Haven Hospice Il, LLC

“It is required that the hospice must develop an individualized written plan of care for each patient. The plan of care must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. This standard was not met as evidenced by clinical record review and interview. In 1 of 17 (6%) clinical records reviewed revealed the agency did not ensure that the individualized plan of care (PO) included interventions and goals based on problems identified in the initial, comprehensive, and updated comprehensive assessments. CLINICAL RECORD 5: This patient elected the hospice benefit on 10/26/2023 with a terminal diagnosis of Alzheimer’s Disease. The Face to Face (F2F) visit dated 11/28/2025 documented the patient ate 2 meals per day and seemed to cough more at lunch and dinner meals. The certificate of terminal illness (CTI) dated 11/28/2025 stated the patient was coughing with thin liquids and a regular diet and was a high aspiration risk. The hospice plan of care was reviewed for the dates of 12/04/2025-01/14/2026. There were no individualized problems, goals, or interventions in the written plan of care specifically addressing the aspiration risk. An interview was conducted with the Vice President of Operations on 01/14/2026 and it was agreed that the plan of care did not include interventions for the aspiration risk.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 17 (6%) clinical records reviewed for patients who received hospice aide services, the agency did not ensure that the hospice aide received written patient care instructions to meet the patient’s needs. CLINICAL RECORD 5: This patient elected the hospice benefit on 10/26/2023 with a terminal diagnosis of Alzheimer’s Disease. The Face to Face (F2F) visit dated 11/28/2025 documented the patient ate 2 meals per day and seemed to cough more at lunch and dinner meals. The certificate of terminal illness (CTI) dated 11/28/2025 stated the patient was coughing with thin liquids and a regular diet and was a high aspiration risk. The hospice plan of care was reviewed for the dates of 12/04/2025-01/14/2026. There were no individualized problems, goals, or interventions in the written plan of care specifically addressing the aspiration risk and no specific instructions for the hospice aide. An interview was conducted with the Vice President of Operations on 01/14/2026 and it was stated that the hospice aide care plan did not provide clear written instructions for the hospice aide.”

“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. A joint review of the agency report titled “Hospice Volunteer Requirement Report” with the Administrator (Personnel Record 7) and Volunteer Coordinator (Personnel Record 9) on 01/14/2026 revealed that the volunteer utilization was 1.47% for the year of 2025, which did not meet the requirement of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. During an interview on 01/14/2026, the Volunteer Coordinator (Personnel Record 9) and Administrator (Personnel Record 7, it was stated that the past year was a transitional year, but the last three months of 2025 saw an increase in volunteer hours and there was an active plan to increase the program. The agency had also implemented a performance improvement plan (PIP) to re-build the volunteer program. A joint review of the agency report titled “Hospice Volunteer Requirement Report” with the Administrator and Volunteer Coordinator on 01/14/2026 revealed that the volunteer utilization was 1.47% for the year of 2025, which did not meet the requirement of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. PERSONNEL INTERVIEW 2: During an interview on 01/14/2026, the Volunteer Coordinator and Administrator stated that the past year was a transitional year, but the last three months of 2025 saw an increase in volunteer hours and there was an active plan to increase the program. The agency had also implemented a performance improvement plan (PIP) to re-build the volunteer program.”