Loyola Medicine Hospice
A hospice in Oak Brook, Illinois 60523
2301 W 22nd Street, Ste 107, Oak Brook, Illinois 60523. (630) 861-5165.
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The short answer
Record last released by CMS on Oct 23, 2026.
- 11 deficiencies cited in the last three years
- 3of 5 family caregiver rating
- 9of 10 CMS’s Hospice Care Index
Each figure’s source sits beside it, in its section below.
What these words mean3
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
11 deficiencies cited in the last three years
The middle of the 30 hospices serving ZIP code 60523 had 6.
The last inspection on record was on May 23, 2025: a reaccreditation inspection by The Joint Commission.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
When those deficiencies happened
11 deficiencies in 1 month of the last 36. Last cited May 2025. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
May 23, 2025: reaccreditation inspection by The Joint Commission11 deficiencies
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Timeframe for completion of assessment (42 CFR 418.54(b))
The inspectors’ words, 94 words
“Observed in Record Review. In 3 of 17 patient records reviewed, the initial comprehensive assessment was not completed within five calendar days of the patient electing the hospice benefit. For example in records RRHV#2 and RRNHV#3 there was no documentation that a Spiritual Counselor had completed an initial assessment and there was no documentation to indicate a refusal or requested postponement of the visit. In record RRNHV#5 the Spiritual Counselor visit was completed day 7 with no documentation to indicate a request for the postponed date. This was confirmed with the Clinical Manager present.”
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Content of comprehensive assessment (42 CFR 418.54(c)(7))
“Observed in Record Review. In 2 of 17 patient records reviewed, it was noted that the initial bereavement assessment was not completed. For example, in records RRBR#3 and RRNHV#3 there was no initial bereavement assessment documented. This was confirmed and discussed with the Clinical Manager present.”
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Plan of care (42 CFR 418.56(b ))
“Observed in Record Review. In 1 of 4 home visits conducted, it was noted in the home binder of RRHV#3 that the patient’s representative/POA had signed a blank addendum, Notice of Non-coverage. This was verified with the Clinical Manager present.”
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Content of plan of care (42 CFR 418.56(c))
The inspectors’ words, 210 words
“Observed in Record Review. In 13 of 17 patient records reviewed, it was noted that the written plan of care was not individualized with goals including time frames. For example, RRHV#1 22 of 22 goals documented had time frames throughout hospice episode and goals were not individualized; Patient/CG verbalizes proper mouth care throughout hospice episode. RRHV#3 14 of 18 goals time frames were throughout hospice episode and goals were not individualized; General hospice care pak will be provided to the patient within 72 hours. RRHV#2 18 of 19 goals and RRHV#4 18 of 20 goals time frames were documented as throughout hospice episode. RRNHV#1 10 of 10 goal’s time frames were documented as throughout hospice episode. Also goals for the MSW and Chaplain stated A (MSW or Chaplain) plan of care will be established that meets the patient’s needs and no interventions. RRNHV#2 12 of 12 goals time frames were documented as throughout hospice episode. Also, goals for the Volunteer, MSW and Chaplain stated A (volunteer, MSW or Chaplain) hospice plan of care will be established that meets the patient’s needs. and no interventions. RRNHV#4, RRNHV#5, RRNHV#6, RRNHV#7, RRNHV#8, RRNHV#9 and RRNHV#10 records with the same time frames and goal quote problems. This was discussed with the Clinical Manager present.”
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Content of plan of care (42 CFR 418.56(c)(2))
“Observed in Record Review. In 2 of 14 patient records reviewed, it was noted that the POC did not include statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs. For example in records RRNHV#5 and RRNHV#9 the POC did not include the frequency of volunteer services. The records did include documentation of visits performed by the volunteer. This was confirmed and discussed with the Clinical Manager present.”
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Coordination of services (42 CFR 418.56(e)(2))
The inspectors’ words, 215 words
“Observed in Record Review. In 5 of 17 patient records reviewed, it was noted that care was not provided according to hospice plan of care. For example, in record RRHV#1 the POC required the MSW to visit the patient 1 time a month and following the initial comprehensive visit there was no documentation of a MSW visit for over 7 weeks. In records RRBR#1 and RRBR#2 the bereavement interventions included mailings at 3 and 6 months and there was no documentation of the mailings. In RRBR#1 there was an intervention for a call at 30 days and there was no documentation of the call and the Bereavement Coordinator stated that the call had not been made because there was no volunteer trained to make the call at the time. This was confirmed and discussed with the Clinical Manager present. It was noted that at the start of care RRHV#4 and RRNHV#8 the nursing admission documentation stated that the patient’s family had requested volunteer services, but there was no documentation of the patient or family being contacted by the coordinator or visits being completed. The Clinical Manager present did locate documentation that the nurse who completed the admission had contacted the volunteer coordinator to have volunteer services started. This was discussed with the Clinical Manager present.”
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Prevention (42 CFR 418.60(a))
The inspectors’ words, 129 words
“Observed in Patient Home. In 2 of 4 home visits conducted, staff did not follow the organizations infection control policy. For example during Hospice RRHV #1 and #2 the RNs were observed to wipe the vital sign equipment off using a 70% alcohol wipe, one item at a time, then immediately integrated back into the bag without allowing to dry or performing hand hygiene. The RNs were observed to perform hand hygiene, don gloves and performed the patient visit touching the patient and patient’s environment including performing a medication reconciliation picking up each bottle to read the label then look into tablet, touching the tablet. Also, observed entering and exiting the clinical bag multiple times without performing hand hygiene or changing gloves. This was discussed with the manager present.”
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Counseling services (42 CFR 418.64(d)(1)(iv))
“Observed in Record Review. In 3 of 3 patient records reviewed, for bereavement services it was noted that the hospice had not developed a bereavement plan of care. For example, in records RRBR#1 and RRBR#2 there were identical lists of interventions however there were no goals documented in either record. In record RRBR#3 the post death bereavement risk assessment indicated that the bereaved were at a high risk, yet there was no plan of care documented, no goal or interventions.”
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Recruiting and retaining (42 CFR 418.78(c))
“Observed in Tracer Activities. During meeting with the Volunteer Coordinator in was noted that the hospice had not documented retention activities for volunteers. This was confirmed with the Regional Quality Nurse.”
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Training (42 CFR 418.100(g)(3))
“Observed in HR File Review. In 2 of 9 HR files reviewed, it was noted that staff competency was not assessed as part of orientation. For example, the volunteer record did not include an initial documented competency. For example, the Spiritual Counselor/Bereavement Coordinator record included a competency document that was only partly completed with entire areas blank including the hospice education area and the field joint visit section. This was confirmed with the HR staff and Volunteer Coordinator present.”
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Discharge or transfer of care (42 CFR 418.104(e)(1)(i))
“Observed in Record Review. In 1 of 1 patient records reviewed, for discharge with transfer of hospice care, it was noted that there was no documentation that the new hospice provider was provided with the reason for the patient’s transfer, a summary of care, treatment and services it had provided to the patient, or the patient’s progress toward goals. This was confirmed with the Clinical Manager present.”
The one inspection in the last three years
| Date | Visit | What the record says |
|---|---|---|
| May 23, 2025 | Reaccreditation inspection by The Joint Commission | 11 deficiencies cited |
Is it certified?
- Medicare-certified hospice since Apr 14, 1994.
- Ownership: non-profit.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency or CMS’s most serious finding: the place’s failure to meet a rule caused, or was likely to cause, serious injury, harm, impairment or death to someone in its care. Source: CMS; 42 CFR 489.3. on record in the last three years.
CMS, Hospice General Information. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Has anything been proven against it?
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- 0 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Who does the caring?
- From Medicare claims (Jan 1, 2023 to Dec 31, 2024): 11 nurse care minutes per routine home care day, 6.9% of skilled nursing minutes at weekends and a visit near death for 91.3% of patients who died.
- Where its patients were cared for (Jan 1, 2024 to Dec 31, 2024): 95% at home, 1% in a nursing facility, 3% in a skilled nursing facility, 1% elsewhere.
CMS, Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | This provider |
|---|---|
| Nurse care minutes per routine home care day | 11.0 min |
| Skilled nursing minutes at weekends | 6.9% |
| Visits near death | 91.3% of patients who died |
Who owns it?
- 16 owners or officers are people: Ray Anderson (corporate director); Marcus A Bowens (corporate officer); Corinne Francis (corporate director); Benjamin E Petersen (corporate officer); Melanie Agbay (managing employee (on the payroll)); Daniel Roth (corporate director); Joshua Moore (corporate director); Donald Mathews (runs it (operational or managerial control)); Daniel Drake (corporate officer); Daniel Drake (corporate director); Alma Phillips (managing employee (on the payroll)); Jaime K Lewis (managing employee (on the payroll)); Robert F Casalou (corporate officer); Robert F Casalou (corporate director); Daniel Isacksen (corporate director); Christine Seppala (corporate officer).
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospice All Owners and Hospice Enrollments. Released Sep 29, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| Trinity Health Corporation | Owns 5% or more through other companies | 100% | Jul 1, 2015 |
What do families say?
- Family caregivers rate it 3 of 5 in CMS’s survey (Oct 1, 2023 to Sep 30, 2025): 77% rated it 9 or 10 out of 10, and 81% would definitely recommend it.
- CMS’s Hospice Care Index: 9 of 10 (Jan 1, 2023 to Dec 31, 2024).
- 100% of patients were assessed on all seven of CMS’s measures at the start of care (Oct 1, 2024 to Sep 30, 2025); 61.5% had visits from a nurse or social worker on at least 2 of their last 3 days (Jan 1, 2023 to Dec 31, 2024).
CMS, CAHPS Hospice Survey and Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Family caregiver survey ratingCMS star rating from its survey of patients’ family caregivers, 1 to 5 | 3 of 5 |
| Hospice Care IndexCMS’s Hospice Care Index, 0 to 10 (higher is better): a point for each of ten measures from Medicare claims on which the hospice meets CMS’s threshold | 9 of 10 |
How does it compare nearby?
- Of the 30 hospices CMS’s data show serving patients in ZIP code 60523, where this hospice’s office is, the middle number of deficiencies cited in the last three years was 6; this one had 11.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
| Place | Deficiencies, 3 years |
|---|---|
| Advocate Hospice | 1 |
| Loyola Medicine Hospice This hospice | 11 |
| Gentiva I | 12 |
| First Health Hospice LLC | 27 |
| Adventist St Thomas Hospice | 1 |
| Rainbow Hospice | 5 |
| Vitas Healthcare Corporation of Illinois | 2 |
| Journeycare - Barrington | 17 |
| Lightways Hospice and Serious Illness Care | Not given |
| Unity Hospice of Chicagoland, LLC | 5 |
| Accentcare Hospice & Palliative Care of Illinois | 18 |
| Elara Caring I | 6 |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- CMS ended its Special Focus Program for hospices with serious problems on Feb 14, 2025, so no hospice is marked as one.
- Hospice quality measures have a gap from October 2025: CMS replaced its patient assessment then, and public results from the new one (HOPE) are expected around November 2027.
Sources
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Centers for Medicare & Medicaid Services, Hospice General Information (yc9t-dgbk).
Released Aug 26, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Provider Data (252m-zfp9).
Released Aug 26, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, CAHPS Hospice Survey (gxki-hrr8).
Released Aug 26, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR hospice inspection reports (Hospice Survey Reports - Oct 2021 through Sep 2026.xlsx).
Released Oct 23, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice All Owners (e983965e-1603-4cb8-82b5-c40090e380d1).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Enrollments (25704213-e833-4b8b-9dbc-58dd17149209).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice ZIP Data (95rg-2usp).
Released Aug 26, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospice
The public record above comes first. Anything the hospice adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospice will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospice”, and paying will never change a finding, a rating or the order of results.