Every finding on record at Limitless Hospice, Inc.

Observed in Individual Tracer. In 1 of 10 patient records reviewed and confirmed by the Director of Patient Care Services. The plan of care had not been reflective of the assessment and assessed need. Example: During review of HOSv#1 . Documentation in patient assessment and reassessment had identified that patient had been dysphagic with swallowing difficulties. The poc or IDG updates had not identified a goal or interventions to address. the dysphagia. During home visit the patient had only been able to tolerate eating popsicles due to the dysphagia.

Observed in Record Review. In 1 of 10 patient records reviewed and confirmed by the Director of Patient Care Services. The patient assessment had not documented the patient's and family's spiritual needs: During the review of patient record HOSv#2 the Chaplain had been refused, however the initial assessment had not documented any spiritual support or patient beliefs.. The assessment of spiritual needs had been blank.

Observed in Individual Tracer. In 1 of 10 patient records reviewed and confirmed by the Director of Patient Care Services. All entries had not been authenticated according to Hospice policy and accepted standards of practice. Example: During review of HOSrr#1 The Chaplain had not signed the discharge plan of care/ summary.

Observed in Document Review. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  - §418.100 and 418.116.

Observed in Patient Home. During the home visit for HV1, the surveyor observed the nurse perform medication reconciliation. It was found that the medication profile was not consistent with the medications in the home. For example, the medication Nitroglycerin tablets on the medication profile was listed as 4 mg and the bottle in the home read 0.4mg. In addition, the patient had tramadol ordered 25mg, one tablet for moderate pain and 50mg, one tablet for severe pain. In the home there was one bottle that read, Tramadol, 50mg give 1/2 tab for moderate pain. These observations were discussed with the staff member performing the patient visit.

Observed in Document Review. It was determined that the organization, as required by Infection Control CoP 418.60(d)(3)(v) did not have a process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC as evidenced by the surveyor not being able to determine the validity of 6 of 14 COVID vaccination cards which had booster doses documented. This was discussed with the Administrator/DPCS designee Observed in Document Review. It was determined that the organization did not have a process, as required by Infection Control CoP 418.60(d)(3)(i), for ensuring all eligible staff have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or services for the organization’s patients as evidenced by the surveyor not being able to determine the validity of 6 of 14 COVID vaccination cards. This was discussed with the Administrator/DPCS designee Observed in Document Review. It was determined that the organization did not have a process, as required by Infection Control CoP 418.60(d)(3)(ii), for ensuring all eligible staff are fully vaccinated for COVID-19 as evidenced by a review of six of 14 COVID vaccination cards. The six cards in question, contained the following information: 1st dose administered- Lot number 027C20A from 1/8-2/25; Second dose administered- Lot number 042L20A from 2/9-3/26; Booster dose administered- Lot number 048C21A from 10/27-12/01. The cards in question belonged to the secretary/co-owner (it was validated this person does occasionally come into the office), both hospice physicians, the Administrator/DPCS, the Administrator/DPCS designee, and the Chaplain. In discussion with the Administrator/DPCS designee, she produced her vaccination registration information with QR code that included the dates of vaccination administration and that she had received the Pfizer vaccine. The card produced at survey with her name had different dates of administration, did not list the facility/organization administering the vaccine and had that it had been the Moderna vaccine. These observations were discussed with the Administrator/DPCS designee who agreed that the cards in question, including hers, could not be validated for compliance. Observed in Document Review. It was determined that the organization was not in compliance with the CMS COVID-19 staff vaccination requirements as evidenced by vaccination rates reported as 100% compliance at the time of survey but after review of the documentation compliance was 64%. In review of the documentation provided for 5 out of 14 COVID vaccination cards, the surveyor was unable to determine that the organization had met CMS requirement for 100% compliance. The 5 cards in question, all contained the following same information: 1st dose administered- Lot number 027C20A from 1/8-2/25; Second dose administered- Lot number 042L20A from 2/9-3/26; Booster dose administered- Lot number 048C21A from 10/27-12/01. So the lot numbers were the same for the 5 cards although given a different times in different locations. For example, the cards in question belonged to the secretary/co-owner (it was validated this person does occasionally come into the office), both hospice physicians, the Administrator/DPCS, the Administrator/DPCS designee, and the Chaplain. In discussion with the Administrator/DPCS designee, she produced her vaccination registration information on her phone which included a QR code and the dates of vaccination administration and that she had received the Pfizer vaccine. The card produced at survey with her name had different dates of administration, did not list the facility/organization administering the vaccine and had that it had been the Moderna vaccine. These observations were discussed with the Administrator/DPCS designee who agreed that the cards in question, including could not be validated for compliance.