Every finding on record at Integrated Palliative and Hospice LLC

Based on a review of clinical records, Staff interviews and Hospice bereavement assessment, in 3 of 19 (Pts. #9, 10, and 19) clinical records reviewed, the Hospice failed to conduct an initial evaluation for bereavement. --- Findings include: 1.  The following clinical records were reviewed from 07/08/25 (1:40 PM) to 07/09/25 (11:30 AM): Pt. #9.    SOC 06/04/25.  Hospice diagnosis: Malignant Neoplasm of Mouth, Unspecified.Pt. #10.  SOC 05/16/25.  Hospice diagnosis: Spinal Stenosis, Site Unspecified. Pt. #19.  SOC 07/01/24.  Hospice diagnosis: Chronic Myelomonocytic Leukemia Not Having Achieved Remission.  Each of the clinical records indicated above lacked documentation that an initial bereavement assessment was conducted.  2. During an interview with the Clinical Manager on 07/09/25 at 1:48 PM, the Clinical Manager stated the nurse conducted the initial bereavement assessment during the Nurse initial comprehensive visit, the bereavement assessment was documented in a section of the assessment form titled, “Family Adaptation – Nurse” whereas the nurse inquired about the following:  “Patient resides, Caregiver’s name, Caregiver is a member of a facility staff, Caregiver resides with patient, Dependent family members, Children under 18, Number of persons living in home, Patient coping effectively, Family coping effectively, Caregiver coping effectively, Patient and family/caregiver interaction, Family conflict, Family/Caregiver emotional status”.  The assessment form lacked documentation of the name(s) of the bereaved, bereavement risk level; the bereaved gender, age, relations, coping challenges, stress/loss, support system, cultural barriers, as required by the Hospice’s Bereavement assessment. During the interview with the Clinical Manager, the above findings were confirmed.

Based on review of the Governing Board minutes and staff interview, the Hospice failed to ensure the frequency and details of the quality assessment and performance improvement program were approved by the Governing Board. --- Findings include:1.  The Governing Board minutes and Hospice quality assessment and performance improvement program were reviewed on 07/09/2025 at 11:30 AM. The 2023, 2024 and 2025 Governing Board minutes lacked documentation that the Governing Board met to approve the data collection, frequency and details of the quality assessment and performance improvement program.2. The findings were confirmed during the interview on 07/09/25 at 11:30 AM, with the Clinical Manager.

Based on a review of clinical records, Staff interviews, a review of the bereavement binder, and Hospice policy, in 1 of 3 (Pt. #19) bereaved clinical records reviewed, the Hospice failed to ensure post bereavement services were provided. --- Findings include: 1.  Pt. #19 was admitted for Hospice services on 07/01/24 with the Hospice diagnosis of Chronic Myelomonocytic Leukemia Not Having Achieved Revision.  The clinical record was reviewed on 07/08/25 at 1:40 PM.  The clinical record contained documentation that Pt. #19 expired on 08/05/24, and that the Hospice mailed a sympathy card to the bereaved 2 weeks after the patient’s death, the record lacked documentation that any other bereavement support was provided. 2.  During an interview with the Clinical Manager on 07/09/25 at 12:17 PM, the Clinical Manager stated that documentation of bereavement support is documented in the bereavement binder. 3.  On 07/09/25 at 1:18 PM, the Clinical Manager presented the bereavement binder.  The binder included a form titled, “Bereavement Plan of Care” with Pt. #19’s name, name of the bereaved, medical record number, and date of the patient’s death.  The form contained documentation that bereavement support was last provided 8/7/24.  The Hospice “Bereavement Plan of Care” form required the following to be conducted: “Three month letter mailed to family/PCG, Quarterly Assessment by Bereavement Coordinator, SW or RN and reviewed by IDG in 3 months, Six month letter mailed to family/PCG, Quarterly Assessment by Bereavement Coordinator, SW or RN and reviewed by IDG in 6 months, Nine month letter mailed to family/PCG, and Quarterly Assessment by Bereavement Coordinator, SW or RN and reviewed by IDG in 9 months”.  As of 07/09/25, the Hospice lacked documentation that bereavement support/services were provided as required by the Hospice. 4.  During the same interview with the Clinical Manager on 07/09/25, the Clinical Manager stated the Hospice is contracted with an outside company to send the bereaved the required mailings.  As of 07/10/25, the Hospice was unable to provide documentation that the outside company sent the required mailings indicated above to the bereaved. During interviews with the Clinical Manager on 07/09/25 at 12:17 PM and 07/10/25 at 11:36 AM, the above findings were confirmed with the Clinical Manager.

Based on review of the Hospice Aide employee files and staff interview, for 2 of 2 Hospice Aides (Employee #1 and 2), the Hospice failed to ensure Hospice Aides received an evaluation of competency skills by direct observation and/or written test. --- Findings include: 1.  The Hospice Aide employee files were reviewed on 07/07/25 at 11:30 AM.  The following Hospice Aide files lacked documentation of observation and/or written skills competency evaluation, prior to providing direct Pt. care:Employee #1.  Date of hire 07/06/22.Employee #2.  Date of hire 05/05/16. 2.  During a Staff interview with the Administrator and Assistant Administrator on 07/09/25 at 12:17 PM, the Administrator stated Employee #1 and Employee #2 are actively providing Pt. care.  During the same interview, the Administrator and Assistant Administrator confirmed the Hospice failed to ensure the Hospice Aides received an evaluation of competency skills, prior to providing Pt. care.

Based on staff interview and document review, the Hospice failed to maintain a signed contract for the Medical Director’s designee, to act in his absence. --- Findings include:        1.  On 07/09/2025 the contract was reviewed for the Medical Director.  The contract included the name of the Medical Director designee, to act in the absence of the Medical Director.     2. On 07/10/25 at 11:25 AM, an interview was conducted with the designee, who stated he is designated to cover the Medical Director in his absence. On 07/10/25, a signed written agreement was requested for the Medical Director designee.  A written agreement was not presented to surveyor by hospice staff.    3. During the interview with the Administrator, on 07/10/25 at 11:30 AM, the findings were confirmed.

A. Based on a review of personnel files, Hospice policy, and staff interviews, it was determined the Hospice failed to ensure that Criminal Background checks were obtained in accordance with requirements. This was found in 3 (Employees #1, #2 and #3) of 4 personnel files reviewed. Findings include: 1. Personnel files were reviewed on 7/26/22 at 2:30 PM. The following personnel files lacked criminal background checks: Employee #1 (RN) Employee #2 (RN) Employee #3 (MD) 2. The Hospice policy under Personnel Administration, titled "Personnel Record Contents Policy No. 1-006.1" was reviewed on 7/27/22 at 3:00 PM, and included: "Purpose: To specify the content of the personnel files for personnel and contract hospice staff... Procedure: Regular, Full, or Part Time Personnel: 1. The content of the personnel files for regular, full, or part-time personnel will include: New Hire Documents: Criminal background check (if applicable)..." 3. During an interview with the Chief Nursing Officer/Director of Nursing on 7/28/22 at 9:15 AM, the Chief Nursing Officer/Director of Nursing confirmed the above findings.

A. Based on a review of volunteer files, the Illinois Administrative Code, Hospice policy and staff interview, it was determined the Hospice failed to ensure the volunteer files were complete. This was found in 2 of 2 (Volunteer #1 and 2) volunteer files reviewed. Findings include: 1. The following volunteer files were reviewed on 7/26/21 at 12:30 PM and 3:20 PM, the files lacked documentation of a written job description: Volunteer #1 (clerical). Volunteer #2 (clerical). 2. 77 Illinois Administrative Code 280.2040j)2) required: "j) The hospuce program shall utilize the services of trained volunteers in accordance with the standards for certification under the Medicare program set forth in the Conditions of Participation in 42 CFR 418. (Section 8(j) of the Act) 2) Each volunteer shall have an accurate written job description. Volunteers shall only be assigned duties directly related to their job functions, as identified in the job description." 3. The Agency's policy titled, "Job Title/Position: Volunteer" was reviewed on 7/27/22 at 3:10 PM and included: "Job Description Summary.... Essential Job Functions/ Responsibilities... Position Qualifications..." This policy also require the Volunteer to sign and date the job description. 4. During the entrance interview on 7/25/22 at 10:20 AM with the Administrator and Chief Nursing Officer/Director of Nursing, the Chief Nursing Officer stated the Hospice has two (2) volunteers that perform clerical duties. 5. During an interview with the Chief Nursing Officer/Director of Nursing on 7/27/22 at 2:55 PM, the Chief Nursing Officer/Director of Nursing confirmed the volunteer personnel files lacked a written job description.