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
141591 A. BUILDING __________
B. WING ______________ 		03/23/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
PALOS COMMUNITY HOSPITAL HOSPICE 15295 E 127TH STREET, LEMONT, IL, 60439
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)
L0692      
44221 A. Based on Clinical Records Review and Staff interviews, it was determined the hospice failed to ensure consent was obtained for all people administering medications and providing wound care for the patient in the home. Thereby the interdisciplinary group failed to ascertain drugs and biologicals were administered to the patient safely. This was found in 1 of 5 records (Pt. #2) reviewed. Findings include: 1. Pt. # 2 SOC 10/06/2021 Primary Diagnosis: Alzheimer's Disease The clinical record was reviewed on 03/23/2022 between 11:00 AM and 11:45 AM. The Record included a consent titled, "Notice of Hospice Election Statement." The consent documented, " ...I designate ..." Pt's daughter, " ...as my primary caregiver. This role will name the person mainly responsible for overseeing my care in my place of residence ... I hereby authorize PH to release verbal medical information to my designated caregiver and to my family and friends as follows: ..." Pt's significant other and daughter are listed. The consent form does not include any additional caregivers as authorized persons. The clinical record contained an SN note dated, 10/08/2021. The SN note documented, " ...Clinical Note ... pt ... accompanied by ..." name of caregiver agency, " ...CG and girlfriend ... (Dulcolax suppository given earlier by CG) ... Who manages medications? Other (specify): CG and girlfriend ..." SN note dated 10/09/2021 documented, " ...Clinical Note ...SO ... and caregiver present ... coccyx dressing changed educated ... CG on dressing changes ..." SN note dated 10/13/2021 documented, "Clinical Note ... visit conducted with pt hired CG and wife ... present ... educated CG on dressing changes ... Who Manages Medication? Other (specify) ..." SN note dated 11/01/2021 documented, " ...weekly hospice visit conducted with pt ... SO ... and CG ... present ... reviewed wound care with ... CG ..." SN note dated 01/21/22 documented, " ... RN provided instruction to CGs to increase morphine dose to 10 mg, and every 2 hours ..." While reviewing clinical records with the Hospice Charge Nurse, she confirmed there is no documentation in Pt. #2's clinical record that includes the caregiver as an authorized person to receive medical information from the hospice. 2. During an interview with E #1 at 12:50 PM, she stated that she becomes aware of who is designated to care for patients during, "our elections, our MSW or chaplain usually completes the election consent, it's [the authorized person(s)] listed on the election consent form." She also stated, "In the event there is a hired caregiver, it is on the form as well." She stated that detailed instruction is given to the person who primarily cares for the patient, however other family members may be there during instruction as well. 3. During an interview with E #2 at 1:00 PM, she stated, "If the patient has a 24-hour caregiver, they are educated along with the POA." She also stated the caregiver is "not usually," on the list of people authorized, "it's stated by the family they want the caregiver to provide care." 4. During an interview with the Clinical Nurse Leader at 4:25 PM, she stated, "If we are notified the live-in caregiver will be providing care for the patient, they would be listed on the notice of election consent." She also stated, "Education should be provided to the authorized people listed on the consent. Sometimes others are present during that time, but we are primarily educating the appointed person." 5. During interviews with the Administrator and Clinical Nurse Lead between 12:00 PM and 4:30 PM. The above findings were confirmed.