Every finding on record at Transitions Hospice Central Illinois II LLC

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 4 of 23 (17%) clinical records reviewed, it was revealed that the agency did not ensure that the hospice interdisciplinary group (IDG), completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. CLINICAL RECORD 4: The patient elected the hospice benefit on 11/14/2024. The record lacked evidence of the Chaplain and the Social Worker completing an initial assessment within five (5) calendar days. The record also lacked documentation that the patient or family/caregiver refused Chaplain and Social Work services during the five (5) day period after the election of hospice care. There was evidence of a Psychosocial/Spiritual initial comprehensive assessment dated 12/05/2024 which was twenty-one (21) days after the election of hospice care. CLINICAL RECORD 9: The patient elected the hospice benefit on 10/02/2024. The record lacked evidence of the Chaplain and the Social Worker completing an initial assessment within five (5) calendar days. The record also lacked documentation that the patient and family/caregiver refused Chaplain and Social Work services during the five (5) day period after the election of hospice care. There was evidence of a phone call made to the daughter on 10/17/2024 which was fifteen (15) days after the election of hospice care. CLINICAL RECORD 12: The patient elected the hospice benefit on 08/13/2024. The record lacked evidence of the Chaplain and the Social Worker completing an initial assessment within five (5) calendar days. The record also lacked documentation that the patient or family/caregiver refused Chaplain and Social Work services during the five (5) day period after the election of hospice care. There was evidence that a phone call was attempted to the daughter on 08/21/2024, eight (8) days after the election of hospice care. There was also evidence that the social worker's phone call was unanswered, and a voicemail was left. No other follow-up was documented. CLINICAL RECORD 14: The patient elected the hospice benefit on 08/27/2024. The record lacked evidence of the Chaplain and the Social Worker completing an initial assessment within five (5) calendar days. The record also lacked documentation that the patient or family/caregiver refused Chaplain and Social Work services during the five (5) day period after the election of hospice care. There was evidence of a phone call made to the wife on 09/12/2024, sixteen (16) days after the election of hospice care. During an interview with the Administrator on 01/31/2025, it was confirmed that the agency did not complete a Chaplain and Social Worker visit within 5 days of the election of the hospice benefit. The agency did not have any documentation supporting the patient or the family/caregiver refused Chaplain and Social Work services. Additionally, the Administrator stated," that the agency is currently working to improve this process.”

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The review of the Hospice Volunteer Requirement Report revealed the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The review of the 2024 Hospice Volunteer Requirement Report revealed that the volunteer percentage of hours worked from January 2024 to December 2024 was 1.88%. The Administrator and the Volunteer Director stated in an interview on 01/31/2025 that the agency "is struggling with finding volunteers and is currently trying to recruit volunteers." The review of the Hospice Volunteer Requirement Report revealed the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.

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, document review and interview. In 4 of 12 (33%) clinical records reviewed it was revealed that the agency did not ensure that a comprehensive assessment including assessment of psychosocial and emotional needs was completed within 5 days of election of hospice care. Document 1: Policy No. 1-014 titled, Comprehensive Assessment stated in part, "A comprehensive assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with the attending physician." Clinical Record 3: The election of the hospice benefit was dated 03/09/2024. The social worker evaluation/assessment was completed on 03/19/2024 (10 days after election of care). The clinical record lacked evidence that the nursing comprehensive assessment completed on 03/09/2024 included a psychosocial assessment that addressed the patient’s and the family’s adjustment to the terminal illness, the social and emotional factors related to the terminal illness, the presence or absence of adequate coping mechanisms, family dynamics and communication patterns, financial resources and any constraints, and obstacles and risk factors that could affect compliance with the plan of care. Clinical Record 8: The election of the hospice benefit was dated 03/07/2024. The social worker evaluation/assessment was completed on 03/18/2024 (11 days after election of care). The clinical record lacked evidence that the nursing comprehensive assessment completed on 03/07/2024 included a psychosocial assessment that addressed the patient’s and the family’s adjustment to the terminal illness, the social and emotional factors related to the terminal illness, the presence or absence of adequate coping mechanisms, family dynamics and communication patterns, financial resources and any constraints, and obstacles and risk factors that could affect compliance with the plan of care. Clinical Record 9: The election of the hospice benefit was dated 07/18/2023. The social worker evaluation/assessment was completed on 08/27/2023 (40 days after election of care). The clinical record lacked evidence that the nursing comprehensive assessment completed on 07/18/2023 included a psychosocial assessment that addressed: the patient’s and the family’s adjustment to the terminal illness; the social and emotional factors related to the terminal illness; the presence or absence of adequate coping mechanisms; family dynamics and communication patterns; financial resources and any constraints; and obstacles and risk factors that may affect compliance with the plan of care. Clinical Record 10: Election of hospice benefit on 05/03/2024, Date of death was 05/29/2024. The clinical record lacked evidence that the patient was seen by the hospice social worker during care or that a comprehensive psychosocial assessment was completed that addressed: the patient’s and the family’s adjustment to the terminal illness; the social and emotional factors related to the terminal illness; the presence or absence of adequate coping mechanisms; family dynamics and communication patterns; financial resources and any constraints; and obstacles and risk factors that may affect compliance with the plan of care.. Personnel Record 2: In a joint interview and record review on 07/10/2024, the Clinical Director confirmed the findings that assessment of the patient's psychosocial and emotional needs was not completed within 5 days of election of hospice care.

It is required that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the patient’s terminal illness that are addressed to promote the patient’s well-being, comfort, and dignity throughout the dying process. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 12 (33%) clinical records reviewed revealed that the agency did not ensure that the comprehensive assessment included the identification of the psychosocial and emotional needs related to the patient's terminal illness to promote the patient's well-being, comfort, and dignity throughout the dying process. Document 1: Policy No. 1-014 revision date December 2018 stated in part "During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient's clinical record, including at least the following information, as relevant: S. The patient's psychosocial status, including emotional barriers to treatment, cognitive limitations, memory and orientation, family relationships, social history, source and adequacy of environmental and other resources, coping mechanisms, and the patient's and family/caregiver's reaction to illness". Clinical Record 3: Election of hospice benefit on 03/09/2024. The social worker evaluation/assessment was completed on 03/19/2024 (10 days after election of care). The clinical record lacked evidence that the nursing comprehensive assessment completed on 03/09/2024 included a psychosocial assessment that addressed: the patient’s and the family’s adjustment to the terminal illness; the social and emotional factors related to the terminal illness; the presence or absence of adequate coping mechanisms; family dynamics and communication patterns; financial resources and any constraints; and obstacles and risk factors that may affect compliance with the plan of care. Clinical Record 8: Election of hospice benefit on 03/07/2024. The social worker evaluation/assessment was completed on 03/18/2024 (11 days after election of care). The clinical record lacked evidence that the nursing comprehensive assessment completed on 03/07/2024 included a psychosocial assessment that addressed: the patient’s and the family’s adjustment to the terminal illness; the social and emotional factors related to the terminal illness; the presence or absence of adequate coping mechanisms; family dynamics and communication patterns; financial resources and any constraints; and obstacles and risk factors that may affect compliance with the plan of care. Clinical Record 9: Election of hospice benefit on 07/18/2023. The social worker evaluation/assessment was completed on 08/27/2023 (40 days after election of care). The clinical record lacked evidence that the nursing comprehensive assessment completed on 07/18/2023 included a psychosocial assessment that addressed: the patient’s and the family’s adjustment to the terminal illness; the social and emotional factors related to the terminal illness; the presence or absence of adequate coping mechanisms; family dynamics and communication patterns; financial resources and any constraints; and obstacles and risk factors that may affect compliance with the plan of care. Clinical Record 10: Election of hospice benefit on 05/03/2024, Date of death was 05/29/2024. The clinical record lacked evidence that the patient was seen by the hospice social worker during care or that a comprehensive psychosocial assessment was completed that addressed: the patient’s and the family’s adjustment to the terminal illness; the social and emotional factors related to the terminal illness; the presence or absence of adequate coping mechanisms; family dynamics and communication patterns; financial resources and any constraints; and obstacles and risk factors that may affect compliance with the plan of care.. Personnel Record 2: In a joint interview and record review on 07/10/2024, the Clinical Director confirmed the findings and stated in part "We had changed our process on comprehensive assessments and will be going back to having the social worker complete the comprehensive assessment piece that addresses psychosocial and emotional needs versus just the nurse completing the entire comprehensive assessment."

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 1 (100%) discharged clinical record reviewed of a patient that was transferred to another hospice, it was revealed that the agency did not ensure that the discharge summary included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient's current plan of care, the patient's latest physician orders, and any other documentation to assist in the post-discharge continuity of care. Document 1: Policy No.1-026 titled, Discharge Summary, revision date December 201,8 stated in part, "All patients discharged from a service and from a hospice will have a discharge summary completed and filed in the clinical record. Hospice personnel who provide care will complete a discharge summary which may include as appropriate: G. A summary of the care or service provided, H. The patient's current plan of care, I. The patient's latest physician orders." Clinical Record 5: The election of the hospice benefit was dated 07/19/2023. The patient was transferred to another hospice on 09/07/2023. The clinical record lacked evidence that the discharge summary included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient's current plan of care, the patient's latest physician orders, and any other documentation to assist in the post-discharge continuity of care. Personnel Record 2: In a joint record review and interview on 07/10/2024, the Clinical Director (personnel record 2) confirmed findings that the clinical record lacked evidence that the discharge/transfer summary included a summary of the patient's hospice stay, including treatments, symptoms, and pain management, the patient's current plan of care, the patient's latest physician orders, and any other documentation to assist in the post-discharge continuity of care and stated in part, "The nurse did not choose the right discharge summary."

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, observation, and interview. 2 of 16 (6%) clinical records reviewed revealed that the medication review was not documented. Record #29058: The patient elected the hospice benefit on 10/29/2021. The initial plan of care orders written on 10/20/2021 identified that the physician ordered emergency medications: Atropine 1% oral solution 2-3 drops under the tongue every 4 hours as needed for increased secretions; Lorazepam liquid 2mg/ml 0.5mg (0.25ml) PO/SL every 4 hours PRN agitation/anxiety; Morphine Sulfate oral concentrate 100mg/5ml 0.25ml (5mg) PO/SL every 1-2 hours PRN pain/breathlessness; Acetaminophen 650mg suppository 1 suppository per rectum every 4 hours PRN pain/fever; Ondansetron 4mg ODT dissolve 1 tablet SL every 8 hours PRN nausea; Hyoscyamine 0.125mg SL tabs 1 tab SL every 4 hours PRN increased secretions; Bisacodyl 10mg suppository 1 suppository per rectum daily PRN constipation. The orders for the emergency medications were not present on the medication profile and were not included in the medication review. Record #44533: The patient elected the hospice benefit on 3/29/2021. During a home observation visit completed on 4/12/2022, it was identified that Cipro 500mg PO BID and Seroquel 25mg 1/2 tablet daily were present on the medication profile but had been discontinued and were no longer in the patient home. Dilaudid 4mg/ml administer 0.5ml (2mg) every 2-4 hours PRN was present in the patient home but was not present on the medication profile. The Administrator and the RNCM were interviewed on 4/12/2022. The RNCM, present at the home visit, corrected the medication profile during the visit. The Administrator corrected the emergency kit medications in the medical record. She had no additional information to provide.

It is required that the comprehensive assessment includes an initial bereavement assessment of 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 considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. 7 of 16 (44%) clinical records reviewed revealed that the initial bereavement assessment was not completed timely. Record #58562: The patient elected the hospice benefit on 12/17/2021. The initial bereavement assessment was completed on 4/10/2022. Record #51295: The patient elected the hospice benefit on 10/1/2021. The initial bereavement assessment was completed on 4/11/2022 Record #29058: The patient elected the hospice benefit on 10/29/2021. The initial bereavement assessment was completed on 3/15/2022. Record #48949: The patient elected the hospice benefit on 6/4/2021. The initial bereavement assessment was completed on 4/7/2022. Record #44533: The patient elected the hospice benefit on 3/29/2021. The initial bereavement assessment was completed on 3/31/2022. Record #79607: The patient elected the hospice benefit on 11/28/2021. The initial bereavement assessment was completed on 4/11/2022. Record #10194: The patient elected the hospice benefit on 10/5/2021. The initial bereavement assessment was completed on 4/11/2022. In an interview with the Administrator on 4/12/2022, she agreed that the bereavement assessments were not being documented as required. The site had identified the issue and was in the process of completing the assessments and retraining the staff. She had no additional information to provide.

It is required that Medical Social Services are provided per the plan of care. The psychosocial assessment is revised as new information is acquired and as progress toward goals is made. This standard was not met as evidenced by clinical record review and interview. 1 of 8 (13%) applicable clinical records reviewed of patients receiving Medical Social Worker services revealed that the Medical Social Worker does not meet the needs of the patient per the plan of care. Record #48949: The patient elected the hospice benefit on 6/4/2021. Social Worker frequencies on the plan of care were ordered one time every month. There was no Social Worker visit documented for March 2022. In an interview with the Administrator on 4/12/2022, she agreed that there were no social worker visits present for the identified patients. She had no additional information to provide.

It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family's beliefs and desires. This standard was not met as evidenced by clinical record review and interview. 1 of 15 (06%) clinical records reviewed of patients receiving chaplain services revealed that spiritual counseling was not provided per the plan of care. Record #48949: The patient elected hospice benefit on 6/4/2021. The plan of care revealed that chaplain frequencies were ordered one time every month. There was no Chaplain visit documented for March 2022. In an interview with the Administrator on 4/12/2022, she agreed that the identified visits were missing for the chaplain. She had no additional information to provide.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. 1 of 14 (07%) clinical records reviewed of patients receiving hospice aide services revealed that aide services provided were not consistent with the visit frequency assigned on the plan of care. Record #55802: The patient elected the hospice benefit on 3/15/2022. The initial plan of care completed on 3/15/2022 indicated that the hospice aide frequencies were ordered at one time every week. There was no visit completed for the week of 3/23/2022 and no documented missed visit. In an interview with the Administrator on 4/12/2022, she agreed that the identified visits were missing for the aide. She had no additional information to provide.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. 1 of 3 (33%) clinical records reviewed of patients who were live discharges revealed that a discharge summary was not sent to the physician. Record #37792: The patient revoked the hospice benefit on 11/5/2021. There was no documentation that the discharge summary was sent to the patient's primary physician. In an interview with the Administrator on 4/12/2022, she agreed that there was no documentation that the discharge summaries were provided to the primary physician. She stated that there is a template that the clinicians typically use to document a discharge and this template was not utilized on this particular discharge. She had no additional information to provide.