VNA Health Care, An Illinois Not-For-Profit Corporation

“Based on a review of the Hospice Emergency Preparedness Plan and staff interview, it was determined that the Hospice failed to conduct / participate in a full-scale Community Based Exercise or Facility Based Exercise to ensure the effectiveness of the Emergency Preparedness Plan. Findings include: 1. The Hospice Emergency Preparedness Plan was reviewed on 02/20/24. The Emergency Preparedness did not include documentation indicating that the Hospice conducted / participated in testing exercise or drills since 2017. 2. During an interview with the Associate Vice President of Quality Improvement on 02/22/24 at 11:00 AM, the Associate Vice President confirmed that the Hospice did not conduct / participate in any testing since 2017.”

“Based on clinical records review, Agency policy review and Staff interview, it was determined that in 4 of 4 (Pts #2, 3, 1 and 4) clinical records reviewed, the Agency failed to ensure the initial bereavement assessment was completed. 4. Patient #1 was admitted to Hospice services on 09/20/23 with diagnosis of Glioblastoma. The clinical record was reviewed on 02/20/24. The Initial Nursing assessment dated 09/20/23, completed by the Registered Nurse, lacked documentation of an initial bereavement assessment. 5. Patient #4 was admitted to Hospice services on 02/07/24 with diagnosis of Alzheimers Disease. The clinical record was reviewed on 02/20/24. The Initial Nursing assessment dated 02/07/24, completed by the Registered Nurse, lacked documentation of an initial bereavement assessment. 6. The findings were confirmed during the interview on 02/21/24 between 9:30 AM and 1:30 PM, with the Director of Home Health and Hospice and on 02/22/24 at 10:00 AM. 3. Patient #3 was admitted to Hospice services on 06/14/23 with Diagnosis of Nontraumatic intracranial hemorrhage. The clinical record was reviewed on 02/20/24. The Initial Nursing assessment dated 06/15/23, lacked documentation indicating that the initial bereavement assessment was completed. Findings include: 1. Hospice Program Admission and Comprehensive Assessment Policy was reviewed on 02/21/24 and indicated: “;....procedure....The Registered Nurse (RN) shall perform a thorough assessment of the patients needs including:.....g. bereavement risk....D. Comprehensive Assessment/Initial Plan of Care....2. The Comprehensive Assessment consists of a thorough evaluation.....d. An evaluation of complications and risk factors, imminence of death, severity of symptoms and bereavement issues....” 2. Patient #2 was admitted to Hospice services on 04/11/23 with Diagnosis of Malignant Neoplasm of Esophagus, unspecified. The clinical record was reviewed on 02/20/24. The Initial Nursing assessment dated 04/11/23, completed by the Registered Nurse, lacked documentation indicating that the initial bereavement assessment was completed.”

“Based on staff interview and Job description review, it was determined Hospice failed to include SW in the Interdisciplinary Group. Findings include: 1. During a telephone interview with the Hospice SW on 02/21/2024 at 10:30 AM, the SW stated he has been a Hospice Social Worker for over a year. During the same interview the SW added he is the only Social Worker on staff. The SW stated he has not participated in any IDT meetings since being an employee for Hospice. 2. The Hospice Job description titled “;Social Worker – Home Health / Hospice” was reviewed on 02/21/2024 at 1:00 PM. The SW job description “;Primary Functions” section failed to include the SW function of participating in Hospice IDT meetings to assist and evaluate with patient / family needs. 3. Finding of Hospice failing to incorporate SW services as part of the IDT was confirmed during an interview with the Vice President of Operations on 02/22/2024 at 10:30 AM.”

“Based on the review of the quality improvement program documents and Staff interview, it was determined the Hospice failed to ensure the licensed MSW participated in the quality assessment and performance improvement program. Findings include: 1. The Hospice quality assessment and performance improvement program was reviewed on 02/20/24 at 1:30 PM and lacked documentation that the licensed MSW participated in the quality assessment and performance improvement program. 2. The findings were confirmed during the interview on 02/20/24 with the Director of Quality and Education and the Associate Vice-President of QI, Risk Management & Corporate Compliance on 02/23/24 at 9:00 AM.”

“Based on document review and staff interview, it was determined the Hospice failed to maintain documentation related to the cost savings achieved with the use of volunteers. Finding include: 1. On 02/21/24 at 9:00 AM a document titled “Hospice volunteer” dated February 2024 was reviewed. The document describes the use of volunteers only for the month of February 2024. 2. During an interview with the Volunteer Coordinator on 02/21/24 at 9:45 AM, the Volunteer Coordinator stated that she has no documentation indicating the cost saving or volunteer utilization for year 2023. 3. Finding of Hospice failing to provide documentation of cost saving or volunteer utilization for year 2023 was confirmed during an interview with the Vice President of Operations on 02/22/2024 at 10:30 AM.”