Every finding on record at Ascendio Health Systems, Inc

Upon patient record review, 2 of 14 (Patient #1, #10) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. #1-No initial bereavement assessment was completed for this patient. #10-The initial bereavement assessment was performed on day 9. The first documentation of patient contact by the SC is on day 7, with the family requesting the assessment be completed 2 days later.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. #7-The MSW was ordered PRN only.

Upon personnel record review, 3 of 15 (Personnel #6, #7, #8) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. #6, #7, #8 - There is no evidence in contract therapy staff personnel records of orientation to hospice philosophy.

Upon patient client record review, 1 of 14 (Patient #10) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 #10-There was no effective date documented on the Election of Medicare Hospice Benefit. There was no identification of physician on the Election of Medicare Hospice Benefit.