Transitions Hospice Central Illinois LLC

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 4 of 23 (17%) clinical records reviewed, it was revealed that the agency did not ensure that the hospice interdisciplinary group (IDG), completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. CLINICAL RECORD 4: The patient elected the hospice benefit on 11/14/2024. The record lacked evidence of the Chaplain and the Social Worker completing an initial assessment within five (5) calendar days. The record also lacked documentation that the patient or family/caregiver refused Chaplain and Social Work services during the five (5) day period after the election of hospice care. There was evidence of a Psychosocial/Spiritual initial comprehensive assessment dated 12/05/2024 which was twenty-one (21) days after the election of hospice care. CLINICAL RECORD 9: The patient elected the hospice benefit on 10/02/2024. The record lacked evidence of the Chaplain and the Social Worker completing an initial assessment within five (5) calendar days. The record also lacked documentation that the patient and family/caregiver refused Chaplain and Social Work services during the five (5) day period after the election of hospice care. There was evidence of a phone call made to the daughter on 10/17/2024 which was fifteen (15) days after the election of hospice care. CLINICAL RECORD 12: The patient elected the hospice benefit on 08/13/2024. The record lacked evidence of the Chaplain and the Social Worker completing an initial assessment within five (5) calendar days. The record also lacked documentation that the patient or family/caregiver refused Chaplain and Social Work services during the five (5) day period after the election of hospice care. There was evidence that a phone call was attempted to the daughter on 08/21/2024, eight (8) days after the election of hospice care. There was also evidence that the social worker’s phone call was unanswered, and a voicemail was left. No other follow-up was documented. CLINICAL RECORD 14: The patient elected the hospice benefit on 08/27/2024. The record lacked evidence of the Chaplain and the Social Worker completing an initial assessment within five (5) calendar days. The record also lacked documentation that the patient or family/caregiver refused Chaplain and Social Work services during the five (5) day period after the election of hospice care. There was evidence of a phone call made to the wife on 09/12/2024, sixteen (16) days after the election of hospice care. During an interview with the Administrator on 01/31/2025, it was confirmed that the agency did not complete a Chaplain and Social Worker visit within 5 days of the election of the hospice benefit. The agency did not have any documentation supporting the patient or the family/caregiver refused Chaplain and Social Work services. Additionally, the Administrator stated,” that the agency is currently working to improve this process.””

“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 review of the Hospice Volunteer Requirement Report revealed the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The review of the 2024 Hospice Volunteer Requirement Report revealed that the volunteer percentage of hours worked from January 2024 to December 2024 was 1.88%. The Administrator and the Volunteer Director stated in an interview on 01/31/2025 that the agency “is struggling with finding volunteers and is currently trying to recruit volunteers.” The review of the Hospice Volunteer Requirement Report revealed the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.”

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 12 (33%) clinical records reviewed it was revealed that the agency did not ensure that a comprehensive assessment including assessment of psychosocial and emotional needs was completed within 5 days of election of hospice care. Document 1: Policy No. 1-014 titled, Comprehensive Assessment stated in part, “A comprehensive assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with the attending physician.” Clinical Record 3: The election of the hospice benefit was dated 03/09/2024. The social worker evaluation/assessment was completed on 03/19/2024 (10 days after election of care). The clinical record lacked evidence that the nursing comprehensive assessment completed on 03/09/2024 included a psychosocial assessment that addressed the patient’s and the family’s adjustment to the terminal illness, the social and emotional factors related to the terminal illness, the presence or absence of adequate coping mechanisms, family dynamics and communication patterns, financial resources and any constraints, and obstacles and risk factors that could affect compliance with the plan of care. Clinical Record 8: The election of the hospice benefit was dated 03/07/2024. The social worker evaluation/assessment was completed on 03/18/2024 (11 days after election of care). The clinical record lacked evidence that the nursing comprehensive assessment completed on 03/07/2024 included a psychosocial assessment that addressed the patient’s and the family’s adjustment to the terminal illness, the social and emotional factors related to the terminal illness, the presence or absence of adequate coping mechanisms, family dynamics and communication patterns, financial resources and any constraints, and obstacles and risk factors that could affect compliance with the plan of care. Clinical Record 9: The election of the hospice benefit was dated 07/18/2023. The social worker evaluation/assessment was completed on 08/27/2023 (40 days after election of care). The clinical record lacked evidence that the nursing comprehensive assessment completed on 07/18/2023 included a psychosocial assessment that addressed: the patient’s and the family’s adjustment to the terminal illness; the social and emotional factors related to the terminal illness; the presence or absence of adequate coping mechanisms; family dynamics and communication patterns; financial resources and any constraints; and obstacles and risk factors that may affect compliance with the plan of care. Clinical Record 10: Election of hospice benefit on 05/03/2024, Date of death was 05/29/2024. The clinical record lacked evidence that the patient was seen by the hospice social worker during care or that a comprehensive psychosocial assessment was completed that addressed: the patient’s and the family’s adjustment to the terminal illness; the social and emotional factors related to the terminal illness; the presence or absence of adequate coping mechanisms; family dynamics and communication patterns; financial resources and any constraints; and obstacles and risk factors that may affect compliance with the plan of care.. Personnel Record 2: In a joint interview and record review on 07/10/2024, the Clinical Director confirmed the findings that assessment of the patient’s psychosocial and emotional needs was not completed within 5 days of election of hospice care.”

“It is required that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the patient’s terminal illness that are addressed to promote the patient’s well-being, comfort, and dignity throughout the dying process. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 12 (33%) clinical records reviewed revealed that the agency did not ensure that the comprehensive assessment included the identification of the psychosocial and emotional needs related to the patient’s terminal illness to promote the patient’s well-being, comfort, and dignity throughout the dying process. Document 1: Policy No. 1-014 revision date December 2018 stated in part “During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient’s clinical record, including at least the following information, as relevant: S. The patient’s psychosocial status, including emotional barriers to treatment, cognitive limitations, memory and orientation, family relationships, social history, source and adequacy of environmental and other resources, coping mechanisms, and the patient’s and family/caregiver’s reaction to illness”. Clinical Record 3: Election of hospice benefit on 03/09/2024. The social worker evaluation/assessment was completed on 03/19/2024 (10 days after election of care). The clinical record lacked evidence that the nursing comprehensive assessment completed on 03/09/2024 included a psychosocial assessment that addressed: the patient’s and the family’s adjustment to the terminal illness; the social and emotional factors related to the terminal illness; the presence or absence of adequate coping mechanisms; family dynamics and communication patterns; financial resources and any constraints; and obstacles and risk factors that may affect compliance with the plan of care. Clinical Record 8: Election of hospice benefit on 03/07/2024. The social worker evaluation/assessment was completed on 03/18/2024 (11 days after election of care). The clinical record lacked evidence that the nursing comprehensive assessment completed on 03/07/2024 included a psychosocial assessment that addressed: the patient’s and the family’s adjustment to the terminal illness; the social and emotional factors related to the terminal illness; the presence or absence of adequate coping mechanisms; family dynamics and communication patterns; financial resources and any constraints; and obstacles and risk factors that may affect compliance with the plan of care. Clinical Record 9: Election of hospice benefit on 07/18/2023. The social worker evaluation/assessment was completed on 08/27/2023 (40 days after election of care). The clinical record lacked evidence that the nursing comprehensive assessment completed on 07/18/2023 included a psychosocial assessment that addressed: the patient’s and the family’s adjustment to the terminal illness; the social and emotional factors related to the terminal illness; the presence or absence of adequate coping mechanisms; family dynamics and communication patterns; financial resources and any constraints; and obstacles and risk factors that may affect compliance with the plan of care. Clinical Record 10: Election of hospice benefit on 05/03/2024, Date of death was 05/29/2024. The clinical record lacked evidence that the patient was seen by the hospice social worker during care or that a comprehensive psychosocial assessment was completed that addressed: the patient’s and the family’s adjustment to the terminal illness; the social and emotional factors related to the terminal illness; the presence or absence of adequate coping mechanisms; family dynamics and communication patterns; financial resources and any constraints; and obstacles and risk factors that may affect compliance with the plan of care.. Personnel Record 2: In a joint interview and record review on 07/10/2024, the Clinical Director confirmed the findings and stated in part “We had changed our process on comprehensive assessments and will be going back to having the social worker complete the comprehensive assessment piece that addresses psychosocial and emotional needs versus just the nurse completing the entire comprehensive assessment.””

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 1 (100%) discharged clinical record reviewed of a patient that was transferred to another hospice, it was revealed that the agency did not ensure that the discharge summary included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation to assist in the post-discharge continuity of care. Document 1: Policy No.1-026 titled, Discharge Summary, revision date December 201,8 stated in part, “All patients discharged from a service and from a hospice will have a discharge summary completed and filed in the clinical record. Hospice personnel who provide care will complete a discharge summary which may include as appropriate: G. A summary of the care or service provided, H. The patient’s current plan of care, I. The patient’s latest physician orders.” Clinical Record 5: The election of the hospice benefit was dated 07/19/2023. The patient was transferred to another hospice on 09/07/2023. The clinical record lacked evidence that the discharge summary included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation to assist in the post-discharge continuity of care. Personnel Record 2: In a joint record review and interview on 07/10/2024, the Clinical Director (personnel record 2) confirmed findings that the clinical record lacked evidence that the discharge/transfer summary included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation to assist in the post-discharge continuity of care and stated in part, “The nurse did not choose the right discharge summary.””