Every finding on record at Ucm Home Care

Based on a review of the Hospice Emergency Preparedness Plan and Staff interview it was determined that the Hospice failed to maintain a communication plan with the names and contact information for current Staff. --- Findings include: 1. The Hospice Emergency Preparedness Plan was reviewed on 01/22/25 at 11:00 AM. The communication plan did not include contact information of current Hospice Staff. 2. During an interview with the Administrator on 01/23/25 at 10:30 AM, the finding of the Hospice not having a communication plan that includes a contact list of current Staff, was confirmed.

Based on the clinical record review and Staff interview, it was determined in 2 of 19 (Pts. #15 and 19) clinical records reviewed, the IDG failed to ensure a completed comprehensive assessment within 5 days after the election. --- 2. Pt. #19 was admitted to the hospice services on 11/03/23 with diagnosis of Malignant Neoplasm of Right female Breast Unspecified Estrogen Receptor Status. The clinical record was reviewed on 01/22/25. The MSW and Chaplain did not assess the patient until 11/09/24 (more than 5 days of the election). 3. During the interviews conducted on 01/22/25 between 2- 3:00 PM, with the Executive Administrator and RN Coordinator, the above findings were confirmed. Findings include: 1. Pt. #15 was admitted to the hospice services on 01/11/24 with a diagnosis of Chronic Obstructive Pulmonary Disease with Lower Respiratory Infection. The clinical record was reviewed on 01/22/25. The MSW and Chaplain did not assess the patient until 01/17/24, which was more than 5 days after the election.

Based on the review of the Governing Board minutes and Staff interview, it was determined the Hospice failed to ensure the frequency and details of the quality assessment and performance improvement program were approved. --- Findings include: 1. The 2024 Governing Board minutes and Hospice quality assessment and performance improvement program was reviewed on 01/22/25 at 11:00 AM. The 2024 Governing Board minutes lacked documentation that the Governing Board met to approve the data collection frequency and details of the quality assessment and performance improvement program. 2. The findings were confirmed during the interview on 01/22/25 at 1:30 PM, with the Executive Administrator.

Based on document review, policy review and staff interview it was determined the Hospice failed to provide documentation of cost savings achieved by utilizing volunteers for the years 2023 and 2024. This has the potential to affect all Pts. receiving Hospice services. --- Findings include: 1. On 01/22/25, documentation of cost savings achieved by using volunteers for the years 2023 and 2024 was requested but could not be provided by the Agency. 2. The Policy titled, ";Volunteer Services" was reviewed on 01/23/25 and required, ";A. Cost savings achieved through the use of volunteers will be documented." 3. On 01/22/25, an interview was conducted with the Interim Volunteer Coordinators, (Executive Administrator and the Bereavement Coordinator/LCSW.) The Executive Administrator stated that since there were no volunteers for the years 2023 and 2024, there was no documentation of any cost savings for those years.

Based on document review, staff interview and policy reviews, it was determined the Hospice failed to ensure that the minimum of 5% cost saving requirement of total Pt. care hours of all Hospice paid employees achieved by using volunteers were met for the years 2023 and 2024. This has the potential to affect all Pts. receiving Hospice services. --- Findings include: 1. The documentation of the use of volunteers and types of services that they provided was requested but was not provided. The Executive Administrator stated that there were no volunteers for the years 2023 and 2024. The Hospice lacked documentation that the 5% cost savings requirement for the years 2023 and 2024 were met. 2. On 01/22/25, an interview was conducted with the Interim Volunteer Coordinators, (Executive Administrator and the Bereavement Coordinator/LCSW). The Executive Administrator stated there had been no volunteers since the year 2020 and currently there is 1 volunteer who signed up, but training will be set up for February 2025. 3. The policy titled, ";Volunteer Services" was reviewed on 01/23/25 and required, ";(Agency) maintains a volunteer staff sufficient to provide administrative support or direct care that amounts to a minimum of 5% of total patient care hours for paid hospice employees of contract staff..." 4. During the same interview on 01/22/25, the Executive Administrator confirmed that since there were no volunteers for the years 2023 and 2024, the Hospice did not meet the required cost savings requirement.

Based on the clinical records review and Staff interviews, it was determined that in 2 of 5 (Pts. # 18 and 19) discharge clinical records review, the Hospice lacked documentation of discharge summary. --- 2. Pt. #19 was admitted to the hospice services on 11/03/23 with diagnosis of Malignant Neoplasm of Right Female Breast Unspecified Estrogen Receptor Status. The clinical record was reviewed on 01/22/25. The clinical record lacked a discharge summary. 3. The findings were confirmed during the interviews on 01/22/25 at 1:30 PM and 01/23/25 at 10:30 AM with the Executive Administrator. Findings include: 1. Pt. #18 was admitted to the hospice services on 02/14/24 with diagnosis of Malignant Neoplasm of Right Ovary. The clinical record was reviewed on 01/22/25. The clinical record lacked a discharge summary.

A. Based on a review of the Emergency Preparedness plan and staff interview, it was determined the Hospice failed to ensure a policy was established to inform State and local officials regarding the inability to contact employees and Pts, during an emergency or disaster. Findings include: 1. The Agency's Emergency Preparedness plan last updated on 5/20/21 was reviewed with the Assistant Director of Quality and Compliance on 1/26/22 at 9:00 AM. The plan lacked a policy for notifying State and local officials of Pts and staff the Hospice is incapable of contacting. 2. During an interview with the Assistant Director of Quality and Compliance on 1/26/22 at 9:00 AM; the Executive Director and Hospice Clinical Manager on 1/26/22 at 3:15 PM, the Administrative Staff confirmed the Hospice lacked a policy informing State and local officials, regarding the inability to contact employees and Pts. during an emergency or disaster.

A. Based on a review of the Emergency Preparedness plan and staff interview, it was determined the Hospice failed to ensure the Plan included a policy regarding communication with emergency preparedness officials for the purpose of Pt. evacuation. This has the potential to affect all Pts. receiving services from the Hospice. Findings include: 1. The Agency's Emergency Preparedness plan last updated on 5/20/21 was reviewed with the Assistant Director of Quality and Compliance on 1/26/22 at 9:00 AM. The plan lacked a policy identifying a process for informing State and local emergency preparedness officials of Pts. needing to vacate their home, in the event of an emergency. 2. During an interview with the Assistant Director of Quality and Compliance on 1/26/22 at 9:00 AM; the Executive Director and Hospice Clinical Manager on 1/26/22 at 3:15 PM, the Administrative Staff confirmed the Hospice lacked a policy regarding communication with emergency preparedness officials for the purpose of Pt. evacuation.

A. Based on a review of the Emergency Preparedness plan and staff interview, it was determined the Hospice failed to ensure the plan included a policy for arranging Pt. care/services with other facilities, in the event the Hospice is unable to provide care/service due to an emergency or disaster. This has the potential to affect all Pts. receiving services from the Hospice. Findings include: 1. The Agency's Emergency Preparedness plan last updated on 5/20/21 was reviewed with the Assistant Director of Quality and Compliance on 1/26/22 at 9:00 AM. The plan lacked a policy pertaining to the arrangement of Pt. care and/or services from another provider, ensuring the continuity of care in the event the Hospice is unable to provide the required care and services due to an emergency event. 2. During an interview with the Assistant Director of Quality and Compliance on 1/26/22 at 9:00 AM; the Executive Director and Hospice Clinical Manager on 1/26/22 at 3:15 PM, the Administrative Staff confirmed the Hospice lacked a policy for arranging Pt. care/services with other facilities.

A. Based on review of the Emergency Preparedness plan and staff interview, it was determined the Hospice failed to ensure the communication plan included the required elements. This has the potential to affect all Pts. receiving services from the Hospice. Findings include: 1. The Agency's Emergency Preparedness plan last updated on 5/20/21 was reviewed with the Assistant Director of Quality and Compliance on 1/26/22 at 9:00 AM. The Plan lacked the names/entities and their contact information that provide services, under a contractual agreement (Medical Director, Durable Medical Equipment and pharmaceutical providers). 2. During an interview with the Assistant Director of Quality and Compliance on 1/26/22 at 9:00 AM; the Executive Director and Hospice Clinical Manager on 1/26/22 at 3:15 PM, the Administrative Staff confirmed the Hospice's communication plan lacked the required elements.

A. Based on clinical record review and staff interview, it was determined the Hospice failed to ensure the IDT completed the comprehensive assessment within 5 days of the SOC/election of Hospice care. This was found in 2 of 13 (Pts. #8 and 10) clinical records reviewed. Findings include: 1. Pt. #8. SOC 9/2/21. Hospice Diagnosis: Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation. The clinical record was reviewed on 1/26/22 at 1:20 PM. The record contained the "Hospice RN Start of Care" assessment form dated 9/2/21, indicating service was initiated on 9/2/21. As of 1/26/22, the record lacked documentation the Chaplain conducted an initial spiritual assessment. 2. Pt. #10. SOC 1/13/22. Hospice Diagnosis: COVID-19. The clinical record was reviewed on 1/26/22 at 9:00 AM. The record contained the "Hospice RN Start of Care" assessment form dated 1/13/22, indicating service was initiated on 1/13/22. As of 1/26/22, the record lacked documentation the Chaplain conducted an initial spiritual assessment. 3. During an interview with the Executive Director, Hospice Clinical Manager and the Assistant Director of Quality and Compliance (Administrative Staff) on 1/27/22 at 10:20 AM, the Administrative Staff confirmed the IDT failed to complete the comprehensive assessment within 5 days of the SOC.

A. Based on clinical record review and staff interview, it was determined the Hospice failed to ensure services were provided as ordered by the Physician in the POC. This was found in 3 of 13 (Pts. #3, 1, and 8) clinical records reviewed. Findings include: 1. Pt. #3. SOC 12/23/21. Hospice Diagnosis: Multiple Myeloma not Having Achieved Remission. The clinical record was reviewed on 1/25/22 at 3:10 PM. The record included the POC effective 12/23/21 to 3/22/22, which contained the Physician's order: "HHA 1WK1, 2WK12, 1WK1." The record lacked documentation the HHA provided any service for the weeks of 12/23/21 to 12/25/21, 12/26/21 to 1/1/22, and 1/9/22 to 1/15/22. The POC effective 12/23/21 also included the Physician's order: "CH effective 1/2/22 1WK1." The record lacked documentation of a Chaplain visit. 2. Pt. # 1. SOC 12/18/21. Hospice Diagnosis: Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 1/24/22 at 1:35 PM. The record contained the POC effective 12/18/21 requiring the SN to provide service: "1WK1, 3WK1, 2WK1, 3WK1, 2WK1, 3WK1, 2WK1, 3WK1, 2WK1, 3WK1, 2WK1, 3WK1, 2WK2". As of 1/24/22, the record lacked documentation the SN provided a second visit during the week of 12/26/21 to 1/1/22, lacked 2 SN visits during the week of 1/2/22 to 1/8/22, and lacked 1 SN visit during the week of 1/16/22 to 1/22/22. 3. Pt. #8. SOC 9/2/21. Hospice Diagnosis: Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation. The clinical record was reviewed on 1/26/22 at 1:20 PM. The record contained the POC for the certification period of 11/1/21 to 12/30/21 requiring the SN to provide service: "2WK9". As of 1/26/22, the record lacked documentation the SN provided a second SN visit during the week of 12/19/21 to 12/25/21. The POC effective 12/31/21 required the Hospice Aide to provide service "3WK8". As of 1/26/22, the record lacked documentation the Hospice Aide provided a third visit during the week of 1/2/22 to 1/8/22. 4. During an interview with the Executive Director, Hospice Clinical Manager and the Assistant Director of Quality and Compliance on 1/27/22 from 10:20 AM to 11:40 AM, the Administrative Staff confirmed the Hospice failed to provide care and/or service, as indicated by the POC developed by the IDG.

A. Based on a review of clinical records and staff interview, it was determined the Hospice failed to ensure the POC was reviewed and revised every 15 days. This was found in 3 of 13 (Pts. #1, 8 and 9) clinical records reviewed. Findings include: 1. Pt. # 1. SOC 12/18/21. Hospice Diagnosis: Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 1/24/22 at 1:35 PM. The record contained the " ...IDG Conference Report" meeting minutes dated 12/21/21. As of 1/24/22, the record lacked any other IDG meeting minutes after 12/21/21. 2. Pt. #8. SOC 9/2/21. Hospice Diagnosis: Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation. The clinical record was reviewed on 1/26/22 at 1:20 PM. The record lacked any " ...IDG Conference Report" meeting minutes during November 2021. The record contained one meeting minute during December 2021 (dated 12/15/21). As of 1/26/22, the record also lacked any meeting minutes during January 2022. 3. Pt #9. SOC 12/13/21. Hospice Diagnosis: Unspecified Malignant Neoplasm of Colon. The clinical record was reviewed 1/26/22 at 9:15 AM. As of 1/26/22, the record lacked any " ...IDG Conference Report" meeting minutes after 12/15/21. 4. During an interview with the Executive Director, Hospice Clinical Manager and the Assistant Director of Quality and Compliance on 1/27/22 at 10:20 AM, the Administrative Staff confirmed the Hospice failed to ensure the POC was reviewed and revised every 15 days.

A. Based on a review of clinical records, Hospice policy and staff interview, it was determined the Hospice failed to ensure bereavement services were provided as required. This was found in 3 of 13 (Pts. #8, 10 and 12) clinical records reviewed. Findings include: 1. Pt. #8. SOC 9/2/21. Hospice Diagnosis: Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation. The clinical record was reviewed on 1/26/22 at 1:20 PM. The record contained the "Hospice RN Start of Care" assessment form dated 9/2/21, indicating service was initiated on 9/2/21. As of 1/26/22 (146 days after the SOC), the record lacked documentation an initial bereavement assessment was conducted. 2. Pt. #10. SOC 1/13/22. Hospice Diagnosis: COVID-19. The clinical record was reviewed on 1/26/22 at 9:00 AM. The record included the "Hospice RN Start of Care" assessment form dated 1/13/22, indicating service was initiated on 1/13/22. As of 1/26/22 (13 days after the SOC), the record lacked documentation an initial bereavement assessment was conducted. 3. Pt. #12. SOC 1/15/21. Hospice Diagnosis: Malignant Neoplasm of Unspecified Part of the Right Bronchus or Lung. The clinical record was reviewed on 1/25/22 at 12:10 PM. The record lacked documentation an initial bereavement risk assessment was conducted. 4. The Hospice policy titled "Bereavement Services" was reviewed on 1/26/22 at 10:00 AM. The policy required: " ...The RN opening the Patient for care will identify individuals to be included in the bereavement program. The Social Worker may also identify individuals to be included in the bereavement program. The RN opening the Patient for care, working collaboratively with the Hospice team, will complete a bereavement risk assessment for all identified individuals within 5 days of the start of care ..." 5. During interviews with the Executive Director, Hospice Clinical Manager, and Assistant Director of Quality and Compliance on 1/27/22 beginning at 10:20 AM to 12:25 PM, the above findings were confirmed.

A. Based on a review of personnel records, Hospice policy and staff interview, it was determined the Hospice Administrator failed to review employee's job performance annually. This was found in 5 of 7 (E #3, 6, 8, 10 and 11) personnel records reviewed of direct professional staff, employed greater than 1 year. Findings include: 1. The following personnel records were reviewed on 1/25/22 at 10:00 AM with the Assistant Director of Quality and Compliance, and lacked documentation the employees received an annual performance evaluation: E #3. DOH 11/4/19. Lacked a performance evaluation for 2020. E #6. DOH 8/19/19. Lacked a performance evaluation for 2020. E #8. DOH 12/6/19. Lacked a performance evaluation for 2020. E #10. DOH 11/4/19. Lacked a performance evaluation for 2020. E #11. DOH 8/9/10. Lacked performance evaluations for 2019 and 2020. 2. The Hospice's policy titled, "Performance Evaluations Policy" was reviewed on 1/26/22 at 11:53 AM. The policy required: " ...3. A performance review is conducted by the employee's immediate supervisor or manager, may be reviewed by the department head ... once every 12 months for all employees and contracted staff where applicable ..." 3. The Hospice's policy titled, "Job Title/Position: Executive Director" was reviewed on 1/26/22 at 2:10 PM. The policy required: " ....5. Reviews... performance evaluations, an ongoing basis ..." 4. During an interview with the Assistant Director of Quality and Compliance on 1/25/22 at 10:00 AM and 1/26/22 at 11:00 AM; the Executive Director and Hospice Clinical Manager on 1/26/22 at 3:15 PM, the Administrative Staff confirmed the personnel records lacked an annual performance evaluation for the employees identified above.

A. Based on a review of personnel records, Hospice policy and staff interview, it was determined the Hospice failed to ensure employees received an initial competency evaluation. This was found in 2 of 11 (E #6 and 8) direct professional staff personnel records reviewed. Findings include: 1. The following personnel records were reviewed on 1/25/22 at 10:00 AM with the Assistant Director of Quality and Compliance, and lacked documentation the Hospice evaluated the employee's skills upon hire: E #6. DOH 8/19/19. E #8. DOH 12/6/19. 2. The Hospice policy titled, "Employee Personal Files" was reviewed on 1/26/22 at 2:20 PM. The policy required: " ...3.0 Employee Personnel Files Shall Contain at Least the Following.... 3.3 A record regarding the employee's ... experience ..." 3. During an interview with the Assistant Director of Quality and Compliance on 1/25/22 at 10:00 AM and 1/26/22 at 11:00 AM; the Executive Director and Hospice Clinical Manager on 1/26/22 at 3:15 PM, the Administrative Staff confirmed the personnel records lacked an initial competency evaluation.

B. Based on employee file review, Illinois Administrative Code, and staff interview, it was determined that the Hospice failed to conduct and complete the health care worker background process through the IDPH Web portal that included eligibility, FEE _APP, initial and annual employment verification, and Internet searches, and the maintenance of documents in personnel files per regulations. This was found in 5 of 5 (E #12, 13, 14, 15 and 16) Hospice Aide files reviewed. Findings Include: 1. The personnel file of E #12 Hospice Aide (DOH 9/20/21) was reviewed on 1/26/22 at 9:00 AM. The file included the IDPH.HCWR printout (not dated), which documented E #12 was eligible to work, and a FEE_APP dated 1/29/18. The file lacked documentation of Internet searches and the maintenance of all documents in E #12's personnel file per regulations. No other documents were in E #12's file. 2. The personnel file of E #13 Hospice Aide (DOH 3/16/20) was reviewed on 1/26/22 at 9:15 AM. The file included the IDPH.HCWR printout (not dated), which documented E #13 was eligible to work, and a FEE_APP dated 9/13/13. The file lacked documentation of Internet searches and the maintenance of all documents in E #13's personnel file per regulations. No other documents were in E #13's file. 3. The personnel file of E #14 Hospice Aide (DOH 6/21/21) was reviewed on 1/26/22 at 9:30 AM. The file included the IDPH.HCWR printout (not dated), which documented E #14 was eligible to work, and a FEE_APP dated 3/3/16. The file lacked Internet searches and the maintenance of all documents in E #14's personnel file per regulations. No other documents were in E #14's file. 4. The personnel file of E #15 Hospice Aide (DOH 12/6/99) was reviewed on 1/26/22 at 9:45 AM. The file included the IDPH.HCWR printout dated 2/26/19, which documented E #15's work eligibility was not yet determined, and a UCIA_NAME check on 7/28/03. The file lacked annual employment verification for the years 2019, 2020 and 2021, documentation of Internet searches, and the maintenance of all documents in E #15's personnel file per regulations. No other documents were in E #15's file. 5. The personnel file of E #16 Hospice Aide (DOH 3/2/11) was reviewed on 1/26/22 at 10:00 AM. The file included the IDPH.HCWR printout (not dated), which documented E #16 was eligible to work, and a FEE_APP dated 12/23/10. The file lacked annual employment verification for the years 2019 and 2020, documentation of Internet searches, and the maintenance of all documents in E #16's personnel file per regulations. No other documents were in E #16's file. 6. Illinois Administrative Code 280.2035 titled: "Health Care Worker Background Check" was reviewed on 1/27/22 at 1:45 PM and required: "...An agency shall comply with the Health Care Worker Background Check Act (225ILCS 46) and the Health Care Worker Background Check Code (77 Ill. Adm. Code 955)... Section 955.115 Implementation of Fingerprint-Based Criminal History Records Checks as a Fee Applicant Inquiry a) Fingerprint-based criminal history records checks shall be initiated through the Department's web application used for the Health Care Worker Registry. The direct care employer or its designee must log into the Health Care Worker Registry through a secure login. (Section 33(i) of the Act) ..." 7. During an interview with the Executive Director, Hospice Clinical Manager and Assistant Director of Quality and Compliance on 1/27/22 at 12:10 PM, the Executive Director stated that the Hospice has an active Web Portal account, but failed to complete the health care worker background check process and maintain documentation in personnel files as per requirements. . A. Based on review of the Illinois Administrative Code, employee training report and staff interview, it was determined the Hospice failed to ensure employees providing direct Pt. care and services, received the required hours of Alzheimer's disease and related dementias training. This was found in 11 of 11 (E #1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11) professional employee training/education records reviewed. Findings include: 1. 77 Illinois Administrative Code 973.140 (c) requires: "c) Staff with direct access to clients with Alzheimer's disease or a related dementia hired after June 2, 2019 shall complete a minimum of 6 hours of initial training in the first 60 days of employment using an Alzheimer's disease and related dementias services curriculum, as defined in subsection (e) Section 30 of the Act ..." 2. 77 Illinois Administrative Code 973.140 (f) requires: "f) As of June 2, 2019, staff with direct access to clients with dementia shall receive 3 hours of advanced training on caring for individuals with Alzheimer's disease and related dementias each year. The initial six hours of training required in subsection (c) shall satisfy the annual training requirement for the staff member's first year of employment ..." 3. On 1/26/22 at 2:00 PM, the Hospice presented an employee training report that was reviewed and indicated the following employees that provide direct Pt. care failed to receive 6 hours of initial training, and/or 3 hours of advance training annually pertaining to Alzheimer's disease and related dementias training: E #1. DOH 11/23/20. Lacked any hours in 2020 and 2021. E #2. DOH 5/10/21. Lacked 3 hours in 2021 E #3. DOH 11/4/19. Lacked 6 hours from 11/4/19 to 12/31/20. E #4. DOH 2/15/21. Lacked 2 hours in 2021. E #5. DOH 6/7/21. Lacked 5 hours in 2021. E #6. DOH 8/19/19. Lacked 6 hours in 2019, 3 hours in 2020 and 3 hours in 2021. E #7. DOH 2/18/20. Lacked 6 hours in 2020. E #8. DOH 12/6/19. Lacked any hours in 2020 and 2021. E #9. DOH 1/5/21. Lacked 6 hours in 2021. E #10. DOH 11/4/19. Lacked 6 hours from 11/4/19 to 12/31/20. E #11. DOH 8/9/10. Lacked 3 hours in 2020 and 3 hours in 2021. 4. During an interview with the Assistant Director of Quality and Compliance on 1/25/22 at 10:00 AM and 1/26/22 at 11:00 AM; the Executive Director and Hospice Clinical Manager on 1/26/22 at 3:15 PM, the Administrative Staff confirmed the employees indicated above lacked the required hours of training pertaining to Alzheimer's disease and related dementias.