Enhabit Hospice

“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 IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by clinical record reviews and interviews with the Clinical Director, and the Director of Operations which revealed the following: Failure of the hospice to ensure that the Hospice Aide received written patient care instructions prepared by a Registered Nurse (RN) responsible for the supervision of the Hospice Aide in 2 of 16 (12%) [HCDT.15.I/L625]; Failure of the hospice to ensure that the Hospice Aide provided visits as ordered by the Interdisciplinary group in1 of 16 (6%) clinical records reviewed [HCDT.16.I/L626]; Failure of the hospice to ensure that the Hospice Aide provided services as instructed in the Hospice Aide care plan in 1 of 16 (6%) clinical records reviewed [HCDT.16.I/L626]; and Failure of the hospice to ensure that the Hospice Aide reported changes in the patient’s needs to the RN in 2 of 16 (12%) clinical records reviewed [HCDT.18.I/L628]. The cumulative effect of these deficiencies has resulted in the hospice agency’s ability to ensure the provision of quality hospice care for the condition of participation CFR 418.76: Hospice Aide and Homemaker Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice aide services from the agency.”

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. 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 that the Interdisciplinary Group (IDG) completed an initial comprehensive assessment no later than 5 calendar days after the patient’s election of hospice care. Clinical Record 3: The patient elected the hospice benefit on 04/10/2024. The initial plan of care (POC) dated 04/10/2024 ordered “Medical Social Worker (MSW) one (1) evaluation visit to assess for psychosocial needs.” On 04/17/2024 the coordination note completed by the MSW documented, “Missed visit 04/14/2024... reason: urgencies with other patients. Spoke with caregiver no urgencies.” In another coordination note dated 04/17/2024, the MSW documented, “Initial assessment not yet completed as SW was away on PTO. Upon arrival was caught up with other patients needs and failed to complete initial assessment.” The initial assessment of the patient’s psychosocial needs was completed by the MSW on 04/19/2024, with nine (9) days outstanding. During an interview on 06/26/2024, the Director of Clinical confirmed that the patient was not seen for the reasons stated. The Director of Clinical and Director of Operations (DOO) stated that there is one full time MSW and a per diem MSW that will cover if needed. In this case the per diem was not contacted. Clinical Record 11: The patient elected the hospice benefit on 04/11/2024. The initial POC dated 04/11/2024 ordered one (1) evaluation visit by a Chaplain to evaluate the patient’s spiritual needs. The Chaplain evaluation visit was completed on 04/26/2024. A review of the clinical record revealed that on 04/18/2024, the Chaplain documented, “Chaplain revised visits due to vacation/PTO taken 04/12/2024 - 04/16/2024.” The finding was confirmed by the Director of Operations (DOO) during an interview. Clinical Record 12: The patient elected the hospice benefit on 05/31/2024. The initial POC dated 05/31/2024 ordered one (1) evaluation visit by a Chaplain to assess the patient’s spiritual needs. The Chaplain evaluation visit was completed on 06/10/2024, with ten (10) days outstanding. During a review of the clinical records and interview, the Clinical Director and DOO confirmed the finding and stated that there was no documented reason for the delay. Clinical Record 14: The patient elected the hospice benefit on 04/10/2024. The initial POC dated 04/10/2024 ordered one (1) evaluation visit by a Chaplain to assess spiritual needs. The Chaplain evaluation visit was completed on April 25, 2024, with 15 days outstanding. During a review of the clinical records and interview, the Clinical Director and DOO confirmed the finding and stated that there was no documented reason for the delay. Clinical Record 19: The patient elected the hospice benefit on 02/27/2024. The initial POC dated 02/27/2024 ordered one (1) evaluation visit by a Chaplain to assess spiritual needs. A review of the clinical record revealed that the Chaplain documented a missed visit on 03/07/2024 because the family declined Chaplain services. During a joint review of the clinical record and interviews, the Director of Operations and the Clinical Director stated that there was no documented evidence that the Chaplain contacted the patient or family before 03/07/2024.”

“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). This standard was not met as evidenced by clinical record review and interview. 1 of 1 (100%) clinical record reviewed of a patient that requested therapy, the agency did not ensure that hospice services followed the patient’s plan of care. Clinical Record 8: The patient elected the hospice benefit on 04/07/2024 with a diagnosis of cerebral infarction due to thrombosis. The Registered Nurse (RN) initial comprehensive assessment documented, “The daughter would like for him to continue to receive speech therapy and physical therapy. Daughter was educated on safety therapies only for hospice patients.” The plan of care dated 04/07/2024 and signed by the physician on 04/21/2024 ordered the Speech Therapist (ST) to provide one (1) visit for an evaluation. A review of the clinical record revealed no evidence that the ST evaluation was completed. During a joint review of the record and interview, the Director of Operations (DOO) confirmed that there was no evidence that the agency provided follow through with ST as ordered on the plan of care. In the agency policy titled Coordination of Services Policy #S05 states in part, “The agency has established procedures regarding documentation and communication which promote coordination of services. Staff implement action which reflect coordination including, developing and implementation of nursing, therapy, chaplain, volunteer and/or medical social services as well as any other discipline providing services care plans for hospice. Staff document action which reflects coordination according to established procedures.””

“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 19 (5%) clinical records reviewed, the agency did not ensure that the plan of care identified interventions based on problems identified during the updated comprehensive assessments. Clinical Record 6: The patient elected the hospice benefit on 01/13/2024 with a diagnosis of hypertensive heart disease. On 04/05/2024, the Registered Nurse (RN) documented that the patient had “audible wheezing and was given albuterol nebulizer treatment” and “+2 pitting and non-pitting edema in bilateral lower extremities.” The comprehensive assessment completed by the RN on 04/08/2024 documented, “4+ pitting edema with weeping in bilateral lower extremities” and “a rash.” The patient was started on Dexamethasone 2 mg for 7 days, and the patient’s Lasix was increased to 40 mg two (2) times a day. On 04/09/2024, the Licensed Practical Nurse (LPN) visit note documented that the patient had “increased edema with weeping and increased shortness of breath” and the LPN obtained a physician’s order: “Dexamethasone 4mg, Azithromycin for 5 days and continue to take Lasix 40mg.” The “as needed” visit note completed by the RN on 04/10/2024 documented that the patient had “continued rash, weeping edema, and wheezing,” and the previous medications were continued. A review of the clinical record revealed no evidence that the agency had updated the plan of care to include interventions and goals for the problems identified during the assessments. During an interview, the Clinical Director confirmed the finding, stating that they could not speak to what they were doing for the weeping edema or why the plan of care was not updated to reflect goals and interventions for problems identified in the comprehensive assessments.”

“It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by document review and interview. In 1 of 16 (6%) clinical records reviewed of patients that accepted Hospice Aide (HA) services, the agency did not ensure that care given by the HA was supervised by a registered nurse or per the plan of care. Clinical Record 13: The patient elected the hospice benefit on 03/25/2024 with a diagnosis of unspecified severe protein-calorie malnutrition. The HA visit note dated 03/27/2024 documented the HA completed the patient’s bath and peri care and changed the patient’s clothes. The HA coordination note dated 03/27/2024 documented that the HA contacted the Registered Nurse (RN) because there was no HA care plan. The HA visit note dated 04/05/2024 documented that the HA completed the patient’s shower, peri care, dressing, oral care, linen change, and hair care. The HA coordination note dated 04/05/2024 documented that the HA contacted the RN because there was no HA care plan and no instruction on the patient’s activities of daily living (ADL). On 04/12/2024, the HA coordination note documented that the HA contacted the RN again regarding no care plan for the patient. The HA visit note dated 04/12/2024 documented that the HA had been asking for the care plan for two weeks and that the HA completed the patient’s peri care, bathing, dressing, oral care, hair care, and linen changes. The HA documented visits and personal care provided on 03/27/2024, 04/03/2024, 04/05/2024, 04/10/2024, and 04/12/2024 with no HA care plan. The RN documented an HA care plan on 04/15/2024. During an interview, the Director of Operations (DOO) confirmed the finding, stating, “Yes, there was no care plan at all until 04/15/2024. All of the above visits were made prior to the aide plan of care being entered.” The Clinical Director confirmed that the RN did not ensure supervision of the Hospice Aide’s services.”

“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 2 of 16 (12%) clinical records reviewed of patients that accepted Hospice Aide (HA) services, the agency did not provide the HA with written patient care instructions. Clinical Record 13: The patient elected the hospice benefit on 03/25/2024 with a diagnosis of unspecified severe protein-calorie malnutrition. The HA visit note dated 03/27/2024 documented the HA completed the patient’s bath and peri care and changed the patient’s clothes. The HA coordination note dated 03/27/2024 documented that the HA contacted the Registered Nurse (RN) because there was no HA care plan. The HA visit note dated 04/05/2024 documented that the HA completed the patient’s shower, peri care, dressing, oral care, linen change, and hair care. The HA coordination note dated 04/05/2024 documented that the HA contacted the RN because there was no HA care plan or instruction on the patient’s activities of daily living (ADL). On 04/12/2024, the HA coordination note documented that the HA contacted the RN again regarding no care plan for the patient. The HA visit note dated 04/12/2024 documented that the HA had been asking for the care plan for two weeks and that the HA had completed the patient’s peri care, bathing, dressing, oral care, hair care, and linen changes. The HA documented visits and personal care provided on 03/27/2024, 04/03/2024, 04/05/2024, 04/10/2024, and 04/12/2024 with no HA care plan. The RN documented an HA care plan on 04/15/2024. During an interview, the Director of Operations (DOO) confirmed the finding, stating, “Yes, there was no care plan at all until 04/15/2024. All of the above visits were made prior to the aide plan of care being entered.” Clinical Record 7: The patient elected the hospice benefit on 02/08/2024. The initial assessment completed by the RN on 02/08/2024 documented that the patient had a Foley catheter in place. The plan of care ordered Hospice Aide services “three (3) times a week.” A review of the HA care plan revealed there were no specific instructions for the HA to follow for the care of the Foley catheter during personal care. During a joint review of the clinical record and interview, the DOO confirmed that there was no documentation of a Foley in the HA care plan.”

“It is required that a hospice aide provides services: ordered by the Interdisciplinary Group; included in the plan of care; and 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 16 (6%) clinical record reviewed of patients that accepted Hospice Aide (HA) services, the agency did not ensure that the HA provided services ordered by the interdisciplinary group. Clinical Record 3: The patient elected the hospice benefit on 04/10/2024 with a diagnosis of senile degeneration of the brain. The initial plan of care dated 04/10/2024 ordered HA visits one (1) time a week for 1 week, three (3) times a week for 12 weeks. Review of documented HA visit notes revealed there were no HA visits made the week of 04/14/2024 through 04/20/2024, one (1) visit was ordered. One (1) HA visit was documented on 04/24/2024, three (3) visits were ordered. There was no evidence of documented missed visits or documented reasons the visits were not made. In an interview and a joint review of the clinical record, the Clinical Director confirmed there was no documentation for the missed visits.”

“It is required that a hospice aide provides services: included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 16 (6%) clinical records reviewed of patients that accepted Hospice Aide (HA) services, the agency did not ensure that the HA provided personal care included in the plan of care. Clinical Record 13: The patient elected the hospice benefit on 03/25/2024 with a diagnosis of unspecified severe protein-calorie malnutrition. The HA visit note dated 03/27/2024 documented the HA completed the patient’s bath and peri care and changed the patient’s clothes. The HA coordination note dated 03/27/2024 documented that the HA contacted the Registered Nurse (RN) because there was no HA care plan. The HA visit note dated 04/05/2024 documented that the HA completed the patient’s shower, peri care, dressing, oral care, linen change, and hair care. The HA coordination note dated 04/05/2024 documented that the HA contacted the RN because there was no HA care plan and no instruction on the patient’s activities of daily living (ADL). On 04/12/2024, the HA coordination note documented that the HA contacted the RN again regarding no care plan for the patient. The HA visit note dated 04/12/2024 documented that the HA had been asking for the care plan for two weeks and that the HA had completed the patient’s peri care, bathing, dressing, oral care, hair care, and linen changes. There was no Ha care plan for the documented visits and personal care provided on 03/27/2024, 04/03/2024, 04/05/2024, 04/10/2024, and 04/12/2024. The RN documented an HA care plan on 04/15/2024. During an interview, the Director of Operations (DOO) confirmed the finding, stating, “Yes, there was no care plan at all until 04/15/2024. All the above visits were made prior to the aide plan of care being entered.””

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 2 of 16 (12%) clinical records reviewed of patients that accepted Hospice Aide services, the agency did not ensure that the Hospice Aide reported changes related to the patient’s plan of care to the Registered Nurse (RN). Clinical Record 3: The patient elected the hospice benefit on 04/10/2024 with a diagnosis of senile degeneration of the brain. The initial plan of care dated 04/10/2024 ordered HA visits one (1) time a week for 1 week, three (3) times a week for 12 weeks. Review of documented HA visit notes revealed there were no HA visits made the week of 04/14/2024 through 04/20/2024, one (1) visit was ordered. One (1) HA visit was documented on 04/24/2024, three (3) visits were ordered. There was no evidence of documented missed visits or communication with the RN. In an interview and a joint review of the clinical record, the Clinical Director confirmed there was no documentation for the missed visits. Clinical Record 5: The patient elected the hospice benefit on 05/20/2024 with a diagnosis of acute chronic systolic heart failure. The initial plan of care ordered HA visits two (2) times a week for one (1) week and three (3) times a week for 12 weeks. There was missed HA visits on 05/23/2024, 05/30/2024, 06/10/2024, and 06/20/2024. There was no documented evidence that the HA notified the RN of the missed visits. In an interview and a joint review of the clinical record, the Clinical Director confirmed the finding.”

“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 agency did not ensure that volunteers provided provide day-to-day administrative and/or direct patient care services in an amount that equaled 5 percent of the total patient care hours of all paid hospice employees and contract staff A joint review of the volunteer program documentation for 01/01/2024 through 06/26/2024 revealed that the total cost savings for 2024 equaled 3.87%. During an interview on 06/26/2024, the Volunteer Coordinator stated that they have been in the position since 09/2023 and noted that the program was quite weak when they started. Currently, there is one (1) active volunteer at the main location and five at the alternative delivery site. An interview was conducted with the volunteer coordinator on 06/26/2024. She has held her position since 09/2023 and noted that the program was quite weak when she started. Currently, there is one active volunteer at the main Marrietta location and five at the Lawrenceville site. A joint review of the volunteer program revealed that the total cost savings for 2024 amounted to 3.87%, which is 1.13% less than the required 5% cost savings.”

“It is required that each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients with Foley catheters, the agency did not ensure that the patient’s record included physician orders. Clinical Record 11: The patient elected the hospice benefit on 04/11/2024 with a diagnosis of sarcopenia. The Registered Nurse (RN) comprehensive assessment dated 06/13/2024 documented that the patient had a Foley catheter in place. A review of the clinical record revealed no evidence that the agency had a physician’s order to maintain the Foley catheter. In an interview and joint review of the record, the Clinical Director stated that the patient had the catheter placed during a visit to the emergency room on 06/12/2024. Clinical Record 7: The patient elected the hospice benefit on 02/08/2024 with the diagnosis chronic ischemic heart disease unspecified. The patient had a Foley catheter in place at the time of admission to hospice services. The RN visit note dated 04/17/2024 documented that the RN cleaned and prepared the patient for a catheter change, inserted a 16 French (F) coude catheter using sterile technique with clear urine return obtained, and inflated the balloon with 10 cc of sterile water. A review of the clinical record revealed no evidence of a physician’s order to maintain the Foley catheter.”

“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 This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed of patients with a live discharge, the agency did not ensure that a copy of the hospice discharge summary was forwarded to the receiving facility. Clinical Record 15: The patient elected hospice care on 10/25/2023 and was discharged on 03/19/2024. The agency’s discharge report documented the reason for the live discharge as “non-compliant with plan of treatment.” A coordination note dated 03/23/2024 documented that the agency received a call that the patient had been admitted to the hospital and was asked for someone to follow up. A non-visit discharge note dated 03/23/2024 documented that the patient “moved out of the service area.” A review of the clinical record revealed that the patient had been admitted to the hospital and revoked hospice services. There was no documented evidence that the agency provided the hospital with a verbal or written report. In an interview, the Clinical Director, and Director of Operations (DOO) confirmed that the agency did not follow through with discharge requirements for this patient.”