Every finding on record at Osf Healthcare System

Based on Hospice document review and staff interview, it was determined for 1 of 1 complaint reviewed, the Hospice failed to ensure its complaint/grievance policy was followed. --- Findings Include: 1. Review of Policy titled Patient Complaint and Grievance (Effective 10/23/24) was completed. The Policy defines ";Patient grievance: A formal or informal written or verbal complaint that is made to the facility by a patient or the patients representative regarding: a. The patients care, when the complaint is not resolved at the time of the complaint by Mission Partners present." The Policy states the process of ";...when a verbal complaint is received immediately take action to resolve if authorized to do so. If unable to resolve the complaint, Mission Partners contact department Leader and/or Administrative Supervisor...The designated Mission Partner resolves, documents, and communicates status of the grievance resolution according to the following guidelines: Leader or designee will address complaint/grievance within required timeframe, as applicable." 2. Pt # 2 SOC 8/13/24 Diagnosis: Cognitive function following CVA (Cerebrovascular Accident). The clinical record was reviewed on 03/10/25 at approximately 12:00 PM. The ";Telephone Encounter" dated 2/11/2025 stated ";...Also, during the telephone call, daughter expressed frustration with nursing visit notification and those visits changing from Tuesdays to Wednesdays without her knowledge. This VC (Volunteer Coordinator) sent a message to the case manager for follow-up". No evidence of follow-up was noted in the patient record. 3. The Complaint and Grievance log for the Facility was reviewed on 3/11/25 at approximately 9:45 am. There was no record of this grievance noted as being recorded on the Complaint and Grievance log. 4. An interview with the Quality and Safety Coordinator (E #2) was completed on 3/11/25 at approximately 3:15 PM. E #2 verbally confirmed no complaint or grievance had been filed for this issue, further stating the grievance ";was not escalated or passed on to leadership as it should have been."

Based on document review and staff interview, it was determined for 1 of 14 (Pt #3) patient records reviewed, the Hospice failed to ensure the POC (Plan of Care) was followed. --- Findings include: 1. A review of the policy titled "Home Care Aide (HCA) Services (effective 1/24/25)" was completed. The policy states, "Process:...2. The Plan of Care is documented in the electronic health record (EHR) and outlines patient demographics and includes specific instructions for patient care that the HCA provides. The HCA documents their interventions in the electronic medical record." 2. Pt # 3 SOC 3/4/25 Diagnosis: Cirrhosis of the liver without ascites. The clinical record was reviewed on 03/10/25 at approximately 12:00 PM. The "Plan of Care-Update A" dated 03/04/25 noted the Aide was to visit the patient 1 time a week for 1 week. During the week of 03/04/25, the record lacked documentation of an Aide visit. 3. During an interview on 3/11/25 at approximately 10:00 AM, E#2 (Quality and Safety Coordinator) reviewed the clinical record of Pt #3. E#2 verbally agreed the visits were not conducted or documented in the EHR as ordered on the POC and should have been.

Based on document review and staff interview, it was determined the Hospice failed to ensure volunteers provided at minimum, 5 percent of day-to-day administrative and/or direct patient care services of total patient care hours. --- Findings include: 1. On 3/11/25 at 9:45 AM, the ";Volunteer Cost Savings Report" was reviewed. The average for the past 12 months indicated 1% of volunteer hours were utilized, under the minimum 5% requirement. 2. On 3/11/25 at 10:00 AM, an interview was conducted with the Volunteer Coordinator (E #7). E #7 reviewed the volunteer hours for 2024 and confirmed the average was below the 5% requirement. E #7 stated, ";Our patient census has been low, and we also had a couple of volunteers off for personal reasons." 3. On 3/13/25 at 10:20 AM, an interview was conducted with the Hospice Director (E #3). E #3 reviewed the volunteer hours for 2024 and stated, "Yes, I'm aware we did not meet that 5% requirement. After COVID our volunteer numbers went down drastically, and it has been a struggle trying to recruit more volunteers. We have been trying to come up with a plan to get our volunteer numbers back up."

Based on document review and interview, it was determined for 1 of 3 (Pt #10) patients records reviewed from the SOC (start of care), the Agency failed to ensure the comprehensive assessment was completed by all disciplines within the 5 days. This has the potential to affect all patients treated by the Agency with a current census of 13 patients. Findings include: 1. Pt #10 SOC: 3/11/22 Diagnosis: Malignant Neoplasm of Cerebellum. The record was reviewed on 3/31/22 at approximately 11:30 AM. The record noted the Pastoral Care and Bereavement visit was conducted on 3/18/22, greater than the 5 day requirement. 2. During an interview on 4/1/22 at approximately 10:00 AM, the Regulatory Coordinator of Quality and Safety (E#1) verbally agreed the Pastoral Care and Bereavement visit had not been conducted within the 5 day requirement and should have been.

Based on observation, document review and interview, it was determined for 1 of 3 (Pt #3) home visits, the Agency failed to ensure the patient's caregiver was educated on medications available and ensured medications were administered per order. This has the potential to affect all patients who receive care by the Agency with a current census of 13 patients. Findings include: 1, During a home visit on 3/29/22 at approximately 1:30 PM, Pt #3's medications were reviewed with the patient's caregiver. The caregiver brought in to plastic tubs and stated one was active medication and the other was as needed medications only. The following discrepancies were identified: *In the active medication tub: a) 3 bottles of Depakote 500 mg (milligram) tablets with fill dates of 10/21/21, 1/16/22 and 1/16/22. The 1/16/22 were from two different pharmacies. b) 2 bottles of Metoprolol 25 mg tablets with fill dates of 10/14/21 and 3/23/22. c) 2 bottles of Trazadone 100 mg tablets with fill dates of 1/29/21 and 7/24/21. The active medication list dated 3/29/22 lack documentation of of how often to take, which route and the indication for the medication. * In the as needed tub: a) 2 bottles of Gabapentin. the bottle filled on 11/30/21 noted Gabapentin 100 mg three times a day and the one dated 1/26/22 noted Gabapentin 300 mg three times a day. The Medication List dated 3/29/22 noted Gabapentin 100 mg three times daily. b) 1 bottle of Cardvedilol 3.125 mg 1 tablet twice daily as needed, although the active medication list dated 3/29/22 lacked documentation of Cardvedilol. c) The bottle of Xanax noted "Take 0.5 mg by mouth 3 times daily as needed..." The bottle of Xanax dated 6/4/21 noted to take the medication four times daily. The active medication list dated 3/29/22 noted the comfort kit medications (Haldol, Anaspaz, Morphine and Compazine) although the medications were not in either tub. 2. During an interview on 3/29/22 at approximately 1:35 PM, Pt #3's caregiver was asked if there were any other medications in the home such as a comfort care kit, the caregiver stated there were no other medications in the home. When Pt #3's caregiver was asked about which medications were given to Pt #3 if there were multiple bottles, the caregiver was unable to differentiate which medications were to be given. 3. During an interview on 3/29/22 at approximately 3:00 PM, the Hospice Manager (E#2) reviewed Pt #3's medication list and the findings in the home were discussed. E#2 verbally agreed the medication discrepancies needed to be clarified and multiple bottles should not have been available to the Pt #3's caregiver. E#2 stated "I will have someone go there and get this straightened out. It sounds like he/she needs a pill box."

Based on document review and interview, it was determined the for 1 of 5 (Pt #2) patients records reviewed, the Agency failed to ensure medication orders were obtained. This has the potential to affect all patients who receive care by the Agency with a current census of 13 patients. Findings include: 1. Pt #2 Start of Care (SOC): 6/14/21 Diagnosis: Ischemic Cardiomyopathy. The record was reviewed on 3/30/22 at approximately 12:50 PM. The Home Visit note authored by the Licensed Practical Nurse (E#3) and dated 2/11/11 at 10:12 AM to 11:08 AM, noted "Questioned if patient was taking her/his Lasix (diuretic to remove excess water in the body), she/he replied yes, 1 20 mg (milligram) tab (tablet) daily." The note lacked documentation of physician notification and/or change in orders. The Home Visit note authored by the Registered Nurse (E#4) and dated 2/15/22 noted "Per patient and son... E#3 d/c (discontinued) lasix." An electronic order authored by E#4 and dated 2/15/22 at 11:11 AM, after the home visit, noted to discontinue the Lasix. The visit note dated 2/22/22 authored by E#3 noted "Patient reported increased shortness of breath and fluid retention. This writer observed bilateral fluid filled pockets under eyes, Edema in lower legs also increased to a 3+ non-pitting... Dr... oxygen ordered and Lasix 80 mg bid (twice daily) x (times) 3 days." 2. During an interview on 3/30/22 at approximately 2:00 PM, the Regulatory Coordinator of Quality and Safety (E#1) reviewed Pt #2's record and verbally agreed an order to discontinue the Lasix had not been obtained and should have been. E#1 verbally agreed E#3 was not qualified to receive physician orders and a skilled nurse should have received the orders to discontinue the Lasix on 2/11/22.