Every finding on record at Silverado Hospice of Illinois, Inc.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the hospice Interdisciplinary Group (IDG) completed an initial comprehensive assessment within five (5) calendar days after the election of hospice care. CLINICAL RECORD 11: The patient elected hospice care on 07/31/2025 with a diagnosis of cerebral atherosclerosis. The patient resided in a skilled nursing facility (SNF). The skilled nursing (SN) assessment dated 07/31/2025 documented, "Requests services of Medical Social Worker (MSW), Aide, Chaplain, Music Therapy, and Massage Therapy, declined volunteer." The psychosocial assessment was completed by the MSW on 08/08/2025, with eight (8) days outstanding. A clinical record review revealed no documentation to explain the delay. During an interview and a joint record review on 09/24/2025, the Administrator confirmed that there was a delayed social work assessment.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 18 (6%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide received written patient care instructions to meet the patient's needs. CLINICAL RECORD 6: The patient elected hospice care on 03/31/2023 with a diagnosis of chronic obstructive pulmonary disease. The patient resided in a skilled nursing facility (SNF). The plans of care for the benefit period dated 09/16/2025 through 11/14/2025 ordered oxygen 4 liters continuous, which had been ongoing since 02/13/2025. Additionally, the plan of care ordered HA services 2 times a week for 9 weeks. The HA care plan updated on 09/22/2025 did not include instructions for the HA regarding the patient's use of oxygen during personal care. During an interview and a joint record review on 09/23/2025, the Administrator confirmed findings and stated, "I can't believe that we just audited these, but that is the way they learn."

It is required that each patient’s individualized written plan of care: reflects patient and family goals; identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 10 (20%) clinical records reviewed in which medical social worker (MSW) services were accepted, it was revealed that the hospice did not ensure the hospice plan of care contained individualized patient and family goals and interventions related to problems identified in the psychosocial assessments. Clinical Record 6: The patient elected the hospice benefit on 11/7/22. The MSW add-on evaluation dated 11/8/22 documented "patient grieving loss of independence" and "indicate whether meals on wheel is available or needed: needed" and "indicate whether area agency on aging is available or needed: needed." In the narrative portion of the visit note the MSW stated, "SW (social work) is working with the family to arrange assistance through various programs. SW working with the family to identify needs and align with providers". The hospice plan of care, effective 11/8/22 to current documented "Hospice MSW eval performed - additional visits required" but does not contain individualized patient and family goals and interventions related to the psychosocial problems identified in the MSW add-on evaluation. The Interdisciplinary Group (IDG) meeting note on 11/22/22 stated "current psychosocial plan effective AEB (as evidenced by) family's continued trust in the (agency name) team," but no further details related to specific goals and interventions were addressed. Clinical Record 10: The patient elected the hospice benefit on 8/19/22. The MSW add-on evaluation dated 8/23/22 documented "mental status issue: anxious and fearful" and "other behavioral assessment findings: anxious and fearful of the unknown and the process of death and dying". The hospice plan of care effective 8/23/22 documented "Hospice MSW eval performed - additional visits required" but does not contain individualized patient and family goals and interventions related to the psychosocial problems identified in the MSW add-on evaluation. The IDG meeting note on 8/30/22 stated "current psychosocial plan effective AEB family's continued trust in the (agency name) team," but no further details related to specific goals and interventions were addressed. In an interview on 12/2/22, the MSW described the assessment of patient and family needs, identification of goals, and implementation of interventions to meet identified needs, but confirmed the individualized goals and interventions were not entered into the plan of care. In an interview on 12/1/22, the Manager of Accreditation confirmed the MSW did not include psychosocial-specific goals and interventions in the hospice plan of care.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: Hand hygiene; Use of gloves, mask, eye protection, or face shield depending on anticipated exposure; Safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids. This standard was not met as evidenced by document reviews, interviews and observation on home visits. In 2 of 3 (67%) visits where direct patient care was observed, it was revealed that the hospice staff did not follow accepted standards of practice, as well as the hospice's policy on hand hygiene, to prevent the transmission of infections and communicable disease. Policy No. 7-009 "Hand Hygiene" states in relevant parts, in procedure section 3, "Hand decontamination using an alcohol-based hand rub should be performed: after contact with body fluids, excretions, mucous membranes, non-intact skin and wound dressings" and "after removing gloves." Home Visit 3: During the observed visit on 11/30/22 with a facility patient (Record 2), the nurse (Staff 3) was observed performing wound care to the patient's right heel. The nurse donned gloves, removed the soiled dressing and did not change gloves or perform hand hygiene prior to performing wound care. After providing wound care, the nurse removed gloves and, without performing hand hygiene, began cleaning used equipment. Home Visit 2: During the observed visit on 11/30/22 with a home patient (Record 8), the aide (Staff 2) donned gloves, cleaned the patient's nails, removed gloves to retrieve a razor, donned new gloves and continued with patient care and did not perform hand hygiene in accordance with policy. In an interview with the Manager of Accreditation (Staff 11) on 11/30/22, it was confirmed that the staff did not follow the agency's policy on hand hygiene.

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group This standard was not met as evidenced by a review of clinical records and interview. 4 of 10 (40%) clinical records reviewed, where hospice aide services were ordered, revealed the hospice did not ensure the hospice aide followed the plan of care with respect to tasks assigned. Clinical Record 3: The patient elected the hospice benefit on 9/21/22. The aide care plan report, effective 11/28/22 assigned the aide to complete shampoo weekly (wash with shampoo, dry, braid hair weekly). During the week starting 11/28/22, the hospice aide documented completion of this task twice on 11/28/22 and 11/30/22. Clinical Record 5: The patient elected the hospice benefit on 10/7/22. The aide care plan report, effective 10/11/22, assigned the hospice aide to "change linens" with a frequency of "first visit of the week". The hospice aide documented completion of a linen change twice a week on two separate weeks in November (11/7/22, 11/9/22, and 11/14/22, 11/16/22). Clinical Record 6: The patient elected the hospice benefit on 11/7/22. The aide care plan report, effective 11/7/22, assigned the hospice aide to "change linens" with a frequency of "first visit of the week, weekly". The hospice aide documented completion of a linen change twice a week on two separate weeks in November (11/15/22, 11/17/22, and 11/22/22, 11/25/22). Clinical Record 7: The patient elected the hospice benefit on 10/14/22. The aide care plan report, effective 10/17/22, assigned a hospice aide task of "shaving" with a frequency of "first visit of the week". The hospice aide documented completion of the shaving task twice a week on two separate weeks in October (10/17/22, 10/19/22, and 10/24/22, 10/26/22). In an interview with the Manager of Accreditation on 12/1/22, it was confirmed the aides did not follow the plans of care.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: the most recent hospice plan of care; hospice election form; physician certification of the terminal illness; hospice medication information. This standard was not met as evidenced by a review of clinical records, interviews and observations. In 1 of 2 (50%) visits to patients residing in a skilled nursing facility (SNF) in which the hospice facility clinical record was reviewed, revealed the hospice did not provide the SNF with copies of the required documentation. Home Visit 3: The patient was admitted on 11/1/2022 with a diagnosis of cerebral atherosclerosis. During the observed home visit on 11/30/22 with a SNF patient (Record 2), a review of the hospice facility's clinical record revealed the record was missing a copy of the most recent hospice plan of care, the hospice election form, the physician certification of terminal illness, and hospice medication information. The RN (Staff 3), present during the visit, confirmed the documents were missing and stated they would "be there after IDG (the interdisciplinary group meeting)". In an interview with the Manager of Accreditation (Staff 11) on 11/30/22, the patient's election of the hospice benefit on 11/1/22 was confirmed and it was stated there have been prior IDG meetings and the paperwork should have been in the chart "by now."