Unity Hospice of Western Illinois

“Based on review of clinical records and staff interviews, it was determined in 3 of 19 (Pts. #7, 13, and 17) clinical records reviewed, the hospice failed to ensure staff provide services as ordered by the Physician. 2. Pt. #13 was admitted to the hospice on 05/31/23 with diagnosis of Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 10/30/24. The clinical record contained a initial POC dated 05/31/23, that required the hospice Aide visits 3 - 5 times for the next 15 days. The record lacked the minimal three hospice Aide visits during 05/31/23 – 06/12/23. 3. Pt. #17 was admitted to hospice on 10/03/23 with diagnosis of Heart Failure. The clinical record was reviewed on 10/29/24. The clinical record contained an initial POC dated 10/03/23, that required the hospice Aide visits 3 - 5 times for the next 15 days. The record lacked the hospice Aide visits during 10/03/23 – 10/12/23. 4. The findings were confirmed during the interviews on 10/30/24 between 9:00 – 3:00 PM, with the Hospice Administrator, Administrator in Training and Director of Clinical Services. 1. Pt. #7 was admitted to hospice on 05/23/24 with the diagnosis of Malignant Neoplasm of Cervix, Uteri, Unspecified. The clinical record was reviewed on 10/29/24. The record included the POC dated 5/23/24 orders that required “2-3 and 1-3” Skilled Nursing Visits per week. The record lacked documentation the SN provided the 2-3 visits ordered for the week of 09/15/24 and the 1-3 visits ordered for the week of 10/06/24.”

“Based on observation during home visits, Hospice policy, and staff interviews, it was determined that in 2 of 4 (Pts. #1 and 4) home visits conducted, the hospice failed to ensure that staff follow infection control measures. 2. Pt. #4 was admitted to hospice on 05/24/24 with Diagnosis of Malignant Neoplasm of Unspecified part of Bronchus. Pt. #4s clinical record was reviewed on 10/29/24. A home visit was conducted on 10/29/24 with the Employee #4. During the home visit Employee #4 was observed carrying her bag and placed the nursing bag onto the dining room floor without using a barrier, as required by policy. 3. The Hospice policy titled “BAG TECHNIQUE / CONTENTS” was reviewed on 10/30/24 at 10:00 AM. The policy required “Outside dirty pockets for gloves and inside clean pockets for equipment like the blood pressure cuff and stethoscope. It specifies the need for two designated clean compartments, one for clean disposables”....” 1...Place barrier on a hard flat surface. Make sure barrier is large enough to hold your bag and supplies needed for the visit....” 4. During an interview with the Hospice Administrator, Administrator in training, and the Director of Clinical Services on 10/30/24 at 2:30 PM, the Director of Clinical Services stated staff are required to remove gloves after providing Pt. care, sanitize their hands, then clean equipment, and return equipment into the bag. Findings of hospice staff not following infection control measures were confirmed during interviews on 10/30/24 between 1:00 PM and 2:30 PM with the above staff. Findings include: 1. Pt. #1 was admitted to hospice on 02/06/24 with the diagnosis of Cerebrovascular Disease, Unspecified. Pt. #1’s clinical record was reviewed on 10/28/24. A home visit was conducted on 10/28/24 with Employee #1. During the visit, Employee #1 was observed applying gloves and a new dressing to Pt. #1’s right heel. Subsequently, Employee #1 used the same gloves to clean the blood pressure cuff and stethoscope, then placed the equipment into a one (1) compartment bag using the same gloves. Employee #1 failed to comply with hospice policy.”

“Based on observation and clinical record review during home visits, hospice policy review, and staff interviews, it was determined in 2 of 3 (Pts. #1 and 3) home visits conducted in a nursing facility, the hospice failed to maintain an updated POC in the nursing facility’s clinical record. 2. Pt. #3 was admitted to hospice on 04/04/24 with a diagnosis of Alzheimers Disease, Unspecified. On 10/29/24 at 1:30 PM, a home visit was conducted in a nursing facility with Employee #3. During the home visit, the patients hospice clinical record was reviewed. Observed that the last POC in the record was dated 05/16/24 - 05/29/24. The hospice failed to maintain a current hospice POC for the facility. 3. The findings were confirmed during staff interviews conducted on 10/30/24 between 10:00 AM and 3:00 PM, with the Hospice Administrator, Administrator in Training, and the Director of Clinical Services. Findings include: 1. Pt. #1 was admitted to hospice on 02/06/24 with a diagnosis of Cerebrovascular Disease, Unspecified. On 10/28/24 at 2:00 PM, a home visit was conducted in a nursing facility with Employee #1. During the home visit, the patients hospice clinical record was reviewed. Observed that the last POC in the record was dated 09/04/24. The hospice failed to maintain a current hospice POC for the nursing facility.”