Journeycare - Barrington

“Based on a review of the clinical records and staff interviews, in 1 of 4 (Pt. #3) clinical records reviewed, Hospice staff failed to ensure Hospice Aide services were provided according to the Plan of Care. Findings include:1. Pt. #3 was admitted to Hospice Services on 06/16/26 with Primary diagnosis of Malignant Neoplasm of the Pancreas. The clinical record was reviewed on 08/05/26 and 08/06/26. The clinical record included a Plan of Care(POC) effective 06/16/26. The POC included an order for Hospice Aide services, two (2) visits per week for 13 weeks. The clinical record lacked documentation of two Hospice Aide visits for the weeks of 06/28/26 to 07/04/26, 07/05/26 to 07/11/26 and the week of 07/12/26 to 07/18/26. There was no documentation indicating missed visits occurred, were attempted, were refused or rescheduled. The clinical record did not contain any IDG revision to the POC that would alter the required Aide frequency. 2. During an interview with the Executive Director on 08/06/26 at 9:40 AM, the Executive Director confirmed the above findings. The Hospice Aide did provide services os ordered in the POC.”

“Based on clinical record review, Hospice policy review and Staff interview in 1 of 5 (Pt. #1) clinical records reviewed the Hospice failed to provide effective pain and symptom management. Findings include: 1. Pt#1 was admitted to Hospice services on 11/11/25 with Diagnosis of Alzheimer’s Disease. The clinical record was reviewed between 06/25/26 and 06/26/26. The clinical record included a Medication Administration Record that describes the following medications administered to Pt#1.On 04/21/26 the following medications were administered: Lorazepam 1mg via Macy catheter at 0853, with a pre-medication assessment documenting “spastic tremors throughout body”, the clinical record lacked documentation of a medication response assessment following administration. Morphine 10mg via Macy catheter at 0853 with a pre-medication assessment documenting “facial grimace and furrowed brow”, the clinical record lacked documentation of a medication response assessment following administration. Morphine 10mg via Macy catheter at 1054 with a pre-medication -assessment documenting “facial grimace with whole body shaking”, the clinical record lacked documentation medication response assessment after administration.Haloperidol Lactate 1mg via Macy catheter at 1052 with a pre-medication assessment documenting “shaking, rattling side rails and footboard”, the clinical record lacked documentation of a medication response assessment after administration.Lorazepam 2mg SQ at 1053 with a pre-medication assessment documenting “seizures / shaking”, the clinical record lacked documentation of a medication response assessment after administration.Lorazepam 2mg SQ at 1154 with a pre-medication assessment documenting “seizure activity”, the clinical record lacked documentation of a medication response assessment after administration. 2. The Hospice policy titled “Provision of care & record management, pain assessment” was reviewed on 06/26/26 the policy required...Procedure...2.A..The patient will be reassessed every visit for the existence and intensity of pain and the effectiveness of interventions to relieve pain”.3. The above findings were confirmed during an interview with the Executive Director (E#6) on 06/26/26 at 2:00 PM”

“Based on Hospice incident report review, clinical record review and staff interview in 1 of 5 (Pt#1) clinical records the Hospice failed to share and maintain effective communication between all disciplines providing care and services to patient. Findngs include: 1. The Hospice incident report log was reviewed on 06/23/26. The Hospice incident log included an entry on 04/22/26 with Pt#1 name, the narration stated “Event summary - (Inpatient Hospice unit) night nurse was drawing morphine and noticed that the morphine was clear and not blue from the bottles that came from the transferring facility. Patient had arrived to the (Inpatient Hospice) on the night of 04/21 and team logged in the liquid volume. The 04/22 night nurse also noted that the liquid lorazepam was very thin, unlike the typical liquid lorazepam that we see from (contracted Pharmacy). Inpatient Hospice Executive Director notified (Team) PCM (Patient Care Manager) of this medication. (Inpatient Hospice) pulled medication from patient bin”2. Pt#1 was admitted to Hospice services on 11/11/25 with Diagnosis of Alzheimer’s Disease. The clinical record was reviewed between 06/25 and 06/26/26. The clinical record lacked documentation indicating the physician and the IDG team were notified of the morphine medication incident on 04/22/26.3. The above finding was confirmed during an interview with the Executive Director (E#6) on 06/26/26 at 2:00 PM.”

“Based on Hospice incident report log review, incident investigated documents review and staff interview, the Hospice failed to develop a written account of controlled substance medication incident and report medication incident to appropriate State authority. This has the potential to affect all patients receiving services. Findings include: 1. Complaint investigation survey was conducted on 06/26/26. The complaint entry included Pt. #1 was transferred from a facility to the Hospice inpatient unit on 04/20/26. Before transfer a Hospice nurse was present to reconcile medications with transferring facility staff. Pt. #1 was transferred with medications used in the transferring facility. Pt. #1 was medicated in the Hospice inpatient unit with the medications sent from the facility. Evening of 04/21/26 inpatient Hospice unit Staff discovered Pt. #1 medications had been tampered.2. The inpatient Hospice unit incident log was reviewed on 06/23/26. The incident log included an entry dated 04/22/26. The entry describes the allegation for complaint. “Event summary - (Inpatient Hospice unit) night nurse was drawing morphine and noticed that the morphine was clear and not blue from the bottles that came from the transferring facility. Patient had arrived to the (Inpatient Hospice unit) the night of 04/21 and team logged in the liquid volume. The 04/22 night nurse also noted that the liquid lorazepam was very thin, unlike the typical liquid lorazepam that we see from (contracted Pharmacy). (Inpatient Hospice Unit) ED (Executive Director) notified (Hospice Team) PCM (Patient Care Manager) of this medication. (Inpatient Hospice Unit) pulled medication from patient bin”.3. During an interview on 06/24/26 at 10:00 AM with the Inpatient Unit Hospice Executive Director (E#1), (E#1) stated that the inpatient Hospice unit initiated an investigation for the alleged tampered medication, during Pt.#1 Hospice care from 04/20/26 to 04/23/26. 4. On 06/24/26 (E#1) provided documents for review on what the in-patient Hospice unit has done on the above mentioned incident. The documents lacked any measures Hospice took to prevent incidents reoccurrence, documentation the Hospice Staff that cared for Pt. #1 before and after transferring to the inpatient Hospice unit were interviewed, documentation of any communication between inpatient unit Hospice Staff and contracted Pharmacy, documentation of inpatient unit conversation with the transferring facility staff involved in Pt. #1 transfer and lacked documentation the Hospice reported medication incident to State authorities or any outside entity. 5. During an interview with (E#1) on 06/25/26 at 1:30 PM, (E#1) stated that the documents provided for review are the only documents Hospice has available for surveyors to review on medication incident for Pt#1. The above findings were confirmed.”

“Upon patient record review, 1 of 30 (Patient #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 13: The nursing comprehensive/CTI showed evidence that the patient is a diabetic. The medication profile indicates patient has Basaglar Kwik- pen BID and Humalog Kwik-pen. There was no evidence of problems, goals, or interventions related to the Endocrine system. Corrected on site. Care plan updated”

“Upon patient record review, 28 of 30 (Patients #1,2,4,5,6,7,8,9,10,11,12,13,14,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs Patients 1,2,4,5,6,7,8,9,10,11,12,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30: The Social Worker and Chaplain visit frequency on Initial Plan(s) of Care, indicated 1PRN for these disciplines. This frequency did not include a baseline visit frequency for the Social Worker or Chaplain. Agency working with Home Care Home Base to assist with the frequency population. Patient 13: The Social Worker and Chaplain visit frequency on Initial Plan of Care, indicated 1PRN for these disciplines. This frequency did not include a baseline visit frequency for the Social Worker or Chaplain.”

“Upon patient record review, 5 of 30 (Patients #1,13,18,19,21) 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 #1: This patient had a front-wheeled walker, wheel chair seat cushion, shower chair and toilet seat raised bar. These were not included on the Plan of Care. Corrected on site-agency obtained a supplemental order during survey. Patient #13: The record reflected that this patient had a wheel chair. This item was not included on the Plan of Care. Corrected on site-agency obtained a supplemental order during survey. Patient #18: The record reflected that this patient had Duo-neb inhalation treatments. The nebulizer machine was not included on the Plan of Care. Corrected on site-agency obtained a supplemental order during survey. Patient #19: The record reflected that this patient had a low air loss mattress. This item was not included on the Plan of Care. Corrected on site-agency obtained a supplemental order during survey. Patient #21: The record reflected that this patient had an APP mattress. This item was not included on the Plan of Care. Corrected on site-agency obtained a supplemental order during survey.”

“Upon patient record review, 2 of 30 (Patients #10, 11) did not have evidence that there is a physician’s brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification forms, or as an addendum to the certification forms. Patient 10: The initial CTI’s for benefit period 1 (10/17/25-1/14/26) was a verbal only (SOC-10/17/25). This CTI form had no physician narrative, signature or date (> 30 day policy to complete note). This record was updated during survey. Patient 11: The initial CTI’s for benefit period 1 (10/10/25-1/7/26) was a verbal only (SOC-10/10/25). This CTI form had no physician narrative, signature or date (> 30 day policy to complete note). This record was updated during survey.”

“Upon observation, there is no evidence building construction is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a two hour fire resistance rating constructed of materials as required for the addition. Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire doors assemblies. Existing construction: 19.3.5.4 During the building tour, pillows were observed stored too close to the ceiling in a patient room closet. In addition, one bolster pad in the storage closet and items stored on top of a built-in cabinet were observed with less than 18 inches of clearance from the ceiling. Per NFPA 101, 19.3.5.4, storage of combustible materials shall be maintained so that the distance between the top of the storage and the ceiling is at least 18 inches where standard-spray sprinklers are installed. Adequate clearance ensures proper sprinkler discharge and fire protection coverage. Corrected on site.”

“Upon observation, there is no evidence building construction is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a two hour fire resistance rating constructed of materials as required for the addition. Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire doors assemblies. Existing construction: 19.3.5.4 During the building tour, pillows were observed stored too close to the ceiling in a patient room closet. In addition, one bolster pad in the storage closet and items stored on top of a built-in cabinet were observed with less than 18 inches of clearance from the ceiling. Per NFPA 101, 19.3.5.4, storage of combustible materials shall be maintained so that the distance between the top of the storage and the ceiling is at least 18 inches where standard-spray sprinklers are installed. Adequate clearance ensures proper sprinkler discharge and fire protection coverage. Corrected on site.”

“Upon observation, there is no evidence the smoke compartmentation and control of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. Existing Construction During the building tour, multiple ceiling tiles were observed to be damaged or misaligned in the following areas: 1. Linen closet east hallway 2. Storage closet west hall x2 3. Volunteer closet 4. Locker room and closet supply 5. Room 111 6. Rear exit door 7. Conference Room #134 Per NFPA 101, 19.3.2.1 and 19.7.5.1, fire and smoke barriers and related assemblies must be maintained to ensure their integrity. Damaged or misaligned ceiling tiles may compromise the smoke and fire resistance of the ceiling system. Corrected on site-Agency replace or repositioned ceiling tiles noted above.”

“Upon observation, there was no evidence the fire alarm systems of a facility are provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. Existing Construction During the building tour, it was observed that the manual fire alarm pull station located at the west pkg lot exit was obstructed by a snow shovel. The obstruction could delay or prevent activation of the fire alarm system during an emergency (19.3.4.1). Corrected on Site- snow shovel obstruction removed. Also during the building tour, it was observed that the Fire Department Connection (FDC) lacked the required identification signage x3. The FDC must be clearly marked and visible from the fire department’s normal point of approach to ensure prompt identification and connection during emergency operations (19.3.4.2).”

“Upon observation, there was no evidence the furnishing and decorations of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. Existing Construction During the building tour, a decorative quilt was observed hanging on the wall room 134. Per NFPA 101, 19.7.5.6, decorative materials must be flame retardant in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films. The observed quilt was not treated with a fire-retardant spray. Corrected on Site-Agency removed decorative quilt.”

“Upon observation, there was no evidence the inpatient facility has adequate supply of hot water temperatures at all times and include plumbing fixtures with control valves that automatically regulate the temperature of hot water used by patients. Review of water temperature logs from January 2025 to the present showed recorded temperatures ranging from 84°F to 132.1°F. There is no policy to address temperature range. The monthly ranges for 2025 are as follows: January-105°F to 110.1°F February- 104°F to 113.°F March- 103°F to 113°F April-102°F to 124°F May-84°F to 112°F June-102°F to 124°F July- 106°F to 123°F August- 104°F to 121.6°F September-106.4°F to 119°F October-98.3°F to 132.1°F November (partial month)- 93.6°F to 129°F Correction on site in process prior to survey: 1. Fox Valley Plumbing replaced a house mixer on 10/21/25. They have returned multiple times to balance test water on 11/4/25, 11/11/25, 11/12/25 to bring water temperature range of 95°F to 110.1°F. 2. Agency has a plan in place for patient safety that water is checked for a temperature <110 °F before providing any bathing/showering with all IPU patients.”