Every finding on record at Seasons Hospice, LLC

Based on clinical record reviews and staff interviews, in 4 of 27 (Pt. # 4, 13, 14 and 26), the Hospice Failed to ensure services were provided as ordered by the Physician in the POC. --- 2.Pt. #13   was admitted to the Hospice services on 07/30/25  with diagnosis of Senile Degeneration of Brain, Not Elsewhere.  The clinical record was reviewed  on 10/08/25. The  POC dated 07/30/25 included SN 3 times a week for 1 week and 1 time a week for 9 weeks.  The Hospice RN failed to provide care during the week of 08/28/25 (week #5).     3. Pt. #14   was admitted to the Hospice services on 07/08/25  with diagnosis of Heart Failure, Unspecified.  The clinical record was reviewed  on 10/08/25. The POC dated 07/08/25 included SN 3 times a week for 1 week and 1 time a week for 8 weeks. The Hospice SN failed to provide care during weeks #5.  The same POC dated 07/08/25 included Aide 1 time a week for 1 week and 2 times a week for 12 weeks. The Hospice Aide failed to provide care during weeks #5. On 08/21/25 the Hospice Volunteer was ordered. The Volunteer failed to provide the ordered service.     4. Pt. #26 was admitted to Hospice 10/13/24 with diagnosis  of Heart Failure, Unspecified. The clinical record was reviewed on  10/07/25. The clinical record included the POC 10/13/24, modified on 11/01/24 to include the Aide 1 time a week for 10 weeks. The Aide failed to provide care during week of 11/01/24 (week #2).     5. The above findings were confirmed with the Director of Clinical Operations and Alternate Executive Director, on 10/08/25  between 1:00 pm and 3:00 PM and on 10/09/25 between 9:00 and 10:00 AM. Findings include:1. Pt. # 4 was admitted to Hospice Services with the diagnosis of Cerebral Infarction, Unspecified. The clinical record was reviewed on 10/07/25. The clinical record included the POC effective 08/20/25 to 11/17/25, that included “HHA 1 wk 1, 2 wk 12”. The clinical record included a Hospice aide visit dated 09/11/25, for the week of 09/14/25 to 09/20/25. The record lacked another Hospice Aide visit for that week. The record lacked documentation the Hospice Aide provided any service for the week of 09/28/25 to 10/04/25. The POC effective 08/20/25 to 11/17/25, included the Physician’s order: “CH 1 wk 1”. The clinical record included a Client Coordination Note Report dated 08/23/25, documenting Chaplain left message for caregiver to schedule an assessment and awaiting return call. The record lacked documentation of a Chaplain visit as ordered.

Based on the review of clinical records, Hospice policy, and Staff interviews, the Hospice failed in 2 of 27 clinical records (Pts. #18 and 20)  to coordinate care effectively. --- 2.   Pt. #18 was admitted for Hospice services on 09/25/25 with the Hospice diagnosis of Malignant Neoplasm of Stomach, Unspecified.  The clinical record was reviewed on 10/07/25.  The clinical record included the SN visit note dated 09/26/25 that contained, the Pt. complained of continuous “stabbing” pain that rated 10 out of 10 (0 equal no pain, 10 equal severe pain); and that the SN notified the Supervisor and Pharmacist of the patient’s condition.   The clinical record included documentation the comfort pack was delivered to the Pt. on 09/29/25 (4 days after the SN completed the initial visit).  SN visit note dated 10/04/25 included the Pt. complained of pain, 10 out of 10, and that Morphine was given.  The SN visit note dated 10/06/25 included the Pt. complained of continuous pain “all the time”.  The initial IDG meeting was scheduled for 10/09/25. During an interview with the RN Coordinator on 10/07/25 at 4:25 PM, the RN Coordinator stated, “The comfort pack is ordered on admission… and delivered by 48 hours by the Hospice’s regular pharmacy…”  The procedure for the delivery of a comfort pack during an emergency, “the Hospice would contact their local pharmacy (or pharmacy preferred by the family…) to deliver the same day.”  The RN Coordinator stated, the IDG could have met before 10/09/25 to address the patient’s pain.   As of 10/07/25, the Hospice failed to coordinate care for the emergency delivery of the ComfortPak and address the patient’s severe pain in a timely manner.  3.  Pt. #20 was admitted for Hospice services on 08/04/25 with the Hospice diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris.  The clinical record was reviewed on 10/08/25.  The clinical record contained the RN SOC Visit Report dated 08/04/25 with a request from the family for the Pt./family to receive a volunteer.  The clinical record lacked documentation of care coordination with the family to arrange a volunteer, until the IDG meeting minutes dated 09/04/25 that included, “… reached out to patient’s (family member) to discuss volunteer services/volunteer visits… a message was left asking… to contact this writer …”  During an interview with the RN Coordinator on 10/07/25 at 4:25 PM, the RN Coordinator stated the Volunteer Coordinator was required to “contact the family within 5 days after the request” to arrange volunteer services.4. The Hospice’s policy titled On-call Weekend Services was reviewed on 10/08/25 and included “POLICY   It is the policy of this hospice to ensure that all covered hospice services are available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and chosen/caregiver…   6. Other hospice services, including social service counseling… shall  be available on a 24- hour basis… Illinois Administrative Code, Title 77… Section 280.2010…” 5.  The Hospice policy titled; “ComfortPak Assessment, Ordering, and Usage” was reviewed on 10/08/25 at 1:33 PM.  The policy required, “Purpose:  ComfortPak (also referred to as Emergency Medication Kits) may be used on an emergency basis for patients who are exhibiting symptoms at the end of life in to provide prompt and effective relief of symptoms.  Protocol:  1.  At the time of admission, the nurse will assess the patient’s residence… 3.  After these assessments are completed, the nurse will contact the pharmacy to order the CP.  4.  If the patient is symptomatic upon admission or becomes symptomatic before the CP arrives at the patient’s residence, the nurse and/or prescriber will contact a local pharmacy to provide the necessary medications to manage the patient’s symptoms…”6.  During interviews with the RN Coordinator on 10/07/25 at 4:25 PM; Associate Executive Director on 10/08/25 at 1:00 PM, the above findings were confirmed. Findings include:1.      Pt. #5   was admitted to the Hospice services on 09/05/25  with Hospice diagnosis of Intrahepatic Bile Duct Carcinoma.  The clinical record was reviewed  on 10/07/25.  On Friday, 09/26/25, the Hospice on-call service documented the family requesting  the need to see the MSW on Monday (9/29/25). The MSW failed to visit on Monday, as requested. The MSW visit was not coordinated until Tuesday 09/30/25, as required by the Hospice policy. Findings include:1.   Pt. #18 was admitted for Hospice services on 09/25/25 with the Hospice diagnosis of Malignant Neoplasm of Stomach, Unspecified.  The clinical record was reviewed on 10/07/25.  The clinical record included the SN visit note dated 09/26/25 that contained, the Pt. complained of continuous “stabbing” pain that rated 10 out of 10 (0 equal no pain, 10 equal severe pain); and that the SN notified the Supervisor and Pharmacist of the patient’s condition.   The clinical record included documentation the comfort pack was delivered to the Pt. on 09/29/25 (4 days after the SN completed the initial visit).  SN visit note dated 10/04/25 included the Pt. complained of pain, 10 out of 10, and that Morphine was given.  The SN visit note dated 10/06/25 included the Pt. complained of continuous pain “all the time”.  The initial IDG meeting was scheduled for 10/09/25. During an interview with the RN Coordinator on 10/07/25 at 4:25 PM, the RN Coordinator stated, “The comfort pack is ordered on admission… and delivered by 48 hours by the Hospice’s regular pharmacy…”  The procedure for the delivery of a comfort pack during an emergency, “the Hospice would contact their local pharmacy (or pharmacy preferred by the family…) to deliver the same day.”  The RN Coordinator stated, the IDG could have met before 10/09/25 to address the patient’s pain.   As of 10/07/25, the Hospice failed to coordinate care for the emergency delivery of the ComfortPak and address the patient’s severe pain in a timely manner.  2.  Pt. #20 was admitted for Hospice services on 08/04/25 with the Hospice diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris.  The clinical record was reviewed on 10/08/25.  The clinical record contained the RN SOC Visit Report dated 08/04/25 with a request from the family for the Pt./family to receive a volunteer.  The clinical record lacked documentation of care coordination with the family to arrange a volunteer, until the IDG meeting minutes dated 09/04/25 that included, “… reached out to patient’s (family member) to discuss volunteer services/volunteer visits… a message was left asking… to contact this writer …”  During an interview with the RN Coordinator on 10/07/25 at 4:25 PM, the RN Coordinator stated the Volunteer Coordinator was required to “contact the family within 5 days after the request” to arrange volunteer services.3.   The Hospice policy titled; “ComfortPak Assessment, Ordering, and Usage” was reviewed on 10/08/25 at 1:33 PM.  The policy required, “Purpose:  ComfortPak (also referred to as Emergency Medication Kits) may be used on an emergency basis for patients who are exhibiting symptoms at the end of life in to provide prompt and effective relief of symptoms.  Protocol:  1.  At the time of admission, the nurse will assess the patient’s residence… 3.  After these assessments are completed, the nurse will contact the pharmacy to order the CP.  4.  If the patient is symptomatic upon admission or becomes symptomatic before the CP arrives at the patient’s residence, the nurse and/or prescriber will contact a local pharmacy to provide the necessary medications to manage the patient’s symptoms…”4.  During interviews with the RN Coordinator on 10/07/25 at 4:25 PM; Associate Executive Director on 10/08/25 at 1:00 PM, the above findings were confirmed.

Based on a review of clinical records, Agency policy review, and staff interviews, it was determined that for the 1 of 6 (Pt. #1) clinical records reviewed, the Hospice failed to ensure that concern/grievance communicated to Agency staff was investigated and resolved. --- Findings include: 1.  Pt. #1 was admitted to Hospice on 8/15/25 with the diagnosis of  Unspecified Sequelae of Cerebral Infarction.  The clinical record was reviewed on 9/15/25. The clinical record included a documents titled “Coordination Note Report.”  The coordination note dated 08/23/2025 documented the SNF nurse called at 7:34 PM and reported, “We just noticed a wound in the patient’s mouth with maggots in it…”  The note also documented the on call nurse was contacted and stated she had just received a call for a death visit for this patient. “…No further action needed…” The Coordination note dated 8/25/25 and time stamped at 6:44 AM was documented as a late entry , "...death unattended time of pronouncement 7:47 PM by (Facility) RN…(Family) upset to discover (Pt. #1) had maggots in mouth/throat. (Family) called (Hospice) triage for assistance and (Pt. #1) expired while (Family) was on the phone with triage…(Family) upset and emotional over the phone…wants (Pt. #1) out of the facility immediately.” The record lacked documentation that the concern was investigated and resolved.  2.  During the Entrance Conference, the Associate Executive Director indicated that all complaints/concerns/grievances are documented on the log titled, “QI Event Report.”  The document which contained complaints/concerns/grievances from 9/2024 through 9/2025 was reviewed on 9/15/25.  The document  did not include documentation of the concern/grievance and its resolution related to Pt. #1. 3.  The Agency policy titled, “Concern-Complaint-Grievance Reporting” revised on 6/13/24 required: “Policy: It is the policy of this agency to investigate and resolve all concerns or complaints whether submitted internally or externally in a satisfactory and timely manner in accordance with certification, state and payer requirements…15.  A log of concerns/complaints C.2.8.2 Concern-Complaint Report tracking Log is maintained by the DPCS or designee contains the type of complaints received, dates of concern/complaints indicated, date and action taken to resolve the complaint…” 4.  The Agency policy titled, “Hospice Patient Bill of Rights” was reviewed on 9/17/25 and required: “4. To have their complaints heard and addressed. Also, to receive an investigation by the hospice of complaints from the patient, chose family/caregiver, or guardian regarding treatment of care, and to have staff document the existence of the complaint and the resolution of the complaint.” 5.  E#2 (RN Coordinator/Director of Clinical Services -Field) was interviewed  on 9/16/25.  E#2 stated that the concern/incident was called in by Pt. #1’s family to the triage nurse and that it was documented in the Coordination Notes. E#2 stated that the protocol is that complaints/concerns are to be reviewed by the Team Manager but since the call for this incident was made during the weekend, it was not reviewed. 6. During interviews with the Executive Director, Associate Executive Director, Area Quality Specialist, RN Coordinator/Director of Clinical Services (Field) and Director of Nutrition on 9/16/25, the above findings were confirmed.

Based on clinical record reviews, policy review and staff interview it was determined that for 1 of 6 (Pt. #3) clinical record reviews, the Hospice failed to ensure that the allegation of abuse was  investigated, resolved and documented. --- Findings include:1.  Pt. #3 was admitted to Hospice on 6/17/25 with the diagnosis of Malignant Neoplasm of Unspecified Site of the Right Female Breast.  The clinical record was reviewed on 9/16/25.  The record included the MSW note dated 6/18/25 and included the documentation, “…At the end of the visit, Pt. reported that hired caregiver (Name) curses at (Pt.) and says, ‘if you tell on me they will fire me and you will be send to the nursing home because you need 24 hour care.’ E#8 (MSW) informed Power of Attorney (POA) who is aware of the interactions.  As E#8 and E#9 (RN) left patient’s home loud shouting and cursing were heard from inside the home.  Patient’s caregiver was shouting and using hyperverbal language towards Pt. stating, ‘why did you call the social worker here it don’t matter what you say to them they cant do s**t to me.’ E#8 and E#9 intervened by ringing the doorbell, E#9 confronted care giver who then began shouting and cursing at us before storming off and reentering the home to further shout at the Pt. E#8 and E#9 called POA to inform of the occurrence and let  POA know that APS will be called, MSW also informed POA that these behaviors are unacceptable considering caregiver is comfortable enough to do this in front of us and (paid caregiver) should be concerned about when they are alone. E#8 encouraged NH (Nursing Home) or a new care giver. POA reported not being able to afford a new care giver and not wanting Pt. to go to NH…E#8 spoke with (name) via APS who reported someone from (Agency) family services will be sent out within the next 48 hours.” 2.  The Hospice investigation report was reviewed on 9/16/25. “Allegation of Abuse was made on 6/18/25. 6/18/25 APS called after the E#8 and E#9 heard the hired caregiver yelling at the patient. E#8 spoke with APS worker (name) re: witnessing emotional/verbal abuse from hired caregiver. APS reported that  someone from (Agency) family services will be sent out within the next 48 hours. 6/25/25, E#8 attempted to contact APS, left voice message for case worker to call. 7/3/25 APS would not release findings as the caller was not the actual reporter.”  There was no other documentation in the clinical record of a follow up. The clinical record lacked a completed investigation and resolution.3.  The clinical record included documentation the paid caregiver continued to provide services for Pt. #3; the paid caregiver signed all the weekly nursing visit notes from 6/26/25 through 8/14/25. 4.  The Agency policy titled, “Reporting Abuse, Neglect, Fraud or Exploitation of Clients” revised on 9/25/24 was reviewed on 9/17/25 and required: “5.  If any employee directly employed or under arrangement suspects that a child/adult/older person has been exposed to abuse, neglect or exploitation, they shall report the concern to their supervisor (Team Director, Director of Clinical Operations, Administrator On-call) within 24 hours.  The employee shall complete an incident report which the Executive Director/Administrator or designee will review following the Incident Reporting Policy.  If the person described above is a patient of the Agency, the patient’s physician or allowed practitioner is notified consistent with the plan of care… Document all communication with the physician in the patient’s medical record.”5.  The Agency policy titled, “Concern-Complaint-Grievance Reporting” revised on 6/13/24 was reviewed on 9/16/25 and required: “Policy: It is the policy of this agency to investigate and resolve all concerns or complaints whether submitted internally or externally in a satisfactory and timely manner in accordance with certification, state and payer requirements... 12. The administrator shall ensure that the concern/complaint has been addressed in a timely manner and resolved, if possible. 15.  A log of concerns/complaints C.2.8.2 Concern-Complaint Report tracking Log is maintained by the DPCS or designee contains the type of complaints received, dates of concern/complaints indicated, date and action taken to resolve the complaint…” 6. During interviews with the Executive Director, Associate Executive Director, Quality Specialist, RN Coordinator/Director of Clinical Services -Field on 9/16/25, the above findings were confirmed.

Based on clinical records review, Agency policy review and staff interview, it was determined the hospice failed to ensure the patient was recieving the care and services ordered in the plan of care.  This has the potential to affect all Pts. receiving care and services. --- Findings include: 1. The hospice failed to ensure care and services were provided as indicated in the plan of care. (L555)The cummulative effect of these systemic practices resulted in the hospices inability to ensure care is provided as ordered.

Based on a review of clinical records, Agency policy, and staff interviews, it was determined that for 3 of 6 (Pts. #1, #2 and #4) clinical records reviewed, the Hospice failed to ensure care and services were provided as indicated in the plan of care. --- Findings include:1.  Pt. #1 was admitted to Hospice on 8/15/25 with the diagnosis of  Unspecified Sequelae of Cerebral Infarction.  The clinical record was reviewed on 9/15/25.  The record included a POC for the certification of 8/15/25 to 11/12/25 and required: “Frequency/Duration of visits: HHA effective 8/17/25 2WK12, 1WK1.”  The record lacked documentation of any Aide visits from 8/17/25 through the end of episode, 8/23/25.  2.  Pt. #2 was admitted to Hospice on 10/1/24 with the diagnosis of Cerebrovascular Disease, Unspecified.  The clinical record was reviewed on 9/15/25.  The record included the document “Hospice IDG Comprehensive Assessment and POC Update Report Benefit Period Dates: 7/28/25 to 9/25/25, IDG Meeting Date 8/13/25.”  The document required the following: “Frequency: Order date 8/5/25, HHA Effective 8/3/25, 10WK1, 2WK1, 1W6; Order date 8/10/25, HHA Effective 8/10/25, 12WK1, 1WK6; Order date 8/11/25, HHA Effective 8/3/25, 6WK1, 12WK1, 1WK6.”  The clinical record included documentation that 2 Aide services, one on 8/6/25 and one on 8/8/25 were provided.  The record lacked 8 Aide visits for the week of 8/3/25 to 8/9/25 and lacked 12 Aide visits for the week of 8/10/25 to 8/16/25.The Hospice IDG Comprehensive Assessment and POC Update Report Benefit Period Dates: 7/28/25 to 9/25/25, IDG Meeting Date 8/13/25 also included the order dated 05/02/2025, "...Nurse will obtain wound care orders and follow wound care protocol for assessment and documentation..." 07/30/2025: “Buttocks Stage 2: Cleanse with NSS, pat dry, cover with dressing Q3D (every 3 days) and PRN;  on 8/10/25, the order indicates: Cleanse site with normal saline. Pat dry and apply Mepilex dressing every 3 days and PRN.The clinical record included a visit note dated 7/30/25 documenting Pt. #2 had 1 stage II pressure ulcer, “Wound #2” which measured 5 cm x 2.75 cm x 0.  The record also included a visit note dated  8/5/25 documenting, “Wound #2” measured 4 cm x 5 cm x 0, and “Wound #4” developed and measured 2 cm x 3 cm x 0.  The visit noted dated 08/10/2025 documented the onset of "Wound #5" measuring 2 cm x 2 cm x 0.The clinical record included visit note reports dated 8/6/25 AM and PM shifts,  8/7/25 AM and PM shifts, 8/8/25 AM and PM shifts, 8/9/25 AM and PM shifts, 8/10/25 AM and PM shifts, 8/11/25 AM and PM shifts, 8/12/25 and 8/13/25.  All the above-mentioned notes lacked documentation of wound assessments for the wounds labeled “Wound#2 and Wound#4,” and lacked documentation that wound treatments were provided. On 08/14/25 the visit note documented wound #4 measured 17 cm x 12 cm x 0.1 cm.The clinical record also included a Physician order dated 8/5/25 that required, “Flush with 50 ml of water Q 2 hours and FWF with 60 cc by hand TID.  The clinical record lacked documentation the above order was implemented on 8/5/25, 8/6/25, 8/7/25, 8/10/25, 8/11/25 and 8/12/25.  3. Pt. #4 was admitted to Hospice on 9/13/25 with the diagnosis of Respiratory Failure related to Sepsis.  The clinical record was reviewed on 9/16/25.  The record included a Plan of Care effective 9/13/25 which required, “Frequency: HHA Effective 9/14/25 10WK1.”  During an interview with the E#2 (RN Coordinator/Director of Clinical Services -Field) on 9/16/25, it was stated that 10WK1 means that a visit should be provided 2 times a day.  As of 9/16/25, the record lacked documentation that any Aide services have been provided.   4. The Agency policy, “Wound care 2005 Protocol” was reviewed on 9/16/25 and required: “4.  The Hospice Nurse will assess wounds at least once per Medicare Week… 6.  The plan of care will be updated to document wound care…” 5. During interviews with the Executive Director, Associate Executive Director, Quality Specialist, RN Coordinator/Director of Clinical Services-Field on 9/16/25,  the above findings were confirmed.

Observed in Record Review. In 1 of 20 patient records reviewed, During HV#1 record review it was noted the MSW did not schedule an initial visit within 5 days of the SOC. The visit appointment was initially scheduled for day 6 after the SOC. This was discussed with the clinical leadership.

Observed in Record Review. In 1 of 20 patient records reviewed, During HV#1 record review it was noted the record did not reflect progress toward goals as the initial POC goals were the same as the second certification. For example: Patient and caregiver competent to administer medications which was added at the initial certification and remains the same during the second certification. This was reviewed with the clinical leader.

Observed in Record Review. In 3 of 20 patient records reviewed, During HV#1 record review it was noted the goals on the POC were not measurable and lacked outcome dates. For example: Patient and caregiver competent to administer medications which was added at the initial certification and remains the same during the second certification. During RR#6 it was noted the goals lacked measurable outcome date. For example: Pt will understand medication schedule, pt/PCG verbalize understanding of skin breakdown, CG verbalize and demonstrate appropriate wound care. During RR#7 it was noted the goals were not measurable. For example: pain is currently managed at an acceptable level for the patient, CG verbalizes causes and how to identify signs and symptoms of pain, pt/family verbalizes understanding of the stages of grief, pt family are aware of available resources, pt discusses life experiences. This was discussed with the Clinical leadership. Observed in Record Review. In 9 of 20 patient records reviewed, the Hospice surveyor noted the goals in patient records were not measurable and specific to the intervention and care needs of the patient. For example, in HV #3, HV #5,HV #6, RR #8, RR #9, RR #10, RR #11, RR #12, RR #13 the goals for the patient where not measurable or specific to the patients. Examples include: Verbalize understanding of pain”, “Understands management of urinary issues and to call hospice if unrelieved”, “Pain managed at acceptable level to patient”, “Constipation is controlled”, Problems concerning patient's personal affairs are identified and plan established to resolve identified issues and Verbalize understanding of how to recognize neurologic issues/changes and need to report to hospice. This was reviewed and validated with the Agency Leadership.

Observed in Record Review. In 1 of 20 patient records reviewed, During HV#1 record review it was noted an order for oxygen therapy the middle of November 2023. The POC was not updated by the IDG to include interventions and goals related to the order for 02 therapy. This was discussed with the clinical leadership.

Observed in Record Review. In 3 of 20 patient records reviewed, The medication orders were not clear and accurate. In RR # 8, the surveyor noted that the physician's orders in the plan of care documented Lactolose and Biscodyl both for PRN constipation with no indication for when to use which for the duplicate therapy. In RR #9 the surveyor noted that the physician's orders in the plan of care documented Biscoldyl Supp and Biscoldyl tab PRN for constipation with no indication for when to use which medication for duplicate therapy . In RR #11, the surveyor noted that the physician orders in the plan of care documented PRN use for Hydrocodone with Acetaminophen and Morphine for pain and MiraLAX and Bisacodyl for constipation with no indication for when to use each duplicate therapy. The organization's policy Medication Profile stated that there will be a review for duplicate therapy. This finding was reviewed with agency leadership.

Observed in Record Review. In 5 of 20 patient records reviewed, the organization did not update the plan of care based on updates to the patient. On review of HV #3, it was noted that the care plan was not updated and did not reflect that chaplain had seen patient multiple certifications ago because there the goal that stated chaplian goals would be developed after eval. On HV #5, it was noted during the home visit that patient had fallen a month earlier and had a wound to the head. The nurse got orders for the wound treatment but the POC had not been updated to reflect new goals for wound. On RR #11, it was noted that the patient had been on service for 7 benefit periods and the plan of care still stated that the MSW and chaplian would develop a plan of care and goals, yet the MSW and chaplian had been in the home since the first benefit period. On HV #6 and RR #13, the hospice nurse surveyor noted that care plan was not updated and did not reflect that MSW and chaplain had seen patient because there were goals that stated goals for MSW and chaplian would be developed after eval. This finding was reviewed with the agency leadership.

Observed in Patient Home. In 3 of 6 home visits conducted, It was noted the Hand Hygiene Protocol 4003 was not followed by the staff during home visits. During HV#1 the aide washed her hands and turned off the faucet with the back of her hands. Paper towels were not available in the bathroom at the beginning of the visit. In addition, the aide changed her gloves multiple times during the visit without hand hygiene preformed prior to donning a new pair of gloves and entered her supply bag without performing hand hygiene. During HV#2 it was noted the SN donned 2 pairs of gloves, removed the patient's soiled dressing and removed the outer pair of gloves, then gathered the supplies to perform wound care. The dressing was then removed, the SN removed her gloves and donned a clean pair without hand hygiene. On HV # 3, it was noted that the HHA changed gloves after doing the bed bath without performing hand hygiene per agency policy. This was reviewed with the Clinical leadership.

Observed in Record Review. In 1 of 20 patient records reviewed, During HV#1 record review it was noted an order for oxygen therapy in the middle of November 2023 without an update of the hospice aide assignment form to include the oxygen therapy order and direction to the aide during personal care on the patient use of oxygen therapy. This was reviewed with the Clinical Leader.

Observed in Record Review. In 1 of 20 patient records reviewed, the home health aide did not follow the aide plan of care. On RR #13, the aide documented Gave pt a bed bath applied lotion dressed and repositioned changed linens and threw away garbage. However the aide care plan did not have orders for applying lotion, repositioning, and linen changes. This finding was reviewed with agency leadership.

Observed in Record Review. In 1 of 20 patient records reviewed, During HV#1 record review it was noted one hospice aide supervision by an RN was not at least once every 14 days. In the middle of October 2023 there was 16 days between supervisory visits. This was discussed with the clinical leadership.

Observed in Building Tour. In 1 of 3 tracers conducted, During building tour of Naperville IPU, it was noted one of the 2 smoke rated doors did not close and latch automatically when doors released. This was reviewed with the Clinical Manger and the Executive Director present during the testing. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy:

Observed in Building Tour. In 1 of 3 tracers conducted, During review of the Naperville IPU it was noted in discussion with the Clinical Manager that patient room water temperature testing in completed monthly by the maintenance service. The documentation of water temperature testing in the patient rooms was not documented in the logs reviewed by the surveyor.

A. Based on clinical record reviews, staff interviews and policy review it was determined the Hospice failed to ensure patient medication was properly labeled. This was found in 1 out of 3 (Pt. #1) clinical records reviewed. Findings Include: 1. Pt. #1 SOC 11/09/2021 Dx: Multiple Myeloma The clinical record was reviewed on 02/10/2022 at 11:00 AM. The clinical record included a SN visit note dated 11/09/2021. The note documented " ...medication reconciliation, medication review complete, yes ..." During an interview with the Senior Director of Clinical Operations at 1:30 PM, she stated the medication was delivered to the patient on 11/08/2021. A coordination note dated 11/09/2021 documented, " ...after SNV, received message from daughter that medication ordered was mislabeled ..." 2. A policy titled, Medication Error effective 02/18/1997, and last reviewed on 04/24/2020 was reviewed on 02/10/2022 at 2:00 PM. The policy documented, "All medication errors will be promptly reported to the physician and documented in the clinical record ... 1. A medication error is due to an error in prescribing, transcribing, dispensing, administering, or monitoring ... examples include ... labeling error ... 2. A medication error may occur on the part of the patient, the caregiver, Seasons Hospice Staff, contracted staff, and/or the prescriber ... 6. The incident, actions taken, and patient response will be documented in the clinical record and on an Adverse Event Report ..." 3. During an interview with the Senior Director of Clinical Operations on 02/10/2022 at 2:30 PM, she confirmed the medication error. She also confirmed the clinical record lacked documentation of physician notification, and documentation of an adverse event report or incident report per Hospice policy.