Ascend Hospice

“Based on medical record review, staff interviews, and a review of facility documents, it was determined that the facility failed to ensure that bereavement services reflect the needs of the bereaved in accordance with facility policies and procedures in three of six medical records reviewed (Patient (P)1, P3, and P4). Findings include:Undated facility policy titled, “Bereavement Services,” stated, “… Procedures: 1. The hospice’s bereavement program is under the supervision of the Bereavement Coordinator … 2. The hospice provides bereavement services to the family, caregivers and/or significant others of deceased hospice patients for twelve months following the patient’s death … 4. Bereavement services provided include, but are not limited to: a. letters [mailings] and supportive information provided at specific intervals after the patient’s death … d. bereavement visits and/or phone calls …” Facility document titled, “Bereavement Program,” dated 04/29/2024, stated, “Bereavement Mailings: 2 Week Condolence Card, 30 Day Letter, 3 Month Letter, 6 Month Letter, 9 Month Letter for Moderate and High Grief Risk Clients, 11 Month Letter, Anniversary Card, 13 Month Letter. Bereavement Phone Calls: 24-72 hour Psychosocial Call, 10 Day Call for Moderate and High Grief Risks Clients, 30 Day Call, 6 Month Call…”Undated facility policy titled, “Bereavement – Files,” stated, “… Procedures: 1. A bereavement file is initiated for each patient by the Bereavement Coordinator and maintained for twelve months after the patient’s death … 2. The bereavement file contains: a. a copy of the bereavement plan of care for the person(s) for whom the hospice will provide bereavement services; and b. bereavement notes documenting all services to and contact with the bereaved person(s). 3. The Bereavement Coordinator updates information in the file as needed …”Undated facility policy titled, “Bereavement – Tracking and Evaluation,” stated, “… Procedures: … 2. The Bereavement Coordinator documents the dates when each of the … services, as specified in the bereaved person’s plan of care, has been completed. 3. At least two attempts are made to reach the family member or significant others of the deceased patient … 5. To ensure that the bereavement program meets the individual bereavement needs of the persons served … Any deviations are documented …”On 09/17/2025 at 12:27 PM, a review of P3’s medical record and their family member’s Bereaved Profile was conducted with Staff (S)2 and revealed the following:On 03/14/2024, Pre Bereavement Assessment completed by a Social Worker resulted in a score of 6 (low risk).On 03/15/2024, Pre Bereavement Assessment completed by a Chaplin resulted in a score of 1 (low risk). On 09/08/2024, P3 expired. The facility was unable to provide evidence that a Post Bereavement Assessment was completed for P3’s family member.On 08/26/2025, an 11 Month Letter was mailed to P3’s family member. On 09/08/2025, a Bereavement Call was made to P3’s family member which resulted in no answer and a voicemail message.On 09/09/2025, an Anniversary Card was mailed to P3’s family member.S2 confirmed that no phone calls or letters were completed for P3’s family member until the 11 Month Letter.On 09/17/2025 at 12:45 PM, a review of P4’s medical record and their family member’s Bereaved Profile was conducted with S2 and revealed the following:On 07/08/2024, Pre Bereavement Assessment completed by a Chaplain resulted in a score of 6 (low risk).On 07/09/2024, Pre Bereavement Assessment completed by a Social Worker resulted in a score of 1 (low risk).On 07/14/2024, P4 expired and P4’s family member accepted Bereavement Services from the facility. The facility was unable to provide evidence that a Post Bereavement Assessment was completed for P4’s family member.The facility was unable to provide evidence that a Bereaved Profile was created for P4’s family member. The facility was unable to provide evidence that the family member received Bereavement Services. The findings were confirmed by S2 and S9. On 9/17/2025 at 11:41 AM, an interview was conducted with S9. When asked about the bereavement program, S9 stated that the bereavement program provides 13 months of support following the patient’s death. S9 stated that the contact information for the primary support person is sent to the Bereavement Coordinator following the patient’s death. S9 stated that after the primary support persons information is sent to the Bereavement Coordinator, there is a discussion at the Interdisciplinary Group meeting, which includes the primary support person’s risk level. S9 stated that “the risk level determines how quickly they [the primary support person] are contacted.” S9 stated that if the primary support person risk level is assessed to be low, they would be contacted within 30 days. S9 stated that all risk levels would receive mailings, if they agreed to them, which would include a 30-day letter, three-month letter, six-month letter, nine-month letter, anniversary of death booklet, and a 13-month closing letter. S9 stated that all phone calls and mailings are electronically documented in the medical record of the primary support person, which is created in KanTime [the facilities electronic medical records database], upon the patient’s death, if the primary support person accepts bereavement services. Findings include:1. Facility policy titled, “Bereavement – Tracking and Evaluation”, lasted revised on 06/16/2022, stated, “Policy: [the facility] monitors the patient’s family, caregiver, and/or significant others receiving bereavement care for twelve months following the death of the patient. Procedures: 1. A bereavement file is initiated at the time of patient’s death that contains documentation related to all bereavement services, intervention and support provided to the patient’s family, caregiver and/or significant other…”On 09/17/2025 at 12:14 PM, Patient (P)1’s medical record was reviewed with Staff (S)9 and revealed the following:On 10/02/2025, P1 expired.On 10/03/2025, a Bereavement Assessment conducted for P1’s family member by the bereavement coordinator resulted in a score of 9 (low risk). The Bereavement Note stated “…[P1’s family member] had a hard time coping with [P1’s] decline, and is deemed a moderate risk for bereavement support. [He/she] has limited supports…”On 10/13/2025, P1’s family member was assigned a high risk for bereavement by S9. S9 assigned a MSW (Social Worker) student intern to conduct bereavement visits for P1’s family member.Facility document titled “Bereavement Care Plan” for P1’s family member stated “Goals: Bereaved [P1’s family member] will experience healthy grieving as evidenced by effective coping and ability to adapt to the death of [P1]. [P1’s family member] will maintain a high bereavement risk and will lessen their high bereavement risk to moderate bereavement risk…”From 10/15/2025 to 4/10/2025, 18 in-person bereavement visits were conducted for P1’s family member. Notes for the visits stated only “MSW student intern [name] provided bereavement visit to [P1’s family member] on [date].” The facility was unable to provide evidence of documentation of the client’s response to care, assessments, interventions, or support provided to P1’s family member during the MSW student intern visits from 10/15/2025 to 4/10/2025. S9 confirmed the findings.On 3/16/2025, a Bereavement Assessment P1’s family member by S9 resulted in a score of 14 (moderate risk). The Bereavement Note stated “…[P1’s family member] reported being in the hospital due to persistent and severe vomiting. Expressed having a broken heart and feels the vomiting is from the sadness. Expressed that [his/her] grief is taking a toll on [his/her] physical health… This writer strongly encouraged [P1’s family member] to find a therapist for [him/herself]… This writer will connect with student intern on therapy resources for [P1’s family member].”On 04/10/2025, MSW student intern conducted final in-person bereavement visit with P1’s family member as internship ended and he/she was no longer available to provide support.On 04/20/2025, S9 conducted a bereavement call with P1’s family member.On 05/01/2025, P1’s family member contacted S9 to “inquire if [he/she] is still eligible for Bereavement Services… [he/she] no longer meets with the MSW student intern [name] and wanted to know what the next steps would be. [S9] confirmed continued access to Bereavement Services. [S9] informed [P1’s family member] that the Bereavement Coordinator [name] was out on medical leave. [S9] contacted the Bereavement Coordinator for South/Southwest on 5/1/2025 and requested [he/she] follow up with [P1’s family member].”On 06/05/2025, [P1’s family member] contacted S9 and “informed [S9] that [he/she] did receive a call from the South/Southwest BC [Bereavement Coordinator] and [P1’s family member] reported that [he/she] returned the BC’s call but never heard back… [P1’s family member] went on to express disappointment with [the facility] that [he/she] is not getting any help… [S9] explained that the BC for South/Southwest cannot provide the same level of support as [MSW student intern] did. [S9] encouraged [him/her] to reach out to the EAP program at [his/her] job and inquire if [he/she] can receive grief counseling or therapy session through EAP…”On 07/02/2025, a 9-month letter for moderate and high grief risk clients was mailed to P1’s family member.On 08/26/25, an 11-month letter was mailed to P1’s family member.On 09/17/2025 at 2:10 PM, an interview was conducted with S9. When questioned about the documentation of the bereavement visits, S9 stated, “I met with the MSW student intern weekly to supervise [him/her] and we discussed [his/her] visits with P1’s family member. The MSW student intern conducted the visits with P1’s family member independently. The MSW student intern was an advanced level intern and able to conduct the visits independently.” S9 stated, the facility does not have a policy on supervision of MSW student intern visits. S9 stated, during P1’s family member was provided with referrals for support groups and therapists while the MSW student intern was conducting in-person visits. S9 stated, “unfortunately it was not documented. My error.” S9 stated, “I always had lots of contact with [P1’s family member]. We have always been in contact through phone calls and texts but it looks like there are some gaps in documentation.”At 2:45 PM, findings were confirmed by S3 and S4. 2. Undated facility policy titled, “Bereavement Services,” stated, “… Procedures: 1. The hospice’s bereavement program is under the supervision of the Bereavement Coordinator … 2. The hospice provides bereavement services to the family, caregivers and/or significant others of deceased hospice patients for twelve months following the patient’s death … 4. Bereavement services provided include, but are not limited to: a. letters [mailings] and supportive information provided at specific intervals after the patient’s death … d. bereavement visits and/or phone calls …” Facility document titled, “Bereavement Program,” dated 04/29/2024, stated, “Bereavement Mailings: 2 Week Condolence Card, 30 Day Letter, 3 Month Letter, 6 Month Letter, 9 Month Letter for Moderate and High Grief Risk Clients, 11 Month Letter, Anniversary Card, 13 Month Letter. Bereavement Phone Calls: 24-72 hour Psychosocial Call, 10 Day Call for Moderate and High Grief Risks Clients, 30 Day Call, 6 Month Call…”Undated facility policy titled, “Bereavement – Files,” stated, “… Procedures: 1. A bereavement file is initiated for each patient by the Bereavement Coordinator and maintained for twelve months after the patient’s death … 2. The bereavement file contains: a. a copy of the bereavement plan of care for the person(s) for whom the hospice will provide bereavement services; and b. bereavement notes documenting all services to and contact with the bereaved person(s). 3. The Bereavement Coordinator updates information in the file as needed …”Undated facility policy titled, “Bereavement – Tracking and Evaluation,” stated, “… Procedures: … 2. The Bereavement Coordinator documents the dates when each of the … services, as specified in the bereaved person’s plan of care, has been completed. 3. At least two attempts are made to reach the family member or significant others of the deceased patient … 5. To ensure that the bereavement program meets the individual bereavement needs of the persons served … Any deviations are documented …”On 09/17/2025 at 12:27 PM, a review of P3’s medical record and their family member’s Bereaved Profile was conducted with Staff (S)2 and revealed the following:On 03/14/2024, Pre Bereavement Assessment completed by a Social Worker resulted in a score of 6 (low risk).On 03/15/2024, Pre Bereavement Assessment completed by a Chaplin resulted in a score of 1 (low risk). On 09/08/2024, P3 expired. The facility was unable to provide evidence that a Post Bereavement Assessment was completed for P3’s family member.On 08/26/2025, an 11 Month Letter was mailed to P3’s family member. On 09/08/2025, a Bereavement Call was made to P3’s family member which resulted in no answer and a voicemail message.On 09/09/2025, an Anniversary Card was mailed to P3’s family member.S2 confirmed that no phone calls or letters were completed for P3’s family member until the 11 Month Letter.On 09/17/2025 at 12:45 PM, a review of P4’s medical record and their family member’s Bereaved Profile was conducted with S2 and revealed the following:On 07/08/2024, Pre Bereavement Assessment completed by a Chaplain resulted in a score of 6 (low risk).On 07/09/2024, Pre Bereavement Assessment completed by a Social Worker resulted in a score of 1 (low risk).On 07/14/2024, P4 expired and P4’s family member accepted Bereavement Services from the facility. The facility was unable to provide evidence that a Post Bereavement Assessment was completed for P4’s family member.The facility was unable to provide evidence that a Bereaved Profile was created for P4’s family member. The facility was unable to provide evidence that the family member received Bereavement Services. The findings were confirmed by S2 and S9. On 9/17/2025 at 11:41 AM, an interview was conducted with S9. When asked about the bereavement program, S9 stated that the bereavement program provides 13 months of support following the patient’s death. S9 stated that the contact information for the primary support person is sent to the Bereavement Coordinator following the patient’s death. S9 stated that after the primary support persons information is sent to the Bereavement Coordinator, there is a discussion at the Interdisciplinary Group meeting, which includes the primary support person’s risk level. S9 stated that “the risk level determines how quickly they [the primary support person] are contacted.” S9 stated that if the primary support person risk level is assessed to be low, they would be contacted within 30 days. S9 stated that all risk levels would receive mailings, if they agreed to them, which would include a 30-day letter, three-month letter, six-month letter, nine-month letter, anniversary of death booklet, and a 13-month closing letter. S9 stated that all phone calls and mailings are electronically documented in the medical record of the primary support person, which is created in KanTime [the facilities electronic medical records database], upon the patient’s death, if the primary support person accepts bereavement services.”

“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, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: The effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed it was revealed that the agency did not ensure that all medications were listed on the medication list in the comprehensive assessment therefor they were not part of the review process. Clinical Record 6: Patient was admitted on 11/27/2024. It was documented on the form titled, Admission Nursing Assessment, that the patient was on Zofran, Fentanyl Patch and Oxycodone and these medications were in the home at the time of admission. The comprehensive assessment dated 11/27/2024 did not contain these medications on the drug profile therefore they were not able to be reviewed and reconciled at the time of admission. During the clinical record review on 12/09/2024, the Clinical Director confirmed that the medications listed in the nursing assessment were not included in the comprehensive assessment. The clinical director reached out to the nurse and the nurse stated that she forgot to document these medications at the time of admission.”

“It is required that each patient’s individualized written plan of care includes drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed it was revealed that the agency did not ensure that all of the medications that the patient was taking were included in the individualized plan of care. Clinical Record 6: The patient was admitted on 11/27/2024 with a diagnosis of malignant neoplasm of the anus. The nurse noted in her admission assessment dated 11/27/2024 that the patient was on Zofran q 4-6 hours prn, Fentanyl patch 25 mcq and Oxycodone. These medications were not documented on the initial plan of care dated 11/27/2024. During the clinical record review on 12/10/2024, the Clinical Director agreed that the medications should have included in the Initial Plan of Care dated 11/27/2024. She reached out to the nurse and the nurse stated that these medications were in the home and the patient was receiving these medications and they should have been included in the Plan of Care.”

“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. During the review of the volunteer cost savings report for the calendar year 2024, the agency documentation of the provision of volunteer services revealed that the percentage of volunteer services provided for the year 2024 to date was 1.8% instead of the 5% that is required. During an interview with the Volunteer Coordinator held on 12/11/2024, she stated that they have been actively recruiting more volunteers and just had an orientation. During review of the volunteer cost savings report for the calendar year 2024, the agency documentation revealed that the volunteer percentage for the year 2024 equaled 1.8% instead of the 5% that is required.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, it was revealed that the agency did not ensure that the clinical record had documented physician orders in place for all of the patient’s current medications. Clinical Record 6: The patient was admitted on 11/27/2024 with a diagnosis of Malignant neoplasm of the anus. The nurse noted in her admission assessment dated 11/27/2024 that the patient was on Zofran q 4-6 hours prn, Fentanyl patch 25 mcq and Oxycodone. The nurse also documented that these medications were in the home at the time of admission. There were no orders for the above medications in the initial plan of care dated 11/27/2024. During a joint clinical record review on 12/10/2024, the Clinical Director confirmed that there were no orders for these medications in the patients clinical record.”