Every finding on record at Residential Hospice Illinois, LLC

Upon patient record review, 2 of 27 (Patient #22, 23) 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 #22 - The hospice medication profile did not contain Psyllium oral powder 1 packet daily or Docusate 100mg every evening. The facility medication profile did not contain Hydrocodone 5mg/325mg 1 tab every 6 hours PRN pain, Lorazepam, or Morphine as ordered by hospice. Patient #23- The facility medication profile did not contain Lorazepam 2mg/ml give 0.5 ml every 4 hours as needed for agitation.

Upon patient record review, 2 of 27 (Patient #16, 18) 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. Patient #16 - POC effective 04/16/26 did not contain frequency of wound care to penial laceration and wound care to L arm skin tear daily and PRN - no modifier for PRN. Patient #18 - POC contained "Change foley catheter as needed, no modifier for as needed

Upon client record review, 1 of 27 (Patient #26) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #26 - POC did not contain order for PT/INR completed on 04/17/26 or urine UA/culture on catheter 04/23/26.

Upon patient record review 1 of 27 (Patient #25) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #25 - Aide gave bed bath 2x week, week of 03/24/26 and 03/30/26 - but bed bath only ordered 1x week.

Upon patient record review 1 of 27 (Patient #20) did not have evidence in the patient record that the hospice aides report: • Changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities • Hospice aides must also complete appropriate records in compliance with the hospice's policies and procedures Patient #20 - The record did not have evidence of collaboration regarding three weeks of aide missed visits or plan to continue or discharge the aide services.

Upon patient record review 2 of 27 (Patient #9, 21) 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 #9 - As of 04/21/26 the record indicated that an aide supervisory visit was last conducted on 03/27/26. Patient #21 - As of 04/21/26 the record indicated that an aide supervisory visit had not been conducted since aide services started on 02/06/26.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The agency did not utilize at least 5% of the total patient care hours in 2025. The total usage of volunteers for 2025 was 1.5%.

Upon patient client record review, 3 of 27 (Patient #13, 16, 26) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #13 - Upon patient record review the Aide documented a missed visit reason on 04/20/26 as "patient death" but patient didn't expire. Patient #16 - SN documented 04/07/26 LPN supervisory visit, but LPN didn't make first visit until 04/21/26. Patient #26 - SN documented on 02/04/26 "PT/INR done" no details on how obtained, if finger stick or venipuncture.

Upon client record review, 1 of 27 (Patient #27) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #27 - POC dated 02/20/26 foley catheter #16/10cc to be changed every 30 days - no documentation in chart as of 04/23/26 that foley catheter had been changed as ordered.

Upon client record review, 2 of 27 (Patient #18, 27) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #18 - SNF resident admitted 02/16/26 with Foley catheter there is no documented evidence of coordinated Plan of Care between the hospice and SNF regarding who is responsible for catheter changes. Patient #27 - SNF resident admitted 11/22/25 with Foley catheter there is no documented evidence of coordinated Plan of Care between the hospice and SNF regarding who is responsible for catheter changes.

Upon patient record review 2 of 23 (Patient #2, 3) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #2 - SOC 11/17/2022 - initial SC visit made 11/30/2022. All disciplines did not complete comprehensive assessment within 5 days per agency policy. Patient #3 - SOC 04/07/2023 initial SC visit made 04/18/2023. All disciplines did not complete comprehensive assessment within 5 days per agency policy.

Upon patient record review, 6 of 23 (Patient #2, 5, 9, 12, 14, 15) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #2 - SOC 11/17/2022 unable to locate initial bereavement. Patient #5 - SOC 01/23/2023 initial bereavement 01/22/2023 completed prior to admission. Patient #9 - SOC 03/20/2023 unable to locate initial bereavement. Patient #12 - SOC 02/05/2023 initial bereavement completed 03/14/2023 greater then 5 days. Patient #14 - SOC 12/09/2022 initial bereavement completed 01/30/2023 greater then 5 days. Patient #15 - SOC 12/16/2022 initial bereavement completed 01/04/2023 greater then 5 days.

Upon patient record review, 1 of 23 (Patient #5) 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. Patient #5 - POC dated 01/23/2023 - Wound care to skin tear on L upper arm did not contain frequency.

Upon client record review, 4 of 23 (Patient #2, 11, 12, 15) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2 - POC dated 02/15/2023 SN visit frequency 1 wk 12 - no SN visit made week of 04/16/2023. Patient #11 - POC dated 02/23/2023 - SN provided PICC line care without order or 03/13/2023, 03/20/2023 and 03/30/2023. PICC line pulled on 04/07/2023 without order. Patient #12 - POC dated 02/05/2023 SC visit frequency effective 02/26/2023 1 every 2 wk 2 - no visit week 02/26/2023 or 03/05/2023. Patient #15 - POC dated 03/16/2023 SN visit frequency effective 04/09/2023 2wk1 only 1 visit made week 04/09/2023.

Upon patient record review 3 of 23 (Patient #6, 7, 8) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #6, 7, 8 - Volunteer services requested by patient/family - agency unable to provide due to no volunteers available in patient area.

Upon client record review, 1 of 23 (Patient #20) 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 #20 - did not have evidence that the hospice forwarded to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested