Every finding on record at Waukegan Hospice LLC

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 01/08/26. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 01/08/26. Standard level deficiencies cited. Abbreviations: SOC: Start of Care POC/PsOC: Plan of Care SN: Skilled Nurse Pt.: Patient RN: Registered Nurse lbs: pounds CM: Centimeter(s)

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical records review and staff interviews, in 3 of 7 (Pts. # 4, 5 and 7) clinical records reviewed, the Agency failed to ensure that the Plans of care were followed. 3. Pt. # 7 was admitted to home health services on 11/22/24 with Diagnoses of Hypertensive Heart Disease with Heart Failure and Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 01/06/25. The clinical record included a POC for certification period 11/22/24 to 01/20/25 that required "Skilled Nurse to obtain weight every visit and notify RN/Physician of gain or loss of 3 lbs within 1 day or less 5 lbs within one week". The completed SN visit notes for the certification period lacked weight assessments. 4. Findings of Agency staff not providing services established in the PsOC were confirmed during interviews with the Executive on 01/07/26 between 11:30 am and 2:00pm. 2. Pt. #5 was admitted for home health services on 07/25/25 with the Diagnosis of, but not, limited to Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, and Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 01/06/26. The clinical record included the POC effective 11/22/25 that included, “…Skilled Nurse to obtain weight every visit and notify RN/Physician of weight gain of 3 lbs within 1 day or 5 lbs within one week… obtain ankle circumference every visit by measuring one inch above ankle’s bony prominence and notify RN/Physician of increase of 2 CM within 1 day…” The SN visit note dated 11/25/25 lacked documentation the SN obtained the patient’s weight. The SN visit note dated 12/22/25 lacked documentation the SN measured the right ankle. Findings include: 1. Pt. # 4 was admitted to home health services on 09/01/25 with the Diagnoses of Basal Cell Carcinoma and Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 01/05/26. The clinical record included a POC for certification period of 10/31/25 to 12/29/25, that required: “…. Skilled Nurse to obtain weight every visit and notify RN/Physician of weight gain of 3 lbs within 1 day or 5 lbs within one week….” The clinical record included SN visit notes dated 11/21/25, 11/28/25, 12/01/25 and 12/19/25 and lacked weight assessments as ordered.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, in 5 of 7 (Pts. #1, 2, 3, 4, 6 and 7) clinical records reviewed, the Agency failed to ensure that Pts. were assessed for Pneumonia vaccination status. Findings include: 1. During the entrance interview with the Executive Director on 01/05/26 at 9:00 AM, it was stated that the Pneumonia vaccination assessment for Pts. are completed at the Start of Care (SOC) and documented as part of the initial SOC assessment. 2. The following clinical records were reviewed from 01/05/26 to 01/07/26. The records lacked documentation of the pneumonia vaccination assessment: Pt. # 1 SOC (Start of Care) 10/23/25 Pt. # 2 SOC 12/22/25 Pt. # 3 SOC 12/23/25 Pt. # 4 SOC 09/01/25 Pt. # 6 SOC 08/26/25 Pt. # 7 SOC 11/22/24 3. During interviews with the Executive Director and Patient Care Manager on 01/07/26 at 11:30 AM and on 01/07/26 with the Executive Director between 1:13 PM and 2:45 PM, the Administrative team confirmed the above findings.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: Pt / Pts. = Patient / Patients PT = Physical Therapy SOC = Start of Care POC = Plan of Care

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: A. Based on review of clinical records and staff interview, it was determined that the Agency failed to ensure staff followed the Plan of Care. This was found in 3 of 7 (Pts. # 1, 5 and 7) clinical records reviewed. Findings include: 1.Pt. #1 SOC 03/17/21 Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 10/04/21 at 12:30 PM. The Plan of Care dated 07/10/22 required the PT to visit 1 time a week for 7 weeks. The PT failed to visit/ assess the patient during the week of 08/014/22 (week #6). The POC was not modified. 2.Pt. #5 SOC 08/29/22 Primary Diagnosis: Urinary Tract Infection, Site not Specified. The clinical record was reviewed on 10/05/22 at 11:30 AM. The Plan of Care dated 08/29/22 required the PT to visit 2 times a week for 4 weeks and 1 time a week for 5 weeks. The PT failed to visit/ assess the patient during the week of 09/18/22 (week #4). The POC was not modified. 3.Pt. #7 SOC 04/05/22 Primary Diagnosis: Chronic Obstructive Pulmonary Disease, Unspecified. The clinical record was reviewed on 10/04/22 at 1:00 PM. The Plan of Care dated 06/04/22 required the PT to visit 1 times a week for 8 weeks. The PT failed to visit/ assess the patient during the month of July (weeks 6-9). The POC was not modified. 4. The above findings were confirmed on 10/06/22 at 11:50 AM, during an interview with the Administrator.