Every finding on record at Dover Hospice Il Stl Metro, LLC

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed it was revealed the agency did not ensure an initial comprehensive assessment was completed no later than five calendar days after the election of hospice care. CLINICAL RECORD 6: The patient elected the hospice benefit on 05/21/2025. The initial nurse assessment was completed on 05/21/2025, the initial medical social services assessment was completed on 05/23/2025, and the initial spiritual care assessment was completed on 05/27/2025 (6 days). During an interview with the alternate Director of Clinical Services, on 08/07/2025, she stated that they work really hard to get out and do the initial comprehensive assessment in a timely manner, and she does remember that there was an issue with the EMR (electronic medical record) but the Chaplain did not document if this was why the assessment was late. She stated that additional education would be provided.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) clinical records reviewed, in which bereaved services were accepted, it was revealed the agency did not ensure the bereavement plan of care was documented and included the types of bereavement services to be offered and the frequency of services. CLINICAL RECORD 11: The patient elected the hospice benefit on 02/25/2025 and died on 03/19/2025. Documentation in the death visit noted that bereavement services were accepted and that bereavement would be in contact. The clinical record review lacked evidence of a bereavement plan of care that included types of bereavement services to be offered and the frequency of those services. CLINICAL RECORD 12: The patient elected the hospice benefit on 05/23/2025 and died on 05/31/2025. Documentation in the death visit noted that bereavement services were accepted and that bereavement would be in contact. The clinical record review lacked evidence of a bereavement plan of care that included types of bereavement services to be offered and the frequency of those services. CLINICAL RECORD 13: The patient elected the hospice benefit on 03/05/2025 and died on 06/09/2025. Documentation in the death visit noted that bereavement services were accepted and that bereavement would be in contact. The clinical record review lacked evidence of a bereavement plan of care that included types of bereavement services to be offered and the frequency of those services. During an interview with the Bereavement Coordinator (Personnel Record 6), on 08/07/2025, he stated that they are new to the electronic medical record and just received education on how to utilize the system for the bereavement plan of care and activities.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s needs. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 2 of 13 (15%) clinical records reviewed of patients who elected hospice aide services revealed that the agency did not ensure that the hospice aides were supervised by a registered nurse with an on-site visit no less frequently than every 14 days. CLINICAL RECORD 6: The patient elected the hospice benefit on 05/21/2025 with hospice aide services ordered. The benefit period dated 05/21/2025 to 08/18/2025 documented hospice aide supervisory visits on 07/11/2025 and then on 07/31/2025 (20 days). CLINICAL RECORD 8: The patient elected the hospice benefit on 04/07/2025 with hospice aide services ordered. The benefit period dated 04/07/2025 to 07/05/2025 documented hospice aide supervisory visits on 06/23/2025 and then on 07/11/2025 (19 days). During an interview with the alternate Director of Clinical Services, on 08/06/2025, she stated that she cannot believe they missed an aide supervisory visit; however, they would continue to monitor the supervisory visits.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed, of patients who revoked the election of hospice services, it was revealed that the agency did not ensure that the discharge summary was sent to the patient's attending physician. CLINICAL RECORD 14: The patient elected the hospice benefit on 03/26/2025 and revoked hospice services on 04/18/2025. The clinical record lacked documented evidence that the discharge summary was sent to the patient's attending physician. During an interview with the Alternate Director of Clinical Services, on 08/06/2025, she stated she did not realize that was a requirement but that she would be sure to educate the staff on sending the discharge summary to the attending physician.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 1 (100%) clinical record reviewed of patients that were discharged from hospice services revealed that the agency did not ensure a discharge summary included at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. CLINICAL RECORD 14: The patient elected the hospice benefit on 03/26/2025 and revoked the benefit on 04/18/2025 to seek aggressive treatment. The record lacked documented evidence of a discharge summary that included at least a summary of the patient's hospice stay, the latest physician orders, and any other documentation to assist with post-discharge continuity of care. The record included evidence of the hospice item set (HIS) discharge that included only the HIS elements. During an interview with the Alternate Director of Clinical Services on 08/07/2025 she stated that they thought the discharge HIS included all the needed information. She also stated that they would be contacting the current electronic medical record vendor to receive instructions on how to generate a discharge summary with the required information.