Every finding on record at Unitypoint at Home

Based on document review and staff interviews, for 1 of 2 (Pt #2) patient's requiring durable medical equipment. the facility failed to coordinate and provide durable medical equipment in accordance with patient and family needs. --- 1. Pt #2’s record was reviewed. Pt #2 was admitted on 3/22/26 with a diagnosis of "Frontal mass of the brain." Pt #2’s record included an order for a Hoyer lift on 5/1/2026. Pt #2’s record lacked documentation that Pt #2 received the Hoyer lift. 2. Review of the facilities policy titled Home Medical Equipment and Supplies (Effective 11/2026), indicated "4. “The Registered Nurse (RN) requests the ordered home medical equipment (HME) from the provider and informs the patient/caregiver of its expected delivery time and ensures that the patient/caregiver receives adequate instruction and information related to the equipment used by the patient through demonstration and teach back. The HME providers also provide education and instruction to the patient and caregiver.”3. An interview was conducted with the Hospice Administrator (E# 3). E #3 reviewed Pt #2’s record and verbally agreed that there is no documentation that Pt #2 received the Hoyer lift as prescribed. E #3 stated, “We do not have a process to track when patients receive their DME.”

Upon patient record review, 3 of 19 (Patient #3,#4,#10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 3:The medication profile includes entries for Calcium Polycarbophil fiber laxative as needed for constipation and oxygen inhale 2 liters per minute into lungs for shortness of breath. There is no evidence that the entry includes the type and amount of diluent for administration of the laxative or a route for administration of the oxygen. Patient 4:The medication profile includes entries for Benadryl ointment and a lidocaine patch. There is no evidence that the entries include a location for administration. Patient 10:The medication profile includes an order for gentamycin cream and there is no evidence that the entry includes the location for administration. The plan of care includes an order for oxygen 2-5 liters per minute via nasal cannula for shortness of breath. There is no evidence that the medication profile includes an entry for oxygen.

Upon patient record review, 4 of 19 (Patient #6,#8,#10,#13) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 6:The medical record included nursing documentation of a chronic wound to the right eye and diagnoses of CHF, cardiomyopathy, aortic valve stenosis, right bundle branch block, and pacemaker. There is no evidence that the plan of care includes problems, goals and interventions for wound management and cardiac. Patient 8:The medical record includes documentation that the patient has a primary diagnosis of late effects CVA, with comorbidities of occlusion of left, middle and right cerebral artery and right carotid with hypertension, blood clotting disorder and history of thrombosis and embolism and is at risk for aspiration due to enteral feeds via gastrostomy tube. There is no evidence that the plan of care includes problems, goals and interventions for the management of neuro and cardiac disease and the risk for aspiration. Patient 10:The medical record includes documentation the patient has a primary diagnosis of hypertensive heart disease with heart failure and is on fluid restrictions of 2500 cc/day. There is no evidence that the plan of care includes problems, goal and interventions to manage cardiovascular disease or a fluid restricted diet. Patient 13:The medical record includes documentation that the patient is currently receiving Macrobid for an active infection, has ongoing symptoms of nausea and vomiting that is being managed with medication, has a colostomy and has a primary diagnosis of colorectal cancer. There is no evidence that the plan of care includes problems, goals and interventions to manage an active infection, gastrointestinal symptoms, colostomy care and the primary diagnosis of cancer.

Upon patient record review, 1 of 19 (Patient #8) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 8:The plan of care includes an order for enteral feeds that notes 24 ml bolus. The order does not include the frequency or how the bolus should be delivered, via gravity or pump.

Upon patient record review, 2 of 19 (Patient #6,#12) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 6:The medical record includes documentation that the patient experienced a fall from slipping out of a wheelchair. There is no evidence that the plan of care includes a wheelchair. Patient 12:Upon observation during the home visit, the patient requires a hospital bed and a sit to stand lift. There is no evidence that the plan of care includes these equipment needs.

Upon patient record review, 1 of 19 (Patient #6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 6:The plan of care includes an order for oxygen continuously at 2 liters per minute via nasal cannula. There is documentation that during a patient visit on 2/21, the hospice RN increased the liter flow of oxygen from 2 liters per minute to 4 liters per minute. There was no update to the order.

Upon patient record review, 1 of 19 (Patient #9) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 9:The plan of care notes that patient is at high risk for falls. The aide plan of care does not include fall precautions.

Upon patient record review, 5 of 13 (Patient #4,9,11,12,13) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #4: Medication profile had the following issues - PRN medications, nitroglycerin and oxygen didn't include indications; flouromethelone eye drops didn't include instructions on which eye to instill in; cholestyramine powder didn't include diluent instructions; restasis eye drops didn't include instructions on which eye to instill in; oxygen didn't include instructions on whether to administer via nasal canula or mask. All items corrected on site. Patient #9: Med profile PRN medications zofran, valium, oxycodone did not include an indication of the PRN. Patient #11: Med profile PRN medication zofran did not include an indication of the PRN. Patient #12: Med profile PRN medication lorazepam did not include an indication of the PRN. Patient #13: Med profile PRN medication morphine concentrate solution did not include an indication of the PRN.

Upon patient record review, 5 of 13 (Patient #4, #9, #11, #12, #13) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #4: Medication orders had the following issues - PRN medications, nitroglycerin and oxygen didn't include indications; flouromethelone eye drops didn't include instructions on which eye to instill in; cholestyramine powder didn't include diluent instructions; restasis eye drops didn't include instructions on which eye to instill in; oxygen didn't include instructions on whether to administer via nasal canula or mask. All items corrected on site. Patient #9: Med orders for PRN medications zofran, valium, oxycodone did not include an indication of the PRN. Patient #11: Med orders for PRN medication zofran did not include an indication of the PRN. Patient #12: Med orders for PRN medication lorazepam did not include an indication of the PRN. Patient #13: Med orders for PRN medication morphine concentrate solution did not include an indication of the PRN.

Upon client record review, 3 of 13 (Patient #6, #7, #13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6: Social Worker ordered 1 time every 30 days effective 12/13/2021. Patient was seen twice during the following 30 days on 12/15 and 1/3. Social Worker was frequency was updated on 1/24 to 1 time every 30 days. Patient was seen twice during the following 30 days on 2/8 and 2/22. No evidence to support a PRN visit or order to include the extra visits. Patient #7: Spiritual Care ordered 1 month 3 on the plan of care effective 12/27/2021. Patient was seen twice in the month of February on 2/4 and 2/28. No evidence to support a PRN visit or change in frequency. Social worker ordered 1 time every 30 days effective 9/25/2021. No visits were performed from 10/9 - 11/7 resulting in greater than 30 days between visits. No visits were performed from 12/1 - 12/30 resulting in greater than 30 days between visits. and no visits were performed 1/25 - 2/24 resulting in greater than 30 days between visits.. No evidence to support a change in frequency. Patient #13: Spiritual Care ordered 1 time every 30 days effective 1/26/2022. 2 visits were made in 30 days on 128 and 2/2. No evidence to support a change in frequency.

Upon observation, there was missing evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #2, Aide visit: Aide was noted to put her bag down on the patients chair without using any type of barrier per agency policy. Patient #3, SC visit: SC was noted to put his bag down on the patients kitchen floor without using any type of barrier per agency policy.

Upon patient record review 3 of 11 applicable (Patient #1, #7, #11) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #1: Aide services ordered on the plan of care two times a week. Weeks of 1/16 and 1/23 only 1 visit was performed. Weeks of 1/30, 2/6, and 2/13 no visits were performed. No evidence to support a change in frequency or missed visit documentation. Patient #7: Aide services ordered daily effective 9/26/2021. No visits were made on 10/2, 10/3, 10/8 or 10/9. No evidence to support a change in frequency. Patient #11: Aide services ordered 3 times a week on the plan of care. The week of 12/7 only 2 visits were performed on 12/8 and 12/10. No evidence to support a missed visit or change in frequency.

Based on document review and interview, it was determined for 1 of 1 (Pt #9) patient record reviewed who had revoked services, the Hospice failed to ensure a discharge summary was completed, the attending physician was notified and sent the record to the attending physician. This has the potential to affect all patients who revoke Hospice services. Findings include: 1. Pt #9 Start of Care: 11/23/21 Diagnosis: Other Specified Disease of Intestine. The record was reviewed on 2/4/22 at approximately 1:30 PM. The Skilled Nurse note dated 1/17/22 noted "Discussed that while on hospice aggressive physical therapy is not offered... they may be interested in revoking services... No decisions have been made at this time. Pt (patient) and grandson are going to think about it and let hospice know." Although the record had a Revocation of Medicare Hospice Benefit form dated 1/18/22 signed by Pt #9, it lacked documentation of the revocation request by the patient, the physician and the Interdisciplinary team were not notified and lacked a discharge summary. 2. During an interview on 2/8/22 at approximately 12:30 PM, the Hospice Administrator (E#1) reviewed Pt #9's record and verbally agreed the record lacked a discharge summary, documentation of the patient's request for revocation and attending physician's notification and should have been.

Based on document review and interview, it was determined for 1 of 1 (Pt #9) patient record reviewed who had revoked services, the Hospice failed to ensure a discharge summary was completed. This has the potential to affect all patients who revoke Hospice services. Findings include: 1. Pt #9 Start of Care: 11/23/21 Diagnosis: Other Specified Disease of Intestine. The record was reviewed on 2/4/22 at approximately 1:30 PM. The record had a "Revocation of Medicare Hospice Benefit" form dated 1/18/22 and signed by Pt #9. The record indicated that the services were ceased at that time. The record lacked a discharge summary of the patients stay including: treatments, symptoms, pain, plan of care and physician's orders. 2. During an interview on 2/8/22 at approximately 12:30 PM, the Hospice Administrator (E#1) reviewed Pt #9's record and verbally agreed the record lacked a discharge summary of the patients stay including treatments, symptoms, pain, plan of care and physician's orders.

Based on document review and staff interview, it was determined for 18 of 18 (Volunteers # 1, #2, #3, #4, #5, #6, #7, #9, #10, #11, #12, #14, #15, #16, #17, #18, #19 and #20) non licensed, direct patient care volunteers, the Hospice failed to comply with the Health Care Worker Background Check (related to fingerprint-based criminal history). This has the potential to affect all hospice patients who receive volunteer care by the Hospice with a current census of 99 patients. Findings include: 1. The State of Illinois Section 245.72 Health Care Worker Background Check regulation was reviewed on 12/20/17 at 1:00 PM. The regulation indicated "An agency shall comply with the Health Care Worker Background Check Act [225 ILCS46] and the Health Care Worker Background Check Code (77 Ill.Adm. Code 955)." Under "955.165 Fingerprint-Based Criminal History Records Check, b) If the individual has not had such a background check or is not active on the Health Care Workers Registry, then the health care employer must initiate a finger print based criminal history records check. c) Educational entities and health care employers shall conduct Internet searches on certain web site, 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 and the website of the Health and Human Services Office of Inspector General to determine if the applicant has been adjudicated a sex offender, has been..." 2. The volunteer personnel files were reviewed on 2/4/22 at approximately 2:00 PM. The following volunteers, lacked documentation that the fingerprint-based criminal history records checks were conducted: -Volunteer #1 DOH (Date of Hire): 6/24/13 -Volunteer #2 DOH: 3/20/14 -Volunteer #3 DOH: 5/2002 -Volunteer #5 DOH: 3/14/14 -Volunteer #6 DOH: 5/19/21 -Volunteer #7 DOH: 8/24/11 -Volunteer #9 DOH: 9/13/04 -Volunteer #10 DOH: 3/07 -Volunteer #11 DOH: 8/2/17 -Volunteer #12 DOH: 10/26/11 -Volunteer #14 DOH: 10/12 -Volunteer #15 DOH: 4/28/19 -Volunteer #16 DOH: 12/1/06 -Volunteer #17 DOH: 3/1/11 -Volunteer #18 DOH: 8/8/09 -Volunteer #19 DOH: 5/2005 -Volunteer #20 DOH: 8/12/2020 3. During an interview with the Hospice Administrator (E#1) on 1/4/22 at approximately 3:00 PM, E#1 verbally confimed the lack of background checks on the volunteers.