Every finding on record at Unity Hospice of Chicagoland, LLC

Based on review of clinical records and staff interview, it was determined in 4 of 27 records (Pts.# 7, 6, 23 and 24) the Hospice failed to ensure the availability of treatments for symptom management. --- 1. Pt. #7 was admitted to Hospice on 12/12/24 with diagnosis of Malignant Neoplasm of unspecified part of unspecified Bronchus or Lung. The clinical record was reviewed on 02/19/25. The clinical record included the initial POC 12/12/24 with admission orders dated 12/13/24 for oxygen via oxygen concentrator 2-4 liters per nasal cannula PRN for comfort/dyspnea/air symptom management. The patient did not receive the Oxygen until 12/31/24. Findings include: 2.Pt. #6 was admitted to Hospice 04/08/24 with diagnosis of Unspecified Protein Calorie Malnutrition. The clinical record was reviewed 02/18/25. The clinical record included the initial POC 04/08/24, with orders for oxygen via oxygen concentrator 2-4 liters per nasal cannula PRN for comfort/dyspnea/air symptom management. The patient did not receive the Oxygen until 04/11/24. 3. Pt. #23 was admitted to Hospice on 04/18/24 with diagnosis of Malignant Neoplasm of Bladder. The clinical record was reviewed 02/18/25. The clinical record included orders on 04/19/24 for oxygen via oxygen concentrator 2-4 liters per nasal cannula PRN for comfort/dyspnea/air symptom management. The patient did not receive the Oxygen until 04/22/24. 4. Pt. #24 was admitted to Hospice 02/01/24 with diagnosis of Malignant Neoplasm of Colon, Unspecified. The clinical record was reviewed 02/19/25. The clinical record included the initial orders on 01/29/24 for oxygen via oxygen concentrator 2-4 liters per nasal cannula PRN for comfort/dyspnea/air hunger symptom management. The record lacked the date of the delivery. The record only documented the Patient received the suction machine on 02/16/24. 5. The above findings were confirmed with the Director of Clinical Services, on 02/19/25 between 11:30 AM and 12:30 PM.

Based on review of clinical records and staff interview, it was determined in 1 of 27 records (Pt. # 23) the Hospice failed to ensure the POC included all medication orders. --- Findings include: 1.Pt. #23 was admitted to Hospice on 04/18/24 with diagnosis of Malignant Neoplasm of Bladder. The clinical record was reviewed 02/18/25. The clinical record included a phone call made by the family on 04/21/24 at 5:34 PM, to the Hospice, regarding patient experiencing itching. The triage nurse instructed the family to use Claritin. The plan of care lacked the orders for the use of Claritin. 2. The above findings were confirmed with the Director of Clinical Services, on 02/19/25 between 11:30 AM and 12:30 PM.

Based on clinical record review and staff interview, it was determined in 1 of 27 records reviewed (Pt. # 23) the hospice failed to ensure services were available on a 24-hour basis 7 days a week. --- 1. Pt. #23 was admitted to Hospice on 04/18/24 with diagnosis of Malignant Neoplasm of Bladder. The clinical record was reviewed on 02/18/25. The clinical record included documentation of triage phone calls made by the family, to the Hospice, for nursing assistance. The triage phone note dated 05/02/24 at 9:11 PM documented, ";caller stated Pt having trouble breathing". The record lacked a nursing visit note on 05/02/24 in response to the triage call at 9:11 PM. The triage phone note dated 05/03/2024 at 7:10 AM documented, ";it is urgent has a question" . An RN visit was not conducted until 1:05 PM upon the patients death. The record lacked documentation of a timely RN visit to address the familys concerns. 2. The above findings were confirmed with the Director of Clinical Services, on 02/20/25 between 10:30 AM and 1:30 PM.

Based on clinical record review, staff interviews and policy review, it was determined that for 1 of 3 patients reviewed (Pt. #1), the Hospice Agency failed to ensure that a controlled medication was accurately labeled. --- Findings include: 1. Pt. #1 was admitted to hospice services on 1/31/24 with the primary diagnosis of Malignant Neoplasm of Prostate. Pt. #1s clinical record was reviewed on 4/15/24. The clinical record included a medication list dated 2/22/24 that documented medication ";oxycodone hydrochloride 5 mg (milligrams) oral tablet, dose:10 mg (2 tablets) oral every 4 hours as needed – indication: pain." The record also included a ";Nurse Progress Note" dated 2/26/24 which showed the documentation: ";... Yesterday, 2/25/24, (Pt.s spouse) noticed the bottle was missing when (Pt.s spouse) went to administer an evening dose..." 2. A telephone interview was conducted with E#4 on 4/15/24 at 3:30 PM. E#4 confirmed being the RN CM for Pt. #1. E#4 stated, ";I had misplaced (Pt. #1s) oxycodone. I had transferred it to another bottle, I thought it had the same medication... I was informed that Pt. #1's oxycodone was missing...but then I found them during my next visit the week after..." The RN failed to verify that the prescription written on the label of the container matched the medication that was placed in the container. 3. The policy titled ";Identification of Medications for Administration" was reviewed and required, ";5. Medications should be properly labeled with the patients name, name of drug, dosage, diluents, date of preparation, expiration date, initials of the preparer and any special instructions as applicable. 6. The nurse will review the medication label for name, drug, dosage, and prescription. 7. All medications will be checked for stability by visualizing the medication and observing for (but not limited to): F. Storage facilities/containers." 4. During an interview conducted with E#3 (Director of Clinical Services/RN Coordinator) on 4/15/24 at 3:45 PM, E#3 confirmed that it is agency policy during medication reconciliation the nurse is to verify that the containers of the medications are accurately labeled. During the same interview, above finding was confirmed.

Based on clinical records review, staff interviews and policy review, it was determined that for 1 of 3 patients reviewed (Pt. #1), the Agency failed to ensure that discrepancies involving a Schedule II-controlled medication were investigated. --- Findings include: 1.Pt. #1 was admitted for hospice services on 1/31/24 with the primary diagnosis of Malignant Neoplasm of Prostate. Pt. #1s clinical record was reviewed on 4/15/24. The clinical record included Pt. #1s medication list dated 2/22/24 that documented medication ";oxycodone hydrochloride 5 mg (milligrams) oral tablet, dose: 10 mg (2 tablets) oral every 4 hours as needed – indication: pain." The record also included a ";Nurse Progress Note" dated 2/26/24 which showed the documentation: ";...Yesterday, 2/25/24, (Pt.s spouse) noticed the bottle (of oxycodone) was missing when (Pt.s spouse) went to administer an evening dose... E#6 (Patient Care Coordinator – North Team) ... made aware." 2. A review of the Hospice Agencys complaint and incident files for the period of October 15, 2023, through April 15, 2024, was conducted on 4/15/24. The files lacked documentation of an incident and investigation pertaining to Pt. #1's missing oxycodone medications. 3. A telephone interview was conducted with E#4 on 4/15/24 at 3:30 PM. E#4 confirmed being the RN CM for Pt. #1. E#4 stated, ";I had misplaced (Pt. #1s) oxycodone. I had transferred it to another bottle, I thought it had the same medication... I was informed that (Pt. #1's) oxycodone was missing...but then I found them during my next visit the week after, and told (Pt.s spouse) ..." 4. A telephone interview was conducted with E#5 on 4/15/24 at 4:00 PM. E#5 stated a phone call was received from Pt. #1s spouse regarding Pt. #1s missing oxycodone medications... E#5 also stated that E#4 called to inform about the missing medications. E#5 also confirmed that this incident was reported to E#6. 5. An interview was conducted with E#6 on 4/15/24 at 4:20 PM. E#6 confirmed receiving a report form E#5 that Pt. #1 had missing medications. 6. During an interview conducted with E#3 (Director of Clinical Services/RN Coordinator) on 4/15/24 at 3:45 PM, E#3 confirmed that E#3 did not receive a report that during a home visit, E#4 had transferred the oxycodone into a different medication bottle or that Pt. #1s spouse called the Hospice agency because Pt. #1s oxycodone was missing. E#3 stated that per policy, the report would have prompted E#3 to generate an incident report, an investigation and give a verbal warning to the staff involved. 7. The policy titled, ";Medications" was reviewed and required, ";16. Medication Incidents – Medication incidents, errors, and adverse medication reactions. A. Shall be reported to a physician and the nursing supervisor..." 8. The policy titled, ";Incident Reporting" was reviewed and required, ";...Hospice will maintain a process for generating incident reports and follow-up corrective action...Incident – defined as an unusual event involving hospice personnel, patient, and family/caregiver. The event is considered unusual if the result was unintended, undesirable and/or unexpected. An incident is also any happening which is not consistent with the routine operation of hospice or the routine care of a patient. It maybe actual or potential... Examples of Specific Events or Occurrences that must be reported... 1. Loss/Breakage... Patient/family/caregiver reports missing articles... 11. Medication Errors..." 9. During an interview with the E#3 on 4/15/24 at 4:00 PM, the above finding was confirmed.

A. Based on a review of personnel records, Hospice policy, the Illinois Administrative Code and staff interview, it was determined the Hospice failed to ensure health and/or education requirements were met. This was found in 14 of 17 employee personnel records (Employee #1, 2, 3, 4, 5, 6, 7, 8, 11, 12, 14, 15, 16 and 17) , and 2 of 2 volunteer records (Volunteer #2 and 3) reviewed of employees and volunteers that provide direct Pt. care and/or services. Findings include: 1. On 2/8/22 at 12:50 PM, 3:20 PM, 3:45 PM; and 2/9/22 at 10:30 AM and 11:00 AM, the following personnel records were reviewed and lacked documentation of an initial health evaluation and/or TB screening, Alzheimer's Disease and related Dementias training: E #1. DOH 9/25/21. Lacked 6 hours of training in 2021. E #2. DOH 9/25/21. Lacked 6 hours of training in 2021. E #3. DOH 11/6/20. Lacked 6 hours of training from 11/6/20 to 01/2021. E #4. DOH 8/16/19. Lacked initial health evaluation. E #5. DOH 9/21/21. Lacked initial TB screening and 6 hours of training in 2021. E #6. DOH 8/3/21. Lacked 3 hours of training in 2021. E #7. DOH 7/9/20. Lacked initial health evaluation, initial TB screening and 6 hours of training in 2020. E #8. DOH 12/3/20. Lacked initial health evaluation and 6 hours of training from 12/3/20 to 02/2021. E #11. DOH 12/20/21. Lacked initial health evaluation. E #12. DOH 2/18/20. Lacked 6 hours training in 2020. E #14. DOH 2/17/21. Lacked 6 hours of training in 2021. E #15. DOH 9/8/20. Lacked 6 hours of training in 2020. E #16. DOH 2/7/21. Lacked 3 hours of training in 2021. E #17. DOH 12/14/20. Lacked 6 hours of training by 02/2021. Volunteer #2. Start date 8/25/21. Lacked 3 hours of training in 2021. Volunteer #3. Start date 8/25/21. Lacked 3 hours of training in 2021. 2. The policy titled, Personnel Record Contents" was reviewed on 2/8/22 at 4:10 PM and contained: "...1. The content of the personnel files for full time personnel will include... Clinical Documents...D. In-service Education Documentation E. Certificates of Clinical Testing... 2...C. TB/Mantoux Test Documentation (yearly)... " 3. 77 Illinois Administrative Code 280.2045 a) c) e) was reviewed on 2/9/22 at 4:00 PM and included: "Each employee shall have an initial health evaluation... The initial health evaluation shall include a physical examination... The initial health evaluation shall include a tuberculin skin test..." 4. 77 Illinois Administrative Code 973.140 c) f) g) was reviewed on 2/9/22 at 4:00 PM and included: "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... 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... all required training shall be documented with the date of the training; the length of time spent on each training topic...maintain training records and make them available to the Department on request. (Section 30 of the Act)" 5. During an interview with the Director of Human Resources and Human Resources Representative on 2/8/22 at 12:50 PM and 3:20 PM, 2/9/22 at 10:30 AM; the Director of Clinical Services and Assistant Director of Clinical Services on 2/8/22 at 3:45 PM; and the Director of Support Services and Volunteer Coordinator on 2/9/22 at 11:00 AM, the Director of the Human Resources, Director of Clinical Services, and the Volunteer Coordinator confirmed the employees indicated above lacked the required health and/or education requirements. B. Based on a review of personnel records, the Illinois Administrative Code and staff interview, it was determined the Hospice failed to log into the Health Care Worker Registry Web Portal prior to employment, and complete the health care worker background process of non-licensed personnel which include employment verification, Internet searches and maintain documents in the personnel file per regulations. This was found in 12 of 17 employee personnel records (Employee #1, 2, 3, 4, 5, 6, 7, 8, 10 and 11) and 2 of 2 volunteers (Volunteer #2 and 3) personnel records reviewed of employees and volunteers that provide direct patient care and/or service. Findings include: 1. On 2/8/22 at 12:50 PM, and 2/9/22 at 11:00 AM, the following personnel records were reviewed, and the Health Care Worker Registry Web Portal profile lacked documentation of Internet searches, employment history and/or employment with this Hospice: E #1. DOH 9/25/21. The Health Care Worker Registry Web Portal profile dated 9/25/21 lacked Internet searches. E #2. DOH 9/25/21. The Health Care Worker Registry Web Portal profile dated 4/4/18 lacked Internet searches, employment history, verification of employment with this Hospice. E #3. DOH 11/6/20. The Health Care Worker Registry Web Portal profile dated 1/17/22 lacked Internet searches. E #4. DOH 8/16/19. The Health Care Worker Registry Web Portal profile dated 11/5/19 lacked Internet searches. E #5. DOH 9/21/21. The Health Care Worker Registry Web Portal profile dated 9/22/21 lacked Internet searches. E #6. DOH 8/3/21. The undated Health Care Worker Registry Web Portal profile lacked Internet searches. E #7. DOH 7/9/20. The Health Care Worker Registry Web Portal profile dated 1/23/22 lacked Internet searches. E #8. DOH 12/3/20. The Health Care Worker Registry Web Portal profile dated 1/31/22 which lacked Internet searches. E #10. DOH 11/27/17. The Health Care Worker Registry Web Portal profile dated 4/13/18 lacked Internet searches. E #11. DOH 12/20/21. The Health Care Worker Registry Web Portal profile dated 12/17/21 which lacked Internet searches. Volunteer #2. Start date 8/25/21. The undated Health Care Worker Registry Web Portal profile lacked Internet searches. Volunteer #3. Start date 8/25/21. The undated Health Care Worker Registry Web Portal profile lacked Internet searches. 2. 77 Illinois Administrative Code 245.72, 955.145 a) 1-2), 955.165 a) c) was reviewed on 2/9/22 at 4:00 PM and included: "..."Each health care employer or its designee shall provide an employment verification and update the demographic information for each employee no less than annually... health care employers shall conduct Internet searches on certain web sites, including without limitation the Illinois Sex Offender Registry, the Department of Corrections' Sex Offender Search Engine, the Department of Corrections' Inmate Search Engine, the Department of Corrections Wanted Fugitives Search Engine, the National Sex Offender Public Registry..." 3. During an interview with the Director of Human Resources and Human Resources Representative on 2/8/22 at 12:50 PM; the Director of Support Services and Volunteer Coordinator on 2/9/22 at 11:00 AM; the Director of the Human Resources and the Volunteer Coordinator confirmed the Hospice has an active Web Portal account, and failed to conduct Internet searches, enter employment verification and employment history as required by 77 Illinois Administrative Code, 245.72 Health Care Worker Background Check.