Every finding on record at Hospice of Kankakee Valley Inc.

A. Based on observation during a home visit, clinical record review and staff interview, it was determined the IDT failed to update the POC to address a change in the patient's skin status. This was found in 1 of 4 (Pt. #4) clinical records reviewed of Pts. requiring wound care. Findings include: 1. Pt. #4. Hospice Diagnosis: Neoplasm of Uncertain Behavior of Trachea, Bronchus and Lung. A home visit was conducted on 9/27/22 at 10:00 AM with E#2. During the home visit, observed a clear plastic bag containing a bandage/dressing inside, taped to a cabinet next to the patient's bed. The plastic bag had the patient's initials written on the bag and instructions to change the dressing to the right great toe every third day. During the visit, also observed a bandage to the right great toe. The clinical record was reviewed on 9/26/22 at 3:00 PM, and contained the recertification POC for the certification period of 7/30/22 to 9/27/22; and IDT meeting minutes dated 8/11/22, 8/25/22, 9/8/22 and 9/22/22. The POC and/or IDT meeting minutes lacked documentation of a description, status and/or wound care of the right great toe. 2. During an interview with the Executive Director, Director of Clinical Services, Director of Social Services, Director of Compliance/QAPI Coordinator, Human Resources Director, Clinical Staff Educator, and Operations Manager on 9/28/22 at 3:25 PM, the administrative staff were not aware that Pt. #4 had a wound to the right great toe and/or received wound care to this site. During the same interview, the above findings were confirmed.

4. Pt. #8. SOC 7/29/22. Hospice Diagnosis: Multiple Sclerosis. The clinical record was reviewed on 9/28/22 at 9:50 AM. The record contained the SN admission visit note dated 7/28/22, which documented Pt. #8 had a stage 2 coccyx pressure ulcer, measuring 0.5 cm long x 0.5 cm wide. The record also included the 7/29/22 SN visit note, which documented the wound was on Pt. #8's "right buttock." The record also contained the 7/29/22 physician's order: "Right buttocks pressure ulcer, cleanse with wound cleanser, apply therahoney, and cover with optifoam, SN will assess weekly ..." The record lacked weekly SN wound assessments/measurements for the week of 7/31/22 to 8/6/22 and the week of 8/7/22 to 8/13/22. 5. The Hospice policy titled "Pressure Ulcers and Wound Care" was reviewed on 9/28/22 at 12:30 PM. The policy required: " ...Must chart on skin condition and wound at least 1x week ...measurements: length x width x depth ..."6. During an interview with the Executive Director, Director of Clinical Services, Director of Social Services, Director of Compliance/QAPI Coordinator, Human Resources Director, Volunteer Coordinator, Clinical Staff Educator, and Operations Manager on 9/28/22 from 1:37 PM to 3:45 PM, the above findings were confirmed. The Director of Clinical Services stated wounds should be assessed during every SN visit, and measured and documented weekly for length, width, depth, color, odor, and presence of drainage. 3. Pt. #7 SOC: 1/11/22 Hospice Diagnosis: Chronic Diastolic Congestive Heart Failure. The clinical record was reviewed on 9/28/22 at 9:58 AM. The record contained the weekly "SN for Visit Summary" notes dated 9/16/22 and 9/22/22 which lacked documentation of an assessment to include measurements, and progress of Pt. #7's pressure ulcers to the buttocks and coccyx. 2. Pt. #4. Hospice Diagnosis: Neoplasm of Uncertain Behavior of Trachea, Bronchus and Lung. A home visit was conducted on 9/27/22 at 10:00 AM with E#2. During the home visit, observed a bandage/dressing in a clear plastic bag taped to a cabinet next to the patient's bed. The plastic bag contained instructions for wound care to the right great toe. During the visit, E#2 removed the patient's right sock and a bandage was observed to the right toe. The clinical record was reviewed on 9/26/22 at 3:00 PM, and contained the SN visit notes for 1 to 2 times a week from 8/3/22 to 9/20/22 which lacked an assessment and/or wound care for the right great toe. A. Based on clinical record review, observation during a home visit, Hospice policy review and staff interview, it was determined the Hospice failed to ensure clinical documentation entered into the clinical record was complete. This was found in 4 of 4 (Pts. #13, 4, 7 and 8) clinical records reviewed, wherein the Pts. required wound care. Findings include: 1. Pt. #13. SOC 5/6/22. Hospice Diagnosis: Alzheimer's Disease. The clinical record was reviewed on 9/28/22 at 9:00 AM. The record included documentation the Pt. had a wound located to the coccyx. The weekly SN visit notes dated 8/5/22, 8/11/22, 8/12/22, 8/17/22, 8/19/22, 8/24/22, 8/26/22, 8/29/22, 9/2/22, 9/6/22, 9/8/22), 9/14/22, 9/19/22 and 9/21/22 lacked documentation of an assessment of the coccyx wound. The SN visit notes dated 9/6/22, 9/8/22, 9/14/22, 9/16/22, 9/19/22 and 9/21/22 lacked an assessment and a description of the newly developed right buttock and right foot wounds. The SN visit notes indicated above lacked documentation of the patient's wounds, as required by the Hospice policy.

2. The volunteer file of Volunteer #2 (date of hire 3/1/13) was reviewed with the Volunteer Coordinator on 9/27/22 at 1:50 PM. The file lacked documentation of annual employment verification in 2020 and 2021. 3. The volunteer file of Volunteer #3 (date of hire 2/25/17) was reviewed with the Volunteer Coordinator on 9/27/22 at 2:03 PM. The file lacked documentation of annual employment verification in 2020 and 2021. 4. The Illinois Administrative Code 955.1456 includes: "Employment Verification a) Each health care employer or its designee shall provide an employment verification and update the demographic information for each employee no less than annually. (Section 33(i) of the Act)." 5. During an interview on 9/28/22 at 1:37 and 2:30 PM with the Executive Director, Director of Clinical Services, Director of Social Services, Director of Compliance/Quality Assurance Performance Improvement Coordinator, Human Resources Director, Volunteer Coordinator, Clinical Staff Educator, and Operations Manager, the above findings were confirmed. B. Based on review of Volunteer files, the Illinois Administrative Code, Hospice Policy and staff interview, it was determined the Hospice failed to ensure health requirements were met. This was found in 6 of 6 Volunteer files that provide direct Pt. care (Volunteers #1, 2, 3, 4, 5, and 6). Findings include: 1. The Volunteer files of Volunteers #1, 2, 3, 4, 5, and 6 were reviewed on 9/27/22 at 1:15 PM, along with the Volunteer Coordinator. All of the above Volunteer files lacked physical examinations/completed health questionnaires. 2. The 77 Illinois Administrative Code 280.2045 c) 1-2) 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." 3. The Hospice Policy titled "Volunteer Medical Requirements" was reviewed on 9/28/22 at 1:00 PM. The policy required: " ...Health screenings and/or additional physicals are suggested for some professions or special situations ...New Volunteers are required to complete the Agency's Health Questionnaire ..." 4. During an interview with the Executive Director, Director of Clinical Services, Director of Social Services, Director of Compliance/Quality Assurance Performance Improvement Coordinator, Human Resources Director on 9/28/22 at 1:37 and 2:30 PM; the Volunteer Coordinator, Clinical Staff Educator, and the Operations Manager confirmed the above findings. . A. Based on a review of personnel and volunteer files, the Illinois Administrative Code, and staff interview, it was determined that the Hospice failed to log into the Health Care Worker Registry Web Portal to complete annual employment verification and maintain documents in volunteers/personnel files per regulations. This was found in 3 of 15 (E#1 and Volunteers #2 and 3) unlicensed volunteers and personnel that provide Pt. care services. Findings include: 1. On 9/27/22 at 1:30 PM, the personnel file of E#1 (Hospice Aide, date of hire 1/28/19) was reviewed. The file lacked a Health Care Worker Registry Web Portal profile page that included documentation of annual employment verification in 2021 with this Hospice.