Enhabit Hospice

“It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes the following: for all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles; demonstration of staff knowledge of emergency procedures; EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years; more frequent training occurs if there is a significant update of EP policies and procedures; a periodic review and rehearsal of the hospice’s EP plan with hospice employees (including non-employee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others; and documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy #E06, “Emergency Preparedness Plan,” stated in part, “All staff, whether employees or contract, will be instructed on the Emergency Preparedness Plan during orientation and annually thereafter.” In 1 of 10 (10%) personnel records reviewed, the hospice did not ensure that emergency preparedness training was provided annually. Personnel Record 3: The Hospice Medical Director was hired on 04/04/2021 as an independent contractor. There was no documented evidence of Emergency Preparedness training annually in 2023, 2024, or 2025 as of 03/06/2025. During a joint record review and interview on 03/06/2025, the Alternate Director of Operations agreed there was no documented evidence that emergency preparedness training was provided annually. During an interview on 03/06/2025, the Director of Operations agreed with the finding and did not have any additional information to provide.”

“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 measures 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, interview, and observation. In 1 of 14 (7%) clinical records reviewed and home visits observed, the hospice did not ensure that the comprehensive assessment included a drug profile that contained the patient’s medications and supplements. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 07/29/2024 with the diagnosis of cerebral infarction due to an unspecified occlusion or stenosis of the right middle cerebral artery. During the home visit with the Registered Nurse (RN) [Personnel Record 5] on 03/04/2025, a medication review was completed comparing the hospice medication profile, dated 03/04/2025, to the patient’s medications. The patient’s spouse presented a list of medications and multiple medication bottles that he reported giving to the patient every day. The spouse confirmed that the patient has been taking the following supplements for months: Fruits and Veggies probiotics capsule (two (2) capsules twice daily), turmeric ginger 1800mg capsules (one (1) capsule twice daily), nitric oxide blood flow #7 (two capsules twice daily), vitamin C 1000mg (once daily), vitamin D3 125mcg 5000IU (once daily), vitamin E 268mg (once daily), Prevagen (once daily), CoQsol 100mg (once daily), DreamWell Ultra (once daily), Relaxium Sleep (once daily). The spouse reported that the patient has been using a nebulizer treatment twice or more daily when needed. The spouse presented the medication dated 02/17/2025, “ipratropium bromide and albuterol sulfate inhalation solution 0.5mg/3ml per 3ml, empty one ampule into the nebulizer, inhale by mouth 4 times daily for shortness of breath.” The supplements and ipratropium bromide inhalation solution were not listed on the hospice medication profile reviewed on 03/04/2025. There was no evidence the supplements and ipratropium bromide inhalation solution were reviewed with the patient’s medication regimen. During the home visit, the RN [Personnel Record 5] stated, “I am not the regular nurse, so I don’t know why these aren’t on our medication list. The regular nurse should have added them. I will get them updated. The RN [Personnel Record 5] agreed there was no documented evidence that the hospice medication profile was updated with these supplements and medication. During a joint record review and interview on 03/05/2025, the Alternate Director of Operations agreed there was no documented evidence that the hospice medication profile included the supplements and Ipratropium Bromide Inhalation Solution. During an interview on 03/06/2025, the Director of Operations agreed with the finding and did not have any additional information to provide.”

“It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes Education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy #I13, “Infection Prevention & Control Plan,” stated in part, “All staff will be educated upon hire, annually during Safety Month and at other times indicated in the diseases listed above, their transmission and use of universal precautions and other infection safety measures as needed.” In 2 of 10 (20%) personnel records reviewed, the hospice did not ensure that infection control education was provided annually per the agency’s policy. Personnel Record 3: The Hospice Medical Director was hired on 04/04/2021 as an independent contractor. Infection control education was last documented on 06/16/2022. There was no documented evidence of infection control education annually in 2023, 2024, or 2025 as of 03/06/2025. Personnel Record 4: The Hospice Medical Director was hired on 10/11/2018 as an independent contractor. Infection control education was last documented on 01/31/2023. There was no documented evidence of infection control education annually in 2024 or 2025 as of 03/06/2025. During a joint record review and interview on 03/06/2025, the Alternate Director of Operations agreed there was no documented evidence that the infection control education was provided annually. During an interview on 03/06/2025, the Director of Operations agreed with the finding and did not have any additional information to provide.”

“It is required that all hospice aide services must be provided by an individual who has successfully completed one (1) of the four (4) training and competency evaluation programs described below. The individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program also described below. The hospice maintains documentation that each hospice aide has met the requirements. A qualified hospice aide has successfully completed a competency evaluation program that evaluates the aide’s competency in the following subject areas by observation of the aide’s performance with a patient or pseudo-patient: communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; reading and recording temperature, pulse, and respiration; appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: bed bath; sponge, tub, and shower bath; hair shampoo (sink, tub, and bed); nail and skin care; oral hygiene; toileting and elimination; safe transfer techniques and ambulation; normal range of motion and positioning. Evaluates the aide’s competency in the following subject areas by written exam, oral examination, or after observation of a hospice aide with a patient or a pseudo-patient during a simulation: observation, reporting, and documentation of patient status and the care or service provided; basic infection control procedures; basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor; maintenance of a clean, safe, and healthy environment; recognizing emergencies and the knowledge of emergency procedures and their application; the physical, emotional, and developmental needs of—and ways to work with—the populations served by the hospice, including the need for respect for the patient, his or her privacy, and his or her property; adequate nutrition and fluid intake; any remaining task(s) that the hospice chooses to have an aide perform. The competency evaluation is performed by a registered nurse in consultation with other skilled professionals, as appropriate. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy #P02, “Home Health/Hospice Aide Competency & Supervision,” stated in part, “The hospice aide must successfully complete a competency evaluation. The Agency confirms that the home health/hospice aides are competent and proficient to perform the assigned duties. The Agency maintains documentation of competency training. The Agency confirms skills learned and/or evaluated elsewhere transfer to the care during orientation as first visit competency evaluation prior to unsupervised patient care.” In 1 of 1 (100%) personnel record reviewed of a Hospice Aide, the agency did not ensure to assess the competency of the Hospice Aide prior to unsupervised patient care. Personnel Record 6: The Hospice Aide was hired on 12/26/2023. A personnel record review revealed no evidence that the hospice agency assessed the competency of the Hospice Aide before unsupervised patient care. During a joint record review and interview on 03/05/2025, the Alternate Director of Operations agreed there was no documented evidence that the competency was completed. During an interview on 03/06/2025, the Director of Operations agreed with the finding. The Director of Operations stated, “One of our nurses is on vacation, and she told us that she has the competency on paper but not with her. “We are going to get the aide competency done this week.””

“It is required that a hospice aide provides services: ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review and interview. In 3 of 12 (25%) clinical records reviewed of patients who accepted Hospice Aide services, the agency did not ensure the Hospice Aide (HA) provided services as ordered by the Interdisciplinary Group. Clinical Record 1: The patient elected the hospice benefit on 07/29/2024. The physician’s order, effective 12/26/2024, ordered Hospice Aide (HA) services “1wk1, 2wk8.” During the week of 01/26/2025 through 02/01/2025, one HA visit was documented on 01/31/2025. There was no documented evidence of a second visit or reason for the missed visit. During the week of 02/02/2025 through 02/08/2026, one hospice aide visit was documented on 02/02/2025. There was no documented evidence of a second visit or reason for the missed visit. Clinical Record 9: The patient elected the hospice benefit on 09/30/2024. The physician’s order, effective 10/01/2024, ordered HA services “2wk9.” During the week of 10/27/2024 through 11/02/2024, one HA visit was documented on 10/30/2024. There was no documented evidence of a second visit or reason for the missed visit. Clinical Record 12: The patient elected the hospice benefit on 09/30/2023. The physician’s order, effective 11/12/2023, ordered HA services “1wk2, 2wk3.” During the week of 12/10/2023 through 12/16/2023, one HA visit was documented on 12/15/2023. There was no documented evidence of a second visit or reason for the missed visit. During a joint record review and interview on 03/05/2025, the Alternate Director of Operations agreed there was no documented evidence that the HA visits were completed and no documented reason for the missed visits. During an interview on 03/06/2025, the Director of Operations agreed with the finding and stated that the aide who missed the visits was no longer with the agency.”

“It is required that a registered nurse makes an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy #P02, “Home Health/Hospice Aide Competency & Supervision,” stated in part, “The Agency provides onsite supervision of skills and compliance to agency policies every 12 months during an onsite visit conducted by a registered nurse. The Licensed Professional documents findings on the Supervisory On-site Visit form or in the mobile device. Date/time of visit and name of aide being supervised. Services Provided. Individualized comments about the relationship between family/patient and aide. Observation of care delivery. Progress toward goals. Any instruction given. In-service training, noting the new skill or theory.” In 1 of 1 (100%) personnel record reviewed of a Hospice Aide (HA), the hospice did not ensure that the Registered Nurse (RN) completed an annual on-site supervisory visit. Personnel Record 6: The Hospice Aide was hired on 12/26/2023. A personnel record review revealed no documented evidence that a Registered Nurse completed an annual onsite visit with the required elements and documented it on the Supervisory On-site Visit form. During a joint record review and interview on 03/06/2025, the Alternate Director of Operations agreed there was no documented evidence that annual onsite supervision of skills was completed and documented according to agency policy. The Alternate Director of Operations stated, “We can see they are doing joint visits with the aides, but we have no evidence that the annual onsite supervisory visits are being documented with all the required information.” During an interview on 03/06/2025, the Director of Operations agreed with the finding and did not have any additional information to provide.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, interview, and personnel record review. Agency Policy #P01, “Personnel Competency & Supervision,” stated in part, “Staff competencies are addressed, completed, and stored...Professional staff will not be assigned to any task until competency for that task is obtained. The Agency confirms that the professional personnel are competent and proficient to perform the assigned duties. “ In 1 of 9 (11%) personnel records reviewed of professional staff, including the volunteer, the hospice did not ensure to assess the competency of the Registered Nurse (RN). Personnel Record 5: The Registered Nurse (RN) was hired on 09/16/2024. There was no documented evidence that the hospice assessed the competency of the Registered Nurse as of 03/05/2025. During a joint record review and interview on 03/05/2025, the Alternate Director of Operations agreed there was no documented evidence that the competency was completed. During an interview on 03/06/2025, the Director of Operations agreed with the finding and did not have any additional information to provide.”

“It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #S10, “Patient Reassessment & Recertification,” stated in part, “The Medical Director completes a written certification of terminal illness no more than 15 days prior to the start of any benefit period.” Agency policy #S01, “Scope of Services,” stated in part, “The Hospice Director is responsible for reviewing the clinical information for each hospice patient, providing written certification that it is anticipated that the patient’s life expectancy is 6 months or less if the illness runs its normal course.” In 2 of 11 (18%) clinical records reviewed of patients with more than one benefit period, the agency did not ensure that the Hospice Medical Director (HMD) completed a physician narrative based on a review of the patient’s medical record for recertification of the terminal illness per the agency’s policy. Clinical Record 4: The patient elected the hospice benefit on 04/16/2021. The recertification of terminal illness for the benefit period dated 10/03/2023 through 12/01/2023, signed by the physician on 09/27/2023, did not include documented evidence that the HMD reviewed the clinical information and completed a physician’s narrative. The physician’s narrative was blank. The recertification of terminal illness for the benefit period 09/27/2024 through 11/25/2024, signed by the physician on 10/18/2024, did not include documented evidence that the HMD reviewed the clinical information and completed a physician’s narrative. The physician’s narrative was blank. Clinical Record 6: The patient elected the hospice benefit on 08/19/2024. The recertification of terminal illness for the benefit period dated 12/17/2024 through 02/14/2024, signed by the physician on 01/08/2025, did not include documented evidence that the HMD reviewed the clinical information and completed a physician’s narrative. The physician’s narrative was blank. During a joint record review and interview on 03/05/2025, the Alternate Director of Operations agreed there was no documented evidence that the Hospice Medical Director completed a physician narrative based on a review of the patient’s medical record for recertification of the terminal illness. The Alternate Director of Operations stated, “This is a problem we identified and are working on.” During an interview on 03/06/2025, the Director of Operations agreed with the finding. The Director of Operations stated, “The Branch Director left in November 2024, and we discovered the certification of terminal illness (CTI) and recertifications by the Medical Director were not being completed properly, timely, and to our standards. In January, our Associate MD took over as Hospice Medical Director.””

“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. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients discharged due to moving out of the service area or being no longer terminally ill, the agency did not ensure that the discharge summary was forwarded to the patient’s attending physician. Clinical Record 11: The patient elected the hospice benefit on 05/15/2024, was discharged, and moved to an out-of-the-service area hospital on 05/28/2024. There was no documented evidence that the discharge summary was forwarded to the attending physician. Clinical Record 12: The patient elected the hospice benefit on 09/30/2023 and was discharged, with an extended prognosis, on 03/13/2024. There was no documented evidence that the discharge summary was forwarded to the attending physician. During a joint record review and interview on 03/06/2025, the Alternate Director of Operations agreed there was no documented evidence that the discharge summary was provided to the attending physician. During an interview on 03/06/2025, the Director of Operations agreed with the finding and did not have any additional information to provide.”