders from the physician. Patient #4: The medication profile indicated the patient was taking Loratadine, Tylenol PM, Duloxetine and Melatonin, but there were no signed physician orders for these medications. Patient #5: The medication profile indicated the patient was taking Vitamin D3, Advil, Albuterol, Folic Acid, Topiramate, and Montelukast, but there were no signed physician orders fir these medications.

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. There was no evidence the agency had specific QAPI plan(s) that specified their priorities based on above.

Upon observation, there was no evidence in the QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. There was no evidence the hospice surveilled the state or community to identify the risk of infections to the population they serve.

Upon personnel record review, 1 of 12 (Personnel #5) 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.) Personnel #5 competency did not include the following: Appropriate and safe techniques in personal hygiene and grooming that include- ·(B) Sponge bath 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.