Every finding on record at Lake Forest Hospice

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees and Federal, state, tribal, regional, and local emergency management agencies. Upon review of the hospice emergency plan, there was not evidence of an alternate means of communication for federal, state, tribal, regional, and local management agencies.

Upon patient record review, 4 of 14 (Patients # 3, 10, 11, 13) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patients # 3, 10, 11, 13: The initial comprehensive assessment in the patients' medical records did not contain evidence that during the comprehensive assessment the imminence of death was assessed and taken into consideration.

Upon patient record review, 1 of 14 (Patient # 1) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient # 1: Upon home visit, during medication reconciliation of medications the patient's medication profile contained orders for, a) Acetaminophen 325 mg, 2 tabs oral, as needed for mild pain and, b) Milk of Magnesia 2400/30ml, 2 tablespoons oral, as needed for constipation. The patient did not have these medications available for use.

Upon patient record review, 2 of 14 (Patients # 1, 4) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/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. Patient # 1: The patient's comprehensive assessment 12/2/25 contained a description of a skin tear to the left forehead. The patient's plan of care did not address the skin tear in the goals and interventions. Patient # 4: The patient's comprehensive assessment 12/23/25 contained a description of redness to the left great toe and an open wound to the left foot. The patient's plan of care did not address the redness or wound in the goals and interventions.

Upon patient record review, 3 of 14 (Patients # 1, 2, 3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient # 1: During home visit and review of patient's supplies, the patient had and was using shampoo, moisture barrier pads, wipes, gloves and adult briefs. These supplies were confirmed with the nurse. The latest plan of care 1/7/26, did not contain these supplies. Patient # 2: During home visit and review of patient's supplies, the patient had and was using moisture barrier pads, wipes, gloves and adult briefs. These supplies were confirmed with the aide. The latest plan of care 1/7/26, did not contain these supplies. Patient # 3: During home visit and review of patient's supplies, the patient had and was using moisture barrier pads, wipes, gloves and adult briefs. These supplies were confirmed with the nurse. The latest plan of care 1/7/26, did not contain these supplies.

Upon personnel record review, 1 of 14 (Personnel # 10) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient. ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. Personnel # 10: The Aide's 2024 and 2025 competency evaluations did not contain evidence that the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff was assessed as part of the annual competencies.

Upon patient record review, 13 of 14 (Patients # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 14) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable. Patient # 1: The aide plan of care dated 12/2/25 contained instructions to change the linens. There was no indication of the frequency for the task to be performed by the aide. Patient # 2: The aide plan of care dated 10/2/25 contained instructions to turn and reposition, record bowel movements, feeding assistance, and change the linens. There was no indication of the frequency for the task to be performed by the aide. Patient # 3: The aide plan of care dated 7/10/25 contained instructions to turn and reposition, record bowel movements, feeding assistance, and change the linens. There was no indication of the frequency for the task to be performed by the aide. Patient # 4: The aide plan of care dated 12/4/25 contained instructions to change the linens. There was no indication of the frequency for the task to be performed by the aide. Patient # 5: The aide plan of care dated 1/9/26 contained instructions to record bowel movements, and change the linens. There was no indication of the frequency for the task to be performed by the aide. Patient # 6: The aide plan of care dated 12/16/25 contained instructions to change the linens. There was no indication of the frequency for the task to be performed by the aide. Patient # 7: The aide plan of care dated 12/11/25 contained instructions to record bowel movements, and change the linens. There was no indication of the frequency for the task to be performed by the aide. Patient # 8: The aide plan of care dated 10/17/25 contained instructions to turn and reposition, record bowel movements, and change the linens. There was no indication of the frequency for the task to be performed by the aide. Patient # 9: The aide plan of care dated 9/14/25 contained instructions to turn and reposition, record bowel movements, feeding assistance, and change the linens. There was no indication of the frequency for the task to be performed by the aide. Patient # 10: The aide plan of care dated 5/15/24 contained instructions to turn and reposition, record bowel movements, feeding assistance, and change the linens. There was no indication of the frequency for the task to be performed by the aide. Patient # 12: The aide plan of care dated 7/23/25 contained instructions to turn and reposition, record bowel movements, feeding assistance, and change the linens. There was no indication of the frequency for the task to be performed by the aide. Patient # 13: The aide plan of care dated 3/6/25 contained instructions to turn and reposition, record bowel movements, feeding assistance, and change the linens. There was no indication of the frequency for the task to be performed by the aide. Patient # 14: The aide plan of care dated 10/24/25 contained instructions to record bowel movements, feeding assistance, change the linens, and assist with oral medication per RN instructions. There was no indication of the frequency for the task to be performed by the aide.

Upon patient record review 1 of 14 (Patient # 5) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient # 5: The patient medical record did not contain evidence of a Registered Nurse completing an on-site supervisory visit every 14 days to assess the quality of care provided by the hospice aide. A supervisory visit occurred on 12/22/25, and the next supervisory visit occurred on 1/12/26.

Upon client record review, 1 of 14 (Patient # 11) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient # 11: The patient's medical record did not contain evidence that a copy of the discharge summary was sent to the attending physician when the patient revoked.

Upon patient record review, 4 of 11 (Patient #1, #5, #6, and #9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patients #1, #5, #6 and #9 medication profile for Miralax 17 grams oral for solution. A diluent was not included.

Upon patient record review, 4 of 11 (Patient #1, 5, 6, 9) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patients #1, #5, #6 and #9 revealed an order for Miralax 17 grams oral for solution. A diluent was not included in the order.

Upon personnel record review, 1 of 15 (Personnel #8) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records since date of hire on 5/17/21.