Every finding on record at Addus Hospice of Illinois

Based on a review of clinical records and staff interviews, for 1 of 4 (Pt. #1) records reviewed, the Agency failed to ensure the patient’s needs were met and skilled services were supervised by an RN. --- Findings Include: 1. Pt. #1 was admitted to Hospice on 11/20/25 with the diagnosis of Malignant Neoplasm of Prostate and discharged on 01/15/26. The clinical record was reviewed and included admission documentation of Pt. assessment of being alert and oriented x 4 and having the ability to safely self-administer medications. The Interdisciplinary Group (IDG) meeting minutes dated 01/04/26 included documentation that the IDG determined Pt. #1’s health declined and ordered increased visit frequencies for Skilled Nurse (SN) and Hospice Aide. On 01/07/26, Social Services conducted a joint visit with the Registered Nurse Case Manager and the Pt. to discuss the need for increased support. The Pt. was adamant about not being placed in a SNF. Per Social Services visit notes dated 01/09/26, the Pt. agreed to a 24-hour caregiver.  The RN visit note report included the following documentation: 01/12/26: “Pt. requires assistance with 5/6 ADLs and is a moderate assist from bed to chair. Pt is unsafe to be ambulating alone. Pt. is oriented but forgetful…Pt. appears very lethargic today…” 01/14/26: “Pt. lying in hospital bed, lethargic, confused and naked, Pt. immediately requested water and clothing upon arrival…Pt. seem to have intermittent confusion and is regularly misplacing his phone.  The patient’s hospital bed was unplugged as well, and the patient was not able to reposition in his bed all morning.  Pt. appears to be declining with each visit… Functional: Pt. required assistance with 5/6 ADLs and is a max assist, Pt. is unsafe to be ambulating alone. Pt. is barely able to hold himself upright while sitting on the side of the bed due to lack in trunk strength, should be supported with pillows. Unable to hold his head up and requires slight assistance to do so… confused and very forgetful… Pt. appears very lethargic today. Pt. is hypotensive: BP 88/32. Last visit BP was 98/48…” The IDG minutes dated 01/14/26 included the documentation, “it is not safe for Pt. to ambulate without assistance, and requires assistance with ADLs, extensive education provided to Pt., POA regarding need for 24/7 caregiver, but family repeatedly says they don’t have financial means to hire 24/7 caregivers, and Pt. still refusing SNF placement, also family purchased a camera in Pt.’s home to monitor Pt.’s activity.” The POA reported to the Hospice the Pt. #1 expired on 01/15/26 at an unknown time. The Hospice failed to provide the continuous care that the Pt. required as per assessment. The clinical record included documentation that on 01/15/26, E #9 arrived at 6:17 to pronounce the patient’s time of death, waste narcotics, call the funeral home, and perform other duties as required. E#9, and POA (witness), wasted 16 ml of Morphine Sulfate 20 milligrams (mg)/milliliter (ml) from a bottle initially contained 15 ml.  The record lacked documentation of investigation of this discrepancy. E#1 (Executive Director / RN/ Administrator) stated the Hospice investigated and discovered that E#3 (Hospice Aide) administered Morphine to Pt. #1 during a home visit on 01/15/26 in the amount of approximately 0.2 ml. The Hospice failed to ensure the RN supervised narcotic administration and documentation. 2.  During interviews conducted with E#1 and E#2 on 05/04/26 and 05/05/26, the above findings were discussed.

Based on staff interviews, clinical record reviews and policy reviews, for 2 of 4 (Pts. #1 and 2) records reviewed, the Agency failed to ensure Hospice Aides provided services that are consistent with state law and aide training. --- Findings include: 1. Pt. #1 was admitted to Hospice services on 11/20/25 with the diagnosis of Malignant Neoplasm of Prostate.  During an interview on 05/04/26, E#1 (Executive Director / RN/ Administrator) stated that Pt. #1 received Hospice services from the Agency until they expired on 01/15/26. On 01/16/26, E#1 was informed Pt. #1’s POA (Power of Attorney) asked E#5 (RN Case Manager) who administered the patient Morphine since it was found opened at the bedside. E#1 stated the Hospice investigated and discovered that E#3 (Hospice Aide) administered Morphine to Pt. #1 during a home visit on 01/15/26. E#1 stated that this incident was reported to their company’s compliance, investigated, and reported to IDPH on 02/02/26.  E#1 confirmed that Hospice Aides are not allowed to administer medications to Pts.  The clinical record was reviewed on 05/05/26.  The record included documentation Pt #1 received Hospice Aide services 2 times a week from 11/20/25 through 01/03/26, and the frequency was increased to 2 times a day starting 01/04/26 until Pt.’s death on 01/15/26. The document titled, “QI Event Summary” was reviewed on 05/04/26. On 01/15/26 (11:36 AM – 2:40 PM) E #3 (Hospice Aide) visited the patient. At 3:56 PM, E#3 informed E#5 (RN – Case Manager) that “today is not a good day” for the patient. E#5 had E#6 (Covering RN) contact the sister-in-law/POA who lives in the same building as the patient, and at 4:16 PM she stated that on the video, he looked” like he was having difficulty breathing” and at 4:52 PM it was suspected that the patient was actively dying. At 4:53 PM E#6 (Covering RN) assigned E#3 (Hospice Aide) and E#9 (RN) to visit patient. Sister-in-law called the Agency to report she was at the patient’s bedside when he expired, before the Hospice staff arrived. E# 3’s visit was cancelled. 6:17 pm E #9 arrived to pronounce the patient’s time of death (6:17 PM), waste narcotics, call the funeral home, and perform other duties as required. E#9, and POA (witness), wasted 16 ml of Morphine Sulfate 20 milligrams (mg)/milliliter (ml) from a bottle initially containing 15 ml.  During the initial investigation by E#1 (Executive Director / RN/ Administrator), E#3 (Hospice Aide) was asked if the patient received Morphine on 01/15/26 and E#3 responded, “Yes” and when asked “how”, E#3 responded, “by mouth.” E#3 stated that the Pt. had asked E#3 to help and give him the unopened morphine that was at his bedside. E#3 opened the bottle and used the oral syringe to draw up less than what was ordered. Pt. had an order of Morphine 5mg (0.25 ml) and E#3 stated, “it was maybe 0.2, wasn’t sure.” A further investigation was carried out by E#1 (Administrator/Executive Director) and E#7 (Human Resources) on 01/20/26 and was reviewed on 05/04/26. E#3 summarized that Pt. #1 was in so much pain and he asked her to help give him morphine. She did administer the medication as she was taught by other companies, and she stated she knew she was not supposed to administer medications with this company. The time of the Morphine administration is not documented in the record and E#1 confirmed it is unknown when E#3 administered Morphine to the Pt. The Hospice’s “Patient and Family Handbook” was reviewed on 05/04/26 and includes documentation…”page 6: …Hospice Aides do not dispense medication and will report any notable changes in your condition to the appropriate team members… ” The Hospice’s policy “Administration and Documentation of Medications Policy updated 05/01/24” was reviewed on 05/05/26, and required, “4.Non-licensed personnel will not administer medications. Where not prohibit by law, non-licensed personnel may assist the patient in the self-administration of medication and complete corresponding documentation…” Title 68: PROFESSIONS AND OCCUPATIONS CHAPTER VII: DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION SUBCHAPTER b: Professions and Occupations Part 1300 Nurse Practice Act section 1300.20 Nursing Delegation section 1300.20 Nursing Delegation a) For the purposes of this Section: "Delegation" means transferring to an individual the authority to perform a selected nursing activity or task, in a selected situation. "Nursing Activity" means any work requiring the use of knowledge acquired by completion of an approved program for licensure, including advanced education, continuing education, and experience as a licensed practical nurse or professional nurse, as defined by this Part... c) A registered professional nurse shall not delegate any nursing activity requiring the specialized knowledge, judgment, and skill of a licensed nurse to an unlicensed person, including medication administration. A registered professional nurse may delegate nursing activities to other registered professional nurses or licensed practical nurses.  The Hospice Aide provided a service that was not in scope of practice per state law.   2.  Pt. #2 was admitted to Hospice services on 03/28/26 with the diagnosis of Senile Degeneration of Brain, not elsewhere classified. The clinical record was reviewed on 05/05/26. Pt. #2 was receiving Hospice Aide services effective 03/29/26. The Visit Note Report dated 04/01/26 stated, "Visit Type: Aide Hospice Visit - Upon arrival Pt. was sitting in dining area. Pt. respond when name was called. HCNA (Hospice Certified Nursing Assistant) unlock(ed) Pt. WC (wheelchair) and was pushing Pt. forward to room. When pushing Pt. forward, Pt. lean(ed) forward and fell on face and (there) was blood on face. Pt. have swelling and gash on forehead. HCNA tried to catch Pt.  HCNA called (Facility) nurse and CM RN (Case Manager Registered Nurse) about the fall…"   The “Client Occurrence Report” included documentation that the RNCM (Registered Nurse Case Manager) was called to facility due to the patient’s fall witnessed by E#4 (Hospice Aide). The RNCM assessed the Pt. before the paramedics transported the Pt. to the hospital. The RNCM documented a large hematoma to the right side of the front side of the head with a small amount of bleeding and bruising to the left side of the patient’s face. The RNCM documented informing the POA (Power of Attorney) and Physician of the fall and transport to the hospital.   The document, “Hospice IDG Comprehensive Assessment and Plan of Care Update Report” includes documentation, 03/28/26: Patient ADLs, IADLs, and Personal care will be met with Hospice Aide… SN- Hospice Aide to assist with ADLs, IADLs and personal care needs… Fall Risk, Potential for Injury… SN -  Teach Patient/Caregiver/Facility Staff on safety measures to minimize fall risk and potential for injury, including assistance with transfers, DME….The document, “Aide Care Plan Report” for the period of 03/28/26 to 06/25/26 was reviewed on 05/05/26 and required, “Care Plan Category/Service: Vital Signs: Pain, ADL services: Bathing (Bed Bath), Aspiration Precautions, Shampoo, Skin care dressing, Fall Precautions (Patient is at risk for falls), IADL services: Change linen, empty trash, PCS Care Plan Tasks, transfer – chair – bed.” An interview was conducted with E#2 (Executive Director) on 05/04/26 at 4:00 PM.  E#2 stated that Pt. #2 resides in a Skilled Nursing Facility (SNF).  E#2 stated that when E#4 was pushing Pt.#2’s wheelchair forward coming from a common area to the bedroom, and Pt. #2 leaned forward and fell.  Pt. #2 sustained an injury on the face needing a few sutures, was sent to the hospital and returned to the SNF. An interview was conducted with E#4 via telephone on 05/05/26 at 1:30 PM. E#4 stated that it was the first visit with Pt. #2. E#4 stated that Pt. #2 was sitting in the dining area and E#4 approached Pt. #2 and stated that E#4 will bring pt. to room. E#4 said the wheelchair was unlocked and started pushing pt. forward towards the hallway and then Pt. leaned forward and fell on the floor. E#4 stated seeing blood on the Pt.'s face. E#4 then called facility staff and called Hospice RN Case Manager who was able to see Pt. before she was transferred to the hospital. E#4 stated that the wheelchair did not have a leg/footrest at the time of the transfer. Per E#4, if there was anything that could have been changed, it would be ensuring that during transport, the wheelchair would have footrests. E#4 stated that the Hospice conducts training during orientation, including assistive devices and wheelchairs. Also, after Pt. #2's fall incident, Hospice staff received training from the SNF, and that training included wheelchairs. E#4 stated that she gets care instructions through the Aide plan of care, and stated that if patients have fall precautions, it means that they are high risk for falls. Fall Precautions include interventions like, using floor mats, lowest bed position and 2-person assistance for transfers or transport. The Hospice Aide did not provide service in accordance with aide training. 3.  During interviews conducted with E#1 and E#2 on 05/05/26 at 4:30 PM, the above findings were confirmed.

Upon patient record review, 7 of 23 (Patient #1,#2,#4,#5,#6,#7,#15) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1:The medication profile contains entries of lidocaine patch 4% for pain and MiraLAX 17 gm po daily. There is no evidence that the medication profile includes the location for placement of the lidocaine patch or a type and amount of diluent for the administration of the medications. The entry on 5/8/24 of Macrobid 100 bid x 7 days remains on the medication profile. Patient 2,5,7:The medication profile includes an entry for oxygen 2 liters per minute as needed for shortness of breath. There is no evidence that the medication profile includes the route for administration of oxygen. Patient 4:The medication profile includes an entry of Relyvrio 3gm-1gm oral powder packet to be administered orally. The patient is receiving medications via G tube. There is no evidence that the medication profile includes the type and amount of diluent needed or the correct route for administration of the medication. Patient 6:The medical record includes nursing documentation on 6/11/24 that the patient reports using acetaminophen for flank pain. There is no entry on the medication profile for acetaminophen. Patient 15:The medication profile includes an entry for diclofenac 1% topical gel 2cm twice daily. There is no evidence that the medication profile includes the location for application of the medication.

Upon patient record review, 4 of 23 (Patient #1,#11,#16,#17) 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 1:The medical record contains nursing documentation that the patient has a foley catheter, a right biliary drain that requires a dressing by the SN and is flushed by the caregiver and is currently on daily anticoagulation therapy. There is no evidence that the plan of care contains problems, goals and interventions for the management and care of the foley catheter, biliary drain and risk for bleeding. Patient 11:The medical record contains documentation that the patient has dysphagia, is an aspiration risk and requires suctioning for excess secretions. There is no evidence that the plan of care includes problems goals and interventions for the care and management of dysphagia, the risk for aspiration or excessive secretions. Patient 16:The medical record contains documentation that the patient is on an altered diet of pureed food with nectar thickened liquids. There is no evidence that the plan of care includes goals and interventions for the care and management of dysphagia or the risk for aspiration. Patient 17:The medical record contains documentation that the patient may use oxygen 2 liters per minute as needed for shortness of breath. There is no evidence that the plan of care includes problems, goals and interventions for the use and safety of oxygen.

Upon patient record review, 8 of 23 (Patient #1,#2,#3,#4,#5,#6,#7,#15) 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 1:The plan of care includes orders for lidocaine patch 4% for pain and MiraLAX 17 gm po daily. There is no evidence that the orders include the location for placement of the lidocaine patch or a type and amount of diluent for the administration of the medications. Patient 2,5,7:The plan of care includes orders for oxygen 2 liters per minute via nasal cannula as needed for shortness of breath. There is no evidence that the order includes the route for administration of oxygen. Patient 3:The plan of care includes an order for placement of a foley catheter. There is no evidence that the order includes the catheter size or balloon inflation. Patient 4:The plan of care includes an order for Relyvrio 3gm-1gm oral powder packet to be administered orally. The patient is receiving medications via G tube. There is no evidence that the order includes the type and amount of diluent needed or the correct route for administration of the medication. Patient 6:The medical record includes nursing documentation on 6/11/24 that the patient reports using acetaminophen for flank pain. There is no evidence of an order for acetaminophen on the plan of care. Patient 8:The medical record contains nursing documentation that the patient was using oxygen at 3 liters per minute via nasal cannula on 5/13/24, 5/23/24, 5/30/24 and 6/6/24. There is evidence that plan of care included an order for oxygen to be delivered at 6 liters per minute. Patient 15:The plan of care includes an order for diclofenac 1% topical gel 2cm twice daily. There is no evidence that the order includes the location for application of the medication. The plan of care includes an order for placement of a foley catheter. There is no evidence that the order includes the catheter size or balloon inflation.

Upon patient record review, 2 of 23 (Patient #10,#13) 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 equipment and supply needs. Patient 10:The medical record contains nursing documentation that the patient uses a walker for ambulation. There is no evidence that the walker is included in the plan of care. Patient 13:The medical record contains nursing documentation that the patient uses a rolling walker for ambulation. There is no evidence that the rolling walker is included in the plan of care.

Upon patient record review, 1 of 23 (Patient #19) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 19:The medical record includes documentation by the MSW on 9/21/23 of a request by the niece to receive bereavement services. There is no evidence that a bereavement plan of care and subsequent services were provided.

Upon patient record review, 4 of 23 (Patient #2,#5,#7,#17) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 2:The aide plan of care includes task of weigh patient monthly. An order was entered on 5/2/24 to change weights to twice weekly. There is no evidence that the aide plan of care was updated to reflect change in frequency. Patient 5:The aide plan of care includes the task of clean nails. There is no evidence of a frequency assigned to delivery of service. Patient 7:The aide plan of care includes the task of clean nails. The frequency assigned to delivery of service is noted as weekly and PRN. Patient 17:The aide plan of care includes the task ear care weekly but details of the care include to file the nails and lotion to hands.

Upon patient record review 3 of 23 (Patient #2,#15,#16) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 2,15 and 16:The aide plan of care includes the task of clean nails weekly and visit frequency of aide is twice weekly. The task was performed on 6/4/24, 6/7/24, 6/11/24 and 6/13/24.

Upon client record review, 1 of 23 (Patient #12) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 12:The plan of care includes an order on 6/3/24 to provide wound care to left gluteal pin head size opening with drainage by applying warm compress daily, cleanse with sterile water and cover with gauze dressing and padded adhesive dressing daily. There is no evidence that the order includes who is to perform the wound care.