Ascend Hospice

“It is required that the hospice provide information on advance directives upon initiation of hospice care. Whether or not the patient has executed an advance directive is documented in a prominent part of the patient’s record. 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 there was evidence of a Do Not Resuscitate (DNR) document in the patient’s medical record. CLINICAL RECORD 17: The patient elected the hospice benefit on 04/10/2025. The initial assessment by the Registered Nurse (RN) was completed on 04/10/2025. The RN documented that the patient was a DNR in the initial assessment. The clinical record did not have documented evidence of a signed DNR document. During a joint record review and interview with the Vice President (VP) of Clinical Operations (Personnel Record 11) on 07/01/2026, it was confirmed that there was no documented evidence of an executed DNR document in the medical record.”

“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 19 (5%) clinical records reviewed, it was revealed that the Agency did not ensure the initial comprehensive assessment was completed within 5 calendar days after the election of hospice care. CLINICAL RECORD 10: The patient elected the hospice benefit on 02/12/2024. The initial nursing assessment was completed on 2/12/2024. On 02/15/2024, there was documentation of a phone call and voicemail left by the MSW to schedule the assessment. An IDG meeting note on 02/20/2024 documented another phone call and voicemail left for the family. On 02/26/2024, another phone call was documented by the MSW, and the assessment was scheduled and completed on 03/01/2024. During a joint record review and interview with the Vice President (VP) of Clinical Operations on 07/02/2026, the VP of Clinical Operations confirmed there was no documented evidence that the initial comprehensive (MSW) assessment was completed within five (5) calendar days after the election of hospice care.”

“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 and any quality assessment and improvement activities. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed of patients who received hospice aide services, it was revealed that the agency did not ensure the hospice aide notified the registered nurse of the changes in the patient’s plan of care. CLINICAL RECORD 5: The patient elected the hospice benefit on 11/05/2024. The Hospice Aide visit note dated 11/14/2024, the aide documented refusal of care due to the facility completing the care. There was no documented evidence that the aide notified the Registered Nurse (RN). The Hospice Aide visit note dated 06/29/2026, documented several categories of care that were not completed as directed on the plan of care. There was no documented evidence that the RN case manager was notified. CLINICAL RECORD 17: The patient elected the hospice benefit on 04/10/2025. The Hospice Aide visit note dated 04/14/2025, the aide documented “No” on bathing and shampooing. There was no documented evidence that the RN was notified that the aide did not perform the tasks on the care plan. CLINICAL RECORD 18: The patient elected the hospice benefit on 11/15/2024. The Hospice Aide visit notes dated 11/18/2024 and 11/19/2024, the patient refused shampoo per the aide’s documentation. There was no documented evidence that the RN was notified. The Hospice Aide visit note dated 11/21/2024, the aide documented shampoo “not required”. There was no documented evidence that the RN was notified. During a joint record review and interview with the Vice President (VP) of Clinical Operations (Personnel Record 11) on 07/01/2026, it was confirmed that there was no documented evidence that the RN was notified by the aide of changes in the patients’ plans of care.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 4 of 5 (80%) clinical records reviewed, the agency did not ensure the individualized plan of care included planned interventions based on problems identified in the initial and updated comprehensive assessments. THIS IS A CONTINUING REQUIRED ACTION Clinical Record 1: The hospice plan of care dated 11/01/2023 did not include interventions and goals for hospice aide services provided to the patient. Clinical Record 2: The hospice plan of care dated 10/31/2023 did not include interventions and goals for hospice aide services provided to the patient. Clinical Record 4: The hospice plan of care dated 11/08/2023 did not include interventions and goals for hospice aide services provided to the patient. Clinical Record 5: The hospice plan of care dated 10/25/2023 did not include interventions and goals for hospice aide services provided to the patient. During an interview on 12/08/2023, the Executive Director of Clinical Operations reviewed the associated records and stated that the aide interventions and goals had been inadvertently omitted and had since been added to the hospice plans of care.”

“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 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 5 (20%) clinical records reviewed, the agency did not ensure the individualized written plan of care included documentation of treatments necessary to meet the needs of the patient. THIS IS A CONTINUING REQUIRED ACTION Clinical Record 5: The skilled nurse documented on the updated comprehensive assessment dated 12/03/2023 wound care was provided to a stage II left buttock wound three times a week by cleansing with normal saline, application of hydrogel to the wound bed and securing with optifoam. The updated hospice plan of care dated 12/06/2023 did not include wound care orders, as of the date of record review on 12/08/2023. During an interview on 12/08/2023, the Executive Director of Clinical Operations reviewed the associated record and stated that the wound care order had been inadvertently omitted and had since been obtained and added to the hospice plan of care.”

“It is required that hospice aides are assigned to a specific patient by a Registered Nurse (RN) who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed, the agency did not ensure the RN prepared written patient care instructions for the hospice aide that included clear and specific instructions to the aide. THIS IS A CONTINUING REQUIRED ACTION Clinical Record 1: The patient elected the hospice benefit on 07/27/2023 with a terminal diagnosis of unspecified protein calorie malnutrition. The RN documented on the 12/03/2023 updated assessment and the 12/06/2023 interdisciplinary team meeting notes that the patient was receiving wound care to a left buttock stage II decubitus ulcer. The 07/27/2023 initial hospice aide plan of care did not include instructions/precautions related to the wound or wound care and there was no updated hospice aide plan of care since the original was created on 07/27/2023. Clinical Record 5: This patient elected the hospice benefit on 11/01/2023 with a terminal diagnosis of Alzheimer’s disease. The RN documented on the initial comprehensive assessment dated 11/01/2023, the patient was using oxygen. The 11/01/2023 initial hospice aide plan of care did not include instructions/precautions related to the patient’s use of oxygen and there was no updated hospice aide plan of care since the original was created on 11/01/2023. During an interview on 12/08/2023, the Executive Director of Clinical Operations reviewed the associated records and stated that the instructions for the aide had been inadvertently omitted and had since been corrected.”