Every finding on record at Enlighten Hospice LLC

Upon observation, there was no evidence the patient record, whether hard copy or in electronic form, is made readily available on request by an appropriate authority. On Wednesday 08/22/25 at 10:00 AM PST, I entered the agency and was greeted by the office manager. I requested to speak to the Administrator, however she was not present and was told she would be there soon. In the meantime, I requested the unduplicated admission report and access to Hospice MD at 10:02AM. I requested again at 10:30AM; 10:55 AM and at 11:15 AM with still no access. Received access at 11:35AM.

Upon patient record review, 1 of 5 records (Patient #5) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #5: The medication profile listed Tylenol 325mg, 2 tablets orally every 4 hours as needed for mild pain and acetaminophen rectal suppository 650mg every four hours as needed for mild pain or fever 100.4 or higher however, there was not evidence of a maximum allowable dose.

Upon patient record review, 1 of 5 records (Patient #5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #5: The record indicated orders for Tylenol 325mg, 2 tablets orally every 4 hours as needed for mild pain and acetaminophen rectal suppository 650mg every four hours as needed for mild pain or fever 100.4 or higher however, there was not evidence of a maximum allowable dose.

Upon patient record review, 1 of 6 (Patient #5) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #5 - The record indicated an order for oxygen 2l/min via nasal cannula as needed for difficulty of breathing, there was no evidence of the oxygen on the medication list.

Upon patient record review, 6 of 6 (Patient #1,2,3,4,5,6) 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 a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Patient 1,2,3,4,5,6 - The record indicated orders for chaplain and social worker visit frequencies as 1x/month and prn. There was no indication in the order of the quantity or indication for the prn visits.

Upon patient record review, 2 of 6 (Patient #1,6) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1,6 - The record indicated an order for A&D ointment apply to skin daily for skin maintenance. The order is not specific to indicate where to apply the ointment. COS

Upon observation of home visits, 1 of 3 applicable (Patient #1) did not have evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1 - Upon observation during the visit the nurse didn't change the gloves she wore to assess the patient and empty the Foley catheter urine bag, prior to cleaning her assessment equipment and putting it pack into her bag.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 1 applicable (Personnel #9) did not have evidence in the personnel file that an aide competency was completed. Personnel # 9 - There is no evidence in the aide's personnel file of a competency assessment completed by an evaluator observing the aide's performance of the required tasks with patient or pseudo-patient. The evaluator marked the vital sign section as evaluated verbally but for all other tasks it was marked as chart review.

Upon patient record review, 1 of 2 applicable (Patient #1) did not have evidence in the patient record that hospice aide assignments and duties include the tasks to be provided and the frequency of those tasks. Patient #1 - The record included an order for "Calmoseptine cream apply to buttocks/groin with each diaper change to maintain skin integrity." The aide care plan indicated the aide was to provide diaper changes, but there was no evidence of the specific instructions to apply the Calmoseptine cream per the order. The patient had an order for pureed diet and nectar thickened liquids. The aide care plan said diet as tolerated, feeding assistance, and aspiration precautions with no specifics for the aide as to the order of a pureed diet and nectar thickened liquids. COS

Upon patient record review, 2 of 2 applicable (Patient #1,6) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #1- The record indicated a 2/26/22 order for aide visits 1x/week. The Alt DPCS upon interview said the agency week is Sunday-Saturday. There was no evidence in the record of an aide visit on Saturday 2/26/22. Patient #6 - The record contained an aide visit frequency order written on 9/13/21 for 2x/week. Documentation revealed no aide visits were made till 11/11/21. On 11/11/21, there was an order for aide visits 1x/week for that week, then 2x/week for personal cares and ADLs. There is no evidence of aide visits the week of 11/14/21. There was an order on 11/29/21 for a visit 1x/week and then 2x/week, but there are 2 visits documented on 11/29 and 12/2. There was no evidence of visits for the weeks of 12/12/21, 12/19/21, or 12/26/21. The record had 1 visit documented for the weeks of 1/2/22 was 1/7/22 when the order was visits 2x/week. There were no visits documented for the week of 1/9/22. There was no evidence of missed visit notes or additional orders.

Upon patient client record review, 1 of 6 (Patient #3) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #3 - The CTI in the record contained a section for the nurse to document her assessment in addition to the physician completing the narrative note. There was conflicting information on the CTI with the nurse documenting KPS/PPS 50/50 and Dr. documenting in the narrative note KPS/PPS 40/40.

Upon client record review, 6 of 6 (Patient #1,2,3,4,5,6) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient 1,2,3,4,5,6 - There is no evidence in the clinical record that the patient/family received a copy of the agency's policy related to management and disposal of controlled medications.