Every finding on record at Essence Home Care, 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; other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy, frug side effects, actual or potential drug interactions, duplicate drug therapy, 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, observation, and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure an accurate review of the medications the patient was currently using to identify any potential adverse effects and drug reactions. CLINICAL RECORD 2/HOME VISIT 2: The patient elected the hospice benefit on 11/12/2024 with a diagnosis of Alzheimer's disease. The patient resided in a skilled nursing facility (SNF). During the home visit observation on 11/19/2025 with the Social Worker (SW) (Personnel Record 4), a medication review was completed by comparing the SNF medication list (the patient’s current home medications) to the hospice medication profile (printed on 11/19/2025). The hospice medication profile included Lorazepam and Santyl. The SNF medication list did not include Lorazepam and Santyl. During interviews on 11/18/2025 and 11/19/2025, the Clinical Director verified the findings and stated the record was corrected prior to the survey exit on 11/20/2025.

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; Includes all services necessary for the palliation and management of the terminal illness. This standard was not met as evidenced by clinical record review and interview. In 7 of 19 (37%) clinical records reviewed, the agency did not ensure the written plan of care included planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 1: The patient elected the hospice benefit on 11/19/2023 with a diagnosis of Alzheimer's disease. The Registered Nurse (RN) documented on the initial nursing assessment dated 11/19/2023 the patient had dysphagia (difficulty swallowing), choking, and recurrent aspiration. The plan of care dated 11/19/2023 did not include interventions and goals related to the patient’s nutritional needs and risk of aspiration. CLINICAL RECORD 2: The patient elected the hospice benefit on 11/12/2024 with a diagnosis of Alzheimer's disease. The plan of care dated 11/12/2024 included an order for oxygen at 2 liters per minute per nasal cannula as needed. The plan of care did not include interventions and goals related to oxygen precautions. CLINICAL RECORD 3: The patient elected the hospice benefit on 02/02/2025 with a diagnosis of senile degeneration of the brain. The admission referral orders dated 02/02/2025 included orders for suction equipment, oxygen at 2 liters per nasal cannula, and Ipratropium small volume nebulizer every 6 hours as needed for shortness of breath. The plan of care dated 02/02/2025 did not include respiratory goals and interventions related to the patient’s use of oxygen, the small volume nebulizer, and suction equipment. CLINICAL RECORD 4: The patient elected the hospice benefit on 10/02/2025 with a diagnosis of Parkinsonism. The nurse documented on the initial nursing assessment dated 10/02/2025 that the patient was using oxygen at 2 liters per nasal cannula. The plan of care dated 10/02/2025 did not include goals and interventions for oxygen safety. CLINICAL RECORD 7: The patient elected the hospice benefit on 10/13/2025 with a diagnosis of malignant neoplasm of left bronchus or lung. The nurse documented on the initial nursing assessment dated 10/13/2025 that the patient had oxygen at 2 liters per minute per nasal cannula continuously. The plan of care dated 10/13/2025 did not include respiratory goals and interventions related to the patient’s diagnosis of lung cancer. CLINICAL RECORD 9: The patient elected the hospice benefit on 10/10/2025 with a diagnosis of acute on chronic heart failure. The nurse documented on the initial nursing assessment dated 10/10/2025 that the patient used oxygen at 2 liters per minute per nasal cannula. The initial plan of care dated 10/10/2025 did not include goals and interventions related to oxygen safety. CLINICAL RECORD 14: The patient elected the hospice benefit on 05/27/2025 with a diagnosis of Alzheimer's disease. The initial nursing assessment dated 05/27/2025 and physician orders dated 05/27/2025 included documentation that the patient was using oxygen. The plan of care dated 10/27/2025 did not include goals and interventions related to oxygen safety. During interviews on 11/18/2025 and 11/19/2025, the Clinical Director verified the findings.

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 5 of 19 (26%) clinical records reviewed, the agency did not ensure the individualized written plan of care included the scope and frequency of services. CLINICAL RECORD 2: The patient elected the hospice benefit on 11/12/2024 with a diagnosis of Alzheimer's disease. The plan of care dated 11/12/2024 included an order for "SC (spiritual counselor) 1 time then PRN (as needed)." The order on the plan of care did not include the scope and frequency for the spiritual counselor (SC) visits and did not include an indication or reason for the SC visits ordered as needed. CLINICAL RECORD 3: The patient elected the hospice benefit on 02/02/2025 with a diagnosis of senile degeneration of the brain. The plan of care dated 02/02/2025 included an order for "Spiritual Counselor 1 time then PRN (as needed)." The order on the plan of care did not include the scope and frequency for the SC visits and did not include an indication or reason for the SC visits ordered as needed. CLINICAL RECORD 4: The patient elected the hospice benefit on 10/02/2025 with a diagnosis of Parkinsonism. The plan of care dated 10/02/2025 included an order for social worker "1 one-time then PRN (as needed)." The order on the plan of care did not include the scope and frequency for the social work (SW) visits and did not include an indication or reason for the SW visits ordered as needed. CLINICAL RECORD 5: The patient elected the hospice benefit on 08/26/2025 with diagnosis of senile degeneration of the brain. The plan of care dated 08/26/2025 included an order for "spiritual assessment 1x/then PRN (as needed)." The order on the plan of care did not include the scope and frequency for the SC visits and did not include an indication or reason for the SC visits ordered as needed. CLINICAL RECORD 9: The patient elected the hospice benefit on 10/10/2025 with a diagnosis of acute on chronic heart failure. The plan of care (need date) included an order for social worker frequency "assess as needed 1x and PRN and recert." The order on the plan of care did not include the scope and frequency for the SW visits and did not include an indication or reason for the SW visits ordered as needed. During interviews on 11/19/2025 and 11/20/2025, the Clinical Director and Executive Director verified the findings.

It is required that each patient’s individualized written plan of care included all services necessary for the palliation and management of the terminal illness, including drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 5 of 19 (26%) clinical records reviewed, the agency did not ensure the individualized written plan of care included drugs and treatment necessary to meet the needs of the patient. CLINICAL RECORD 3: The patient elected the hospice benefit on 02/02/2025 with a diagnosis of senile degeneration of the brain. The admission referral orders dated 02/02/2025 included orders for suction equipment and oxygen at 2 liters per nasal cannula. The plan of care dated 02/02/2025 did not include the dose and frequency of administrator for oxygen and did not include instructions on when to use the suction equipment. CLINICAL RECORD 9: The patient elected the hospice benefit on 10/10/2025 with a diagnosis of acute on chronic heart failure. The plan of care dated 10/10/2025 included an order for Lidocaine patch "apply to affected area." The medication order on the plan of care did not include specific instructions for where to apply the lidocaine patch. CLINICAL RECORD 11: The patient elected the hospice benefit on 08/31/2025 with a diagnosis of chronic obstructive pulmonary disease. The plan of care dated 08/31/2025 included orders for Budesonide inhalation therapy every 6 hours "as needed for shortness of breath/wheezing" and Levalbuterol inhalation every 6 hours "as needed for shortness of breath/wheezing." The medication orders on the plan of care did not include instructions for when to give Budesonide and Levalbuterol, or which medication should be given first, and did not include parameters that would indicate which medication to administer for the patient’s level of shortness of breath. CLINICAL RECORD 12: The patient elected the hospice benefit on 08/08/2025 with a diagnosis of chronic obstructive pulmonary disease. The plan of care dated 09/01/2025 included medication orders for Nystatin cream to "affected areas" and Clotrimazole topical cream for "fungal nail infection." The medication orders on the plan of care did not include specific instructions for where to apply the Nystatin cream and which nail(s) to apply the Clotrimazole cream. The plan of care also included a medication order for Z-pak as directed; however, the order did not include specific directions for administration of the medication. CLINICAL RECORD 14: The patient elected the hospice benefit on 05/27/2025 with a diagnosis of Alzheimer's disease. The plan of care dated 10/29/2025 included an order for Lidocaine patch "to affected area." The medication order on the plan of care did not include specific instructions for where to apply the lidocaine patch. During interviews on 11/18/2025 and 11/19/2025, the Clinical Director verified the findings and stated the records were corrected prior to the survey exit on 11/20/2025.

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. The hospice did not ensure volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent of the total patient care hours of all paid hospice employees and contract staff. During a review of the agency’s volunteer program and interview with the Volunteer Coordinator (Personnel Record 6) on 11/18/2025, it was revealed that the agency did not have a Volunteer Coordinator from January 2024 until 11/07/2025. There was also, no documented evidence that the agency had volunteers available from January 2024 through the date of review on 11/20/2025. Review of the volunteer report from January 2024 to January 2025 revealed the volunteer percent of total patient care hours was 0%. The agency had a performance improvement project related to the issue and was able to show evidence of recruitment efforts for 2024 and 2025. The Volunteer Coordinator was hire on 11/07/2025 and there were currently 10 volunteers in the recruitment process. During an interview on 11/20/2025, the Executive Director verified the finding and stated the Volunteer Coordinator was hired on 11/07/2025. During the interview on 11/18/2025 with the volunteer coordinator (PR6) it was revealed that the agency did not have a volunteer coordinator in place from January 2024 until 11/07/2025. There were no volunteers employed from January 2024 through date of review 11/20/2025. The agency had 0% volunteer hours from January 2024 to January 2025, and January 2025 to date of review 11/20/2025. There was a performance improvement plan (PIP) in place 2023 through 2025 which did not record updates related to attempts to hire a volunteer coordinator or volunteers. There were ads placed on 06/05/2023, 06/05/2024, and 01/05 2025 on INDEED and Craig's List for a volunteer coordinator and volunteers. A volunteer coordinator was hired on 11/07/2025 and is currently in training and developing a training program for volunteers, there are currently approximately 10 volunteers in the recruitment process.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum: any advance directives. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure documentation of the patient’s advance directive. CLINICAL RECORD 6: The patient elected the hospice benefit on 10/21/2025 with a diagnosis of chronic obstructive pulmonary disease. The nurse documented on the initial nursing comprehensive assessment that the patient was a DNR (do not resuscitate). The POLST (physician orders for life sustaining treatment) form documented patient requested CPR (cardio-pulmonary resuscitation) to be attempted. The clinical record patient information sheet documented patient was "full code." The documentation in the clinical record related to the patient’s advance directives was not clearly documented. During an interview on 11/19/2025, the Clinical Director confirmed the finding and stated the documentation was corrected prior to the survey exit on 11/20/2025.

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 a review of clinical records and interviews. 3 of 9 (33%) records reviewed for patients receiving hospice aide services revealed the agency did not ensure that the hospice aide provided services as ordered on the plan of care (POC). Clinical Record 8: The patient elected hospice care on 8/26/2022. The POC dated 8/26/2022 ordered hospice aide (Aide) services three times a week. A review of completed Aide visit notes revealed one missed aide visit for the week ending 12/31/2022. There was no evidence of a documented missed visit or communication with the physician changing the visit frequency. Clinical Record 3: The patient elected hospice care on 10/7/2022. The POC dated 10/7/2022 ordered Aide services two times a week. A review of completed Aide visit notes revealed one missed Aide visit for the weeks ending 12/17/2022 and 12/24/2022. There was no evidence of documented missed visits or communication with the physician changing the visit frequency. Clinical Record 2: The patient elected hospice care on 12/17/2022. The POC dated 12/17/2022 ordered Aide services three times a week. A review of completed Aide visit notes revealed one missed aide visit for the week ending 12/31/2022. There was no evidence of a documented missed visit or communication with the physician changing the visit frequency. During an interview and joint review of the records on 1/4/2023, the Administrator and Director of Nursing confirmed that the aide visits were missed and that the agency did not have documentation of why the missed visits were not provided.

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 a review of clinical records and interviews. 1 of 1 (100%) record review of a patient discharged from hospice care revealed the agency did not ensure that a discharge summary was forwarded to the patient's attending physician. Clinical Record 13: The patient elected hospice care on 1/11/22 and was discharged from hospice care on 8/30/22. A review of the record revealed that a discharge summary was not forwarded to the attending physician. During an interview and a joint review of the record on 1/4/23, the Executive Director and Director of Patient Care confirmed that the discharge summary was not forwarded to the attending physician.