Every finding on record at Waukegan Hospice LLC

Based on a review of the Hospice Emergency Preparedness Plan and staff interview, it was determined that the Hospice failed to present documentation indicating the Hospice activated or conducted testing of the Emergency Preparedness since 2023. --- Findings Include:1.  The Hospice Emergency Preparedness Plan was reviewed on 8/13/25 at 1:00 PM.   The Emergency Preparedness Plan failed to include documentation indicating that the Hospice activated or conducted any testing exercise since 2023.2.  During an interview with the Interim Executive Director and Pt. Care Manager on 8/14/25 at 2:00 PM, both confirmed the above finding.

Based on clinical records review and staff interview, the Hospice failed to ensure that the initial comprehensive assessment was completed within 5 days of election of Hospice benefits. This was found in 3 of 19 clinical records reviewed. (Pts. # 3, 10 and 1) --- 3.  Pt. #1 was admitted to Hospice services on 6/27/25 with the Hospice diagnosis of Unspecified Severe Protein-Calorie Malnutrition.  The clinical record was reviewed on 8/11/25.  The clinical record included a Hospice election form dated 6/27/25.  The SW conducted the initial psychosocial assessment on 7/7/25 (more than 5 days of the election on 6/27/25).  4.  During staff interviews with Interim Executive Director and Pt. Care Manager on 8/14/25 at 11:04 AM and 2:15 PM, both confirmed the above findings.   Findings include:1.   Pt. #3 was admitted to Hospice services on 6/03/25 with diagnosis of Hypertension Heart and Chronic Kidney Disease without Heart Failure.  The clinical record was reviewed on 8/12/25.  The record included a signed election form dated 6/3/25.  The initial spiritual counselor assessment was completed on 6/9/25 (6 days after election date) and the initial MSW assessment was completed on 6/12/25 (9 days after the election date). No physician orders were found indicating the delay in completion of initial assessments.2.  Pt. #10 was admitted to Hospice services on 3/4/25 with diagnosis of Functional Quadriplegia.  The clinical record was reviewed on 8//13/25 and included a signed election form dated 3/4/25.  The clinical record lacked the initial spiritual counselor assessment.  No physician orders were found indicating the delay in completion of initial assessment.

Based on a review of clinical records and staff interview, in 3 of 19 (Pts.# 9, 11, 12 ) clinical records reviewed, the Hospice failed to ensure an initial bereavement assessment was completed. --- Findings include:1.   Pt. #9 was admitted to hospice services on 11/08/23 with diagnosis of Cerebral Atherosclerosis. The clinical record was reviewed on 8/12/25. The clinical record lacked documentation of an initial bereavement completed by SN, MSW or Spiritual counselor.2.  Pt. #11 was admitted to hospice services on 6/2/25 with diagnosis of Metabolic Encephalopathy. The clinical record was reviewed on 8/13/25. The clinical record lacked documentation of an initial bereavement completed by SN, MSW or Spiritual counselor.3.  Pt. # 12 was admitted to hospice services on 10/16/24 with diagnosis of Alzheimer’s Disease, Unspecified. The clinical record was reviewed on 8/13/25. The clinical record lacked documentation of an initial bereavement completed by SN, MSW or Spiritual counselor.4.  During an interview with Interim Executive Director and Pt. Care Manager on 8/14/25 at 2:15 PM, both confirmed the above findings.

Based on clinical record review and staff interviews, in 9 of 17 (Pts #1, 5, 6, 8, 18, 9, 13, 4, and 14) clinical records reviewed of Pts. receiving Hospice Aide services, the Hospice failed to ensure Hospice Aide supervisory visits were conducted by the RN every 14 days. --- Findings include: 1.  Pt. #1 was admitted to Hospice services on 6/27/25 with the Hospice diagnosis of Unspecified Severe Protein-Calorie Malnutrition.  The clinical record was reviewed on 8/11/25.  The clinical record included documentation the RN supervised the Hospice Aide on 7/1/25.  The Hospice Aide provided services 1 to 2 times a week from 7/2/25 to 7/18/25.  As of 8/11/25, the record lacked documentation the RN supervised the Hospice Aide from 7/2/25 to 7/18/25.  2.  Pt. #5 was admitted to Hospice services on 10/8/24 with the Hospice diagnosis of Alzheimer’s Disease with Late Onset.  The clinical record was reviewed on 8/13/25.  The clinical record included the Hospice Aide visit notes from 6/9/25 to 6/27/25.  As of 8/13/25, the record lacked documentation the RN supervised the Hospice Aide from 6/9/25 to 6/27/25.   The RN supervised the Hospice Aide on 7/14/25.  The Hospice Aide provided service 4 to 5 times a week from 7/15/25 to 7/30/25.  As of 8/13/25, the record lacked documentation the RN supervised the Hospice Aide from 7/15/25 to 7/30/25. 3.  Pt. #6 was admitted to Hospice services on 1/20/25 with the Hospice diagnosis of Alzheimer’s Disease, Unspecified.  The clinical record was reviewed on 8/13/25.  The clinical record included the documentation the RN supervised the Hospice Aide on 7/10/25.  The Hospice Aide provided service 2 times a week from 7/14/25 to 8/7/25.  As of 8/13/25, the record lacked documentation the RN supervised the Hospice Aide from 7/14/25 to 7/30/25. 4.  Pt. #8 was admitted to Hospice services on 1/23/24 with the Hospice diagnosis of Alzheimer’s Disease, Unspecified.  The clinical record was reviewed on 8/13/25.  The clinical record included documentation the RN supervised he Hospice Aide on 6/24/25.  The Hospice Aide provided service 1 to 3 times a week from 6/245/25 to 8/13/25.  The record lacked documentation the RN supervised the Hospice Aide after 6/24/25.   5.  Pt. #18 was admitted to Hospice services on 10/17/24 with the Hospice diagnosis of Acute on Chronic Diastolic (Congestive) Heart Failure.  The closed clinical record was reviewed on 8/13/25.  The closed clinical record included documentation the RN supervised the Hospice Aide on 12/9/24.  The Hospice Aide provided service 4 to 5 times a week from 12/10/24 to 12/25/25.  As of 8/13/25, the record lacked documentation the RN supervised the Hospice Aide from 12/10/24 to 12/25/25.   The RN supervised the Hospice Aide on 1/13/25.  The Hospice Aide provided service 3 to 5 times a week from 1/15/25 to 1/30/25.  As of 8/13/25, the record lacked documentation the RN supervised the Hospice Aide from 1/15/25 to 1/30/25.  8.  Pt.  #4 was admitted to Hospice services on 8/25/23 with diagnosis of Hemiplegia Following Cerebral Infarction After Right Dominant Side.  The clinical record was reviewed on 08/13/25. The clinical record included  Hospice Aide visit notes 3 times a week from 6/15/23 to 8/13/25.  The record lacked the hospice Aide visits were supervised.9.  Pt. #14  was admitted to Hospice services on 4/16/25 with diagnosis of Chronic Respiratory Failure with Hypoxia.  The clinical record was reviewed on 08/13/25.   The clinical record included Hospice Aide visit notes 2 times a week from 6/16/25 to 8/14/25. The record lacked the hospice Aide visits were supervised.     10.  The above findings were confirmed with the Interim Executive Director and Pt. Care Manager on 8/14/25  at 11:04 AM, 1:30 PM and 2:15 PM. 6.  Pt.  #9 was admitted to hospice services on 11/08/23 with diagnosis of cerebral atherosclerosis.  The clinical record was reviewed on 08/12/25.    The clinical record included completed twice a week Aide visits from 07/01/25 to 07/31/25 with no documented RN supervision.7.  Pt. #13 was admitted to hospice services on 10/02/24 with diagnosis of cerebrovascular disease, unspecified.  The clinical record was reviewed on 08/12/25.    The clinical record included completed twice a week Aide visits from 05/15/25 to 06/23/25 with no documented RN supervision. Findings include:  1.  Pt. #1 was admitted to Hospice services on 6/27/25 with the Hospice diagnosis of Unspecified Severe Protein-Calorie Malnutrition.  The clinical record was reviewed on 8/11/25.  The clinical record included documentation the RN supervised the Hospice Aide on 7/1/25.  The Hospice Aide provided services 1 to 2 times a week from 7/2/25 to 7/18/25.  As of 8/11/25, the record lacked documentation the RN supervised the Hospice Aide from 7/2/25 to 7/18/25.  2.  Pt. #5 was admitted to Hospice services on 10/8/24 with the Hospice diagnosis of Alzheimer’s Disease with Late Onset.  The clinical record was reviewed on 8/13/25.  The clinical record included the Hospice Aide visit notes from 6/9/25 to 6/27/25.  As of 8/13/25, the record lacked documentation the RN supervised the Hospice Aide from 6/9/25 to 6/27/25.   The RN supervised the Hospice Aide on 7/14/25.  The Hospice Aide provided service 4 to 5 times a week from 7/15/25 to 7/30/25.  As of 8/13/25, the record lacked documentation the RN supervised the Hospice Aide from 7/15/25 to 7/30/25.  3.  Pt. #6 was admitted to Hospice services on 1/20/25 with the Hospice diagnosis of Alzheimer’s Disease, Unspecified.  The clinical record was reviewed on 8/13/25.  The clinical record included the documentation the RN supervised the Hospice Aide on 7/10/25.  The Hospice Aide provided service 2 times a week from 7/14/25 to 8/7/25.  As of 8/13/25, the record lacked documentation the RN supervised the Hospice Aide from 7/14/25 to 7/30/25. 4.  Pt. #8 was admitted to Hospice services on 1/23/24 with the Hospice diagnosis of Alzheimer’s Disease, Unspecified.  The clinical record was reviewed on 8/13/25.  The clinical record included documentation the RN supervised he Hospice Aide on 6/24/25.  The Hospice Aide provided service 1 to 3 times a week from 6/245/25 to 8/13/25.  The record lacked documentation the RN supervised the Hospice Aide after 6/24/25.   5.  Pt. #18 was admitted to Hospice services on 10/17/24 with the Hospice diagnosis of Acute on Chronic Diastolic (Congestive) Heart Failure.  The closed clinical record was reviewed on 8/13/25.  The closed clinical record included documentation the RN supervised the Hospice Aide on 12/9/24.  The Hospice Aide provided service 4 to 5 times a week from 12/10/24 to 12/25/25.  As of 8/13/25, the record lacked documentation the RN supervised the Hospice Aide from 12/10/24 to 12/25/25. The RN supervised the Hospice Aide on 1/13/25.  The Hospice Aide provided service 3 to 5 times a week from 1/15/25 to 1/30/25.  As of 8/13/25, the record lacked documentation the RN supervised the Hospice Aide from 1/15/25 to 1/30/25. 6.  Pt.  #9 was admitted to hospice services on 11/08/23 with diagnosis of cerebral atherosclerosis.  The clinical record was reviewed on 08/12/25.    The clinical record included completed twice a week Aide visits from 07/01/25 to 07/31/25 with no documented RN supervision. 7.  Pt. #13 was admitted to Hospice services on 10/02/24 with diagnosis of cerebrovascular disease, unspecified.  The clinical record was reviewed on 08/12/25.    The clinical record included completed twice a week Aide visits from 05/15/25 to 06/23/25 with no documented RN supervision. 8.  Pt.  #4 was admitted to Hospice services on 8/25/23 with diagnosis of Hemiplegia Following Cerebral Infarction After Right Dominant Side.  The clinical record was reviewed on 08/13/25. The clinical record included  Hospice Aide visit notes 3 times a week from 6/15/23 to 8/13/25.  The record lacked the hospice Aide visits were supervised.9.  Pt. #14  was admitted to Hospice services on 4/16/25 with diagnosis of Chronic Respiratory Failure with Hypoxia.  The clinical record was reviewed on 08/13/25.   The clinical record included Hospice Aide visit notes 2 times a week from 6/16/25 to 8/14/25. The record lacked the hospice Aide visits were supervised.     10.  The above findings were confirmed with the Interim Executive Director and Pt. Care Manager on 8/14/25  at 11:04 AM, 1:30 PM and 2:15 PM.

Based on a review of the Volunteer Report, and staff interview, 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 was met for the years 2023 and 2024.  This has the potential to affect all Pts. receiving Hospice services. --- Findings include:1.  The Volunteer Monthly Hours Report for 2023 was reviewed on 8/13/25 at 1:45 PM.  The Report included the savings of 4.2%, the requirement was not met in 2023.  The Hospice failed to provide a report to indicate cost savings in 2024.  2.  During an interview with the Volunteer Manager on 8/13/25 at 2:05 PM, the Volunteer Manager confirmed the Hospice failed to meet the 5% cost saving requirement in 2023 and 2024.