Suncrest Hospice Illinois LLC

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene; [and] use of gloves. This standard was not met as evidenced by document review, interview and observation. In 1 of 6 (17%) home visits observed, the agency did not ensure hand hygiene was performed when indicated per the agency’s policy. DOCUMENT 1: Policy No. 7-009 Hand Hygiene (revision date December 2025) read in part, “Hand decontamination using an alcohol-based hand rub should be performed: after removing gloves.” HOME VISIT 2: The patient elected hospice care on 11/24/2024 with a diagnosis of senile degeneration of the brain. During the home visit observation on 09/23/2026, the Registered Nurse (RN) [Personnel Record 2] was observed providing wound care. The RN donned gloves and cleansed the wounds to the patient’s sacral region. After cleansing the wound, the RN removed the soiled gloves and donned clean gloves. The RN applied Thera honey, calcium alginate, and covered the wounds with a foam pad. The RN did not follow agency policy to perform hand hygiene after removing gloves. During an interview on 09/24/2026, the Executive Director/Alternate Administrator confirmed the findings and the agency policy that hands should be cleansed after glove removal.”

“It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 23 (9%) clinical records reviewed of patients who received Licensed Practical Nurse (LPN) visits, the agency did not ensure that a Registered Nurse (RN) provided supervision of the LPN services as per agency policy. DOCUMENT 1: Policy No. 1-031 Responsibilities/Supervision of Clinical Services (revision date May 2024) read in part, “A monthly patient visit will be completed by a registered nurse to supervise licensed practical/vocational nursing services.” CLINICAL RECORD 14: The patient elected hospice services on 06/08/2026 with a diagnosis of heart failure. The hospice certification and recertification plans of care for benefit periods 06/08/2026 through 09/05/2026 and 09/06/2026 through 12/04/2026 ordered Skilled Nursing (SN) one to two times a week throughout the benefit periods. Skilled nursing visits were provided by the Licensed Practical Nurse (LPN) on 07/16/2026, 08/21/2026, and 09/18/2026. Supervision of the LPN was documented on 09/22/2026. The review revealed that LPN supervision was not performed monthly per agency policy. CLINICAL RECORD 27: The patient elected hospice services on 09/10/2025 with a diagnosis of senile degeneration of the brain. The hospice certification and recertification plans of care for benefit periods 09/10/2025 through 12/08/2025 and 12/09/2025 through 03/08/2026 ordered Skilled Nursing (SN) two times a week throughout the benefit periods. Skilled nursing visits were provided by the Licensed Practical Nurse (LPN) on 09/24/2025, 10/01/2025, 10/08/2025, 10/15/2025, 10/22/2025, and 12/23/2025. The clinical record did not document LPN supervision. The review revealed that LPN supervision was not performed monthly per agency policy. In a joint record review and interview on 09/23/2026, the Alternate Administrator/Executive Director (Personnel Record 8) confirmed that LPN supervisory visits were not completed monthly per agency policy.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care and are documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review, document review and interview. CLINICAL RECORD 11: The patient elected hospice services on 07/21/2026 with a diagnosis of Senile degeneration of the brain. The comprehensive assessment completed by the social worker on 07/24/2026 documented, “Volunteer: Accepted.” A clinical record review revealed no documented evidence that volunteer services were provided, a follow-up assessment was completed, or a care plan was initiated to address volunteer needs. During the joint record review and interview on 09/23/2026, the Alternate Administrator/Executive Director (Personnel Record 8) confirmed that the clinical record did not include evidence that volunteer services were implemented based on needs identified in the comprehensive assessment. During the joint record review and interview on 09/23/2026, the Volunteer Coordinator (Personnel Record 10) confirmed that the clinical record did not include evidence that volunteer services were implemented based on needs identified in the comprehensive assessment and stated in part. “We missed this one, I will get this assigned right away.””

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services equal to five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. DOCUMENT 5: A joint review of the “Volunteer Hours “ reports dated 01/01/2024 through 12/31/2024, 01/01/2025 through 12/31/2025, and 2026 year-to-date with the Alternate Administrator and the Volunteer Coordinator on 09/23/2026 revealed that volunteers provided 2.04% of day-to-day administrative and/or direct patient care services for 2024, 1.38% for 2025, and 2.54% year-to-date for 2026. The Volunteer Coordinator (Personnel interview 10) confirmed that volunteer utilization was below the required 5% for 2024, 2025, and 2026 year-to-date and stated in part, “I started in December of 2025, since then I have onboarded 54 new volunteers. We are moving in the right direction.” During an interview on 09/23/2026, the Alternate Administrator (Personnel Record 8) confirmed that volunteer utilization was below 5% for 2024, 2025, and year-to-date 2026. The agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services equal to five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.”

“Based on interview and record review, the Hospice agency failed to provide volunteer services in an amount equal to five percent of the total patient care hours. This had the potential to affect 502 of the 502 active patients receiving services from the agency who may have benefited from volunteer services. Findings include: Review of the Quality Assessment Performance Improvement (QAPI) documentation, provided by the agency and dated for 2025, revealed the agency’s monthly volunteer percentages were: January – 1.95 percent (%)February – 1.94%March – 2.18%April – 1.83%May – 1.25%June – 0.95%July – 0.95%August – 1.47%September – 0.84%October – 1.32%November – 1.3%December – 0.55% During a home visit observation on 02/19/26 at 9:30 AM, Family Member (F1), P9’s spouse/caregiver, stated, “I didn’t know volunteers were available. No one told me about that. I think that could be helpful at times.” During an interview on 02/20/26 at 12:30 PM, the Executive Director (ED) confirmed the agency had not been able to reach the volunteer services minimum of five percent of the total patient care hours of paid and contracted hospice personnel and that a performance improvement project (PIP) was a part of the agency’s QAPI program to achieve the goal. The ED also stated the Volunteer Coordinator was out of the state on vacation and was not available for an interview. Review of the Hospice agency policy titled, “Volunteer Services,” dated December 2025, revealed, “Patient care volunteers provide personal care or emotional support and practical assistance which enhance the comfort and quality of life for patients and family/caregivers. These services include being available for companionship, listening, simply ‘being there,’ and preparing meals. Patient care volunteers may also provide relief for caregivers or assist them with household chores . . . The Volunteer Coordinator will track the use of volunteers, the cost savings achieved, and that the hours of volunteer services will exceed 5% of the total patient care hours of paid and contracted hospice personnel . . .””

“It is required that the documented comprehensive assessment include a drug profile that contains the patient’s current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met, as evidenced by a review of the clinical records, interviews, and observations. In 1 of 2 (50%) observed home visits in which a medication profile was obtained from the assisted living, the agency did not ensure that they had reviewed all medications for potential side effects. HOME VISIT 1/CLINICAL RECORD 4: During the observed home visit with the Registered Nurse (RN) (Personnel Record 1) on 08/25/2025, a medication profile was reviewed at the assisted living facility (ALF). The ALF medication profile listed medications that were not listed on the hospice medication profile and/or the plan of care. The following medication was listed on the facility’s medication profile but was not included in the hospice plan of care: Guaisorb DM 100mg/5ml, 20ml, administered orally every 4 hours as needed. The order date was 09/17/2024, and continued on the facility’s medication profile. Additionally, a Melatonin, 5 mg at bedtime, was documented as received on 11/13/2023 and continued on the facility’s medication profile. The hospice did not review these medications for potential medication interactions. During an interview with the RN (Personnel Record 1) on 08/25/2025, the RN stated that medications were reviewed by their software from the medication profile. During an interview on 08/26/2025 with the Vice President of Compliance, who jointly reviewed records and stated that their process will be changed related to medication collaboration, as the facility pharmacy profiles print differently and have caused some confusion about the accuracy of medications.”

“It is required that each patient’s individualized written plan of care: include all services necessary for the palliation and management of the terminal illness, including the following: Drugs and treatment necessary to meet the needs of the patient. This standard was not met, as evidenced by a review of the clinical record, interview, and observation. In 2 of 5 (40%) clinical records and home visit observations reviewed, the agency did not ensure that the medications listed on the plan of care were accurate when compared to the assisted living medication profile. HOME VISIT 1/CLINICAL RECORD 4: The election of the Hospice Benefit was documented as effective 06/17/2025 with a primary diagnosis of Senile Degeneration. During the observed home visit on 08/25/2025, with the Registered Nurse (RN) (Personnel Record 1), a medication profile from the facility was reviewed. The discrepancies between the facility’s medication profile and the current plan of care were as follows: Guaisorb DM 100mg/5ml, 20ml, administered orally every 4 hours as needed, and Melatonin, 5mg at bedtime. These medications had not been listed on the current plan of care. HOME VISIT 2/CLINICAL RECORD 5: The election of the Hospice Benefit was documented as effective 07/20/2025 with a primary diagnosis of Parkinson’s. During the observed home visit on 08/25/2025, the RN (Personnel Record 1) reviewed a medication profile from the facility. The facility’s medication profile documented that the medication midodrine 10mg oral tablet was taken 3 times a day for hypotension and to be held for a systolic blood pressure greater than 120. This medication was not on the current plan of care. During an interview on 08/26/2025 with the Vice President of Compliance, who jointly reviewed records and stated that their process will be changed related to medication collaboration, as the facility pharmacy profiles print differently and have caused some confusion.”