Survey Report for 141560

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
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	141560	A. BUILDING __________ B. WING ______________	05/24/2022
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
FHN HOSPICE	773 WEST LINCOLN BLVD STE 403, FREEPORT, IL, 61032
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)
L0784
L0784	38794 A. Based on personnel file review, the Illinois Administrative Code review and Staff interviews, it was determined that the Agency failed to ensure social services staff were licensed as per Illinois Administrative Code Title 77, part 280 Hospice Programs. This was found in 3 of 4 (Employees #2, 3 and 4) Social Services staff. Findings include: 1. On 05/24/2022 at 11:36 AM, the personnel files were reviewed with Human resources staff. Employee #2 (Medical Social Worker/BSW/ DOH 08/10/1992) Employee #3 (Medical Social Worker/MSW/ DOH 01/09/2017) Employee #4 (Medical Social Worker/BSW/ DOH 12/04/2000) Employees #2, 3 and 4 did not have a license as a Clinical Social Worker per State requirement. 2. On 05/24/2022 at 11:45 AM, review of Illinois Administrative Code Title 77, part 280 Hospice Programs; Section 280.2040 Personnel Policies contained: "d) Where applicable, every hospice program employee must be licensed, certified, or registered in accordance with federal, State and local laws. (Section 8(n) of the Act)." 3. On 05/24/2022 at 3:00 PM, an interview was conducted with Administrator, who confirmed that Employees #2, 3 and 4 do not have a Social Worker license.