Every finding on record at Osf Healthcare System

Based on record 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. During a review of Illinois Hospice Volunteer Statistics for October 2023 through September 2024 on 12/5/24, documentation indicated that total hours were 4784 and total volunteer hours were 80.85. This amount is less than 5% (1.69%). 2. During an interview with the Hospice Liaison (E #5) on 12/5/24 at 10:00 AM, the above findings were confirmed.

Based on observation, document review and interview, it was determined for 1 of 3 (Pt #3) patients observed during a home visit, the agency failed to ensure the patient's medication profile was updated to reflect the most current medication changes, including over the counter medications. This has the potential to affect all patients receiving hospice services. (current census of 20) Findings include: 1. During a home visit to Pt #3's home with Registered Nurse (E #3), on 11/30/2021 at approximately 2:30 PM, the following medication discrepancies were identified: The physician prescribed medication, Famotidine (Pepsid) 40 mg (milligram) 1/2 tablet twice daily (patient was not taking this medication) was observed in the home and was not listed on the medication profile dated 11/29/2021. The following over the counter medication were observed in the home, which were not listed on the medication profile dated 11/29/2021. During the home visit, the patient's wife stated that the patient was taking the following over-counter medications found in the home: Iron 65 mg 2 tablets a day; Centrum Men's Multivitamin 1 tablet daily; Calcium tablets 600 mg 2 tablets daily; Magnesium 250 mg 2 tablet daily; and B12 2,500 mcg (microgram) 2 tablets daily The following medications had a discrepancy between what was ordered; how the patient was taking the medication verses how the medication was is listed on the medication profile dated 11/29/2021; Allopurinal (Xyloprim) 100 mg tablet by mouth every day - Medication profile indicated the medication was discontinued, yet the patient was still taking it; Pt #3 was taking Metolazone (Zaroxolyn) 2.5 mg tablet twice weekly. Medication Profile indicated the dose was 2.5 mg by mouth once a month; and Pt #3 was taking Xarelto 15 mg tablet by mouth daily with food. Medication Profile indicated medication was discontinued. 2. The policy titled "Medication Reconciliation and Drug Review (A8600-0)" (effective by the facility; 5/10/2021) was reviewed on 12/1/2021 at approximately 2:00 PM. The policy required, "The clinician will review and validate the medication profile on each visit and will identify new or changes to current medications." 3. During an interview on 11/30/2021 at approximately 2:45 PM, with E #3 after the home visit, E #4 agreed and confirmed the Medical Profile had not been updated.