Every finding on record at Haven Hospice Il LLC

It is required that the hospice must develop an individualized written plan of care for each patient. The plan of care must reflect patient and 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. This standard was not met as evidenced by clinical record review and interview. In 1 of 17 (6%) clinical records reviewed revealed the agency did not ensure that the individualized plan of care (PO) included interventions and goals based on problems identified in the initial, comprehensive, and updated comprehensive assessments. CLINICAL RECORD 5: This patient elected the hospice benefit on 10/26/2023 with a terminal diagnosis of Alzheimer's Disease. The Face to Face (F2F) visit dated 11/28/2025 documented the patient ate 2 meals per day and seemed to cough more at lunch and dinner meals. The certificate of terminal illness (CTI) dated 11/28/2025 stated the patient was coughing with thin liquids and a regular diet and was a high aspiration risk. The hospice plan of care was reviewed for the dates of 12/04/2025-01/14/2026. There were no individualized problems, goals, or interventions in the written plan of care specifically addressing the aspiration risk. An interview was conducted with the Vice President of Operations on 01/14/2026 and it was agreed that the plan of care did not include interventions for the aspiration risk.

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 1 of 17 (6%) clinical records reviewed for patients who received hospice aide services, the agency did not ensure that the hospice aide received written patient care instructions to meet the patient's needs. CLINICAL RECORD 5: This patient elected the hospice benefit on 10/26/2023 with a terminal diagnosis of Alzheimer's Disease. The Face to Face (F2F) visit dated 11/28/2025 documented the patient ate 2 meals per day and seemed to cough more at lunch and dinner meals. The certificate of terminal illness (CTI) dated 11/28/2025 stated the patient was coughing with thin liquids and a regular diet and was a high aspiration risk. The hospice plan of care was reviewed for the dates of 12/04/2025-01/14/2026. There were no individualized problems, goals, or interventions in the written plan of care specifically addressing the aspiration risk and no specific instructions for the hospice aide. An interview was conducted with the Vice President of Operations on 01/14/2026 and it was stated that the hospice aide care plan did not provide clear written instructions for the hospice aide.

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. A joint review of the agency report titled "Hospice Volunteer Requirement Report" with the Administrator (Personnel Record 7) and Volunteer Coordinator (Personnel Record 9) on 01/14/2026 revealed that the volunteer utilization was 1.47% for the year of 2025, which did not meet the requirement of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. During an interview on 01/14/2026, the Volunteer Coordinator (Personnel Record 9) and Administrator (Personnel Record 7, it was stated that the past year was a transitional year, but the last three months of 2025 saw an increase in volunteer hours and there was an active plan to increase the program. The agency had also implemented a performance improvement plan (PIP) to re-build the volunteer program. A joint review of the agency report titled "Hospice Volunteer Requirement Report" with the Administrator and Volunteer Coordinator on 01/14/2026 revealed that the volunteer utilization was 1.47% for the year of 2025, which did not meet the requirement of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. PERSONNEL INTERVIEW 2: During an interview on 01/14/2026, the Volunteer Coordinator and Administrator stated that the past year was a transitional year, but the last three months of 2025 saw an increase in volunteer hours and there was an active plan to increase the program. The agency had also implemented a performance improvement plan (PIP) to re-build the volunteer program.

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 a review of clinical records, interviews and observations. In 3 of 11 (27%) clinical records reviewed, the written plans of care were not individualized to include planned interventions and patient and family goals related to problems identified by the Registered Nurse in the initial and updated comprehensive assessments. Clinical Record 1 - Patient with election of hospice benefit on 1/10/23 with a hospice diagnosis of Senile Degeneration of the Brain. The nursing comprehensive assessment visit note dated 1/10/23 documented, "edema noted to bilateral extremities 2+... increased difficulty swallowing as well as some coughing while and after eating and drinking." During a joint home visit to the patient on 2/15/23, the registered nurse confirmed the presence of edema as an ongoing problem and stated, "she (the patient) has an issue with dependent edema in her feet and her feet turn purple". There were no individualized problems, goals, or interventions in the written plan of care specifically addressing edema or dysphagia. Clinical Record 3 - Patient with election of hospice benefit on 2/3/23 with a hospice diagnosis of Senile Degeneration of the Brain. The nursing comprehensive assessment visit note dated 1/27/23 documented, "edema noted to BLE (bilateral lower extremities) 2+... pureed diet with thin liquids and must be fed. Pt (patient) is high risk for aspiration". There were no individualized problems, goals, or interventions in the written plan of care specifically addressing edema or the risk for aspiration. Clinical Record 6 - Patient with election of hospice benefit on 1/13/23 with a hospice diagnosis of Cerebral Atherosclerosis. The nursing comprehensive assessment visit note dated 1/13/23 documented, "dysphagia leading to recurrent aspiration... patient is on a pureed diet." The assessment also documented, "dyspnea on exertion... dyspnea score: 5" (on a 0-10 scale), and "patient-reported dyspnea score goal of 0 (zero)" on a scale of 0-10". In addition, a nursing visit note updating the comprehensive assessment on 1/15/23 documented the insertion of an indwelling Foley catheter. There were no individualized goals, or interventions in the written plan of care specifically addressing dyspnea, dysphagia, or an indwelling Foley catheter. Staff 2 - In an interview on 2/16/23, the Alternate Administrator agreed the plan of care should be more specific and individualized in relation to the issues identified by the registered nurse in the assessments.

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 a review of clinical records and interviews. In 2 of 9 (22%) clinical records reviewed in which hospice aide services were provided, it was revealed that the agency did not provide specific instructions on the hospice aide care plan. Clinical Record 3 - Patient with election of hospice benefit on 2/3/23. The nursing comprehensive assessment visit note dated 2/3/23 documented, "transfer patient from bed to Broda chair with the use of a Hoyer (lift)." The hospice aide plan of care included a task to "transfer client from bed/chair" with a frequency of "every visit" but did not include instructions related to the use of a Hoyer lift. Clinical Record 6 - Patient with election of hospice benefit on 1/13/23. A nursing visit note dated 1/15/23 documented the insertion of an indwelling Foley catheter. The hospice aide care plan did not alert the aide that the patient had an indwelling Foley catheter and did not include instructions for catheter care the aide was to follow. Staff 1 - In an interview on 2/16/23, the Administrator confirmed the hospice aide plans of care were missing some of the specific instructions to guide the aide.