Enhabit Hospice

“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 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, interview and observation. In 1 of 14 (7%) clinical records reviewed it was revealed that the agency did not ensure that the comprehensive assessment included a updated medication profile that contained the patient’s current medications. HOME VISIT 1/CLINICAL RECORD 4: During the home visit with the Hospice Aide (Personnel Record 7) on 09/09/2026, the patient’s hospice medication profile (printed on 09/08/2026) and the Assisted Living Facility (ALF) medication profile were compared. The ALF medication list included: Bisacodyl 5mg tablet take 1 tablet by mouth every day start 6/2/26, Melatonin 5mg tablet take 1 tablet by mouth at bedtime start 6/27/2026, Hydroxyzine 25mg capsule take one cap by mouth every 6 hours as needed for itching start 6/3/2026. The hospice medication profile did not include Bisacodyl, Melatonin and Hydroxyzine as current medications. During a joint record review and interview on 09/09/2026, the Administrator agreed that the hospice medication profile did not include all of the patient’s current medications.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group, and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 10 (20%) clinical records reviewed in which hospice aide services were provided, the agency did not ensure that the Hospice Aide followed the plan of care as ordered. CLINICAL RECORD 2: The hospice aide plan of care dated 09/04/2025 ordered bathing (shower) every visit. The hospice aide visit note on 09/15/2025 and 09/18/2025 documented bed bath given. CLINICAL RECORD 3: The hospice aide plan of care dated 01/27/2026 ordered bathing (bed bath) every visit. The hospice aide visit note on 03/04/2026 documented shower given. During a joint record review and interview on 09/09/2026, the Administrator agreed that the aide did not follow the plan of care as ordered.”

“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. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 2 of 10 (20%) clinical records reviewed in which hospice aide services were provided, the agency did not ensure that the Hospice Aide reported changes in the patient’s needs related to the plan of care to the Registered Nurse. CLINICAL RECORD 2: The hospice aide plan of care dated 09/04/2025 ordered bathing (shower) every visit. The hospice aide visit note on 09/15/2025 and 09/18/2025 documented bed bath given. The hospice aide plan of care dated 04/07/2026 ordered safety precautions, patient is to wear soft helmet for safety, dry hair before reapplying soft helmet to head every visit. The 06/15/2026 hospice aide visit coordination note documented, “Upon arrival, Pt wasn’t wearing padded helmet. After shower was completed Pt stated she wasn’t wearing padded helmet that it was stupid. HHA educated Pt on not wearing helmet vs wearing one. Pt said throw it away. HHA placed helmet on bathroom sink.” There was no documented evidence that the hospice aide notified the Registered Nurse. CLINICAL RECORD 3: The hospice aide plan of care dated 01/27/2026 ordered bathing (bed bath) every visit. The hospice aide visit note on 03/04/2026 documented shower given. There was no documented evidence that the hospice aide notified the Registered Nurse. During a joint record review and interview on 09/09/2026, the Administrator agreed that the aide did not report changes related to the plan of care to the Registered Nurse.”

“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 2 of 2 (100%) clinical records reviewed of patients that were live discharges, the agency did not ensure that the discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 11: The patient elected their hospice benefit on 06/12/2025 and discharged, no longer terminally ill, on 12/08/2025. There was no documented evidence that the agency forwarded the discharge summary to the patient’s attending physician. CLINICAL RECORD 12: The patient elected their hospice benefit on 09/19/2025 and discharged, revoked the hospice benefit on 12/05/2025. There was no documented evidence that the agency forwarded the discharge summary to the patient’s attending physician. During a joint record review and interview on 09/10/2026, the Administrator agreed that there was no documented evidence that the discharge summary was provided to the attending physician.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: The hospice election form and any advance directives. This standard was not met as evidenced by interview and observation. In 1 of 1 (100%) home visit observations with a patient residing in a long term care facility it was revealed that the hospice did not provide the hospice election form to the facility. HOME VISIT 2: During the home visit with the Chaplain (Personnel Record 6) on 09/09/2026, the hospice binder was reviewed. There was no evidence that the hospice election form was provided to the long-term care facility. During an interview on 09/10/2026, the Administrator confirmed there was no evidence that the election form was provided to the facility.”