Every finding on record at Dw Care Solutions

Upon patient record review, 1 of 14 (Patient #3) 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 #3 - The medication list contained MiraLax 30 gm daily for constipation. There was no evidence that a diluent was included in the medication instructions. The plan of care included an education for the safe use of oxygen as an intervention. The medication profile did not include oxygen. These were corrected onsite.

Upon patient record review, 3 of 14 (Patient #1,3,4) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #1 - Patient was admitted on 09/18/24. There is no evidence that an initial bereavement assessment was completed by any IDG member within the first 5 days of admission. A bereavement assessment was completed during this survey. Patient #3 - Patient was admitted on 07/02/25. There is no evidence that an initial bereavement assessment was completed by any IDG member within the first 5 days of admission. A bereavement assessment was completed during this survey. Patient #4 - Patient was admitted on 04/07/24. There is no evidence that an initial bereavement assessment was completed by any IDG member within the first 5 days of admission. A bereavement assessment was completed during this survey.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #4 - The medical record showed a coordination note dated 09/16/25, documented a call into the agency by one of the patient's son. The son stated they had not yet received the patient's fentanyl patches from the pharmacy. The RN taking the call then noted that a call was placed to the pharmacy to locate the fentanyl. The pharmacist stated the medication was delivered but delivered to another family member who resides at the patient's home. The RN then called the son to give him this information. There was no documented follow up on if the patient received their medication.

Upon patient record review, 2 of 14 (Patient #2,3) 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 medication profile included aspirin as a blood thinner. There were no bleeding risk problems, goals or interventions listed on patient's plan of care. This was corrected onsite. Patient #3 - The initial certification of terminal illness narrative written by the hospice physician dated 07/02/25, outlined diabetes as related diagnosis to the terminal prognosis and hospice team was managing this and patient was on Lantus. There were no problems, goals or interventions related to the endocrine system. This was corrected onsite.

Upon patient record review, 1 of 14 (Patient #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 medications and treatments. Patient #3 - There was no evidence that a diluent was included in the physician order for MiraLax 30 gm daily for constipation. The plan of care also included an education for the safe use of oxygen as an intervention. There was no evidence of a physician order for oxygen. These were corrected onsite.

Upon patient record review, 1 of 14 (Patient #6) 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 #6 - Patient expired on 12/10/24. The last contact to the bereaved was on 01/03/24 with a condolence card. There was no evidence of any follow up since that time and no updates to the bereavement plan of care. There was no evidence that the bereaved declined any follow up.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78 The cost savings report in the EMR had no evidence that any volunteer hours had been entered into the system. The report showed a negative savings.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The EMR Volunteer Activity report, showed 0% volunteer hours documented in 2024.

Upon patient client record review, 4 of 14 (Patient #2,3,4,10) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #2 - Upon admission on 07/19/25, the POA elected to receive an addendum to the Election of Benefit. The addendum was signed by the POA without any related/unrelated diagnosis or list of non covered items. These sections were left blank. Patient #3 - On page one of the Election of Benefit form, the area to document the effective date for the hospice benefit to begin was left blank. Patient #4 - On page one of the Election of Benefit form, the area to document the effective date for the hospice benefit to begin was left blank. On page 2 of the Election of Benefit form, the patient/POA neither declined or requested the admission addendum - these boxes were left blank. The addendum was signed and dated for on 04/07/25 but did not include any related/nonrelated information. The form was left blank. Patient #10 - Upon admission on 04/29/25, the patient elected to receive an addendum to the Election of Benefit. The addendum was signed without any related/unrelated diagnosis or list of non covered items. These sections were left blank.

Based on personnel files review and Staff interview, the Hospice failed to complete the web portal background checks for 2 of 3 (Employees #1 and #3) Home Health Aides upon hire. --- Findings include:1.  The personnel file for Employee #1 date of hire 12/27/24 was reviewed on 08/07/25.  The personnel file included an undated Illinois Department of Public Health (IDPH) Health Care Worker Registry web site profile page.  The profile page includes Work Eligibility as “Eligible”. The profile document lacked the required 6 website searches and lacked the initial employment verification.2.  The personnel file for Employee #3 date of hire 06/12/25 was reviewed on 08/07/25.  The personnel file included an IDPH Health Care Worker Registry web site profile page dated 07/08/25.  The profile includes Work Eligibility “Eligible” the profile document lacked the name of the Hospice as the registering Agency.  The document also lacked the required 6 website searches and FEE APP selection.  3.  During an interview with the Director of Nursing (DON) on 08/07/25, the DON confirmed the Hospice failed to implement the required criminal background check process for Hospice Aides through the IDPH Health Care Worker Background Check web -portal site upon hire.

Upon patient record review, 2 of 5 (Patient #3 and 4) 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 3: The medication profile contained PRN Breo, no evidence of indication for PRN use. Corrected on Site. Patient 4: The medication profile contained PRN Cyclobenzaprine, no evidence of indication for PRN use. Corrected on Site.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 1: Clinician did not wash hands with soap or hand sanitizer prior to putting on gloves at start of visit or prior to touching patient. Clinician wore stethoscope around neck entire visit and when cleaning other equipment stethoscope continued to swing and touch clean equipment. Patient 2: Clinician wore dirty stethoscope around neck during entire visit and while cleaning other equipment, stethoscope continued to swing and touch clean equipment. Clinician left home with uncleaned stethoscope around neck. Washed hands with patients bar soap in the bathroom. Patient 3: Clinician wore dirty stethoscope that was still hanging from around neck from prior patient home into this patients home. Cleaned equipment was placed back on dirty side of barrier.

Upon patient record review 2 of 3 applicable (Patient #1, #3) 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 1: The medical record contains an ordered aide frequency of twice weekly. There was evidence of 1 aide visit during week of 7/24/22, on 7/28/22. There was evidence of only 1 aide visit during week of 10/2/22, on 10/8/22. Corrected on Site Patient 3: The medical record contains an ordered aide frequency of twice weekly. There was evidence of 1 aide visit during week of 7/24/22, on 7/29/22. Corrected on Site.

Upon patient client record review, 4 of 5 (Patient #2, #3, #4, #5) did not have evidence that each patient record contains Advance Directives. Patient 2: The medical record did not show evidence of advance directives, POLST form was signed by patient only, not dated, and form was blank. Patient 3: The medical record did not show evidence of advance directives. Patient 4: The medical record did not show evidence of advance directives, POLST form was signed by patient only, not dated, and form was blank. Patient 5: The medical record did not show evidence of advance directives.