Enhabit Hospice

“Based on interview and record review, the agency failed to provide volunteer services when requested by the patient/family members or referenced in the patient assessment for 4 (#s 16, 17, 18, and 19) of 19 sampled patients. Findings include: 1. Patient #16Review of patient #16’s visit note report, dated 2/24/25 at 2:31 p.m., with staff member F, showed:- ... “INDICATE ALL COMMUNITY SERVICES INVOLVED OR NEEDED IN THE PATIENT’S CARE ...- OTHER (SPECIFY)- ADDITIONAL DETAILS REGARDING COMMUNITY RESOURCES:- PT MAY BENEFIT FROM SOCIALIZATION THROUGH VOLUNTEER SERVICES. ... and- PLAN (SPECIFIC FOCUS OF THE NEXT VISIT, SPECIFIC INTERVENTIONS OR FOLLOW UP NEEDED) MSW TO PLACE REFERRAL FOR SOCIALIZATION AND EFFORTS TO SUPPORT PT AND FAMILY TO PREVENT SOCIAL DECLINE. ...”Review of the agency’s document titled, Hospice Volunteer Requirement Report, dated 11/3/24-11/3/25, showed no volunteer hours recorded for February 2025 through October 2025.2. Patient #17Review of patient #17’s visit note report, dated 2/6/25 at 2:04 p.m., with staff member F, showed:- ... “DOES THE PATIENT HAVE ANY NEW/CHANGED VOLUNTEER NEEDS?- YES - ... DOCUMENT ALL DETAILS OF CARE COORDINATION RELATED TO THE PATIENT/VISIT, INCLUDING NAMES AND CREDENTIALS OF WHO YOU COORDINATED WITH:- PT SEEKING TO HAVE A VOLUNTEER COME AND VISIT - ... OBJECTIVE FINDINGS - ... PATIENT REPORTED, ‘I FEEL ALONE AT TIMES AND COULD USE A VOLUNTEER TO TALK WITH’.” ... 3. Patient #18Review of patient #18’s visit note report, dated 7/15/24 at 2:21 p.m., showed:- ... “DOES THE PATIENT HAVE ANY NEW/CHANGED VOLUNTEER NEEDS?- YES- ... SPOKE TO PTS [Family member, name] REGARDING PTS CURRENT STATUS AND HISTORY. SENT MESSAGE TO HOSPICE VOLUNTEER COORDINATOR REGARDING A POSSIBLE VOLUNTEER.- ... [Name] WOULD LOVE FOR HER MOTHER TO HAVE A VOLUNTEER VISIT IN THE EARLY EVENINGS WHEN PT BECOMES MORE ANXIOUS TO HELP GROUND HER AND PROVIDE SOCIALIZATION/COMPANIONSHIP.” ...During an interview on 11/6/25 at 1:27 p.m., staff member B stated there was no documentation in patient #18’s chart of any volunteer visits, and a volunteer plan of care was not completed. 4. Patient #19Review of patient #19’s visit note report, dated 11/29/24 at 12:40 p.m., Hospice RN Start of Care, showed:- ... “IDENTIFY THE PATIENT AND CAREGIVER RESOURCE NEEDS AT THE TIME OF THE ASSESSMENT- VOLUNTEER SUPPORT- INDICATE REFERRAL ACCEPTANCE FOR VOLUNTEER SUPPORT- REFERRAL MADE ...”During an interview on 11/5/25 at 2:10 p.m., staff member B stated there were no volunteers at the main branch currently, only a volunteer coordinator. She stated the volunteer program was part of quality assurance at this time, with a performance improvement project in place.During an interview on 11/6/25 at 1:27 p.m., staff member B stated there was no documentation in patient #19’s chart of any volunteer visits, and a volunteer plan of care was not completed.”

“Based on observation, interviews and record review, the agency failed to manage pain and distressing symptoms during the end of life for 2 (#1 and 4) and failed to ensure facility had the necessary pain medications and oxygen supplies for 3 (#’s 3, 5, and 6) of 6 sampled patients. This practice resulted in pain, anxiety, and hallucinations during the end of life for patient #1 and unnecessary pain for patient #4. Findings include: 1. Record review of patient # 1’s EMR, reflected she began hospice services on 11/30/23, with a primary diagnosis of Alzheimer’s disease. Patient #1 resided in [Facility name] assisted living facility. During an interview on 9/30/24 at 11:00 a.m., NF2 stated the agency was very unresponsive to patient #1’s needs and she was having changes in her condition. NF2 stated patient #1 was calling out and screaming in pain, while grabbing at the air. The nurse on duty and the family attempted many calls to the agency staff, without any updated pain and anxiety orders or services offered. NF2 stated when patient #1 died during the night, and after many hours without a response, the facility had to contact EMS to pronounce the patient’s time of death. NF2 stated frustrations with the agency continued to occur with medications and oxygen being delivered timely, hospital bed access, pain medication syringes being filled timely, getting the correct supplies for patients, and communication. NF2 stated concerns were reported to staff member F and staff member E when they were in the facility but have not been corrected or continue to reoccur. Review of facility records, RT tasks, dated 12/30/23 at 9:29 a.m., reflected patient #1 died on 12/30/23 at approximately 2:00 a.m., and the hospice agency was called several times without a response. The facility then called EMS who sent the fire department to pronounce the patient’s death. 2. Review of patient #4’s EMR reflected she began hospice services on 1/18/24, with a primary diagnosis of senile degeneration of the brain. Patient #4 resided in [Facility name] assisted living facility. During an interview on 9/30/24 at 5:14 p.m., NF6 reviewed medications in the medication cart with the surveyor. NF6 showed the surveyor all medication cards and orders on the MAR for patient #4. It was discovered patient #4 was out of their scheduled melatonin and hydrocodone. NF6 stated patient #4 had been out of the melatonin for weeks, and had been out of the hydrocodone for three days. During an observation on 9/30/24 at 5:16 p.m., patient #4 was observed sitting in the dining room at a table. Patient #4 was grimacing, and not moving her neck. NF6 approached patient #4 and asked her about her pain level and location. Patient #4 stated her “... neck and back hurt, closer to a 10 (10/10 pain level).” Patient #4 was guarding her neck and not turning her neck to face the nurse; she was turning her torso instead. NF6 called the agency for PRN medication approval because the facility did not have the scheduled hydrocodone from the agency. 3. Review of patient # 3’s EMR reflected she began hospice services on 5/13/24, with a primary diagnosis of Acute and Chronic Respiratory Failure. Patient #3 resided in [Facility name] assisted living facility. Review of patient # 5’s EMR reflected she began hospice services on 7/15/24, with a primary diagnosis of frontotemporal neurocognitive disorder. Patient #5 resided in [Facility name] assisted living facility. Review of patient # 6’s EMR reflected she began hospice services on 4/15/24, with a primary diagnosis of Alzheimer’s disease. Patient #6 resided in [Facility name] assisted living facility. During an interview on 9/30/24 at 11:43 a.m., NF4 stated the facility had difficulty getting medication orders, oxygen and medications delivered on time. NF4 stated oxygen was supposed to be delivered on Friday and was not, so patient #3, who required continuous oxygen, had to stay in her room on the concentrator all weekend. NF4 stated patient #4 had pain and had no hydrocodone/acetaminophen, patient #3 was almost out of hydromorphone, patient #5 was still waiting for refills since 9/26/24, and patient #6 had been out of oxycodone for six days. During an interview on 10/1/24 at 9:15 a.m., staff member C stated patient #6’s medications were delivered on 9/28/24, so she was out of pain medication for three days. During an interview on 9/30/24 at 9:57 a.m., staff member D stated the agency’s pain management protocol was to have facilities call and get approval for all PRN medications each time they were needed. Staff member D stated she would often receive messages by text, or the facility would contact the office for PRN approval. During an interview on 9/30/24 at 10:30 a.m., NF1 stated, “We gave up calling [Agency name], we don’t call, we just give PRNs now.” During an interview on 9/30/24 at 11:28 a.m., NF3 stated it took a long time to get responses from the agency for medications. NF3 stated due to the issues with reaching on-call staff at the agency, the facility nurses have been told if they could not reach the agency on-call staff, they were to call the facility manager on-call and they would approve the PRN medications. NF3 stated she shared concerns at the Friday meetings with staff member F regarding medication issues and supplies not received or the wrong size/type. During an interview on 9/30/24 at 12:07 p.m., staff member E stated the pain management protocol for agency patients included advising the caller on next steps or going to see the patient. Staff member E stated the agency used a mail order pharmacy for scheduled medications and a local pharmacy for crisis medications. Staff member E stated she went to the facility twice a week and was not aware of the medication shortages, oxygen outage, or the on-call issues. Staff member E stated she had been at the facility on the morning of this interview and was made aware that the briefs delivered to the facility were tape up briefs instead of pull ups, as the facility requested. During an interview on 9/30/24 at 4:02 p.m., with staff member A and C, staff member A stated pain medications had been ordered for the four patients (#’s 3, 4, 5, and 6) in question at the facility. Staff member A stated the oxygen delivery service stated he did not deliver oxygen on Friday because he assumed the patients did not need more oxygen since they had not needed more the previous Friday. Staff member A stated oxygen was being delivered on the day of the interview. Staff member A stated, “We need to do better on communication.” Staff member C stated staff member E did receive a call over the weekend for pain medication outage for patient # 6; ordered it, and told the facility to use the PRN syringes in the meantime. Staff member C stated the facility would have to call for approval with each dose of the PRN given. Staff member A stated he talked to staff member E and staff member E assured him she checked and confirmed all medications were full for two weeks. Staff member A stated the observation done by the surveyor indicated the nurse was dishonest with him. Staff member C stated the process for on-call services for the agency was for families and facilities to call the call center or office directly and the call center will contact the appropriate on-call nurse. If the on-call nurse did not respond within a few minutes, the call center would then try a second time, then proceed to contact the on-call administrator. Staff member C stated she was surprised this was not done with patient #1. Staff member A stated the nurses should not be using text messaging and direct calls to their phones from facilities and families. Staff member A stated all calls should have been coming through the on-call service or the office directly to ensure patients’ needs were met. Staff member A stated he was planning an emergency meeting to ensure all staff were aware of the proper process for calls and to notify their patients and facilities. During an interview on 10/1/24 at 10:36 a.m., staff member A stated the agency was pulling staff member E off hospice due to personal issues, and staff member E should have caught and reported the issues in the facility sooner. On 9/30/24 at 4:30 p.m., the surveyor requested the agency’s policy on medication ordering and PRN medication administration process. No policy addressing these areas was provided prior to the exit of the survey.”

“Based on interviews and record review, the facility failed ensure an effective system of communication was in place between facilities and the interdisciplinary team to direct, coordinate, and supervise care for 5 (#’s 1,3,4,5, and 6) of 6 sampled patients. This practice resulted in unnecessary pain for residents #1 and 4. Findings include: 1. Record review of patient #1’s EMR, reflected she began hospice services on 11/30/23, with a primary diagnosis of Alzheimer’s disease. Patient #1 resided in [Facility name] assisted living facility. During an interview on 9/30/24 at 11:00 a.m., NF2 stated the agency was very unresponsive to patient #1’s needs as she was having changes in her condition. NF2 stated patient #1 was calling out and screaming in pain, while grabbing at the air as she hallucinated. The nurse on duty and the family attempted many calls to the agency staff, without any updated pain and anxiety orders or services offered. NF2 stated when patient #1 died during the night, and after many hours without a response, the facility had to contact EMS to pronounce the patient’s time of death. NF2 stated frustrations with the agency continued to occur with medications and oxygen being delivered timely, hospital bed access, pain medication syringes filled timely, getting the correct supplies for patients, and communication. NF2 stated concerns were reported to staff member F and staff member E when they were in the facility, but have not been corrected or continue to reoccur. Review of facility records, RT tasks, dated 12/30/23 at 9:29 a.m., reflected patient #1 died on 12/30/23 at approximately 2:00 a.m., and the hospice agency was called several times without a response. The facility called EMS who sent the fire department to pronounce the death of the patient. 2. Review of patient #4’s EMR reflected she began hospice services on 1/18/24, with a primary diagnosis of senile degeneration of the brain. Patient #4 resided in [Facility name] assisted living facility. During an interview on 9/30/24 at 5:14 p.m., NF6 reviewed medications in the medication cart with the surveyor. NF6 showed the surveyor all medication cards and orders on the MAR for patient #4. It was discovered patient #4 was out of their scheduled melatonin and hydrocodone. NF6 stated patient #4 had been out of the melatonin for weeks, and had been out of the hydrocodone for three days. During an observation on 9/30/24 at 5:16 p.m., patient #4 was observed sitting in the dining room at a table. Patient #4 was grimacing, and not moving her neck. NF6 approached patient #4 and asked her about her pain level and location. Patient #4 stated her “... neck and back hurt, closer to a 10 (10/10 pain level).” Patient #4 was guarding her neck and not turning her neck to face the nurse; she was turning her torso instead. NF6 called the agency for PRN medication approval because the facility did not have the scheduled hydrocodone from the agency. 3. Review of patient # 3’s EMR reflected she began hospice services on 5/13/24, with a primary diagnosis of Acute and Chronic Respiratory Failure. Patient #3 resided in [Facility name] assisted living facility. Review of patient # 5’s EMR reflected she began hospice services on 7/15/24, with a primary diagnosis of frontotemporal neurocognitive disorder. Patient #5 resided in [Facility name] assisted living facility. Review of patient # 6’s EMR reflected she began hospice services on 4/15/24, with a primary diagnosis of Alzheimer’s disease. Patient #6 resided in [Facility name] assisted living facility. During an interview on 9/30/24 at 11:43 a.m., NF4 stated the facility had difficulty getting medication orders, oxygen, and medications delivered on time from the agency. NF4 stated oxygen was supposed to be delivered on Friday and was not, so patient #3 who required continuous oxygen had to stay in her room on the concentrator all weekend. NF4 stated patient #3 was not able to go to dining or participate in activities all weekend. NF4 stated she had again notified the agency nurse this morning for oxygen needs. NF4 stated patient #4 had pain and had no hydrocodone/acetaminophen, patient #3 was almost out of hydromorphone and no response from the agency, patient #5 was still waiting for refills since 9/26/24, and patient #6 had been out of oxycodone for six days. During an interview on 9/30/24 at 10:30 a.m., NF1 stated, “We gave up calling [Agency name], we don’t call, we just give PRNs now.” During an interview on 9/30/24 at 11:28 a.m., NF3 stated it took a long time to get responses from the agency on medications. NF3 stated due to the issues reaching on-call staff, the facility nurses have been told if they could not reach an agency on-call staff, they were instructed to call the facility manager on-call and they would approve the PRN medications. NF3 stated she shared concerns at the Friday meetings with staff member F regarding medication issues, supplies not received, or the wrong size/type of supplies. During an interview on 9/30/24 at 12:07 p.m., staff member E stated the pain management protocol for facility patients included advising the caller on the next steps, or going to see the patient. Staff member E stated the agency used a mail order pharmacy for scheduled medications and a local pharmacy for crisis medications. Staff member E stated she went to the facility twice a week and was not made aware of the medication shortages, oxygen outage, or the on-call issues. Staff member E stated she had been at the facility on the morning of this interview and knew the briefs that were delivered were tape up briefs instead of pull ups, as the facility requested. During an interview on 9/30/24 at 12:16 p.m., staff member B stated she was not aware of the facilities concerns with oxygen or medications deliveries. During an interview on 9/30/24 at 4:02 p.m., with staff member A and C, staff member A stated pain medications have now been ordered for the four patients (#’s 3, 4, 5, and 6) in question at the facility. Staff member A stated the oxygen delivery service stated he did not deliver oxygen on Friday because he assumed the residents did not need more oxygen since they had not needed more the previous Friday. Staff member A stated oxygen was being delivered on the day of the interview. Staff member A stated, “We need to do better on communication.” Staff member C stated staff member E did receive a call over the weekend for pain medication outage for patient # 6, she ordered it, and told the facility to use the PRN syringes in the meantime. Staff member C stated the facility would have to call for approval with each dose of the PRN given. Staff member A stated he had talked to staff member E and staff member E had assured him she checked and confirmed, and all medications were full for two weeks. Staff member A stated the observation completed by the surveyor indicated the nurse was dishonest with him. Staff member C stated the process for on-call services at the agency is for families and facilities to call the call center or office directly and the call center would contact the appropriate on-call nurse. If the on-call nurse did not respond within a few minutes, the call center would then try a second time, then proceed to contact the on-call administrator. Staff member C stated she was surprised this was not done with patient #1. Staff member A stated the nurses should not be using text messaging and direct calls to their phones from facilities and families. Staff member A stated all calls should have been coming through the on-call service or the office directly to ensure patients’ needs were met. Staff member A stated he was planning an emergency meeting to ensure all staff were aware of the proper process for calls and to notify their patients and facilities. During an interview on 10/1/24 at 10:36 a.m., staff member A stated the agency was pulling staff member E off hospice due to personal issues, and staff member E should have caught and reported the issues in the facility sooner.”