Enhabit Hospice

“Based on record review and interview the facility failed to complete the comprehensive assessment within 48 hours of admission for 1 (P [Patient] 6) out of 19 (P1-P19) patients reviewed. This deficient practice could lead to a failure in planning care for all patients being admitted to the hospice. The findings are: Record review of P6’s medical record under Election of Benefits signed by P6’s spouse and admitting nurse was dated 03/18/2024. Record review of P6’s chart under Visit Note Report dated 03/18/2024. The hospice Registered Nurse (RN) started the initial assessment on 03/18/2024 at 11:37am and the assessment completion date and time is 03/24/2024. During an interview with S [staff] 3 (clinical staff) on 08/08/2024 at 9:00 am, S3 confirmed the RN’s initial assessment was late and completed after the 48-hour time frame.”

“Based on record review and interview the facility failed to meet the 5 day timeframe for completion of the comprehensive assessment by the entire Hospice interdisciplinary group (IDG- group of individuals caring for the hospice patient including an attending physician, Registered nurse, medical social worker, and counselor or pastoral personnel) for 5 patients ((P) P6, P7, P10, P11, and P17) out of 19 (P1-P19) patients being reviewed. This deficient practice is likely to lead to the patients hospice needs being unmet. The findings are: A. Record review of P6’s chart under visit notes, P6’s start of care was 03/18/2024 and had a late 5-day initial visit for social needs by S8 (clinical staff member) this initial visit was started on 04/01/2024 at 9:25 am and was completed on 04/01/2024 at 11:15 am. B. During an interview with S [staff] 3 (clinical staff) on 08/08/2024 at 9:00 am, S3 confirmed S8 (clinical staff) was late with P6’s initial assessment and should have been completed within 5 -days after admission. C. Record review of P7’s medical chart under visit note, P7 was admitted on 03/28/2024 with the spiritual initial assessment being completed by S9 (clinical staff) on 04/03/2024. The spiritual assessment was completed outside the 5-day timeframe. D. During an interview with S3 on 08/08/2024 at 9:05 am, S3 confirmed that the spiritual need initial assessment was completed late and outside the 5-day timeframe. E. Record review of P10’s chart under visit notes the start of care was dated 04/09/2024. Under visit notes for social services the initial assessment completed by S10 (clinical Staff) was completed on 04/19/2023. F. During an interview with S3 non-clinical staff on 08/08/2024 at 9:10 am, S3 confirmed S10 (clinical staff) was late with the initial social services assessment. 5-day initial assessment. G. Record review of P11s medical record under visit notes the Start of Care date was 11/09/2023, and the initial spiritual needs assessment was completed on 11/14/2024 by S6 (clinical staff). H. During an interview with S3 on 08/08/2024 at 9:15 am, S3 confirmed that spiritual needs assessment by S6 was not within the 5-day initial spiritual assessment. I. Record review of P17s medical record revealed P17 was admitted on 05/17/24. The patients spiritual assessment was not completed by an IDG team member until 05/29/24. J. During an Interview with S3 on 08/08/24 8:45 am, when asked when the spiritual assessment was completed, S3 stated that S6, clinical staff member, initially reached out to P17 on 05/24/24, which was out of the 5 day window, and completed the spiritual aspect of the comprehensive assessment on 05/29/24.”

“Based on record review, observation and interview the facility failed to evaluate and maintain medical supplies by not following standard precautions by preventing unopened and unexpired medical supplies from being available for patient home delivery. This deficient practice can lead to the increased chance of transmission of infections and communicable diseases to all patients. The findings are: A. Record review of facilitys “;Agency Operations Medical supply management A16” dated 10/10/2023, 3.0 Policy section 3.1.1 stated “;3.1.1.1 The Administrative Specialist is responsible for maintaining medical supply stock levels. 3.1.1.1 The Administrative Specialist via periodic visual inspections evaluates/maintains office stock levels.” B. During an observation of the medical supplies and equipment shelves (for staff use in patient homes), on 08/05/24 at 3:05 pm, the facilitys supply closet revealed: 1. One (1) box of catheters (plastic tube used to help remove urine from the bladder) with a manufacturer expiration date of 05/31/24. 2. Five (5) single use packets of Bactrim Ointment (an antibiotic used to prevent infections) with an expiration date of 07/24. 3. Ace bandage (stretchy fabric, elastic bandage) with the label that has a patients name. This bandage had and expiration date of August 18, 2019. C. During an interview on 08/08/24 at 9:34 am with Staff (S)3, Registered Nurse Branch Director, S3 confirmed she was in charge of the medical supplies, and she was aware it was expired. S3 stated “;We are all well aware of the supplies procedure”. (Checking all supplies and removing the expired dates and open packages and restocking with new supplies) S3 Stated “;Yes, I order it, and its rotated and checked every Tuesday. Im not sure why these expired items are here.””