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
141696 A. BUILDING __________
B. WING ______________ 		03/31/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
SUNCREST HOSPICE ILLINOIS LLC 5 REVERE DR, STE 130, NORTHBROOK, IL, 60062
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)
L0549      
25996 . A. Based on a review of the complaint log, clinical record review, Hospice policies and staff interview, it was determined the Hospice failed to ensure medication was delivered promptly, and administered appropriately. This was found in 2 of 3 (Pts. #1 and 3) clinical records reviewed. Findings include: 1. The Hospice's complaint log for 2021 was reviewed on 3/31/22 at 10:50 AM and record contained the complaint log for 2021 which included an investigation concerning Pt. #1. The Pt. did not receive pain medication in a timely manner. 2. Pt. #1. SOC 10/20/21. Hospice Diagnosis: Malignant Neoplasm of the Prostate. The clinical record was reviewed on 3/31/22 at 1:00 PM. The clinical record contained a Physician order received on 11/4/21 (8:09 AM) for the Pt. to receive the medication "Pyridium" for inability to urinate, pain and burning. The RN visit note (4:00 PM) included: "Patient remains in terrible pain ..." The medication was delayed, scheduled to arrive at 6:00 PM. The SN visit note dated 1/4/22 (4:00 PM) contained documentation the RN had to obtain an emergency supply of the medication, deliver to the Pt./caregiver. 3. Pt. #3. SOC 12/14/21. Hospice Diagnosis: Senile Degeneration of Brain Not Elsewhere Classified. The clinical record was reviewed on 3/31/22 at 1:00 PM. The record contained the RN visit note dated 12/20/21 which included documentation the patient's POA contacted the patient's neurologist concerning the Pt. receiving Lorazepam, and the POA requested not to use Lorazepam. The RN visit note dated 1/3/22 included the Pt. received Lorazepam twice with little or no relief. The Hospice Physician was contacted and the dose was increased to 2 milligrams every 2 hours as needed. The RN visit note dated 1/4/22 included the Pt. was very agitated and not responding to the increased dose of Lorazepam. 4. The Interdisciplinary Group Meeting minutes dated 12/23/21 contained: "use of lorazepam- per spouse prefer not to use lorazepam due to patient reacting to it very strongly and taking several days to recover." The Interdisciplinary Group Meeting minutes dated 1/6/22 lacked documentation that the POA requested not to give the Pt. Lorazepam, but included, " ...severe agitation treated with PRN lorazepam and morphine." The Hospice failed to discontinue the Lorazepam, as requested by the POA. 5. The policy titled, "Bill of Rights" was reviewed on 3/31/22 at 2:15 PM and included: " ...A patient, who has not been judged to lack legal capacity, may designate someone (surrogate decision maker), to act as his/her representative. This representative, on behalf of the patient may exercise any of rights provided ... F. Refuse care or treatment. 6. During an interview with the Director of Clinical Services and the Office Manager on 3/31/22 at 3:15 PM, the Director of Clinical Services stated the pharmacy was supposed to deliver the medication to Pt. #1 during the "noon run (12:00 PM to 2:00 PM)", but the medication was delivered on the evening run (scheduled to arrive at 6:00 PM). During the same interview the Director of Clinical Services confirmed the Hospice failed to ensure medication was delivered promptly, and administered appropriately.
L0551      
25996 . A. Based on a clinical record review, Hospice policies and staff interview, it was determined the Hospice failed to document the POA's disagreement with the POC, as required by the Hospice's policy. This was found in 1 of 3 (Pt. #3) clinical records reviewed. Findings include: 1. Pt. #3. SOC 12/14/21. Hospice Diagnosis: Senile Degeneration of Brain Not Elsewhere Classified. The clinical record was reviewed on 3/31/22 at 1:00 PM. The record contained the "Discharge Summary" completed by a RN and dated 1/31/22. The Summary contained, "Discussion with ... (POA) who expressed that she had concerns patient has been over medicated ..." As of 3/31/22, the complaint log for 2022 lacked documentation, investigation and resolution of this concern/complaint. 2. The hospice policy titled, "Complaint/Grievance Process" was reviewed on 3/31/22 at 2:15 PM and included: " ...Any difference of opinion, dispute or controversy between a patient or family/caregiver or patient representative and ... Hospice concerning any aspect of services ... will be considered a grievance ... Procedure ... 4. Complaints and any action taken will be documented on a complaint form ..." 3. The hospice policy titled, "Bill of Rights" was reviewed on 3/31/22 at 2:30 PM and included: "1. The Bill of Rights statement defines the right of the patient to ...Q. Receive an investigation by ... Hospice of complaints made by the patient or the patient's family or guardian regarding treatment or care that is (or fails to be) furnished... and that... Hospice will document the existence of the complaint and the resolution of the complaint. 4. During an interview with the Director of Clinical Services and the Office Manager on 3/31/22 at 3:15 PM, the Director of Clinical Services confirmed the Hospice failed to document the POA's disagreement with the POC, as required by the Hospice's policy.
L0552      
25996 . A. Based on review of a clinical record, Interdisciplinary Group meeting minutes, Agency policy and staff interview, it was determined that the Interdisciplinary Group failed to review the POC as frequently as patient's condition required. This was found in 1 of 3 (Pt. #3) clinical records reviewed. Findings include: 1. Pt. #3. SOC 12/14/21. Hospice Diagnosis: Senile Degeneration of Brain Not Elsewhere Classified. The clinical record was reviewed on 3/31/22 at 1:00 PM. The record contained the RN visit note dated 1/29/22 which included documentation the Pt. yelled and screamed loudly for duration of the RN visit. The POA was convinced the Pt. was being over-medicated, and that the Hospice RN "agreed that a "medication evaluation by MD(s) would be warranted and will take place early next week. However, nurse pointed out that clearly ... is suffering right now ... 5 mg Roxanol given ..." The RN failed to notify the hospice Medical Director immediately that a medication evaluation was needed for this Pt. 2. The Interdisciplinary Group meeting minutes dated 1/6/22 included documentation of the patient's falls on 12/28/21, 1/15/22 and 1/20/22 with injury; and ongoing issues with pain, agitation and anxiousness of Pt. #3. Based on the skilled nursing assessments, the Interdisciplinary Group failed to meet the patient's needs, re-evaluate the level of care provided to this Pt., considering inpatient care for diagnostic testing and/or symptom management. 3. The hospice policy titled, "Comprehensive Assessment" was reviewed on 3/31/22 at 1:20 PM and contained: " ...5. The comprehensive assessment is updated by the interdisciplinary group as frequently as the patient's condition requires..." 4. The hospice policy titled, "Interdisciplinary Group Coordination of Care" was reviewed on 3/31/22 at 1:30 PM and contained: The type and scope of services provided by the interdisciplinary group will be based upon comprehensive and ongoing assessments regarding the needs of the patient ... The exact combination of services and the level of care will be unique to each patient ... and will change as the needs of the patient and family/caregiver evolve over the course of their involvement with hospice. 5. The hospice's policy titled, "Monitoring Patient's Response/Reporting to Physician" was reviewed on 3/31/22 at 1:45 PM and included: " ...3. The patient's physician and/or the hospice Medical Director will be contacted on the same day when any of the following occur, or as applicable .... E. Changes in the patient's expected response to hospice care or medications ..." 6. During an interview with the Director of Clinical Services and the Office Manager on 3/31/22 at 3:15 PM, the Director of Clinical Services confirmed the Hospice failed to review Pt. #1's POC, as frequently as patient's condition required.
L0557      
25996 A. Based on a clinical record review, Interdisciplinary Group meeting minutes, Agency policy and staff interview, it was determined the Hospice failed ensure effective correspondence between disciplines was conducted, information communicated to others and contained in the clinical record was accurate. This was found in 1 of 3 (Pt. #3) clinical records reviewed. Findings include: 1. Pt. #3. SOC 12/14/21. Hospice Diagnosis: Senile Degeneration of Brain Not Elsewhere Classified. The clinical record was reviewed on 3/31/22 at 1:00 PM. The record contained the Hospice RN visit note dated 1/11/22 which included the FN reported earlier that morning, the Pt. was given Haldol due to screaming. Pt. also received Morphine and Lorazepam PRN. The RN visit note also included the Hospice RN spoke with the Primary Care Physician's Nurse Practitioner and requested a medication review. The clinical record lacked documentation of whether a medication review was conducted and if so, the outcome of the review. The record included the Hospice's Discharge Summary completed by a RN and dated 1/31/22. The Summary included documentation the POA had concerns of the Pt. being over medicated. The POA revoked hospice and had the Pt. sent to the hospital. The same Discharge Summary included documentation the patient's discharge condition was "stable" and the reason for the hospice discharge was the Pt. had " Moved Outside Service Area". The clinical record was inaccurate and lacked documentation the Pt. was unstable, and reason for discharge was that hospice was revoked and Pt. was sent to the hospital. 2. The hospice's policy titled, "Interdisciplinary Group Coordination of Care" contained: " ...6. Written evidence of care coordination will be found ...in the patient's clinical record, and will involve the hospice patient's attending physician." 3. The hospice policy titled, "Clinical/Service Data Collection" was reviewed and included: " ...Documentation in the clinical/service record will be ...accurate ...3. Entries into the clinical/service record will be ... concise, and specific statements of fact ..." 4. During an interview with the Director of Clinical Services and the Office Manager on 3/31/22 at 3:15 PM, the Director of Clinical Services confirmed the above findings.