Every finding on record at Maple Creek Hospice Inc

Based on document review and staff interview it was determined that the Agency failed to ensure that volunteers provided a minimum of 5% of total patient care hours of all hospice paid employees. --- 1. On 1/15/24, a document titled, ";Volunteer Branch Reporting" for January 2024 through January 2025 was reviewed. Documentation indicated that the Facilitys total number of patient care hours were 1,765.52 and total volunteer hours were 37.5. When computed, this amount is equal to 2.13%, which is less than 5%. 2. During an interview with the Administrator (E #2) on 1/15/25 at 2:00 PM, the above findings were confirmed. E#2 states they have made social media posts, attended vendor fairs, and sent out mail to local businesses this year to recruit volunteers. The facility has an upcoming interview scheduled for this month.

Based on document review and staff interview it was determined the Hospice failed to ensure when the medical director is not available, a physician designated by the hospice assumes the same responsibilities and obligations as the medical director. Findings include: --- 1. On 01/14/25 at approximately 1:00 PM, a request was made to the administrator (E#2) for documentation designating a replacement for the medical director when he/she is not available. E#2 provided the personnel record on the individual the Hospice has designated as a replacement (E#8 - Physician). Upon review of the personnel record, E#8 does not hold a license to practice medicine in the State of Illinois. 2. A Hospice document titled, "Professional Services Agreement Team Physician" dated 12/12/24, and signed by E#1 (VPO - Vice President of Operations), E#2, and E#8 includes the following - "... This Agreement is made this 12th day of December 2024, effective as of December 13th, 2024, by and between (Name of Hospice) and (E#8), a physician ... 1. Purpose: (Name of Hospice) desires to engage a qualified physician to act as a Team Physician for their hospice care program. The Team Physician is a physician ..., is licensed as a Doctor of Medicine or Osteopathy in the State of Illinois, ... 2. Obligations of Team Physician: 2.1 Status and Membership. The Team Physician will remain in full compliance with all of the following conditions continuously during the entire term of this Agreement. Failure of the Team Physician to satisfy any or all of the following conditions will constitute grounds for automatic termination of this Agreement ... A. Team Physician will be licensed as a Doctor of Medicine or Osteopathy in the State of Ilinois without restriction ...; B. Team Physician will be a member in good standing of the active category of the Medical Staff of (Name of Hospice) without restriction ...; C. Team Physician ... and in direct compliance with all state ... regulations, and standards. 3. An interview was conducted with E#2 on 01/14/25 at 2:00 PM. E#2 reported E#8 was hired in December of 2024 as the back-up physician and paperwork for a license to practice medicine in Illinois is pending.

Based on a request for documents and staff interview it was determined the Hospice failed to ensure when the medical director is not available, a physician designated by the hospice assumes the same responsibilities and obligations as the medical director. This has the potential to affect all patients serviced by the Hospice with a current census of 6 patients and an unduplicated 12-month census of 38 patients. Findings include: 1. On 12/27/21 at approximately 1:30 PM, a request was made to the administrator (E #1) for documentation designating a replacement for the medical director when he/she is not available. E#1 was unable to provide a name or documentation that the Hospice has a replacement designated. 2. An interview was conducted with E#1 on 12/27/21 at 2:00 PM. E#1 reported they have been looking for a back up medical director and have not been able to find an interested physician as of this survey.