Ascent Hospice LLC

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: Prescription and over the counter (OTC) drugs; Supplements; Herbal remedies; Other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record review, observation, document review and interview. In 1 of 3 (33%) home visits, the agency did not ensure that the medication profile was complete and able to be reviewed for all medications that the patient was taking to identify potential interactions. Agency Policy #2-004 titled, Medication Profile, (reviewed 2023) stated in part, “A drug regimen review will be performed at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. The review will identify drug/food interactions potential adverse effects and drug reactions, ineffective drug therapy, duplicative drug therapy, and noncompliance with drug therapy. The interdisciplinary group will conferee with an individual with education in drug management to ensure the drugs and biologicals meet the patient’s needs. HOME VISIT 1/CLINICAL RECORD 1: Hospice benefit period 2 (05/11/2025 - 08/08/2025) was reviewed. The Facility medication profile documented medications given on 07/29/2025, the day of the visit, Metoprolol Succinate 50 mg daily. The agency medication profile listed Metoprolol Tartrate 25mg twice a day. The following medications were given by the facility but not documented on the updated agency plan of care: Milk of Magnesia as needed for constipation, Multi vitamin 400mg daily, Amlodipine 5mg daily, Vitamin C 500mg daily, Vitamin B12, 1000mcg daily, Hydrochlorothiazide 25 mg daily, Lexapro 20 mg daily and Losartan 10 mg daily. The hospice medication review did not include all medications, prescription and over the counter that the patient was taking. During interview with the Director of Nursing on 07/30/2025 it was stated the medication profile was not updated correctly.”

“It is required that each patient’s individualized written plan of care: Includes all services necessary for the palliation and management of the terminal illness, including the following: Drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 3 (33%) clinical records of patients with a home visit, the agency did not ensure that the medications that the patient was taking were documented on the current plan of care. HOME VISIT 1/CLINICAL RECORD 1: The hospice benefit period 2 (05/11/2025 - 08/08/2025) was reviewed. The Facility medication profile with medications given on 07/29/2025 the day of the visit, listed Metoprolol Succinate 50 mg daily but the agency medication profile was Metoprolol Tartrate 25mg twice a day. The following medications were given by the facility but not documented on the updated agency plan of care: Milk of Magnesia as needed for constipation, Multi vitamin 400mg daily, Amlodipine 5mg daily, Vitamin C 500mg daily, Vitamin B12, 1000mcg daily, Hydrochlorothiazide 25 mg daily, Lexapro 20 mg daily and Losartan 10 mg daily. The updated plan of care for the agency did not document the current medications that the patient was receiving at the skilled nursing facility, During interview with the Director of Nursing on 07/31/2025 stated that the medications lists were not correct.”

“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. This standard was not met as evidenced by clinical record review and interview. In 3 of 13 (23%) clinical records reviewed in which the hospice aide was accepted and provided care for greater than 14 days, the agency did not ensure that RN supervision was provided every 14 days. CLINICAL RECORD 8: The hospice benefit period 1 dated 01/30/2025 - 04/29/2025 was reviewed. The first home health aide visit was documented on 02/5/2025. The first supervisory documentation of the home health aide by the RN was completed on 03/04/2025, which occurred 28 days after the initial visit; and 14 days late. The home health aide visits continued to be completed biweekly per order. The next supervisory visit by the RN was on 03/26/2025, which was 22 days after the last supervisory visit; this was 8 days late. The RN supervisory visits continued weekly or every 14 days through the date of the site visit without delay. CLINICAL RECORD 10: The benefit period 2 was dated 04/16/2025 - 07/14/2025. A supervisory visit was completed on 05/08/2025 during the second benefit period. The next supervisory RN visit was not completed until 06/02/2025, which was 26 days - this was 12 days late. Hospice aide supervisory visits were completed by the RN weekly or every 14 days through the site visit date without delay. CLINICAL RECORD 11: The benefit period 1 was dated 07/26/2024 - 10/23/2024. The first hospice aide visit was documented on 07/30/2024. The first supervisory documentation of the hospice aide by the RN was completed on 07/30/2024. The next supervisory documentation occurred 08/20/2024, which occurred at 21 days and was 7 days late. The hospice aide visits continued to be completed weekly per order. The next supervisory visit by the RN was on 08/27/2024, within the proscribed time frame. The RN supervisory visits continued weekly or every 14 days through the date of discharge on 01/17/2025. During the interview with the director of nursing on 07/30/2025, who reviewed the records, stated that supervision was not documented every 14 days.”

“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. The hospice documents the cost savings achieved through volunteers. Documentation includes: The identification of each position that is occupied by a volunteer; The work time spent by volunteers occupying those positions. Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1 and for the durations noted in Item 2. This standard was not met as evidenced by document review and interview. During the review of the volunteer program binder, the agency did not ensure that a cost saving of 5% or over was accomplished for the agency. The binder contained cost savings of 0.8% in the first quarter of 2024, 0.9% the second quarter of 2024, and 0.5% the third quarter and 0.6% the fourth quarter, with an annual savings of 2.8%. For 2025 the first quarter was 0.5% and the second quarter was 0% with a savings of 0.5% so far this year. During interview with the administrator/volunteer coordinator stated that the process improvement plan is in place, as well as documentation of recruitment and retention efforts, which continue from the team. During the review of the volunteer program binder, the agency did not ensure that a cost saving of 5% or over was accomplished for the agency. The binder contained cost savings of 0.8% in the first quarter of 2024, 0.9% the second quarter of 2024, and 0.5% the third quarter and 0.6% the fourth quarter, with an annual savings of 2.8%. For 2025 the first quarter was 0.5% and the second quarter was 0% with a savings of 0.5% so far this year.”