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
141539 A. BUILDING __________
B. WING ______________ 		09/10/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
LIGHTWAYS HOSPICE AND SERIOUS ILLNESS CARE 250 WATER STONE CIRCLE, JOLIET, IL, 60431
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)
L0579      
37373 . Based on observations, Hospice policy review, Agency document review and staff interview, it was determined that the Hospice facility failed to ensure staff followed infection control measures. Findings include: 1. Upon arrival to Hospice facility on 09/10/2021 at 9:00 AM Surveyor was not fully screened for COVID-19 before entering facility. 2. During the entrance interview on 09/10/2021 at 9:20 AM with the Inpatient Unit (IPU) Manager. The IPU Manager stated that Hospice practice is that prior to entering the facility - staff, visitors and volunteers are screened for COVID-19 by the facility receptionist. The screening includes taking a temperature check with surveillance camera and reception staff asks screening questions as recommended by IDPH/CDC. 3. On 09/10/2021 a document with the list of Hospice staff with a positive COVID-19 test results was reviewed. The document contained 6 staff members with a positive COVID-19 test results in the month of August 2021. Employee #1 (positive - 08/17/2021) and Employee #2 (positive - 08/13/2021) were IPU staff. Employees #3 (positive - 08/10/21) #4 (positive 08/17/21), #5 (positive 08/19/21) and #6 positive 08/09/21) were Field staff. 4. Hospice policy titled "Infectious Disease Outbreak Policy" was reviewed on 09/10/2021 at 11:00 AM the policy required...IPU..."Outbreak Guidance - The first round of testing will be done as soon as an outbreak is detected. All previous negative patients and staff will be tested 3-7 days after the first round of testing and continue to test every 3-7 days until no new positive are identified for 14 days". 5. During an interview with the Infection Control nurse on 09/10/2021 at 1:30 PM. The Infection control stated that Hospice IPU did not conduct any patient / staff testing after positive Covid test. 5. Document titled "Response to Positive COVID test" was reviewed on 09/10/2021. The document required that if a Field Staff has a positive test - "Triage:....Patients and their families must be notified that a member of their hospice team has tested positive for COVID and to monitor themselves for COVID symptoms for 14 days and recommend a 14- day quarantine". 6. During an interview the Director of Clinical Services, the Director stated that per Hospice practice and policy - after a field staff has a positive test, the Hospice traces back 2 days prior to positive date and notifies patients / staff and facilities that staff member was in contact. The Director stated that Hospice has no log or document indicating notifications. 7. During interviews with the Inpatient Unit Manger, Director of Clinical Services and Infection Control Nurse on 09/10/2021 between 9:20 AM and 3:00 PM findings of Hospice staff failing to screen surveyor upon entry to facility, Agency not following Hospice policy for wide testing for IPU patient and staff. Agency failing to notify patients and facilities after staff positive COVID -19 positive test were confirmed.