DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
261600 A. BUILDING __________
B. WING ______________ 		12/28/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
ASCEND HOSPICE 783 NE ANDERSON LANE, LEES SUMMIT, MO, 64064
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0509      
29982 Based on agency admission booklet on patient rights, the agency's complaint log, record review, and interview, the agency failed to immediately investigate alleged violations and take action to prevent further potential violations for one patient (Record/Patient #1) of three records reviewed. This deficient practice has the potential to adversely affect the rights of all the agency's patients. Findings included: Review of the agency's policy titled, "Assessment of Possible Abuse/Neglect," dated revised April 2018, failed to show that the agency would immediately investigate alleged violations and take immediate action to prevent further potential violations. Review of the agency's admission booklet, dated revised April 2021, showed the following: -The patient has the right to be free from mistreatment, neglect, verbal, mental, sexual, and physical abuse, corporal punishment, injuries of unknown source, and misappropriation of patient property; -All mistreatment, abuse, neglect, injury and exploitation complaints by anyone furnishing service on behalf of hospice are reported immediately by agency staff to the hospice administrator; and -All reports will be promptly investigated and immediate action taken to prevent potential violations during the agency investigation. Review of the agency's complaint log, dated 12/16/2021, showed LPN (licensed practical nurse) A, reported to the agency regional manager that Patient #1 had alleged that agency staff member hospice aide B had been rough with him/her in the shower and hit him/her in the mouth and was argumentative with him/her at the dining room table. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the agency on 08/20/2019. The terminal diagnosis was senile degeneration of the brain (dementia that is characterized by a decrease in cognitive abilities or mental decline). The patient lived in an assisted living facility and was 106 years old. The hospice aide was to visit twice weekly and the hospice nurse was to visit weekly. During an interview on 12/27/2021 at 12:50 PM, the executive director stated that: -He/she was aware of the allegation; -That hospice aide B would not be allowed to care for Patient #1; -Did not immediately interview any other patient's that hospice aide B had cared for; and -Hospice aide B was allowed to continue to care for all other patients. The agency failed to complete an immediate investigation and take immediate action to prevent potential violations.