Every finding on record at Aspen Hospice and Palliative Care LLC

Based on interview and agency policy review, the hospice agency failed to implement its grievance policy and procedures by not identifying, documenting, or resolving grievances from 03/25/25 through 03/27/26. This failure had the potential to cause patients and caregivers' concerns unaddressed for 33 active patients.Findings include: --- During an interview on 03/27/26 at 3:47 PM, the Administrator acknowledged that grievance forms had not been completed to document patient and caregiver grievances or their resolutions in accordance with the agency’s grievance policy. The Administrator was responsible for documenting grievances when reported but confirmed that prior complaints, including dissatisfaction with staff members, had been addressed informally without being formally recorded.Review of the agency's policy titled " Resolution of Patient Conflicts, Grievances or Complaints," reviewed 12/01/25, provided by the agency, revealed "… Policy I. The Hospice will investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family … VI. Documentation will include, but not be limited to, the name, address and phone number of the person filing the complaint, the nature of the complaint, and the remedy/relief the person is seeking. VII. The Hospice will complete the investigation and documentation of the resolution per state guidelines upon receipt of the complaint … XII. All actions taken and follow-up performed will be documented on the complaint form, as well as reported to the management staff …"

Based on interview, observation, record review, review of the Certified Nursing Assistant (CNA) job description, review of Lippincott Nursing Procedure, and policy review, the hospice agency failed to ensure care and services were provided per the patients plan of care  for one (Patient (P) 2) out of a total of 14 sampled patients. This failure had the potential to result in the patient having unmet care needs.  Findings include: --- Review of P2's "Patient Profile," provided by the agency, revealed P2 was admitted to hospice on 03/20/26 with a diagnosis of a cerebral infarction (CVA).Review of P2's "Plan of Care," dated 03/26/26, provided by the agency, revealed P2 would receive a bed bath weekly by the hospice aide.During a home visit observation on 03/26/26 at 10:12 AM CNA 1 completed a bed bath for P2. CNA1 used a washcloth to clean P2's abdomen and then groin and perineum and let it air dry, and then discarded her gloves, washed her hands, and put on a new pair of gloves. CNA1 used a washcloth to clean P2's right leg and left leg but did not clean P2's right or left foot or web spaces.During an interview on 03/26/26 at 11:00 AM, CNA1 confirmed P2's feet were not washed. CNA1 stated that a bed bath included cleaning and drying the right and left foot. CNA1 received supervised visits by the registered nurses, completed competency for a bed bath upon hire, and received training on bed baths. CNA1 stated that the purpose of the bed bath was to ensure that P2 was clean.During an interview on 03/27/26 at 9:33 AM, the Administrator expected CNA1 to perform a bed bath in accordance with standards of practice and per the care plan. The Administrator stated that hospice aides should clean the patients from head to toe to leave them in a dignified clean state. Review of the CNA1's "Hospice Certified Nursing Assistant Job Description," signed on 11/02/23, provided by the agency, revealed "…  Responsibilities of the certified nursing assistant include, but are not limited to, the following: I. Performing personal care needs after given a patient's assignment and attending to his/her requests promptly …"Review of the "Lippincott® Nursing Procedure Ninth Edition," page 55, provided by the agency, revealed the procedure for a bed bath included to "Use a fourth cloth to clean the patient's right leg, right foot, and web spaces Use a fifth cloth to clean the patient's left leg, left foot, and web spaces …"Review of the agency's policy titled "Hospice Aide/Homemaker Competency Evaluation," reviewed 09/01/24, provided by the agency, revealed " … Policy I. The Hospice will ensure that each hospice aide successfully completes a hospice aide skills and competency evaluation in accordance with federal and state laws and regulations prior to the aide performing care independently … Procedure … 1. The following subject areas must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient: … c. Appropriate and safe techniques in performing personal hygiene and grooming tasks, including: (1) Bed bath, …"

It is required that the hospice designates a registered nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any); the patient or patient representative; the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by a review of clinical records and interviews. In 3 of 6 (50%) records reviewed revealed the hospice did not ensure the chaplain followed the plan of care as ordered. Record #3: This patient was admitted to hospice on 6/12/2022. The plan of care dated 6/12/2022 documented the chaplain visit frequency as "1wk13." The nursing visit completed on 6/12/2022 documented the patient accepted chaplain services. During the weeks of 6/19/2022-6/25/2022, 6/26/2022-7/2/2022, and 7/3/2022-7/9/2022 there was no documented evidence of a chaplain visit or documented reasons for the missed visits. Record #4: This patient was admitted to hospice on 6/20/2022. The plan of care dated 6/20/2022 documented the chaplain visit frequency as "1wk1." The nursing visit completed on 6/20/2022 documented the patient accepted chaplain services. During the week of 6/20/2022-6/25/2022, there was no documented evidence of a chaplain visit or documented reasons for the missed visit. Record #6: This patient was admitted to hospice on 6/20/2022. The plan of care dated 6/20/2022 documented the chaplain visit frequency as "2wk1." The nursing visit completed on 6/20/2022 documented the patient accepted chaplain services. During the week of 6/20/2022-6/25/2022, there was a chaplain visit on 6/22/2022. There was no documented evidence of a second chaplain visit or documented reason for the missed visit. The Administrator was interviewed on 8/11/2022 and confirmed, the chaplain did not follow the plan of care as ordered.

It is required that a hospice aide provides services are ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 5 (20%) records reviewed of patients receiving hospice aide services revealed the hospice did not ensure the hospice aide followed the plan of care as ordered.. Record #6: This patient was admitted to hospice on 6/20/2022. The plan of care dated 6/20/2022 documented, "hospice aide 3w12." During the week of 6/26/2022-7/2/2022, there were hospice aide visits documented as completed on 6/29/2022 and 7/1/2022. There was no evidence of a third hospice aide visit completed that week. During the week of 7/3/2022-7/9/2022, there was a hospice aide visit documented as completed on 7/8/2022. There was no evidence of a second or a third hospice aide visit completed that week. There were no reasons documented for the missed visits and no evidence of communication with the physician. The Administrator was interviewed on 8/11/2022 and confirmed, the hospice aide did not follow the plan of care as ordered. Record 6: This patient was admitted to hospice on 6/20/2022. The plan of care on 6/20/2022 assigned a hospice aide 3w12. During the week 6/26/2022-7/2/2022, there was a hospice aide visit on 6/29/2022 and 7/1/2022. There was no documented evidence of a third hospice aide visit that week. During the week 7/3/2022-7/9/2022, there was a hospice aide visit on 7/8/2022. There was no documented evidence of a second or third visit that week. There were no documented reasons for the missed visits. The Administrator was interviewed on 8/11/2022 and agreed, the hospice aide did not follow the plan of care as ordered.

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 a review of clinical records and interviews. 4 of 6 (67%) records reviewed revealed the hospice did not ensure the clinical record included a physician’s order for nursing visits. Record #2: This patient was admitted to hospice on 6/30/2022. Review of the clinical record revealed PRN (as needed) nursing visits were completed on 7/2/2022, 7/3/2022, and 7/15/2022. There was no documented evidence of communication with the physician or a physician's order for the "as needed" visits. Record #3: This patient was admitted to hospice on 6/12/2022. Review of the clinical record revealed PRN (as needed) nursing visits were completed on 6/14/2022, 6/18/2022, and 6/20/22. There was no documented evidence of communication with the physician or a physician's order for the "as needed" visits. Record #4: This patient was admitted to hospice on 6/20/2022. Review of the clinical record revealed a PRN (as needed) nursing visit was completed on 7/6/2022. There was no documented evidence of communication with the physician or a physician's order for the "as needed" visit. Record #5: This patient was admitted to hospice on 6/22/2022. Review of the clinical record revealed a PRN (as needed) nursing visit was completed on 6/24/2022. There was no documented evidence of communication with the physician or a physician's order for the "as needed" visit. The Administrator was interviewed on 8/11/2022 and confirmed, there were no documented physician orders for the PRN visits. Record 2: This patient was admitted to hospice on 6/30/2022. Review of the clinical record revealed PRN (as needed) nursing visits were completed on 7/2/2022, 7/3/2022, 7/15/2022. There was no documented evidence of a physican’s order for the visits. Record 3: This patient was admitted to hospice on 6/12/2022. Review of the clinical record revealed PRN (as needed) nursing visits were completed on 6/14/2022, 6/18/2022, 6/20/22. There was no documented evidence of a physican’s order for the visits. Record 4: This patient was admitted to hospice on 6/20/2022. Review of the clinical record revealed a PRN (as needed) nursing visit was completed on 7/6/2022. There was no documented evidence of a physican’s order for the visit. Record 5: This patient was admitted to hospice on 6/22/2022. Review of the clinical record revealed a PRN (as needed) nursing visit was completed on 6/24/2022. There was no documented evidence of a physican’s order for the visit. The Administrator was interviewed on 8/11/2022 and agreed, there were no documented physician orders for the PRN visits.