Every finding on record at Fhn Hospice

Based on clinical records review, policy review and Staff interview, it was determined the Hospice failed to ensure the plan of care included all interventions identified in the initial assessment. This was found in 1 of 2 records (Pt. #3) with wounds. --- Findings include: 1. Patient #3 was admitted to hospice on 10/15/2020 with a diagnosis of Malignant Neoplasm of unspecified part of unspecified bronchus of lung. On 3/22/2023 the hospice clinical record for Patient #3 was reviewed and included a plan of care dated 10/15/2020. The plan of care included, ";SN: Assess skin for excoriation, breakdown, friction, shearing or pressure areas..." The clinical record also included an initial assessment SN visit note dated 10/15/2020, that documented, ";...Integumentary...other: skin breakdown left foot..." and a SN visit note dated 10/16/2020 that documented, ";...Interventions performed...wound assessment/wound care...wound care required by clinician or patient/caregiver: yes..." There were no other orders for wound care or documentation of physician notification included in clinical record. The clinical record lacked a plan of care that included the initial assessment and intervention of skin breakdown to left foot. 2. The Hospice policy titled, ";FHN Hospice Wound Procedure" was reviewed. The Policy included, ";...SN to initially assess wound and measure...notify primary care provider or Hospice medical director, obtain orders if needed, and initiate treatment..." 3. The above findings were confirmed during an interview with the Hospice Administrator on 03/22/2023 between 1:30 PM and 3:15 PM.

A. Based on a review of clinical records and staff interview, it was determined that the Hospice failed to ensure staff provide service at the frequency indicated on the POC. This was found in 2 of 13 (Pts. #1 and 10) clinical records reviewed. --- Findings include: 1. Pt. #1. SOC 8/26/22. Hospice Diagnosis: Chronic Respiratory Failure with Hypoxia. The clinical record was reviewed on 1/24/23 at 2:00 PM. The record contained the "Hospice Plan of Care" effective 11/24/22 that included the visit frequency for the Aide: "1-3 wk 14 wk 25 PRN : visits as needed for ADL support." The record lacked documentation the Aide provided any service during the week of 12/26/22 to 1/1/23. 2. Pt. #10. SOC 11/5/22. Hospice Diagnosis: Gastrointestinal Hemorrhage. The clinical record was reviewed on 1/24/23 at 3:00 PM. The record contained the "Hospice Plan of Care" effective 11/5/22 that included the visit frequency for the Aide: "1-3 wk 14 wk 25 PRN : visits as needed for ADL support." The record lacked documentation the Aide provided any service during the weeks of 11/27/22 to 12/4/22, and 1/2/23 to 1/8/23. 3. During an interview with the Director of Care Transitions, Operations Leader, Quality Risk Specialist and the Chief Operating Officer/Chief Nursing Officer on 1/25/23 from 1:15 PM to 3:00 PM, the above findings were confirmed.

A. Based on a review of clinical records, observation during a home visit, procedure review and staff interview, it was determined the Hospice failed to ensure that clinical documentation entered into the record was complete. This was found in 3 of 3 (Pts. #10, 3 and 4) clinical records reviewed of Pts. that require wound care. --- 2. Pt. #3. SOC 10/3/22. Hospice Diagnosis: Chronic Combined Systolic and Diastolic Heart Failure. A visit was conducted on 1/24/23 at 9:00 AM, along with E8. During this visit the Pt. was observed to have a wound to her left outer wrist, which was approximately 6 cm long x 3 cm wide, and contained an open area within the wound bed that measured approximately 1 cm long x 1 cm wide x 0.2 cm in depth, with scanty seriously drainage. A gauze wrap which had been placed over this wound had slid upward on the Patients arm, leaving the wound partially open to air. The clinical record was reviewed on 1/24/23 at 10:10 AM. The record included the SN note dated 1/19/22, which noted the onset of this wound as 1/15/23, and described the wound as ";moist, pink, edematous, with a small amount of serous drainage." This SN note, as well as the following SN note dated 1/23/23, both lacked wound measurements. 3. Pt. #4. SOC 8/23/22. Hospice Diagnosis: Alzheimers Disease with Late Onset. The clinical record was reviewed on 1/24/23 at 1:30 PM. The record contained documentation the SN first noted a wound to the Patients left lower outer leg on 11/3/22, described as ";dry, black, no drainage, covered with a sock." This assessment lacked wound measurements. The SN visit note dated 11/28/22 contained documentation the Patients wound now contained ";yellow slough tissue, with erythema of the peri wound skin, with yellow sanguinous/bloody drainage, with a bordered foam dressing changed daily." The SN note dated 12/15/22 included documentation the Patients wound ";declined, with a moderate amount of yellow-green drainage," and the facility Physician added the wound treatment ";Santyl PRN for odor and medihoney." The SN visit note dated 12/27/22 contained documentation ";the facility Nurse reports that the wound on her ankle is looking better...their wound Doctor debrided it..." The SN visit note dated 12/29/22 included documentation the wound had a ";small amount of yellow-green drainage," and the facility Physician changed the wound treatment to include a ";collagen and bordered foam" dressing. The record contained documentation the SN visited the Pt. twice weekly from 11/3/22 to 1/19/23; all of these notes lacked wound measurements. 4. The Agency procedure titled ";Standardized Skin/Wound Treatment" was reviewed on 1/25/23 at 12:45 PM. The policy required: ";...SN to initially assess wound, notify MD, initiate treatment...Wounds to be measured minimum of weekly." 5. During interviews on 1/25/23 at 1:15 PM and 2:20 PM with the Director of Care Transitions, Operations Leader, Quality Risk Specialist, and Chief Operations Officer/Chief Nursing Officer, the above findings were confirmed. The Operations Leader stated wounds should be measured weekly, and this information should be documented in the SN visit notes. 1. Pt. #10. SOC 11/5/22. Hospice Diagnosis: Gastrointestinal Hemorrhage. The clinical record was reviewed on 1/24/23 at 3:00 PM. The record contained the SN visit notes from 11/22/22 to 12/19/22, indicating the Pt. had a wound to the right lower anterior leg, right lower leg calf and that wound care was required. The SN provided service during the week of 11/21/22 to 11/26/22 (on 11/22/22 and 11/25/22), week of 11/27/22 to 12/4/22 (on 11/29/22 and 12/1/22), week of 12/5/22 to 12/11/22 (on 12/6/22 and 12/8/22), and the week of 12/12/22 to 12/18/22 (on 12/13/22 and 12/16/22), the SN visit notes lacked documentation the SN measured the wounds weekly, as required by the hospice. The SN provided service during the week of 12/19/22 to 12/25/22, the SN visit note dated 12/19/22 lacked a description of any of the wounds.

A. Based on a review of personnel files, Illinois Administrative Code and staff interview, it was determined the Hospice failed to log into the Illinois Department of Public Health - Health Care Worker Registry Web Portal prior to employment, complete the health care worker background process that included, eligibility, verify criminal background results, Internet searches, employment history, employment verification, certification and maintain documents in the personnel file per regulations. This was found in 14 of 14 Volunteers (Volunteers #1 thorough 14), and 3 of 4 (Employee #1, 2 and 3) non-licensed employees that provide Pt. care and/or service. --- 2. The personnel file of E #1 Certified Nurse Assistant (DOH 12/18/00) was reviewed on 1/23/23 at 2:30 PM. The file included undated the undated Illinois Department of Public Health Care - Health Care Worker Registry printout, documenting E #1 is eligible to work, and a FEE_APP dated 8/13/13. The file lacked annual employment verification for the years 2021 and 2022 conducted through the IDPH Web Portal by this Agency. No other documents were in E #1s file. 3. The personnel file of E #2 Certified Nurse Assistant (DOH 2/21/05) was reviewed on 1/23/23 at 2:45 PM. The file included the undated Illinois Department of Public Health Care - Health Care Worker Registry, documenting E #2 is not eligible to work, and a UCIA_NAME dated 9/28/04. The file lacked annual employment verification for the years 2020 and 2021 conducted through the IDPH Web Portal by this Agency. No other documents were in E #2's file. 4. The personnel file of E #3 Volunteer Coordinator/Hospice Chaplain (DOH 5/16/22) was reviewed on 1/23/23 at 3:00 PM. The file included theIllinois Department of Public Health Care - Health Care Worker Registry printout dated 5/16/22, documenting E #3 is eligible to work, and a FEE_APP dated 4/12/21. The file lacked complete Health Care Worker Background process, including the Internet searches conducted through the IDPH Web Portal by this Agency. No other documents were in E #3's file. 5. 77 Illinois Administrative Code 280.2035 Health Care Worker Background Check requires: "A hospice program shall comply with the Health Care Worker Background Check Act and the Health Care Worker Background Check Code." 6. During an interview with the Volunteer Coordinator/Hospice Chaplain on 1/23/23 at 3:31 PM; the Director of Care Transitions, Chief Operating Officer/Chief Nursing Officer, Quality Risk Assessment, Talent Acquisition Specialist/PRA, and the Senior Human Resource Business Partner on 1/24/23 at 12:02 PM; and 1/25/23 from 1:15 PM to 3:00 PM with the Director of Care Transitions, Operating Chief Officer/Chief Nursing Officer, and the Quality Risk Specialist, it was confirmed the Hospice has an active Web Portal account, and failed to conduct criminal background checks as required by 77 Illinois Administrative Code, 280.2035 Health Care Worker Background Check. Findings include: 1. The personnel files of volunteers that provide direct Pt. care were reviewed on 1/23/23 at 3:31 PM with the Volunteer Coordinator/Hospice Chaplain, and lacked an Illinois Department of Public Health - Health Care Worker Registry Web Portal profile page for the following Volunteers:Volunteer #1. DOH 11/1/18.Volunteer #2. DOH 7/5/19.Volunteer #3. DOH 11/16/17.Volunteer #4. DOH 6/6/11.Volunteer #5. DOH 6/2/16.Volunteer #6. DOH 10/11/19.Volunteer #7. DOH 11/10/15.Volunteer #8. DOH 5/8/17.Volunteer #9. DOH 11/9/15.Volunteer #10. DOH 11/12/15.Volunteer #11. DOH 10/1/22.Volunteer #12. DOH 10/1/22.Volunteer #13. DOH 8/7/18.Volunteer #14. DOH 6/1/13.

A. Based on a review of volunteer and employee personnel files, Illinois Administrative Code and staff interview, it was determined the Hospice failed to ensure health requirements were met. This was found in the personnel files of 2 of 2 direct Pt. care volunteers (Volunteer #11 and 12), and 4 of 4 direct employees (E #3, 4, 5 and 8) hired after 1/31/20. --- Findings include: 1. The personnel files of volunteers that provide direct Pt. care were reviewed on 1/23/23 at 3:31 PM. The following files lacked documentation that the volunteers received a physical examination before providing Pt. care and/or service: Volunteer #11. DOH 10/1/22. Volunteer #12. DOH 10/1/22. 2. The personnel files of direct employees that provide Pt. care were reviewed on 1/23/23 at 2:30 PM and 1/24/23 at 11:20 AM. The following files lacked documentation the employees received a physical examination before providing Pt. care and/or service: E #3. DOH 5/16/22. E #4. DOH 7/19/21. E #5. DOH 6/7/21. E #8. DOH 4/4/22. 3. 77 Illinois Administrative Code 280.2045 c) 1-2) d) requires: "c) The initial health evaluation shall include a physical examination. The examination shall include at a minimum any procedures needed to: 1) Detect any unusual susceptibility to infection and any conditions that would increase the likelihood of the transmission of disease, and 2) determine that the employee appears to be physically able to perform the job functions that the hospice program intends to assign to the employee. d) The health inventory and physical examination shall be completed no more than 30 days prior to and no more than 30 days after the date of initial employment." 4. During an interview with the Volunteer Coordinator/Hospice Chaplain on 1/23/23 at 3:31 PM; and 1/25/23 from 1:15 PM to 3:00 PM with the Director of Care Transitions, Operations Leader, Quality Risk Specialist and the Chief Operations Officer, the above findings were confirmed.

A. Based on personnel file review, the Illinois Administrative Code review and Staff interviews, it was determined that the Agency failed to ensure social services staff were licensed as per Illinois Administrative Code Title 77, part 280 Hospice Programs. This was found in 3 of 4 (Employees #2, 3 and 4) Social Services staff. Findings include: 1. On 05/24/2022 at 11:36 AM, the personnel files were reviewed with Human resources staff. Employee #2 (Medical Social Worker/BSW/ DOH 08/10/1992) Employee #3 (Medical Social Worker/MSW/ DOH 01/09/2017) Employee #4 (Medical Social Worker/BSW/ DOH 12/04/2000) Employees #2, 3 and 4 did not have a license as a Clinical Social Worker per State requirement. 2. On 05/24/2022 at 11:45 AM, review of Illinois Administrative Code Title 77, part 280 Hospice Programs; Section 280.2040 Personnel Policies contained: "d) Where applicable, every hospice program employee must be licensed, certified, or registered in accordance with federal, State and local laws. (Section 8(n) of the Act)." 3. On 05/24/2022 at 3:00 PM, an interview was conducted with Administrator, who confirmed that Employees #2, 3 and 4 do not have a Social Worker license.