Every finding on record at Willow Hospice and Palliative Care LLC

Based on a review of the Hospice Emergency Preparedness Plan and staff interview, it was determined the Hospice failed to ensure the Emergency Preparedness Plan was based on a facility and community risk assessment, utilizing an all-hazards approach. --- Findings include: 1. The Hospice Emergency Preparedness Plan was reviewed on 12/18/24 at 11:00 AM. The plan lacked documentation that the Emergency Preparedness Plan was based on a facility-based and or community-based risk assessment, utilizing an all-hazards approach. 2. Findings of the Hospice Emergency Preparedness Plan lacking the risk assessment was confirmed during an interview with the Administrator on 12/19/24 at 12:30PM.

Based on a review of the Hospice Emergency Preparedness Plan, and Staff interview, it was determined that the Agency failed to ensure that the Hospice conducted / participated in a full-scale Community Based Exercise or Facility Based Exercise to ensure the effectiveness of the Agency's Emergency Preparedness Plan. --- Findings Include: 1. The Hospice Emergency Preparedness Plan was reviewed on 02/18/24 at 11:00 AM. The Emergency Preparedness Plan failed to include documentation indicating that the Agency conducted / participated in any testing of the Emergency Preparedness Plan. 2. During an interview with the Administrator on 12/19/24, the Administrator confirmed that the Agency failed to conduct / participate in a community and/or facility-based testing or drill. Findings Include: 1. The Hospice Emergency Preparedness Plan was reviewed on 12/18/24 at 11:00 AM. The Emergency Preparedness Plan failed to include documentation indicating that the Agency conducted / participated in any testing of the Emergency Preparedness Plan. 2. During an interview with the Administrator on 12/19/24, the Administrator confirmed that the Agency failed to conduct / participate in a community and/or facility-based testing or drill.

Based on the clinical records review and Staff interview, it was determined in 1 of 2 (Pts. # 3) clinical records reviewed, the IDG failed to meet every 15 days to review the POC. --- Findings include: 1. Pt. #3 was admitted to the hospice services on 12/12/23 with diagnosis of Chronic Systolic (Congestive) Heart Failure. The clinical record was reviewed on 12/17/24. The clinical record included IDG meetings dated 12/15/23 and 01/11/24 (more than 15 days). 2. The findings were confirmed during the interview on 12/18/24 at 11:30 AM, with the Agency Supervisor.

Based on the review of the hospice documents and Staff interview, it was determined the hospice failed to implement, and maintain an effective, ongoing, hospice-wide data-driven quality assessment and performance improvement program. This has the potential to affect all Pts. receiving hospice care services. --- Findings include: 1.The hospice failed to maintain/track/analyze the quality assessment in all areas of the operations. (L562) 2. The hospice failed to ensure the frequency and details of the quality assessment and performance improvement program were approved. (L565) 3. The hospice failed to ensure the ongoing maintenance and annual evaluation of the QAPI program. (L574) The cumulative effect of these systemic practices resulted in the Hospices inability to ensure an effective QAPI Program.

Based on the review of the Governing Board minutes, QAPI documents and Staff interview, it was determined the hospice failed to maintain/track/analyze the quality assessment in all areas of the operations. --- Findings include: 1. The Governing Board minutes for 2023 and 2024 were reviewed on 12/18/24 at 11:00 AM and lacked the measurements/tracking for QAPI indicators. 2. The QAPI documents were reviewed on 12/18/24 at 11:00 AM, and lacked the measurements/tracking. The hospices quality assessment and performance improvement program was last documented as: ";01/2021 4th quarter". 3. The findings were confirmed during the interview on 12/18/24 at 11:30 AM, with the QA Director.

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 Governing Board minutes for 2023 and 2024 were reviewed on 12/18/24 at 11:00 AM, and lacked documentation of the Governing Body approval for QAPI projects and QAPI indicators. 2. The hospice quality assessment and performance improvement program was reviewed on 12/18/24 at 11:00 AM and lacked documentation that the Governing body met to approve the data collection frequency and details of the quality assessment and performance improvement program. 3. The findings were confirmed during the interview on 12/18/24 at 11:30 AM, with the QA Director.

Based on the review of the Governing Board minutes and Staff interview, it was determined the hospice failed to ensure the ongoing maintenance and annual evaluation of the QAPI program. --- Findings include: 1. The Governing Board minutes for 2023 and 2024 were reviewed on 12/18/24 at 11:00 AM and lacked the annual QAPI evaluation, for 2023 and 2024. 2. The hospice quality assessment and performance improvement program was reviewed on 12/18/24 at 11:00 AM and lacked the annual QAPI evaluation for 2023 and 2024. 3.The findings were confirmed during the interview on 12/18/24 at 11:30 AM, with the QA Director.

Based on the review of the quality improvement program documents and Staff interview, it was determined the hospice failed to ensure the licensed staff participated in the quality assessment and performance improvement program. --- Findings include: 1. The hospice quality assessment and performance improvement program was reviewed on 12/17/24 at 1:30 PM and lacked documentation that the licensed Staff participated in the quality assessment and performance improvement program. 2. The findings were confirmed during the interview on 12/18/24 at 11:30 AM, with the QA Director.

Based on Staff list review, clinical record review and Staff interview, it was determined that the hospice failed to use volunteers in day to day administrative roles or direct patient care roles, failed to maintain documentation and demonstrate ongoing efforts to recruit and maintain volunteers and failed to document any positions held by volunteers, amount of time spent by volunteers in those positions and estimate the cost savings related to use of volunteers. This has the potential to affect services provided to patients --- Findings include: 1. The hospice failed to use volunteer services in day to day administrative or direct patient care roles. (L644) 2. The hospice failed to maintain documentation and demonstrate ongoing efforts to recruit and maintain volunteers. (L645) 3. The hospice failed to ensure it documented any positions held by volunteers, amount of time spent by volunteers in those positions and estimate the cost savings related to use of volunteers. (L646) The cumulative effect of these systemic practices resulted in the hospices inability to ensure that the hospice volunteer services were provided to patients.

Based on Staff interviews, Staff list review and clinical record review, it was determined that the hospice failed to use volunteer services in day to day administrative or direct patient care roles. --- . Findings include: 1. During entrance interview with the Agency Supervisor on 12/17/24 at 11:32 AM and with the Social Worker on 12/18/24 at 9:30 AM, both stated that there are no volunteers for the hospice. 2. The Staff list was reviewed on 12/18/24 and lacked hospice volunteers. 3. The clinical records for Pts. # 1, 2, 3 and 4 were reviewed from 12/17/24 to 12/18/24. The clinical records lacked the use of volunteers. 4. During an interview with the Agency Supervisor on 12/18/24 at 9:48 AM, the Agency Supervisor confirmed that the hospice did not provide or use volunteer services in day to day administrative or direct patient care roles.

Based on hospice volunteer program review and Staff interview, it was determined that the hospice failed to maintain documentation and demonstrate ongoing efforts to recruit and maintain volunteers. --- Findings include: 1. The hospice volunteer program was reviewed on 12/18/24. There was no documentation for ongoing recruitment efforts for volunteers. 2. During interview with the Agency Supervisor on 12/18/24 at 9:48 AM and 11:45 AM, the Agency Supervisor stated that the census is low at this time and confirmed that the hospice did not have ongoing efforts to recruit volunteers.

Based on a review of the hospice volunteer program and Staff interview, it was determined that the hospice failed to ensure it documented any positions held by volunteers, amount of time spent by volunteers in those positions and estimate the cost savings related to us of volunteers. --- Findings include: 1. The hospice volunteer program was reviewed on 12/18/24. There was no documentation that the hospice identified volunteers, positions held, amount of time spent and estimated cost savings related to use of volunteers. 2. During an interview with the Agency Supervisor on 12/18/24 at 11:45 AM, the Agency Supervisor confirmed that the hospice did not have any volunteers and therefore have no documentation of cost savings related to use of volunteers.

Based on review of the hospice patient admission folder and staff interview, it was determined the hospice Administrator failed to ensure the patient admission folder contained the correct hospice name and hospice contact information. --- Findings include: 1. The hospice patient admission folder was reviewed on 12/18/24. The admission folder contained "1st Choice Total Senior Care" as the name of the hospice and not Willow Hospice and Palliative Care. 2. On 12/17/24 the telephone number displayed on the patient admission folder was called by surveyor, the telephone number corresponds to "1st Choice Senior Care". 3. During an interview with the Administrator, on 12/18/24 at 2:00 PM, the Administrator confirmed the admission folder contains incorrect hospice name and contact information.

Based on clinical record review and Staff interview, it was determined that in 1 of 1 (Pts. #3 ) live discharge records reviewed, the hospice failed to ensure that a hospice discharge summary was completed. --- 2. Pt. #3 was admitted to the hospice services on 12/12/23 with diagnosis of Chronic Systolic (Congestive) Heart Failure. The clinical record was reviewed on 12/17/24. The clinical record included a live-discharge note dated 01/19/24 and lacked the discharge summary. 3. Pt. #4 was admitted to the hospice services on 04/15/23 with diagnosis of Unspecified Chronic Systolic (Congestive) and Diastolic Heart Failure. The clinical record was reviewed on 12/17/24. The clinical record included a live-discharge note dated 05/25/23 and lacked the discharge summary. 4. The findings were confirmed during the interview on 12/18/24 between 11:30 AM and 1:00 PM, with the Agency Supervisor. Findings include: 1. Pt. #2 was admitted to hospice services on 09/19/22 with the diagnosis of: Chronic combined systolic (congestive) and diastolic (congestive) heart failure. The clinical record was reviewed on 12/17/24. The clinical record included a live discharge note dated 05/14/23, indicating Pt. was discharged to home. There was no hospice discharge summary.

Based on Staff interview, it was determined that the hospice failed to ensure the hospice has an agreement with a facility to provide pain control, symptom management, and respite purpose. This has the potential to affect services provided to patients --- Findings include: 1. The hospice failed to have a facility agreement for inpatient care of symptom management and pain control. (L706) 2. The hospice failed to have a facility agreement for respite purpose. (L708) 3. The hospice failed to have an inpatient care under arrangement. (L711) The cumulative effect of these systemic practices resulted in the hospices inability to ensure that the hospice patients receive services in an inpatient facility for pain control and respite care.

Based on document request and Staff interview it was determined that the hospice failed to have an arrangement agreement with a facility to provide inpatient care for pain control and symptom management. --- Findings include: 1. On 12/18/24 a request was made to the Agency Supervisor for hospice agreement document for inpatient care facility. 2. During an interview with the Agency Supervisor on 12/18/24 at 12:00 PM. The Agency Supervisor stated that the hospice does not have an agreement with any facility to provide inpatient care for pain control and symptom management. 3. During an interview with the Administrator on 12/19/24 at 12:30 PM, the Administrator confirmed that the hospice does not have an agreement with any facility for inpatient care.

Based on document request and staff interview it was determined that the hospice failed to have an arrangement agreement with a facility to provide respite care. --- Findings include: 1. On 12/18/24 a request was made to the Agency Supervisor for hospice agreement document for inpatient respite care facility. 2. During an interview with the Agency Supervisor on 12/18/24 at 12:00 PM. The Agency Supervisor stated that the hospice does not have an agreement with any facility to provide respite care. 3. During an interview with the Administrator on 12/19/24 at 12:30 PM, the Administrator confirmed that the hospice does not have an agreement with any facility for respite care.

Based on document request and staff interview it was determined that the hospice failed to have an arrangement agreement with a facility to provide short-term inpatient care. --- Findings include: 1. On 12/18/24 a request was made to the Agency Supervisor for hospice agreement document for short term inpatient care facility. 2. During an interview with the Agency Supervisor on 12/18/24 at 12:00 PM. The Agency Supervisor stated that the hospice does not have an agreement with any facility to provide short term inpatient care. 3. During an interview with the Administrator on 12/19/24 at 12:30 PM, the Administrator confirmed that the hospice does not have an agreement with any facility for short term inpatient care.

A. Based on a review of the Hospice Emergency Preparedness Plan, Hospice Emergency Preparedness policy and Staff interview, it was determined the Hospice failed to ensure the Emergency Preparedness Plan was based on a facility and community risk assessment, utilizing an all hazards approach. Findings include: 1. The Hospice Emergency Preparedness Plan was reviewed on 12/15/21 at 11:15 AM. The plan lacked documentation that the EP was based on a facility-based and or community-based risk assessment, utilizing an all-hazards approach. 2. The Hospice policy titled, "Emergency Operation" was reviewed on 12/15/21 at 11:15 AM. The policy required: ..."Responsibility: The Safety Director is responsible for developing, implementing and monitoring all aspects of the Emergency Operations Plan ... including hazard vulnerability analysis, mitigation, preparedness response and recovery ... Hospice cooperates with all local, county and state emergency management drills if applicable." 3. On 12/16/21 at 10:30 AM, during the interview with the Administrator, it was confirmed that the Hospice lacked documentation of the Emergency Preparedness facility-based or community-based risk assessment.

A. Based on a review of the Hospice Emergency Preparedness Plan, Hospice Emergency Preparedness policy and Staff interview, it was determined the Hospice failed to conduct the required annual testing and training. This has the potential to affect all patients. Findings include: 1. The Hospice Emergency Preparedness Plan was reviewed on 12/15/21 at 11:15 AM. The emergency preparedness plan lacked documentation that the EP testing and training were provided in 2020 and 2021. 2. The Hospice policy titled, "Emergency Operation" was reviewed on 12/15/21 at 11:15 AM. The policy required: ..."Responsibility: The Safety Director is responsible for developing, implementing and monitoring all aspects of the Emergency Operations Plan ... including hazard vulnerability analysis, mitigation, preparedness response and recovery ..." 3. On 12/16/21 at 10:30 AM, during the interview with the Administrator, it was confirmed that the Hospice lacked documentation of any Emergency Preparedness testing and training.

A. Based on a review of the Hospice Emergency Preparedness Plan, Hospice Emergency Preparedness (EP) policy and Staff interview, it was determined the Hospice failed to conduct the required exercises and mock drills. This has the potential to affect all patients. Findings include: 1. The Hospice Emergency Preparedness Plan was reviewed on 12/15/21 at 11:15 AM. The plan lacked documentation of the EP drills and full scale exercises in 2020 and 2021. 2. The Hospice EP policy included "Annual Evaluation of the Emergency Operations Plan's Objective, Scope, Performance and Effectiveness " was reviewed on 12/15/21 at 11:15 AM. The policy required: ..."The performance and effectiveness of the Emergency Operations Plan shall be reviewed by the Administration." 3. The findings of the lack of EP exercises or drills was confirmed during interviews with the Agency Supervisor and the Administrator on 12/16/21 at 10:30 AM.

A. Based on clinical record review and staff interview, it was determined the Hospice failed to ensure the IDG completed the comprehensive assessment within 5 days of patients Hospice admission date. This was found in 5 of 6 clinical records reviewed (Pts. #1, 2, 3, 4, and 6) Findings Include: 1. The Clinical Records were reviewed between 12/15/2021 and 12/16/2021. The following patients lacked documentation of MSW and Chaplain/ Spiritual Counselor completing assessment within 5 days of SN completing initial SOC assessment. The comprehensive assessments were completed after 5 days of initital assessement. Pt. #1 SOC 04/15/2020 Pt. #2 SOC 07/02/2020 Pt. #3 SOC 09/06/2020 Pt. #4 SOC 06/28/2021 Pt. #6 SOC 06/12/2019 2. Findings of IDG not completing the comprehensive assessment within 5 days of patients admission to Hospice services were confirmed during interviews with the Administrator and Agency Supervisor between 10:20AM and 11:30AM.

A. Based on the clinical record review and Staff interview, it was determined the Comprehensive assessment was not updated by the IDG every 15 days as required. This was found in 5 of 6 records reviewed (Pts. #1, 2, 3, 4 and 6). Findings include: 1. The following patient's clinical records were reviewed on 12/15/2021 at 10:45 AM through 12/16/2021 at 10:30 AM. The records lacked documentation that the comprehensive assessment was updated by the IDG as required. Pt # 1 SOC 04/15/2020 Pt # 2 SOC 07/02/2020 Pt.# 3 SOC 09/06/2020 Pt. #4 SOC 06/28/2021 Pt. #6 SOC 06/12/2019 2. During an interview with the Administrator and Agency Supervisor on 12/16/2021 between 10:15 AM and 11:00 AM the above findings were confirmed.

A. Based on Hospice In-service and policy review it was determined the Hospice failed to provide documentation of the annual Infection Control training as required per Hospice Policy. This has the potential to affect all patients being served bbythe hospice. Findings include: 1. The Hospice In-service binder was reviewed on 12/15/2021 at 2:30 PM. The binder included an infection control in-service titled, "COVID 19 IDPH Guidance for Employers and Employees Rights and Safety," dated 10/19/2020. The in-service binder lacked the names/signatures of the employees that participated in any infection control training for the year 2021. 2. The Hospice Infection/Exposure Control Plan was reviewed on 12/15/2021 at 4:20 PM. The policy included, " ...Procedure ...3. Infection control in-services will be scheduled no less than annually. A. Attendance will be mandatory and will be documented." 3. During an interview with the Agency Supervisor on 12/15/2021 at 3:45 PM it was confirmed that there is no infection control training documented for the year of 2021.

A. Based on a review of Hospice Bereavement Program document, review of clinical records and staff interviews, it was determined the Hospice failed to ensure bereavement services were provided as required. This was found in 2 of 3 bereavement clinical records reviewed, wherein the Pts. had expired. (Pts. # 2 and 3) Findings include: 1. Pt # 2. SOC 07/02/2020. Hospice Diagnosis: Chronic Kidney Disease. The clinical record was reviewed on 12/15/2021 at 1:00 PM. The record lacked documentation that the Hospice provided Bereavement services at One month, Six month and 12 months after patient expired on 10/05/2020. 2. Pt. # 3. SOC 09/06/20. Hospice Diagnosis: Alzheimer's disease. The clinical record was reviewed on 12/15/2021 at 11:45 AM. The record lacked documentation that the Hospice provided Bereavement services at One month and Six month after patient expired on 04/30/2021. 3. The Hospice document titled, "Bereavement Program (revised 1/12/21)" was reviewed on 12/16/2021 at 9:30 AM. The program required: " ...The Bereavement plan of care is as follows: (4) One month, phone call ... (5) Six month, phone call ... (6) 12 month, Discharge Letter". 4. The findings of patients not receiving Bereavement follow up after patient expired as required, were confirmed during interviews with the Administrator and Agency Supervisor on 12/16/2021 between at 10:20 AM to 11:30 AM.

A. Based on the home visit interview and Staff interview, it was determined that the hospice failed to ensure the Medical Director services and drugs were available on a 24 hours basis. This was found in 1 of 1 active Patient (Pt.#1) home visit conducted. Findings include: 1. Pt. #1 SOC 04/15/2020 Diagnosis: Chronic Lymphocytic Leukemia On 12/16/21 at 1:30 PM, a home visit was conducted for Patient #1 at the Facility with the Hospice Administrator. During an interview with the Facility Nurse at 1:30 PM, The Facility Nurse stated that the Hospice Physician was not available for medication orders for Patient #1. 2. The findings related to the lack of 24 hour service availability from the Medical Director to the Hospice patient was confirmed on 12/16/21 at 3:30 PM with the Agency Supervisor and Administrator.

A. Based on the onsite observations and Staff interview, it was determined that the hospice failed to orient the Medical Director to address the required job duties. This was found in 1 of 1 required positions (Medical Director and Designated Physician). Findings include: 1. On 12/15/21 between 10:30 AM and 4:00 PM, it was observed that the Hospice was not able to provide a personnel file documenting the orientation of job duties for the Medical Director. 2. The findings related to the lack of orientation addressing the required job duties was confirmed during the interview on 12/16/21 at 3:30 PM with the Agency Supervisor and Administrator.

A. Based on the onsite observations, contract review and Staff interview, it was determined the Hospice failed to meet the Medical Director requirements. This has the potential to affect all patients being served by the agency. Findings include: 1. The Hospice failed to designate a physician to act in the absence of the Medical Director (Employee #3) (L665). 2. The Hospice failed to ensure written certifications by the Medical Director or designee. (L667) The cumulative effect of the hospice practices resulted in the inability to provide medical supervision for all patients receiving care through the hospice.

A. Based on the lack of the personnel files and Staff interview, it was determined that the Hospice failed to designate a physician to act in the absence of the Medical Director (Employee #3). This was observed throughout the survey. Findings include: 1. On 12/15/21 at 11:30 am, the Hospice was not able to present a personnel file to review for the Medical Director (Employee #3) or a Medical Director designee to act in the absence of the Medical Director, as requested by the surveyor. 2. On 12/15/21 at 12:10 PM during the interview with the Medical Director, it was stated that he did not designate another physician to serve as his Hospice physician designee because he is available 24 hours 7 days a week. He further stated if needed, he is covered by a Nurse Practitioner. 3. On 12/16/21 at 9:00 AM, the Agency Supervisor stated that the IDG Team meeting scheduled for 12/16/21, would need to be rescheduled for next week due to the unavailability of the medical director. It was observed that there was not a designated person to act in the absence of the Medical Director (Employee #3), on 12/16/21. 4. The Hospice was unable to provide documentation that the medical director was orientated to his job duties which would require him to be available 24/7 or have a designated alternate physician available in his absence. 5. The findings related to the lack of a physician designee for the Hospice was confirmed on 12/16/21 at 9:05 AM with the Agency Supervisor and Administrator on 12/16/21 at 10:40 AM.

A. Based on clinical records review and staff interview it was determined the Hospice failed to ensure the Medical Director provided documentation of the initial hospice certification. This was found in 6 of 6 records reviewed. (Pts. #1, 2, 3, 4, 5 & 6). Findings include: 1. The Clinical Records were reviewed 12/15/2021 beginning at 10:15 AM through 12/16/2021 at 10:30 AM. The records lacked documentation of the initial hospice certification. Pt. #1 SOC 04/15/2020 Pt. #2 SOC 07/02/2020 Pt. #3 SOC 09/06/2020 Pt. #4 SOC 06/28/2021 Pt. #5 SOC 03/19/2021 Pt. #6 SOC 06/12/2021 2. During an interview with the Agency Supervisor and Administrator on 12/16/2021 at 10:45 AM the above findings were confirmed. The initial hospice certification is not available.