Public Disclosure Statement of Northern Illinois Hospice

Date Issued: February 1, 2024

Northern Illinois Hospice is a nonprofit 501(c)(3) professional medical organization. We are committed to meeting quality and safety standards when providing care for our patients and families. Northern Illinois Hospice will annually complete a written public disclosure statement, signed by the Chief Executive Officer.

Upon request, the following information will be made available to the patients of Northern Illinois Hospice, or the public:

a.   Names and addresses of individuals or corporations having a combined direct or indirect ownership or controlling interest of 5% or more in Northern Illinois Hospice;

b.   Names and addresses of subcontractors in which Hospice has a direct or indirect ownership or 5% or more;

c.   Names and addresses of individuals who are related as spouse, parent, child, or sibling to individuals described in the 2 above bullets;

d.   Names and addresses of individuals in the above 3 bullets with an ownership or controlling interest in a Medicare or Medicaid facility;

e.   Names and addresses of officers, directors, or partners if Northern Illinois Hospice is a corporation or partnership;

f.    The circumstances of any criminal offense conviction involving Medicare, Medicaid, or Title XX programs on the part of any person(s) or organization(s) in the above first 3 bullets and/or on the part of any agent or managing employee of Northern Illinois Hospice;

g.   Names and addresses of any current employees in managerial, accounting, auditing or similar capacity who were employed by the organization’s fiscal intermediary during the past twelve (12) months;

h.   Changes in the Chief Executive Officer, Directors, and/or Medical Director during the past twelve (12) months;

i.     The dates of any change in ownership or control during the past twelve (12) months;

j.     The dates of anticipated changes in ownership or control in the next twelve (12) months;

k.   The dates of anticipated bankruptcy filings;

l.     The dates of operational changes by a management company;

m.  The dates of leasing arrangements in whole or in part by another organization; and

n.   The dates of changes in address for the parent or branches.

This information will be disclosed:

1. To the state survey agency at the time of the organization’s initial request for certification;
2. For each subsequent survey by the state agency; and
3. At the time of any change in ownership or management.