Every finding on record at Ascend Hospice Care, LLC

Based on record review and interview, the Hospice agency failed to ensure all hospice aides received at least 12 hours of in-service training during each 12 month period for 2 (S3HHA, S4HHA) of 2 Hospice aides currently employed by the agency for at least one year.   Findings: --- Review of the agency's current staff list revealed S3HHA and S4HHA were full time employees. Review of personnel record for S3HHA revealed the date of hire as 04/04/2023. There was no evidence of any documented in-service training hours from January 01, 2024 through December 31, 2024. Review of personnel record for S4HHA revealed the date of hire as 03/14/2023.  There was 7 hours of documented in-service training hours from January 01, 2024 through December 31, 2024. On 11/13/2025 at 3:45 p.m., an interview with S1Adm confirmed S3HHA and S4HHA did not complete 12 hours of required in-service training for the year of 2024. On 11/13/2025 at 4:50 p.m., an interview with S2DON confirmed HHAs were required to complete 12 hours of in-service training during each 12 month period. S2DON further confirmed S3HHA and S4HHA did not complete their 12 hours of required in-service training for the year of 2024.

Based on record review and interview, the hospice provider failed to ensure that each patients record must include clinical notes for 1 (#1) of 3 (#1, #2, and #3) patient clinical records reviewed. The hospice provider failed to ensure a skilled nurse visit note was completed for patient #1. --- Findings: Review of the Patient Clinical Record Policy (Undated) included in part: Purpose: The clinical record shall be a comprehensive compilation of information that is documented promptly for all services provided. The record will be organized to facilitate retrieval of information. Specific entries to the clinical record shall be made and signed by the person providing the service. All services, whether provided by employees, person under contract, or volunteers shall be documented in the clinical record. Review of the medical record revealed patient #1s start of care date was 08/10/2024. Further review revealed patient #1 had expired and was discharge on 09/12/2024. Review of the medical record revealed patient #1 had a primary diagnosis of malignant neoplasm of unspecified part of right bronchus or lung. Further review revealed a secondary diagnosis as other pulmonary embolism with acute cor pulmonale-related and shortness of breath-related. Review of Care Plan/Physician Order revealed a certification period from 08/10/2024 – 11/07/2024. Review further revealed the orders for discipline and treatments included a skilled nurse was to be implemented one time per week for one week then two times per week for thirteen weeks. Review of the medical record revealed there was no documented evidence of a skilled nurse visit note being completed for patient #1 on the dates of 08/12/2024 and 08/19/2024 to indicate the status of patient #1s condition on those dates. On 10/30/2024 at approximately 1:45 p.m., S1Administrator was notified of the findings noted above. She revealed that S2Registered Nurse (RN) had been assigned the skilled nurse visits with patient #1 on the dates of 08/12/2024 and 08/19/2024. S1Administrator confirmed that she had not spoken with S2RN to determine why a note was not completed. S1Administrator further confirmed that a skilled nurse visit note was to be completed for all patients receiving hospice services, in accordance with the providers policy. /

Based on record review and interview the provider failed to ensure all volunteer staff that provided services to patients had a background check for 1(S2Voluntere) of 3 Volunteer personnel records reviewed. Findings: --- Review of the personnel record for S2Volunteer revealed a training start date of 09/26/22. Further review revealed there was no documented evidence that a state wide criminal background and nationwide sex offender check was completed for the volunteer. Interview on 02/22/23 at 2:30pm, with S1Adinistrator/ DON (/Director of Nurses) stated all volunteers who provide services to the hospice patients in their homes are to have a state wide criminals background and nationwide sex offender check obtained with the results prior to being introduced into the patients home. After S1/Administrator/DON reviewed S2volunteers personnel record and patients electronic health records she confirmed the date of hire for S2Volunteer is 09/26/22 and S2 volunteer was first introduced into a patient's home to provide services on 10/03/22. S1Administrator/DON further confirmed there was no documentation that a statewide background check and national wide sex offenders check with results had been obtained prior to being introduced into the patient's home.