Dover Hospice Il Chicago Metro, LLC

“It is required that each patient’s individualized written plan of care reflects patient and family goals and includes measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. In 6 of 14 (43%) clinical records reviewed it was revealed that the agency did not ensure that the agency included patient directed, specific, measurable goals related to the treatment of identified areas of concern in the patient’s assessment. Agency Policy: The hospice policy titled, Interdisciplinary Group (IDG) Care Planning Process (9.12.1), revised January 2020, included in part, “Hospice will utilize data/information gathered during the comprehensive assessment, updates...and reassessments in the care planning process to provide care that is consistent with the patient and family needs, with patient’s needs and goals as a priority.” CLINICAL RECORD 1: During the Registered Nurse (RN) visit on 12/02/2025, the patient experienced shortness of breath (SOB) with minimal exertion, fatigued easily during movement and transfers, remained in bed for most of the day, and required continuous oxygen at 3 liters per minute (LPM) via nasal cannula (NC). The physician’s certification of terminal illness for the benefit period from 12/29/2025 to 02/26/2026 identified a terminal diagnosis of malignant neoplasm of the lung, with a comorbid history of ongoing pleural effusion requiring the placement of a PleurX drain to manage respiratory symptoms. The patient was documented as dependent in 6/6 activities of daily living (ADLs) due to severe fatigue and SOB, and the medication profile included continuous oxygen 2–6 LPM via NC, Duoneb every 4 hours as needed for SOB, and Morphine 20 mg/mL, 0.5 mL every 4 hours PRN for pain or dyspnea. Review of the Plans of Care (POCs) for the benefit periods 10/30/2025 to 12/28/2025 and 12/29/2025 to 02/26/2026 confirmed identification of the problem of impaired gas exchange; however, the associated goals were limited to general statements such as participating in breathing treatment regimens, verbalizing understanding of dyspnea triggers, implementing interventions, noting SOB at rest, and monitoring the presence of the PleurX drain. The record contained no patient-specific, measurable goals that defined an expected outcome or improvement target related to the patient’s SOB or respiratory status. CLINICAL RECORD 4: The patient was admitted on 12/04/2025 with the terminal diagnosis of vascular dementia with agitation. The physician’s certification of terminal illness for the benefit period from 02/02/2026 to 04/02/2026 documented that the patient exhibited significant neuropsychiatric symptoms, including frequent crying, agitation, and aggressive behaviors such as hitting and spitting, despite ongoing treatment with Escitalopram and Donepezil. The patient’s scheduled medication regimen also included Mirtazapine for depression, Escitalopram for depression/anxiety, Donepezil for memory loss/confusion, and Haloperidol for agitation. Review of the Plans of Care (POCs) for the benefit periods 12/04/2025 to 02/01/2026 and 02/02/2026 to 04/02/2026 confirmed the identification of multiple problems—altered mental function related to dementia and confusion, anxiety, and depression. However, no corresponding interventions or patient-specific, measurable goals addressing these identified problems were documented. CLINICAL RECORD 6: The patient, who resided at an assisted living facility (ALF), elected the hospice benefit on 1/06/2025 with the terminal diagnosis of senile degeneration of the brain with comorbid conditions of dementia with behaviors, anxiety disorder, and delusional disorder. The physician’s certification of terminal illness for the benefit period from 01/01/2026 to 03/01/2026 noted the patient with end-stage dementia and a FAST of 7D and exhibited frequent confusion and agitation. The patient had bilateral upper extremity contractures and had documented pain of 4-5/10. The patient was also on continuous Oxygen 2-6 liters per minute by nasal cannula for shortness of breath with minimal exertion. The patient’s medication profile included Lorazepam 2mg/mL (1mg four times a day and every 2 hours as needed - PRN for anxiety and Morphine 20mg/mL (10 mg daily and every 4 hours PRN for pain). The patient’s plans of care for the benefit periods from 11/02/2025 to 12/31/2025 and 01/01/2026 to 03/01/2026 identified altered mental function, confusion, and anxiety with the goals documented for the family, caregiver, and Interdisciplinary Team (IDT) to identify contributing factors related to altered mental functioning, provide safety measures to prevent injuries, reorient the patient to person, place, time, and event. There was no identified patient-specific measurable goal for the treatment of the patient’s agitation. Pain was not identified as a problem for the patient and therefore no goal documented. Impaired gas exchange and dyspnea was identified as a problem for the patient with the goal to participate in breathing treatments and verbalize an understanding of the causative factors of dyspnea and appropriate interventions was set for the family, caregiver, and IDT. There was no patient-focused measurable goal identified for the treatment of the patient’s shortness of breath. CLINICAL RECORD 7: The patient, who resided in a nursing facility, elected the hospice benefit on 03/14/2023 with the terminal diagnosis of senile degeneration of the brain and comorbid conditions of dementia with behaviors and polyarthritis. The physician’s certification of terminal illness for the benefit period from 12/28/2025 to 02/25/2026 noted the patient was alert and oriented to person only, confused and required Lorazepam twice daily for behaviors and Morphine three times a day for pain. Additionally, also documented was that the patient was short of breath with minimal exertion. The patient had orders for Oxygen 2-6 liters per minute by nasal cannula for shortness of breath. The patient’s plan of care for the same benefit period included the identified problems of altered mental status, confusion, and dementia. The documented goals were set for the family, caregiver, and Interdisciplinary Team (IDT) and were to provide safety measures to prevent injuries and to reorient to person, place, time and event. There was no identified measurable patient-goal for the treatment of confusion, anxiety, and behaviors with Lorazepam. Additionally, there was the problem of impaired gas exchange and dyspnea with the goal for the patient to participate in breathing treatments, but no noted outcome goal for the treatment of the patient’s shortness of breath. CLINICAL RECORD 9: During the Registered Nurse’s (RN) start of care visit on 12/08/2025, the patient was experiencing aching shoulder pain. The physician’s certification of terminal illness for the benefit period from 12/08/2025 to 03/07/2025 also documented that the patient continued to experience aching pain. The patient’s medication regimen included Acetaminophen 625 mg every 4 hours PRN for pain and Celecoxib 200 mg daily; an anti-inflammatory prescribed for ongoing pain management. However, review of the patient’s Plan of Care (POC) for the same benefit period confirmed that pain was not identified as a problem, and there were no patient-specific, measurable goals established to address the patient’s reported pain or guide the effectiveness of the pain management interventions. CLINICAL RECORD 14: The patient elected the hospice benefit on 04/15/2025 with the terminal diagnosis of senile degeneration of the brain and the comorbid condition of anxiety disorder. On 04/15/2025, the Registered Nurse (RN) documented that the patient reported pain rated 8/10 in the right lower quadrant, mid-abdomen, and bilateral lower extremities, with the worst pain reaching 10/10; however, the acceptable pain level field was left blank. During an RN visit on 06/30/2025, the patient was documented as moaning constantly, with pain rated 4/10, described as generalized and achy, and managed with Morphine. The RN documented an acceptable pain goal of 0/10. The patient’s medication list included Acetaminophen 1000 mg twice daily for pain, Gabapentin 100 mg twice daily for pain, and Morphine 20 mg/mL PRN for pain. RN visits on 06/23/2025 and 06/30/2025 also documented ongoing restlessness, and the medication profile included Ativan 2 mg/mL (0.5 mL every 4 hours PRN for anxiety/restlessness). Review of the Plan of Care (POC) for the benefit period from 04/15/2025 to 07/13/2025 showed that pain/discomfort was identified as a problem; however, the only goal established was for the family, caregiver, and Interdisciplinary Team (IDT) to understand pain management, with success measured by reporting pain at or below the patient’s acceptable level. The POC and IDT updates contained no documentation of the patient’s acceptable pain score, despite repeated RN assessments of pain. Anxiety was also identified as a problem, but the only goal documented was for the family, caregiver, and IDT to demonstrate effective coping strategies to decrease the patient’s anxiety, as evidenced by encouraging engagement in social activities. No patient-specific, measurable goals were documented to address the patient’s pain, restlessness, or anxiety symptoms. The patient died on hospice services on 07/11/2025. During ongoing joint clinical record reviews and interviews with the Director of Clinical Services (DCS) (Personnel Record 3) on 02/10/2026, 02/11/2026, and 02/12/2026. The DCS, who has been in the role since 01/26/2026, acknowledged during the discussions that the goals documented in the reviewed plans of care were largely not patient-directed and did not correspond to the symptoms for which the patients were receiving interventions. The DCS further agreed that the absence of patient-specific, measurable goals made it difficult to evaluate progress toward those goals and to determine the effectiveness and success of the implemented interventions.”

“It is required that all hospice aide services must be provided by an individual who has successfully completed a competency evaluation that addresses each of the following subject areas evaluated by observation of an aide’s performance with a patient or pseudo-patient, including: communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; reading and recording temperature, pulse, and respiration; appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: bed bath; sponge, tub, and shower bath; hair shampoo (sink, tub, and bed); nail and skin care; oral hygiene; toileting and elimination; safe transfer techniques and ambulation; and normal range of motion and positioning. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 1 (100%) hospice aide’s personnel record reviewed revealed that the agency did not ensure that a Registered Nurse (RN) observed all required hands-on tasks with a patient every 12 months to verify the HA’s competence. Agency Policy: The agency policy, “Staff Competency Program” (no number or date), stated “...Hospice Aides will be competency assessed by an RN at least annually (every 12 months) onsite where the patient is receiving care...” PERSONNEL RECORD 7: A personnel file review of the hospice aid hired 02/01/2021, included a full, complete HA Competency Assessment Skills Checklist with all required skills observed by a Registered Nurse (RN) with a patient completed on 10/07/2025. The annual “competency forms” for 2023 and 2024 only included a bed bath one year and a shower chair the other year with “vital signs” listed as competent. None of the other required skills were demonstrated or included on the form: other baths, shampoo, peri care, transfer/position of patient, etc. During a joint personnel record review and interview with the Executive Director (ED) (Personnel Record 2) and the Director of Clinical Services (DCS) (Personnel Record 3) on 02/12/2026, both individuals reviewed the documentation and confirmed its accuracy. The ED acknowledged that the agency needed to “work on their personnel records,” indicating awareness of gaps in required documentation and the need to strengthen processes. The DCS, who was newly hired on 01/26/2026, also concurred with the identified deficiencies during the review.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 12 (8%) clinical records reviewed it was revealed that the hospice aide did not notify the Registered Nurse (RN) of vital signs outside of the documented parameters on the plan of care. CLINICAL RECORD 10: The patient’s plan of care (POC) for the benefit period from 11/25/2025 to 02/22/2026 included orders for the hospice aide to provide care three times weekly. The hospice aide plan of care dated 11/25/2025 included a specific intervention requiring the hospice aide to document the patient’s vital signs at each visit and to report to the Registered Nurse (RN) any oxygen saturation reading less than 90% on room air or while on supplemental oxygen. During the hospice aide visit on 01/21/2026, the hospice aide documented an oxygen saturation of 84%. There was no documented evidence that the RN was notified of the oxygen saturation less than the parameters established by the physician. During a joint clinical record review and interview with the Director of Clinical Services (DCS) (Personnel Record 3) on 02/12/2026, the DCS reviewed the aide documentation for 01/21/2026 and confirmed that the oxygen saturation of 84% met the POC threshold requiring immediate RN notification. The DCS further verified that the record contained no evidence of RN notification, including no Interdisciplinary/IDG note, or any communication note documenting communication of the low oxygen saturation reading.”

“It is required that the hospice maintains, documents, and provides hospice volunteer orientation and training that is consistent with hospice industry standards. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 1 (100%) volunteer personnel records reviewed it was revealed that the agency did not ensure that there was a documented orientation at the time of hire. Agency Policy: The hospice policy titled, Employee Orientation (4.27.1), revised February 2022, read in part, “Each employee and contracted staff who has patient and family contact will receive an orientation about the Hospice philosophy. Orientation for all employees will be performed and documented by supervisory staff and preceptors. The Orientation Checklist will be used to document orientation for all staff, including contract staff.” PERSONNEL RECORD 8: A review of the personnel record for the Volunteer, hired 10/21/2024, revealed no documented evidence of volunteer orientation upon hire. During a joint personnel record review and interview with the Executive Director (ED) (Personnel Record 2), the Director of Clinical Services (DCS) (Personnel Record 3), and the Volunteer Coordinator (VC) (Personnel Record 5) on 02/12/2026, all three individuals reviewed the records and confirmed that no orientation documentation could be located for the personnel file reviewed. Each participant acknowledged the absence of required orientation documents, and all agreed that the agency’s personnel file management and onboarding processes require focused improvement.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. In review of the Volunteer Program documents it was revealed that the agency did not provide volunteer services in an amount that equaled five percent or more of the total patient care hours of all paid hospice employees and contract staff. Review of the volunteer program documents and interview with both the Social Worker also acting as the Volunteer Coordinator (VC) (Personnel Record 5) and the Director of Clinical Services (DCS) (Personnel Record 3) on 02/12/2026 revealed that the average volunteer contribution for January 1, 2025 to December 31, 2025 was 0.03%, which fell below the requirement for volunteers to contribute at least 5% of the total patient care hours performed by all paid hospice employees and contract staff. This prompted a QAPI Performance Improvement Project initiated on 08/22/2025. The DCS, who joined the agency on 01/26/2026, stated that he planned to work with the Social Worker/Volunteer Coordinator on strategies to increase the volunteer percentage During the review of the Volunteer Program documents and an interview with both the Social Worker also acting as the Volunteer Coordinator (VC) (Personnel Record ) and the Director of Clinical Services (DCS) (Personnel Record ) on 02/12/2026 it was determined that the average volunteer contribution for January 1, 2025 to December 31, 2025 was 0.03%, which falls below the requirement for volunteers to contribute at least 5% of the total patient care hours performed by all paid hospice employees and contract staff. This prompted a QAPI Performance Improvement Project initiated on 08/22/2025. Documented recruitment efforts were posting of flyers, reaching out to various churches, and, most recently, attempting to find a contact at a local college nursing program. The DCS, who joined the agency on 01/26/2026, stated that he plans to work with the Social Worker/Volunteer Coordinator on strategies to increase the volunteer percentage.”

“It is required that the hospice provide an orientation on the hospice philosophy to all employees and contracted staff who have patient and family contact. This standard was not met as evidenced by document review, interview and personnel record review. In 3 of 8 (38%) personnel records reviewed it was revealed that the agency did not ensure that there was documented hospice orientation upon hire for each employee or contracted staff member. Agency Policy: The hospice’s policy “Employee Orientation (4.27.1)” revised February 2022 read in part that “Each employee and contracted staff who has patient and family contact will receive an orientation about the Hospice philosophy...Orientation for all employees will be performed and documented by supervisory staff and preceptors. The Orientation Checklist will be used to document orientation for all staff, including contract staff...” PERSONNEL RECORD 1: The personnel file for the Hospice Medical Director, with a contract effective date of 05/07/2025, was reviewed on 02/12/2026 and contained no documented evidence of hospice orientation. PERSONNEL RECORD 5: The personnel file for the Social Worker/Volunteer Coordinator, with a hire date of 07/14/2025, was reviewed on 02/12/2026 and contained no documented evidence of hospice orientation. PERSONNEL RECORD 6: The personnel file for the Chaplain/Bereavement Coordinator, with a hire date of 09/22/2025, was reviewed on 02/12/2026 and contained no documented evidence of hospice orientation. During a joint personnel record review and interview with the Executive Director (ED) (Personnel Record 2) and the Director of Clinical Services (DCS) (Personnel Record 3) on 02/12/2026, the ED acknowledged that the agency needed to “work on their personnel records.””

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by personnel record review and document review. In 1 of 3 (33%) personnel records reviewed it was revealed that the agency did not ensure there was a documented clinical competency for all staff providing care. Agency Policy titled, Staff Competency Program (no number/no date), read in part, “Hospice will provide for initial and ongoing competency assessments for all patient care staff...Patient care staff will be competency assessed...during orientation and annually thereafter.” PERSONNEL RECORD 6: The personnel file for the Chaplain/Bereavement Coordinator (CH/BC), with a hire date of 09/22/2025, was reviewed on 02/12/2026 and contained no documented evidence of CH/BC Clinical Competencies. During a joint personnel record review and interview with the Director of Clinical Services (DCS) (Personnel Record 3) and the Executive Director (ED) (Personnel Record 2) on 02/12/2026, the missing clinical competency assessments could not be located and the ED acknowledged that the personnel files “need some work.””