Every finding on record at Grace Hospice of Illinois, LLC

It is required that each patient’s individualized written plan of care: reflects patient and family goals; [and] identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure that the patient's plan of care included planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 11: The patient elected the hospice benefit on 07/22/2025 with a diagnosis of neurocognitive disorder with Lewy bodies. The initial skilled nursing (SN) assessment, dated 07/22/2025, documented: "Patient is diabetic and taking an anti-diabetic medication." The plan of care dated 07/22/2025 through 10/19/2025 did not include interventions related to the management of diabetes. CLINICAL RECORD 12: The patient elected the hospice benefit on 09/05/2025. The initial SN assessment, dated 09/05/2025, documented: "Patient is diabetic and taking insulin." The plan of care dated 09/05/2025 through 12/02/2025 did not include interventions related to the management of diabetes. During the joint record reviews and interview on 11/26/2025, the Clinical Manager confirmed the above findings that interventions were not included in the patients' plans of care for diabetes management.

It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the patient's individualized written plan of care included all medical supplies and appliances necessary to meet the patient's needs. CLINICAL RECORD 7: The patient elected the hospice benefit on 10/18/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). A physician's order dated 10/19/2024 ordered "Oxygen 5 liters via nasal cannula continuously." The plans of care for the certification periods dated 10/18/2024 to 01/15/2025, 01/16/2025 to 04/15/2025, 04/16/2025 to 06/14/2025, and 06/15/2025 to 08/13/2025 did not include documentation of the patient's oxygen supplies. During a joint record review and interview on 11/25/2025, the Clinical Manager confirmed that oxygen supplies were not included in the patient's plan of care until 08/14/2025.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IID (intermediate care facility/Individuals with Intellectual Disabilities) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: the types of bereavement services to be offered; and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients discharged due to death, the agency did not ensure that services documented in the bereavement plan of care were provided. CLINICAL RECORD 13: The patient elected the hospice benefit on 07/25/2025 and died on 08/06/2025. The bereavement plan of care dated 08/06/2025 documented "Bereavement risk assessment to be completed within one month after the patient passes." A clinical record review revealed no documentation of a bereavement risk assessment after the patient's death on 08/06/2025. CLINICAL RECORD 14: The patient elected the hospice benefit on 09/19/2025 and died on 10/14/2025. The bereavement plan of care dated 10/14/2025 documented "Bereavement risk assessment to be completed within one month after the patient passes." A clinical record review revealed no documentation of a bereavement risk assessment after the patient's death on 10/14/2025. During joint record reviews and an interview on 11/26/2025, the Regional Quality Manager confirmed the above findings, stating, "There is no documentation of a bereavement risk assessment after these patients passed away."

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 5 of 11 (45%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide received written patient care instructions to meet the patient's needs. CLINICAL RECORD 1: The patient elected the hospice benefit on 09/29/2025 with a diagnosis of chronic obstructive pulmonary disease (COPD). A physician's order dated 09/19/2025 ordered "Hospice Aide 4 times weekly." A physician's order dated 11/21/2025 documented "Oxygen 2-5 liters via nasal cannula as needed for shortness of breath." The skilled nursing (SN) visit note dated 11/05/2025 documented "Placed external catheter on patient." The Hospice Aide care plan dated 09/19/2025 was not updated to include oxygen and external catheter care instructions. CLINICAL RECORD 3: The patient elected the hospice benefit on 06/11/2024 with a diagnosis of cerebral atherosclerosis. The patient resided at an assisted living facility (ALF). The plans of care dated 08/05/2025 through 10/03/2025 and 10/04/2025 through 12/02/2025 ordered "Hospice Aide 4 times weekly." A physician's order dated 08/11/2025 ordered wound care with a dressing to a wound on the patient's left buttock. The Hospice Aide care plan dated 09/18/2025 assigned the HA the task of "Bed bath every visit." The Hospice Aide care plan did not include instructions for the HA should the wound dressing on the patient's left buttock become dislodged during the bed bath. CLINICAL RECORD 5: The patient elected the hospice benefit on 09/24/2025 with a diagnosis of intracerebral hemorrhage. The plan of care dated 09/26/2025 through 11/24/2025 ordered "Maintain 20 French (Fr) Foley catheter." A physician's order dated 10/10/2025 ordered "Hospice Aide 1 time weekly." The current Hospice Aide care plan, dated 11/21/2025, did not include instructions for the HA for Foley catheter care. CLINICAL RECORD 11: The patient elected the hospice benefit on 07/22/2025 with a diagnosis of neurocognitive disorder with Lewy bodies. A physician's order dated 07/30/2025 ordered wound care with a dressing to a wound on the patient's sacrum. The plan of care dated 07/22/2025 through 10/19/2025 ordered "Hospice Aide one (1) time weekly starting week of 07/27/2025." The Hospice Aide care plan dated 07/22/2025 assigned the HA the task of "Bed bath every visit." The Hospice Aide care plan was not updated to include instructions for the HA should the wound dressing become dislodged during the bed bath. CLINICAL RECORD 14: The patient elected the hospice benefit on 09/19/2025 with a diagnosis of cerebral infarction. A physician's order dated 09/29/2025 ordered wound care with a wound dressing to a wound on the patient's sacrum. The plan of care dated 09/19/2025 through 12/17/2025 ordered "Hospice Aide 2 times weekly." The Hospice Aide care plan dated 09/23/2025 assigned the HA the task of "Bed bath every visit." The Hospice Aide care plan did not include updated instructions regarding the wound dressing on the patient's sacrum, should the dressing become dislodged during the bed bath. During joint record reviews and interviews on 11/24/2025, 11/25/2025, and 11/26/2025, the Clinical Manager confirmed the above findings, stating, "There are no wound dressing, oxygen, or catheter care instructions on the aide care plans. We need to do education with the nurses on aide care plans".

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that volunteers provided day-to-day administrative or direct patient care services equal to 5% of the total patient care hours of all paid hospice employees and contract staff. A review of the agency's report titled "Volunteer Cost Savings" for 2024 and 2025 revealed that the agency's volunteer hours for January 2024 through December 2024 totaled 0.82%, and for January 2025 through October 2025, totaled 1.76%. During a joint review of the Volunteer Cost Savings report, the Regional Quality Manager confirmed that the agency's volunteer hours for 2024 and 2025 were less than 5%. The agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that equaled five percent of the total patient care hours of all paid hospice employees and contract staff.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies and procedures on advance directives. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. This standard was not met as evidenced by interview and personnel record review. In 1 of 10 (10%) personnel records reviewed of employees or contracted staff with patient contact, the agency did not ensure that each employee received orientation on the hospice philosophy. PERSONNEL RECORD 10: The volunteer's date of hire was 01/21/2025. The personnel record did not include documentation of orientation to the hospice philosophy. During joint record reviews and an interview on 11/26/2025, the Regional Quality Manager confirmed that documentation of orientation to the hospice philosophy was not included in the personnel file, stating, "This volunteer was hired in with our previous company, and we are missing some items from their personnel file."

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that all physicians' orders were included in the patient's clinical record. CLINICAL RECORD 1: The patient elected the hospice benefit on 09/29/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). The skilled nursing (SN) visit note dated 11/05/2025 documented "External catheter placed on patient." A clinical record review revealed no evidence of a physician's order for the external catheter. During a joint record review and interview on 11/24/2025, the Clinical Manager confirmed the above finding, stating, "There is not an order in the chart for the patient's external catheter."

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. This standard was not met as evidenced by interview and personnel record review. In 1 of 10 (10%) personnel records reviewed of employees or contracted staff with direct patient contact or access to patient records, the agency did not ensure that criminal background checks were completed for all hospice employees with direct patient contact or access to patient records. PERSONNEL RECORD 10: The volunteer's date of hire was 01/21/2025. The personnel record did not include documentation of a criminal background check. During a joint record review and interview on 11/26/2025, the Regional Quality Manager confirmed that documentation of a criminal background check was not included in the personnel file, stating, "This volunteer was hired in with our previous company, and we are missing some items from the personnel file".

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs and the drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when a new medication is added or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records and interviews. 3 of 11 (27%) clinical records reviewed revealed the agency did not ensure the medication profile documented all ordered medications. Clinical Record 2: Nursing visit note documented on 10/20/2022 stated, "patient using Oxygen at 2 LPM (liters per minute) intermittently per nasal cannula." Oxygen was not documented on the medication profile on review 11/01/2022. Interview with the Administrator on 11/01/2022 stated after a review of the records that the medication profiles had not been updated with oxygen orders and were consequently corrected. Clinical Record 3: Oxygen was documented on the medication profile reviewed on 11/01/2022. The nursing visit notes from 09/21/2022 – 10/13/2022 stated, "the oxygen was no longer being used." The Oxygen was not discontinued from the medication profile. Interview with the Administrator on 11/01/2022 stated after a review of the records that the medication profiles had not been updated with oxygen orders and were consequently corrected. Clinical Record 6: Nursing visit note documented on 10/25/2022 stated, " the patient was using Oxygen at 2 LPM per nasal cannula." Oxygen was not documented on the medication profile. Interview with the Administrator on 11/01/2022 stated after a review of the records that the medication profiles had not been updated with oxygen orders and were consequently corrected.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records and interview. 2 of 11 (18%) clinical records reviewed revealed the agency did not ensure the plans of care contained individualized interventions based on nursing assessments and problems identified. Clinical Record 2: The 10/19/2022 hospice plan of care include the diagnosis of Type 2 Diabetes Mellitus (DM) and Metformin (a medication to control blood sugar) on the medication list. The 10/27/2022 nursing assessment indicated the daughter was checking blood sugars twice daily and the nurse would continue monitoring. The hospice plan of care did not include interventions for glucose monitoring and management. An interview with the Administrator on 11/01/2022 stated that the plans were not accurate for interventions for active problems identified in the nursing assessments. Clinical Record 10: The 01/08/2022 hospice plan of care include the diagnosis of Type 2 Diabetes Mellitus (DM) and Lantus (insulin to lower blood sugar) and Humalog (fast-acting insulin to decrease blood sugar) insulin on the medication list. The 01/08/2022 nursing assessment indicated the caregiver was checking blood sugars four times per day and administering insulin as ordered and the nurse would continue monitoring. The hospice plan of care did not include interventions for DM or glucose monitoring and management. An interview with the Administrator on 11/01/2022 stated that the plans were not accurate for interventions for active problems identified in the nursing assessments.

It is required that each patient’s individualized written plan of care: identifies planned interventions based on problems identified in the initial and updated comprehensive assessments; drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by a review of clinical records and interview. 5 of 11 (45%) clinical records reviewed revealed the agency did not ensure the hospice plan of care included all medications and treatments based on assessments. Clinical Record 2: The patient was utilizing intermittent oxygen at 2 LPM via nasal cannula per the 10/20/2022 nursing assessment. There was no documented evidence of a physician order for oxygen on the 10/19/2022 hospice plan of care to date. An interview with the Administrator on 10/31/2022 stated that the plans were not accurate for completed medication and treatment orders. Clinical Record 5: The 09/19/22022 hospice plan of care, stated "may irrigate Foley with NS (normal saline) and change catheter every 30 days and PRN (as needed)." There was no amount of Normal Saline specified nor a frequency for irrigation included and there were no prn qualifiers for the prn catheter change. The 09/19/2022 wound care orders on the hospice plan of care, stated "Stage 4 coccyx, cleanse with Dakins (treats skin and tissue infections) solution, apply Dakins wet to dry dressing, cover with foam dressing or ABD (abdominal) pad, change every day and prn" with no prn qualifiers. An interview with the Administrator on 11/01/2022 stated that the plans were not accurate for completed medication and treatment orders. Clinical Record 6: The patient was utilizing oxygen at 2 liters per minute via nasal cannula intermittently per the 10/25/2022 nursing assessment. There was no evidence of a physician order for oxygen on the 10/24/2022 hospice plan of care. An interview with the Administrator on 10/31/2022 stated that the plans were not accurate for completed medication and treatment orders. Clinical Record 10: The 01/08/2022 hospice plan of care read wound care right upper buttock, clean with wound cleanser, cover with hydrocolloid (absorptive/protective dressing) and change every 3 days and PRN (as needed) with no prn qualifiers. An interview with the Administrator on 11/01/2022 stated that the plans were not accurate for completed medication and treatment orders. Clinical Record 11: The 09/01/2022 nursing start of care assessment documented that the patient had nephrostomy (a tube thru the skin into the kidney) tubes that were covered with 2x2 gauze and Tegaderm (breathable clear occlusive dressing) upon clinician arrival. The assessment also indicated the patient had a gastrostomy (a tube passed thru the skin into the stomach) and that the caregiver was administering bolus feedings and site care as ordered. The 09/03/2022 nursing assessment indicated the right nephrostomy tube was flushed with ease and the left nephrostomy tube could not be flushed at the time of the visit. The 09/01/22 hospice plan of care did not include physician orders for nephrostomy or gastrostomy care. The 09/01/2022 hospice plan of care, "the coccyx wound, cleanse with wound cleanser and apply wet to dry dressing, and cover with ABD (abdominal) pad and foam dressing to be changed daily and PRN (as needed)," with no specification of what solution was to be used for the wet to dry component and no prn dressing change qualifiers. The 09/03/2022 physician's order read to cleanse the wound with wound cleanser, pack with gauze soaked in Dakin's solution then cover with ABD pad and tape daily and prn with no prn qualifier. An interview with the Administrator on 11/01/2022 stated that the plans and physician orders were not accurate for completed treatment orders.

It is required that a hospice aide provides services ordered by the interdisciplinary group and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interview. 1 of 8 (12%) records in which a hospice aide provided service, the agency did not ensure the aide performed the tasks as assigned on the hospice aide care plan. Clinical Record 7: The 08/23/2022 aide task assignment sheet completed by the RN read nail care weekly. The aide's visit notes dated 08/26/2022-10/25/2022 indicated the task was completed with each visit. Aide visits were provided three times a week. An interview with the Administrator on 11/01/2022 stated that the nail care was provided each visit and not weekly as ordered.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated, and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by a review of clinical records and interviews. 11 of 11 (100%) clinical records reviewed revealed the agency did not ensure all medical record entries included credentials with the associated signature. Clinical Record 1: All physician's orders, plans of care, and coordination notes entered by the Administrator did not include the Administrator's Registered Nurse (RN) credentials. An interview with the Administrator on 10/31/2022 stated after a review of the records that the signature did not contain the required RN credentials. Clinical Record 2: All physician's orders, plans of care, and coordination notes entered by the Administrator did not include the Administrator's Registered Nurse (RN) credentials. An Interview with the Administrator on 10/31/2022 stated after a review of the records that the signature did not contain the required RN credentials. Clinical Record 3: All physician's orders, plans of care, and coordination notes entered by the Administrator did not include the Administrator's Registered Nurse (RN) credentials. An interview with the Administrator on 10/31/2022 stated after reviewing the records that the signature did not contain the required RN credentials. Clinical Record 4: All physician's orders, plans of care, and coordination notes entered by the Administrator did not include the Administrator's Registered Nurse (RN) credentials. An interview with the Administrator on 10/31/2022 stated after reviewing of the records that the signature did not contain the required RN credentials. Clinical Record 5: All physician's orders, plans of care, and coordination notes entered by the Administrator did not include the Administrator's Registered Nurse (RN) credentials. An interview with the Administrator on 10/31/2022 stated after reviewing of the records that the signature did not contain the required RN credentials. Clinical Record 6: All physician's orders, plans of care, and coordination notes entered by the Administrator did not include the Administrator's Registered Nurse (RN) credentials. An interview with the Administrator on 10/31/2022 stated after reviewing of the records that the signature did not contain the required RN credentials. Clinical Record 7 All physician's orders, plans of care, and coordination notes entered by the Administrator did not include the Administrator's Registered Nurse (RN) credentials. An interview with the Administrator on 10/31/2022 stated after reviewing of the records that the signature did not contain the required RN credentials. Clinical Record 8: All physician's orders, plans of care, and coordination notes entered by the Administrator did not include the Administrator's Registered Nurse (RN) credentials. An interview with the Administrator on 10/31/2022 stated after reviewing of the records that the signature did not contain the required RN credentials. Clinical Record 9: All physician's orders, plans of care, and coordination notes entered by the Administrator did not include the Administrator's registered nurse (RN) credentials. An interview with the Administrator on 10/31/2022 stated after reviewing of the records that the signature did not contain the required RN credentials. Clinical Record 10: All physician's orders, plans of care, and coordination notes entered by the Administrator did not include the Administrator's Registered Nurse (RN) credentials. An interview with the Administrator on 10/31/2022 stated after reviewing of the records that the signature did not contain the required RN credentials. Clinical Record 11: All physician's orders, plans of care, and coordination notes entered by the Administrator did not include the Administrator's Registered Nurse (RN) credentials. An interview with the Administrator on 10/31/2022 stated after reviewing of the records that the signature did not contain the required RN credentials.