Enhabit Hospice Birmingham

“It is required that each patient’s individualized written plan of care: reflects patient and family goals; [and] 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 30 (13%) clinical records reviewed, the agency did not ensure that the patient’s plan of care reflected the patient’s and family’s goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 3: The patient elected hospice care on 06/14/2025 with a primary diagnosis of ASHD (arteriosclerotic heart disease). On admission, the patient was taking alprazolam 1 mg twice daily for anxiety. On 08/07/2025, the dose was increased to 3 times a day related to the patient’s increased anxiety. The interdisciplinary team (IDT) documented on 09/03/2025 and 09/17/2025 did not update the plan of care to include documentation of the patient’s problem with anxiety or interventions to address it. The plans of care had not been updated to include planned interventions and patient and family goals to address the identified increase in the patient’s anxiety as of the 08/03/2026 clinical record review. The patient continues the medication as of the review on 08/03/2026. During interviews and joint record reviews on 08/04/2026 and 08/05/2026, the Clinical Director confirmed that the plans of care had not been updated with individualized interventions.”

“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: 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 2 of 30 (7%) clinical records reviewed, the agency did not ensure that the patient’s plan of care included the drugs and treatments necessary to meet the patient’s needs. CLINICAL RECORD 4: The patient elected hospice care on 01/28/2025 with a primary diagnosis of Parkinson’s disease. On admission, the patient had a suprapubic catheter. Orders were written on 06/25/2025 to change the catheter monthly. A physician order was written on 01/06/2026 to flush the catheter. The plans of care dated 01/28/2025 and continued through 08/03/2026 ordered: “insert or change catheter per order and instruct the patient regarding irrigation of catheter.” The catheter was an 18 French with a 30cc balloon. The plan of care orders for irrigation did not include documentation of what to irrigate the catheter with or how much to irrigate with. CLINICAL RECORD 8: The patient elected hospice care on 05/21/2025 with a primary diagnosis of CVA (cerebrovascular accident). The patient was admitted with a supra pubic catheter. The plan of care dated 05/21/2025 and updated every two weeks ordered: “Insert or change catheter per orders. Instruct patient caregiver regarding irrigation of catheter.” On 06/02/2025, the physician ordered a “16 FR catheter/ 5cc balloon change monthly. May flush with 50 cc normal saline as needed. The physician order dated 07/24/2025 ordered a 16 FR catheter/10cc balloon; change monthly. Flush with 30cc sterile water as needed.” On 11/25/2025, the physician ordered flushing with 50 cc of sterile water PRN (as needed). On 01/13/2026, the physician ordered a 16 FR catheter with a 5cc balloon. On 02/24/2026, the physician ordered a 16 FR catheter with a 10cc balloon. The orders did not change after that date. The plans of care, updated every two weeks, were not updated to include the physician’s orders for catheter care interventions. During interviews and joint record reviews on 08/04/2026 and 08/05/2026, the Clinical Director confirmed that the plans of care had not been updated with the orders and interventions.”

“It is required that the the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan: a revised plan of care includes: information from the patient’s updated comprehensive assessment. This standard was not met as evidenced by clinical record review and interview. In 1 of 30 (3%) clinical records reviewed, the agency did not ensure that the patient’s plan of care was updated to include information from the patient’s updated comprehensive assessment. CLINICAL RECORD 14: The patient elected hospice care on 07/08/2026 with a primary diagnosis of congestive heart failure. The updated Skilled Nursing (SN) comprehensive assessment dated 07/24/2026 documented the patient’s decline and orders for placement of a 16 FR/10 cc Foley catheter with a large drainage bag, to be changed monthly. The updated plan of care did not document interventions for the catheter, as the last IDT (interdisciplinary team meeting) was on 07/29/2026. The plan of care was not updated to include that a Foley catheter had been placed. During interviews and joint record reviews on 08/04/2026 and 08/05/2026, the Clinical Director confirmed that the plans of care had not been updated with individualized interventions.”

“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; [and] use of gloves, mask, eye protection, or face shield depending on anticipated exposure. This standard was not met as evidenced by interview, observation, and clinical record review. Agency policy #102 “Hand Hygiene” stated in part, “At a minimum, personnel will perform hand hygiene in the following instances: Before and after any glove use.” In 1 of 6 (17%) home visits observed, the agency did not ensure that hand hygiene was performed when indicated per the agency’s policy. HOME VISIT 3/CLINICAL RECORD 3: During the visit with the Registered Nurse (RN) [Personnel Record 3] on 08/04/2026, the RN, preparing to provide wound care, repositioned the patient who was found to have some BM (bowel movement). The RN cleaned up the BM and provided peri care. The RN removed the dirty gloves and donned a clean pair of gloves, without hand sanitization. The wound was cleaned with wound cleanser and gauze to pat the wound dry; the gloves were removed, and new gloves were donned, without hand sanitization. Supplies were prepared for what would be applied to the wound, and gloves were removed; hands were sanitized, and clean gloves were donned. The rest of the glove changes and wound care were provided with hand hygiene followed. During an interview, the Clinical Manager, who observed the home visit, confirmed that the RN’s hands were not sanitized at all glove changes.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse 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 4 of 25 (16%) clinical records reviewed in which Hospice Aide (HA) services were provided, the agency did not ensure that the Hospice Aide received written patient care instructions. CLINICAL RECORD 4: The patient elected hospice care on 01/28/2025 with a primary diagnosis of Parkinson’s disease. The patient was admitted with a supra pubic catheter that was maintained through 08/03/2026. A review of the clinical record and HA care plan on 08/03/2026 revealed no assigned task for catheter care during personal care. The HA care plan did not include an update since 01/29/2025. CLINICAL RECORD 10: The patient elected hospice care on 06/23/2026 with a primary diagnosis of Alzheimer’s Disease. The patient was admitted with a supra pubic catheter. The HA care plan documented on 06/23/2026 did not document a task for catheter care as of review 08/05/2026. CLINICAL RECORD 12: The patient elected hospice care on 06/16/2026 with a primary diagnosis of congestive heart failure, hypertension, and Alzheimer’s disease. The HA care plan was documented on 06/23/2026, with no updates, and the HA was assigned the tasks of showering every visit, partial chair bath per patient request, and shampoo per patient request. There were two baths assigned; the patient has Alzheimer’s disease, and there was no other identified decision maker. The patient had family that could have been the identified decision maker for baths. CLINICAL RECORD 30: The patient elected hospice care on 02/01/2026 with a primary diagnosis of congestive heart failure. The patient’s condition was declining, and an order was received on 02/16/2026 to place a Foley catheter 18 FR/!0cc to dependent drainage. The plan of care dated 02/01/2026 ordered HA services two times a week. The HA care plan documented on 02/01/2026 was not updated to include the task for Foley care and a bed bath that was provided starting 02/05/2026, as the patient had become bedbound. During interviews on 08/04/2026 and 08/05/2026, the Clinical Director and Team Leaders who reviewed the Aide plans confirmed the assigned tasks had not been updated.”

“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 clinical record review and interview. In 1 of 30 (3%) clinical records reviewed, the agency did not ensure the patient’s record contained physician orders to meet the patient’s care needs. CLINICAL RECORD 4: The patient elected the hospice benefit on 01/28/2025 with a primary diagnosis of Parkinson’s disease. The physician order dated 01/26/2026 ordered a PRN (as needed) visit to flush the patient’s catheter. The order did not document the amount or what to flush the catheter with. During an interview on 08/04/2026, the Clinical Director stated that this was a current process improvement project for the organization.”