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
151583 A. BUILDING __________
B. WING ______________ 		01/05/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
UNITY HOSPICE OF NORTHWEST INDIANA LLC 3313 EAST 83RD PLACE, MERRILLVILLE, IN, 46410
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      
41135 Based on record review and interview, the agency failed to ensure licenses for registered nurses (RN) were current and active in the state of Indiana in 3 of 7 active personnel records reviewed. (A, D, E) The findings include: 1. Review of an agency policy obtained 1/5/2022, and updated January 2014, titled "Personnel Record Contents" stated, "... Unity Hospice will maintain accurate and complete personnel files on all personnel. ... The content of the personnel files for full time personnel will include: ... Verified Professional Licenses ...." 2. Review of an agency policy obtained 1/5/2022, and updated January 2014, titled "Licensure/Certification/Registration" stated, "... All organization personnel must maintain and show proof of licensure/certification/registration as appropriate. ... Personnel must comply with requirements to maintain such licensure/certification/registration in accordance with applicable state law and regulation. A current copy of or other proof of licensure, certification, and/or registration will be kept in the personnel file." 3. Personnel record review on 1/5/2022, for RN A, date of hire 3/5/2020, evidenced a document identified by the Director of Human Resources to be the Indiana RN license verification. This document indicated the RN license expired 10/31/2021. No other document was provided to indicate the RN license was active. During an interview on 1/5/2022 at 11:33 AM, the Director of Human Resources indicated RN A accidentally marked he was not a United States citizen on his license renewal. When queried about what was the status of his license currently, the Director of Human Resources indicated he would go check. Review of a document provided by the Director of Human Resources on 1/5/2022 at 11:53 AM titled "Search Results" indicated the RN license for RN A was expired. During an interview on 1/5/2022 at 11:53 AM, the Director of Human Resources indicated there was no current license verification in the personnel record for RN A. The Director of Human Resources indicated he knew the license was pending and indicated he thought that maybe due to Covid the license renewal was "taking awhile." During an interview on 1/5/2022 at 12:18 PM, RN A indicated he was not aware his license was not renewed and the status was expired until today. 4. Personnel record review on 1/5/2022, for RN D, date of hire 12/7/2020, evidenced a document identified by the Director of Human Resources to be the Indiana RN license verification. This document indicated the RN license expired 10/31/2021. During an interview on 1/5/2022 at 12:36 PM, the Director of Human Resources indicated the RN's license renewal was on hold related to a "hold-up" during the time of renewal. The Director of Human Resources indicated he did not verify her license after expiration in October 2021 and print it for the personnel record. At 12:58 PM, the Director Human Resources indicated the agency was aware the RN had difficulty with her license renewal and indicated the RN license was not verified before today. 5. Personnel record review on 1/5/2022, for RN E, date of hire 1/30/2021, evidenced a document from entity A titled "Lookup Detail View" which evidenced the RN had an active RN license in the state of Illinois. Review failed to evidence the RN had an active license in the state of Indiana. During an interview on 1/5/2022 at 12:08 PM, the Director of Human Resources indicated he believed RN E had a compact nursing license. When queried if there was an Indiana license verification for RN E, the Director of Human Resources indicated no and indicated he "would go look it up." 6. During an interview on 1/5/2022 at 10:47 AM, the Director of Human Resources indicated he verified the licenses for nurses as they expired to ensure licenses were renewed and indicated the personnel file should contain verification of licensure.