Every finding on record at Ascent Home Health and Hospice, Inc

Upon patient record review 2 of 11 (Patient #3, 8) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #3: Admission 4/19/24. MSW initial assessment 5/1/24 and SC initial assessment 4/29/24. The RN assessment did not meet the spiritual assessment requirements. Answered "not assessed". Patient #8: Admission 1/2/24. RN documented did not perform spiritual assessment. Spiritual Counselor did not perform initial visit/assessment until 1/10/24.

Upon patient record review, 2 of 11 (Patient #3, 7) 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. Patient #3: Admitted 4/19/24. Initial bereavement assessment not completed until MSW 5/1/24 initial MSW assessment. Patient #7: Admitted 1/16/24. RN documented bereavement not assessed. There was no MSW initial assessment visit documented. SC saw patient, but did not perform initial bereavement assessment.

Upon observation during home visits, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. the RN used paper towel as barrier for nursing bag. Agency Policy for Bag Technique requires waterproof disposable barrier.

Upon personnel record review, 1 of 11 (Personnel #9 ) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel #9 did not have evidence of orientation to job description, as indicated by no signed job description available.

Upon personnel record review, 1 of 11 (Personnel # 5) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #5: No evidence of competency for bereavement coordinator could be located during survey.

Upon patient client record review, 2 of 11 (Patient #7, 10) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient #7: There is no CTI by attending. Patient #10. There is no CTI by attending.

Upon inpatient contract review, 2 of 5 (Prague Hospital and Parkland Manor contracts) did not have evidence that the hospice patient's inpatient clinical record includes a record of all inpatient services furnished and events regarding care that occurred at the facility; that a copy of the discharge summary be provided to the hospice at the time of discharge; and that a copy of the inpatient clinical record is available to the hospice at the time of discharge. Prague Hospital and Parkland Manor Contracts: The contract is not specific to documentation to be included in record and has no reference to discharge plan or process included in either contract.

Upon inpatient contract review, 2 of 5 (Prague Hospital and Parkland Manor contracts) did not have evidence that the inpatient facility has identified an individual within the facility who is responsible for the implementation of the provisions of the agreement. Prague Hospital: There is no reference to a designated individual responsible for the implementation.

Upon inpatient contract review, 2 of 5 (Prague Hospital and Parkland Manor contracts) did not have evidence that the hospice retains responsibility for ensuring that the training of personnel who will be providing the patient's care in the inpatient facility has been provided and that a description of the training and the names of those giving the training are documented. There is no reference to training by hospice in either contract.

Upon inpatient contract review, 2 of 5 (Prague Hospital and Parkland Manor contracts) did not have evidence of a method for verifying that the requirements for ACHC standard HSP1-8B and CFR 418.108c (1)-418.108c(5)are met. There is no documented reference to review or verification process.

Upon SNF/NF contract review, 1 of 5 (Parkland Manor contracts) did not have evidence that specifies the provision of hospice services in the facility, including: A provision that the SNF/NF or ICF/IID immediately notifies the hospice if: • A significant change in a patient's physical, mental, social or emotional status occurs • Clinical complications appear that suggest a need to alter the plan of care • When a need to transfer a patient from the SNF/NF or ICF/MR arises, and the hospice makes arrangements for, and remains responsible for, any necessary continuous care or inpatient care necessary related to the terminal illness and related conditions • A patient dies Parkland Manor Contract: The contract does not specify facility reporting to hospice the significant changes and/or complications or transport or death of patient as described above

Upon SNF/NF contract review, 1 of 5 (Parkland Manor contract) did not have evidence of a provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided. The level of care is not specifically referenced in the contract, and therefore, it is not clearly stated that the hospice retains responsibility for determination

Upon SNF/NF contract review, 1 of 5 (Parkland Manor contract) did not have a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation. There is no such provision for reporting included in contract.

Upon observation, there was no evidence the hospice provides orientation to personnel of a SNF/NF or ICF/IID regarding the policies and procedures of the provision of care/service including all required content. The agency has no documented evidence of facility training/orientation, although reportedly have communicated informally.