Every finding on record at Addus Hospice of Illinois, LLC

Upon patient record review, 1 of 30 (Patient #13) 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 13: The nursing comprehensive/CTI showed evidence that the patient is a diabetic. The medication profile indicates patient has Basaglar Kwik- pen BID and Humalog Kwik-pen. There was no evidence of problems, goals, or interventions related to the Endocrine system. Corrected on site. Care plan updated

Upon patient record review, 28 of 30 (Patients #1,2,4,5,6,7,8,9,10,11,12,13,14,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30) 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 Patients 1,2,4,5,6,7,8,9,10,11,12,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30: The Social Worker and Chaplain visit frequency on Initial Plan(s) of Care, indicated 1PRN for these disciplines. This frequency did not include a baseline visit frequency for the Social Worker or Chaplain. Agency working with Home Care Home Base to assist with the frequency population. Patient 13: The Social Worker and Chaplain visit frequency on Initial Plan of Care, indicated 1PRN for these disciplines. This frequency did not include a baseline visit frequency for the Social Worker or Chaplain.

Upon patient record review, 1 of 30 (Patient #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 #15: This patient had an order on Plan of Care indicating MiraLAX 17gm powder. There was no diluent indicated with MiraLAX. Corrected on Site-Agency obtained a supplemental order.

Upon patient record review, 5 of 30 (Patients #1,13,18,19,21) 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 #1: This patient had a front-wheeled walker, wheel chair seat cushion, shower chair and toilet seat raised bar. These were not included on the Plan of Care. Corrected on site-agency obtained a supplemental order during survey. Patient #13: The record reflected that this patient had a wheel chair. This item was not included on the Plan of Care. Corrected on site-agency obtained a supplemental order during survey. Patient #18: The record reflected that this patient had Duo-neb inhalation treatments. The nebulizer machine was not included on the Plan of Care. Corrected on site-agency obtained a supplemental order during survey. Patient #19: The record reflected that this patient had a low air loss mattress. This item was not included on the Plan of Care. Corrected on site-agency obtained a supplemental order during survey. Patient #21: The record reflected that this patient had an APP mattress. This item was not included on the Plan of Care. Corrected on site-agency obtained a supplemental order during survey.

Upon personnel record review, 1 of 14 (Personnel #4) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #4: The LPN hired on 11/4/24 did not have Initial Skills Competency in his file. Corrected on site-during survey agency had LPN/RN complete his skills competency.

Upon patient record review, 2 of 30 (Patients #10, 11) did not have evidence that there is a physician's brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification forms, or as an addendum to the certification forms. Patient 10: The initial CTI's for benefit period 1 (10/17/25-1/14/26) was a verbal only (SOC-10/17/25). This CTI form had no physician narrative, signature or date (> 30 day policy to complete note). This record was updated during survey. Patient 11: The initial CTI's for benefit period 1 (10/10/25-1/7/26) was a verbal only (SOC-10/10/25). This CTI form had no physician narrative, signature or date (> 30 day policy to complete note). This record was updated during survey.

Upon observation, there is no evidence building construction is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a two hour fire resistance rating constructed of materials as required for the addition. Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire doors assemblies. Existing construction: 19.3.5.4 During the building tour, pillows were observed stored too close to the ceiling in a patient room closet. In addition, one bolster pad in the storage closet and items stored on top of a built-in cabinet were observed with less than 18 inches of clearance from the ceiling. Per NFPA 101, 19.3.5.4, storage of combustible materials shall be maintained so that the distance between the top of the storage and the ceiling is at least 18 inches where standard-spray sprinklers are installed. Adequate clearance ensures proper sprinkler discharge and fire protection coverage. Corrected on site.

Upon observation, there was no evidence the inpatient facility has adequate supply of hot water temperatures at all times and include plumbing fixtures with control valves that automatically regulate the temperature of hot water used by patients. Review of water temperature logs from January 2025 to the present showed recorded temperatures ranging from 84°F to 132.1°F. There is no policy to address temperature range. The monthly ranges for 2025 are as follows: January-105°F to 110.1°F February- 104°F to 113.°F March- 103°F to 113°F April-102°F to 124°F May-84°F to 112°F June-102°F to 124°F July- 106°F to 123°F August- 104°F to 121.6°F September-106.4°F to 119°F October-98.3°F to 132.1°F November (partial month)- 93.6°F to 129°F Correction on site in process prior to survey: 1. Fox Valley Plumbing replaced a house mixer on 10/21/25. They have returned multiple times to balance test water on 11/4/25, 11/11/25, 11/12/25 to bring water temperature range of 95°F to 110.1°F. 2. Agency has a plan in place for patient safety that water is checked for a temperature <110 °F before providing any bathing/showering with all IPU patients.

Upon patient record review, 1 of 20 (Patient #12) 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 Patient #12: Chaplain visit frequency of, "effective 8/11/22, 3 PRN visits for spiritual/emotional support." This frequency did not include a baseline visit frequency for the Chaplain.

Upon patient record review, 3 of 20 (Patients #1, #2 and #3) 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 #1: This patient had a hospital bed, wheelchair, O2 concentrator/O2 tank, cane and nebulizer machine. These were not included on the Plan of Care. Patient #2: This patient had a walker and wheelchair. These were not included on the Plan of Care. Patient #3: This patient had a hospital bed, BST, fall mat. These were not included on the Plan of Care.

Upon client record review, 1 of 20 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: The POC listed Skilled Nursing visit frequency of 2x3w. For Benefit Weeks 10/2/22 and 10/9/22 there was only 1 visit made each week on 10/6/22 and 10/11/22 only.

Upon patient record review 3 of 20 (Patients #1, #3 and #6) 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 Patient #1: The POC listed Aide visit frequency of 1w1 for first benefit week. There were no visits made for this week. Patient #3: The POC listed Aide visit frequency of 2 times per week. On 10/21/22 there was a declined visit only. There were no other visit attempts made for this week. Patient #6: The POC listed Aide visit frequency of 4 times per week. For Benefit week 10/23/22 only 3 visits were made, not 4 visits.

Upon patient client record review, 1 of 20 (Patient #8) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #8: The Beneficiary elected to receive the "Patient Notification of Hospice Non Covered Items" on one of 3 methods to request (electronic and paper versions) at SOC date 11-3-22. Hospice did not furnish this addendum within 5 days requested at SOC. The acknowledgement of receiving the addendum has been signed and dated on 11-29-22.

Upon SNF/NF contract review, 1 of 4 (contract) did not have the reporting to SNF/NF Administrator "within 24 hours" clause to notify of any alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property. During survey added addendum to include the above requirements. Corrected on Site 12/1/22.