Hospice Care of Illinois

“Observed in Record Review. In 1 of 21 patient records reviewed, the organization failed to document reassessment. During record review for HOS RRNHV#3, the Hospice Nurse Surveyor observed the patient had two wounds to the left shin. One wound was a stage 3 and the other was a stage 4. The wounds were not being assessed as part of the comprehensive assessment. Upon conversation with the Hospice Director, it was noted that the facility manages the wound so they would not be there necessarily to assess. The wound was not assessed for 2 months. 

This was discussed and reviewed with the Hospice Team.”

“Observed in Record Review. In 2 of 21 patient records reviewed, the organization failed to plan the patient’s care. During record review for HOS RRNHV#8 and HOS RRNHV#10, the care plan did not reflect patient and family goals with measurable outcomes. 

In HOS RRNHV#8, the patient had a goal of desired nutrition hydration needs will be met through cert which was not measurable. 

In HOS RRNHV#10, the patient had lung cancer and a respiratory goal of changes to respiratory system will continue to be identified which was not patient centered or measurable. 

This was discussed and reviewed with the Hospice Team. Observed in Record Review. In 6 of 21 patient records reviewed, the organization failed to plan the patient’s care. During record review for HOS RRHV#3, HOS RRHV#4, HOS RRHV#5, HOS RRNHV#1, HOS RRNHV#2, and HOS RRMHV#4, the care plan did not reflect patient and family goals with measurable outcomes. 

For example in HOS RRHV#3, the patient had a goal of patient desired nutrition needs will be met which did not have detail of what the patient specific goal was and was to be met throughout cert. 

In HOS RRHV#4, the patient had a goal of pain will not interfere with sleep, activities time with family and friends throughout cert. The goal did not contain details of measurable outcomes and the timeframe was not individualized. 

In HOS RRHV#5, the patient had a goal of will verbalize acceptable level of anxiety throughout cert without detail of what level was acceptable. 

In HOS RRNHV#1, the patient had a recent wound to the axilla and a goal of comfort, manage drainage, control odor, maintain integument which was not complete or measurable. 

In HOS RRNHV#2, the patient had a SW goal of SW will make biweekly visits for emotional support but SW visits had been discontinued and the goal was not completed. 

In HOS RRNHV#4, the patient had a goal of chaplain visits every two weeks which was not individualized or patient centered. 

This was discussed and reviewed with the Hospice Team. 


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“Observed in Record Review. In 3 of 21 patient records reviewed, the organization failed to plan the patient’s care. During record review for HOS RRHV#4, HOS RRNHV#3, and HOS RRNHV#7, the Hospice Nurse Surveyor observed not all elements of the plan of care were documented. 

For example in HOS RRHV#4, the patient had been struggling with anxiety that was also affecting her sleep but it was not addressed on her POC. 

In HOS RRNHV#3, the patient had increased dyspnea but the goals were closed out previously and there were no interventions on the POC. 

In HOS RRNHV#7, the patient had goals and interventions for wound but the wound was healed. The goals were not closed out. 

This was discussed with the Hospice Team.”

“Observed in Record Review. In 1 of 2 resident records reviewed, the organization failed to supervise effectively. During record review for HOS RRHV#6, the Hospice Nurse Surveyor observed the patient aide services were being supervised once a month, not every 14 days as required. 

This was discussed and reviewed with the Hospice Team. Observed in Record Review. In 1 of 2 patient records reviewed, the organization failed to supervise effectively. During record review for HOS RRNHV#12, the Hospice Nurse Surveyor observed the patient aide services were not being supervised at least every 14 days. 

In HOS RRNHV#12, the aide had been making visits for approximately a month and no supervision had taken place. 

This was discussed and reviewed with the Hospice Team.”

“Observed in Record Review. In 3 of 21 patient records reviewed, the organization failed to document clinical review for the initial certification of terminal illness. During record review for HOS RRHV#5, HOS RRHV#6 and HOS RRNHV#1, the Hospice Nurse Surveyor observed the CTI did not consider all required elements. 

For example in HOS RRHV#5, the documentation from the provider did not contain documentation that a review had taken place of the current subjective and objective data, current medical findings and the current medications and treatments. 

In HOS RRHV#6, the documentation did not contain documentation that a review had taken place of related diagnosis, current medical findings and current medications and treatments.

HOS RRNHV#1, the patient was admitted 6 weeks prior to survey but the CTI was blank and not signed. 

This was discussed and reviewed with the Hospice Team. Observed in Record Review. In 3 of 21 patient records reviewed, the organization failed to document review of the initial clinical information related to the certification of terminal illness, During record review for HOS RRNHV#8, HOS RRNHV#9, and HOS RRNHV#10, the Hospice Nurse Surveyor observed the all required documentation was not included in the review of certification of terminal illness. 

For example in HOS RRNHV#8, the physician failed to document review of the medical record. The only documentation on the CTI stated diagnosis and comfort measures. 

In HOS RRNHV#9, the documentation review did not include all required elements, such as comorbidities, current treatments and medications. 

In HOS RRNHV#10, the documentation failed to include information that comorbidities, current treatment and medications were reviewed. 

This was discussed and reviewed with the Hospice Team.”

“Observed in Record Review. In 2 of 21 patient records reviewed, the organization failed to document review of the patient clinical information. During record review for HOS RRHV#2, and HOS RRHV#6, there was lack of documentation for the CTI for recertification. 

For example in HOS RRHV#2, the Hospice Nurse Surveyor observed the recertification narrative was blank. 

In HOS RRHV#6, the documentation for recertification did not include subjective/ objective data, medical findings and current medication and treatment. 

This was discussed and reviewed with the Hospice Team. Observed in Record Review. In 3 of 21 patient records reviewed, the organization failed to document clinical review before the recertification process. During record review for HOS RRHV#8, HOS RRNHV#9, and HOS RRNHV#10, the documentation was not completed. 

For example HOS RRHV#8, the medical director failed to document review of patient comorbidities, current treatment and medications. 

In HOS RRNHV#9, the documentation failed to include patient comorbidities treatment and medications. 

In RRNHV#10, the documentation only included the diagnosis, it did not contain information that comorbidities, treatment and medications were reviewed. 

This was discussed and reviewed with the Hospice Team.”