DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
141525 A. BUILDING __________
B. WING ______________ 		09/10/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
JOURNEYCARE - BARRINGTON 405 LAKE ZURICH ROAD, BARRINGTON, IL, 60010
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0651      
25996 . A. Based on staff interviews, review of Governing Body meeting minutes, State of Illinois - IDPH licensure application and the organizational chart, it was determined the Hospice failed to ensure the Governing Body approved the appointment of the Hospice Administrator, updates were made to the licensure application and that the organizational chart was clear and accurate. This has the potential to affect all patients receiving hospice care services. Findings include: 1. During an interview with the Senior Compliance Director and the Vice President of Hospice on 9/9/20 at 3:00 PM, the Senior Compliance Director stated that E #1 was hired as the Administrator on 7/5/20. During an interview with E #1 on 9/9/20 at 3:20 PM, E #1 stated she was hired in "July 2020", and that the role of the Administrator include: "In charge of clinical operations, all field teams report to me, I oversee pediatrics and 2 care centers (inpatient facilities)". 2. An interview was conducted with the Team Manager for the Birch Team (RN) on 9/10/20 at 10:20 AM, that stated she reports to E #1 who is the Administrator. An interview was conducted with the Team Manager for the Cedar Team (RN) on 9/10/20 at 10:32 AM, that stated she reports to E #1 who is the Administrator. 3. The Governing Body (Board of Directors) meeting minutes dated 8/20/20 were reviewed on 9/9/20 at 11:58 AM, and lacked documentation the Governing Body approved E #1 as the Hospice Administrator. No other Governing Body meetings were conducted after E # 1's hire date of 7/5/20. 4. On 9/9/20 at 11:00 AM, the State of Illinois - IDPH licensure application was reviewed and indicated the application was last updated on 6/30/20. The application contained E #5 as the Hospice Administrator. During an interview with the Senior Compliance Director and the Vice President of Hospice on 9/10/20 at 1:30 PM, both stated there were no other updates made to the application since 6/30/20 to include E #1, as the new Administrator. 5. The Hospice's 7 page organizational chart effective 7/5/20 was reviewed on 9/9/20 at 1:00 PM. Page 1 of the chart contained documentation the 2 APNs report only to the Vice President of Hospice. Pages 2 through 7 contained documentation the 2 APNs report directly to the Vice President of Hospice and indirectly to the Medical Director. The organization charts contained conflicting documentation as to who the APNs report. 6. During an interview with E #14 on 9/9/20 at 2:34 PM. E #14 stated her manager is E #15, but clinically she reports to E #16 (Team Physician) and E #4 who is the Medical Director for this Hospice. E #14 stated if there is an issue with a patient, this is communicated to the Team Managers for that perspective team. 7. During an interview with the Vice President of Hospice and the Senior Compliance Director on 9/10/20 at 1:30 PM, the Senior Compliance Director confirmed the Governing Body failed to approve the appointment of E #1 as the Administrator, update the IDPH licensure application indicating E #1 as the new Hospice Administrator, and ensure the organizational chart was clear and accurate.
L0664      
25996 A. Based on a review of clinical records and staff interview, it was determined the Hospice failed to ensure that the Medical Director initiated a new certification for patients that had a new election for Hospice ; and failed to ensure that the Medical Director or the Designated Alternate review and complete the recertification. This has the potential to affect all patients that received care from teams not directly managed by the Medical Director. Findings Include: 1. In 2 of 2 clinical records, the Hospice failed to ensure that the Medical Director initiated a new certification for patients that had a new election for Hospice (L667). 2. In 1 of 1 clinical records, the Hospice failed to ensure that the Medical Director or the Designated Alternate review and complete the recertification (L668). The cumulative effect of the above practices resulted in the Hospice's inability to ensure that the Medical Director's supervision was implemented.
L0667      
25996 . A. Based on a review of clinical records and staff interview, it was determined the Hospice failed to ensure that the Medical Director initiated a new certification for patients that had a new election for Hospice. This was found in 2 of 2 (Pt. #1 and 4) clinical records reviewed, wherein the patient was assigned to a team that was not directly managed by the Medical Director. Findings include: 1. Pt. #1. SOC 8/5/20. Hospice Diagnosis: Alzheimer's Disease. The clinical record was reviewed on 9/9/20 at 2:00 PM. The record contained a Clinical Note dated 7/30/20 completed by the SW which included: "SW spoke with pt's dtr...regarding upcoming internal transfer of pt..." The record contained: "Election of Medicare/ Medicaid Hospice Benefit" and the "Informed Consent Agreement" signed by the patient's family member and dated 8/4/20; the "Team Care Plan" with the admission date of 8/5/20; Initial Visits conducted by a Registered Nurse and SW dated 8/5/20, and a Spiritual Initial Visit conducted by a Chaplain and dated 8/25/20. The record also contained, the certification for hospice with the benefit period of 7/27/20 to 9/24/20 and signed by E #8 ( Team Physician). The record lacked documentation the Medical Director or Team Physician initiated a new certification effective the SOC/admit date of 8/5/20. 2. Pt. #4. SOC 5/11/20. Hospice Diagnosis: Acute on Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure. The clinical record was reviewed on 9/14/20 at 4:00 PM. The record contained the initial certification for Hospice signed by a Hospice Team Physician (E #19) and dated 5/14/20. 3. During an interview with the Vice President of Hospice and the Senior Compliance Director on 9/10/20 at 3:30 PM, the Senior Compliance Director confirmed the Hospice Medical Director or Team Physician did not initiate a new certification for Hospice effective 8/5/20.
L0668      
25996 . A. Based on clinical record review and staff interview, it was determined the Hospice failed to ensure that the Medical Director or the Designated Alternate review and complete the recertification. This was found in 1 of 1 (Pt. #4) clinical record reviewed of patients recertified by the Hospice. This has the potential to affect all patients of teams that are not directly managed by the Medical Director. Findings include: 1. Pt. #4. SOC 5/11/20. Hospice Diagnosis: Acute on Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure. The clinical record was reviewed on 9/14/20 at 4:00 PM. The recertification for Hospice was signed by a different Team Physician (E #20) and dated 8/6/20. The record lacked documentation that the Medical Director or the Medical Director's designated alternate conducted the recertification for Pt. #4.. 2. During the entrance interview with the Vice President of Hospice and the Senior Compliance Director on 9/9/20 at 10:20 AM, both stated each Hospice Team have their own Hospice Team Physician(s) that conduct the recertifications for their perspective teams. 3. During an interview with the Vice President of Hospice and the Senior Compliance Director on 9/10/20 at 3:30 PM, both confirmed the above findings.