Every finding on record at Enso Hospice LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: The effectiveness of drug therapy; Drug side effects; Actual or potential drug interactions; Duplicate drug therapy; and Drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the medications were reviewed for duplicate drug therapy. CLINICAL RECORD 7: The patient elected the hospice benefit on 06/05/2025. The medication profile reviewed on 10/16/2025 included documentation of Furosemide (generic name for Lasix) Oral Tablet 80 MG, take 1 tablet by mouth once a day, started 06/05/2025 and Lasix Oral Tablet 80 MG, take 1 tablet by mouth daily, started 06/05/2025. There was no documented evidence in the clinical record that the patient’s medications were reviewed for duplicate drug therapy. During a joint clinical record review and interview on 10/17/2025, the Interim Director of Nursing confirmed that there was no documented evidence the medications were reviewed for duplicate drug therapy.

It is required that 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 if any of them so desire, and the primary caregiver in accordance with the patient’s needs if any of them so desire. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (18%) clinical records reviewed with spiritual care services, the agency did not ensure hospice care and services were provided as ordered in the plan of care. CLINICAL RECORD 8: The patient elected the hospice benefit on 06/12/2025. The plan of care order dated 09/02/2025 included documentation, "Chaplain 1/mo. PRN 2 [one time a month and two as needed visits]." The Chaplain documented on the Missed Visit Form (Chaplain/Counselor Visit) dated 09/25/2025, "Chaplain visit was not conducted today due to circumstances beyond control. A new visit has been scheduled within a week to complete chaplain services." The next Chaplain visit was documented on 10/08/2025 (14 days later). The record lacked additional attempts for a visit in the month of September 2025. During a joint clinical record review and an interview on 10/17/2025, the Interim Director of Nursing confirmed that additional chaplain visits were not attempted for the records listed.

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the plan of care included planned interventions and goals based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 6: The patient elected the hospice benefit on 09/18/2025. The primary hospice diagnosis was nonrheumatic aortic (valve) stenosis with comorbidities including a personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits. The RN [Registered Nurse] Initial Assessment dated 09/18/2025 documented that the patient had difficulty swallowing food, difficulty chewing, "angina [chest pain] at rest...prior CVA [cerebral vascular accident] with dysarthria and chronic dysphagia [difficulty swallowing] 11/2020." The RN Skilled Nursing Visit dated 09/29/2025 and the RN 14 Day Visit note dated 10/13/2025 included documentation that the patient had dysphagia. The plan of care dated 09/18/2025 did not include problems, interventions, and goals for angina and dysphagia. During a joint review of the record and interview on 10/17/2025, the Interim Director of Nursing confirmed that there was no documented evidence that the plan of care included problems, goals, and interventions for the problems identified in the assessments.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following: a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the plan of care included a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. CLINICAL RECORD 12: The patient elected the hospice benefit on 08/20/2024. The plan of care dated 09/19/2024 did not include a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. During a joint clinical record review and interview on 10/17/2025, the Interim Director of Nursing confirmed that the record lacked a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs in the plan of care.

It is required that the Interdisciplinary Group (IDG), in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires; but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the organization did not ensure the individualized plan of care was reviewed, revised, and documented by the IDG no less frequently than every 15 calendar days. CLINICAL RECORD 1: The patient elected the hospice benefit on 12/17/2024. There was no documented evidence of an IDG meeting or plan of care update between 05/27/2025 to 10/15/2025 where the IDG reviewed, revised, and documented the individualized care plan. During a joint clinical record review and interview on 10/17/2025, the Interim Director of Nursing confirmed that the record lacked evidence that the individualized plan of care was reviewed and documented by the IDG no less frequently than every 15 calendar days. During the interview, the Alternate Administrator explained the Director of Nursing was unavailable for interview due to a medical emergency and it is possible she could provide more explanation.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, observation, and interview. In 1 of 3 (33%) home visit observations, the agency did not ensure the staff performed hand hygiene as required by agency policy. Agency policy IC.15 Hand Hygiene, last reviewed 09/01/2024, required in part, "I. Hand Hygiene with soap and water. Staff will identify and gather appropriate supplies. Staff will wet hands and wrists with water using temperature that is conformable. Staff will apply the amount of product recommended by the manufacturer to hands and rub hands together vigorously for at least 15 seconds (with the recommendation of 20 seconds, but either time is acceptable), covering all surfaces of the hands and fingers. Staff will rinse hands and wrists thoroughly with water. With hands held upright, staff will dry hands and wrists thoroughly with a clean paper towel. They will use a paper towel to turn off the faucet." HOME VISIT 3: During the home visit observation on 10/15/2025 with the Hospice Aide (HA) (Personnel Record 8), the HA was observed to wash the hands with soap and water. The HA looked around for a towel and turned off the water with the wet hands. The HA looked in the bathroom drawers for a towel. The HA retrieved a cloth towel and dried the hands. The HA stated hands are usually washed, dried with a paper towel, and then the water is turned off with the paper towel. The HA did not follow the agency’s hand hygiene policy when hands were washed. During a joint review of the site visit and interview on 10/17/2025, the Administrator/Bereavement Coordinator/Volunteer Coordinator and the Interim Director of Nursing agreed the hospice aide did not follow the agency’s hand hygiene policy.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered, the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed with patient discharge due to death, the hospice did not ensure documentation that bereavement services were provided to the bereaved. CLINICAL RECORD 13: The patient elected the hospice benefit on 10/21/2024. The patient died on 12/14/2024. There was no documented evidence in the clinical record of a bereavement plan of care, that bereavement services were provided, or that the caregiver/family declined bereavement services. CLINICAL RECORD 14: The patient elected the hospice benefit on 03/18/2025. The patient died on 04/06/2025. There was no documented evidence in the clinical record of a bereavement plan of care, that bereavement services were provided, or that the caregiver/family declined bereavement services. During a joint clinical record review and interview on 10/16/2025, the Administrator/Bereavement Coordinator/Volunteer Coordinator reported making phone calls and the Chaplain would manage the bereaved with "deeper needs." The Administrator/Bereavement Coordinator/Volunteer Coordinator confirmed that the bereavement services were not being documented. During a joint clinical record review and interview on 10/16/2025, the Alternate Administrator agreed there was no documented evidence that bereavement services were provided. The Alternate Administrator stated that a Performance Improvement Project was initiated on 09/23/2025 after a review of the clinical records revealed that bereavement services were not being documented.

It is required that hospice aides are assigned to a specific patient by a Registered Nurse (RN) who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 3 of 11 (27%) clinical records reviewed with hospice aide services provided, the hospice did not ensure the Registered Nurse provided patient specific care instructions to the Hospice Aide. CLINICAL RECORD 8: The patient elected the hospice benefit on 06/12/2025. The aide care plans dated 06/12/2025 and 09/10/2025 assigned the aide the tasks of "Complete Bed Bath PRN [as needed] and Complete Shower Every Visit." The aide care plans did not provide clear instructions to the hospice aide regarding the type of bath. CLINICAL RECORD 9: The patient elected the hospice benefit on 09/14/2025. The aide care plan dated 09/14/2025 assigned the aide the tasks of "Complete Bed Bath as Needed and Complete Shower as Needed." The aide care plan did not provide clear instructions to the hospice aide regarding the type of bath. CLINICAL RECORD 10: The patient elected the hospice benefit on 07/08/2025. The aide care Plan dated 07/08/2025 assigned the aide the tasks of "Complete Bed Bath as Needed and Complete Shower Every Visit as Tolerated." The care plan did not provide clear instructions to the hospice aide regarding the type of bath. During a joint clinical record review and interview on 10/17/2025, the Interim Director of Nursing agreed the instructions on the hospice aide care plan were not specific for the baths.

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 1 of 11 (9%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aide provided services ordered by the Interdisciplinary Group and included in the plan of care. CLINICAL RECORD 7: The patient elected the hospice benefit on 06/05/2025. The hospice aide care plan dated 08/04/2025 assigned the aide the tasks of assist to dress, complete bed bath, comb hair, foot care, peri care, shampoo hair, skin care, oral hygiene denture care, check pressure areas, nail care, change linen, light housekeeping clean patient area, turn or position, catheter care, incontinent care, and last bowel movement document date. The hospice aide visits notes dated 08/04/2025, 08/06/2025, 08/08/2025, 08/11/2025, 08/13/2025, 08/15/2025, 08/18/2025, 08/20/2025, 08/22/2025, 08/25/2025, 08/27/2025, 08/29/2025, and 09/10/2025 did not include documentation of the tasks that were performed by the aide during the visit. During a joint clinical record review and interview on 10/17/2025, the Alternate Administrator (AA) stated that a Performance Improvement Project (PIP) was initiated on 09/23/2025 after discovering that an aide was entering visit times and signing the notes without a care plan that included interventions/instructions for the aide to complete for Clinical Record 7. The AA stated that the aide would go into the actual care plan to see what the patient's needs were. The AA reported that the aide failed to complete a narrative of the completed tasks and did not notify the RN or supervisor about the absence of an aide care plan. Education with the aide occurred as part of the PIP. The AA stated that the visit notes were deleted and recreated on 10/14/2025 for the aide to complete. The visit notes had not been completed as of the date of record review.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. The agency did not ensure documentation of volunteer recruitment and retention efforts. Review of the volunteer program revealed the agency had not consistently documented volunteer recruitment and retention efforts. A flyer was provided that the Administrator/Bereavement Coordinator/Volunteer Coordinator stated had been taken to some churches, but there was no documentation of when and where the flyer had been distributed. During a joint document review and interview on 10/16/2025, the Administrator/Bereavement Coordinator/Volunteer Coordinator confirmed that the recruitment and retention efforts were not documented consistently. Upon reviewing the volunteer program, the documentation lacked evidence of efforts to retain volunteers since March 2024 to date. There was a flyer that the Administrator/Beravement Coordinator/Volunteer Coordinator stated taking to some churches but it was not documented.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. Review of the agency’s volunteer program revealed the agency did not ensure hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours. Review of the volunteer program revealed the total administrative and direct care service volunteer hours and direct patient care hours for all paid hospice employees and contracted staff from October 2024 through September 2025 equaled 3.93%. The agency did not ensure that volunteer hours accounted for at least five percent of the total patient care hours provided by paid and contract staff. During a joint review of the volunteer program records and interview on 10/16/2025, the Administrator/Bereavement Coordinator/Volunteer Coordinator confirmed that the agency did not meet the volunteer percentage of 5% from October 2024 through September 2025. Upon reviewing the volunteer program, the total administrative and direct care service volunteer hours and direct patient care hours for all paid hospice employees and contracted staff from October 2024 through September 2025 equaled 3.93%. The agency admitted the first patient in March 2024. There were no documented volunteer hours from March 2024 through September 2024. The agency did not ensure that volunteer hours accounted for at least five percent of the total patient care hours provided by paid and contract staff.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed with patient transfer, the agency did not ensure the discharge summary was sent to the receiving Medicare/Medicaid certified facility. CLINICAL RECORD 12: The patient elected the hospice benefit on 08/20/2024 and was transferred to another hospice provider on 11/25/2024. There was no documented evidence in the clinical record that the discharge summary was forwarded to the receiving hospice. During a joint record review and interview on 10/17/20253, the Interim Director of Nursing confirmed that the record lacked evidence that the discharge summary was sent to the receiving hospice provider.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed with patient revocation of hospice benefit, the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 11: The patient elected the hospice benefit on 01/17/2025 and revoked the hospice benefit on 05/28/2025. There was no documented evidence in the clinical record, that the discharge summary dated 05/28/2025 was forwarded to the patient's attending physician. During a joint record review and interview on 10/17/2025, the Interim Director of Nursing confirmed that the record lacked evidence that the discharge summary was forwarded to the patient’s attending physician.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following, a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed with patient discharge, the agency did not ensure the discharge summary included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; and the patient’s latest physician orders. CLINICAL RECORD 11: The patient revoked the hospice benefit on 05/28/2025. The discharge summary dated 05/28/2025 did not include a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; and the patient’s latest physician orders. CLINICAL RECORD 12: The patient was transfer to another hospice agency on 11/25/2024. The discharge summary did not include a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; and the patient’s latest physician orders. During a joint record review and interview on 10/17/2025, the Interim Director of Nursing confirmed that the records lacked evidence of a completed discharge summary that included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; and the patient’s latest physician orders.