Enhabit Hospice

“Based on observation, record review, interview, and policy review, the Hospice Agency failed to meet the Condition of Participation Interdisciplinary Group, Care Planning, and Coordination of Services. The agency failed to 1. Educate patients and caregivers; 2. Provide appropriate patient symptom pain management; and 3. Ensure that patient care plans incorporated measurable data elements in care plan goals. These deficient practices have the potential to affect all 39 patients receiving services from the Hospice Agency. 1. The Hospice Agency failed to educate two of four (Patient (P) 6 and P13) patients on aspiration precautions with tube feedings, the dangers of smoking while using supplemental oxygen, and the dangers of cutting an extended-release narcotic tablet in half. (Refer to L544). 2. The Hospice Agency failed to provide appropriate symptom pain management for P3 and P7 (Refer to L546). 3. The Hospice Agency failed to ensure that patient care plans incorporated measurable data elements to assess if progress toward expected outcomes of care plan goals were being met for 14 of 14 sampled patients (Patient (P) 1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14) reviewed for care plan development. (Refer to L548).”

“Based on interview, and policy review, the Hospice Agency failed to provide Emergency Preparedness training to agency staff. This deficient practice had the potential to affect all 39 patients receiving services from the Hospice Agency. The findings are: Review of the agency’s undated policy titled “Emergency Preparedness” revealed “ ... All staff, whether employees or contract, will be instructed on the Emergency Preparedness and Response Plan during orientation and annually thereafter during safety training ... “ During an interview on 08/27/24 at 1:30 PM, the Administrator confirmed that Emergency Preparedness training was not performed for 36 out of 36 staff members.”

“Based on record review, observation, policy review, and interview, the Hospice Agency failed to ensure all medications listed on the medication list were available in the patient’s home for one of four (Patient (P) 6) patients observed. This had the potential for P6 to have unmet healthcare needs. Review of P6’s “Medicine List” dated 08/06/24, found in P6’s Electronic Medical Record (EMR) under the “Medications” tab, indicated that P6 was prescribed midodrine 10 milligram (mg) tablets (used to treat low blood pressure) and sertraline (used to treat depression) 25 mg tablets. During medication review in P6’s home on 08/27/24 at 11:35 AM, it was observed that midodrine and sertraline were not found with the other medications. The caregiver looked for the two bottles of medications but was unable to locate them. During an interview on 08/27/24 at 11:40 AM, the patient’s caregiver stated that he/she had never heard of midodrine and sertraline when asked if the two medications were in the home. Review of the agency’s undated policy titled “Medications” revealed “ ... The licensed professional provides ongoing medication assessments and teaches the patient and/or caregiver about use, actions, interactions, and side effects of medications he/she is taking, according to their documented knowledge base deficits. ... “”

“Based on observation, record review, interview, review of the “National Institutes of Health (NIH)” website, and policy review, the Hospice Agency failed to educate two of four (Patient (P) 6 and (P)13) patients on aspiration precautions with tube feedings, the dangers of smoking while using supplemental oxygen, and the dangers of cutting an extended-release narcotic tablet in half. These deficient practices have the potential for both residents to have healthcare issues. 1. During an observation in P13’s home on 08/28/24 at 9:15 AM, with the agency’s Master of Social Work (MSW) 1, two surveyors noted a strong cigarette odor upon entering the home. The patient was observed lying in bed with nasal cannula oxygen tubing on his/her face and the oxygen concentrator was running at 4 liters per minute (lpm). MSW1 did not provide education to the patient or the patient’s caregivers on the dangers of smoking with or near supplemental oxygen when in use. Review of P13’s “Medicine List”, dated 08/19/24, found in P13’s Electronic Medical Record (EMR) under the “Medications” tab, indicated that P13 was prescribed oxygen gas for inhalation at 2-5 lpm as needed for shortness of breath. Review of P13’s “Patient Information Report”, dated 08/19/24, found in the EMR under the “Diagnoses/Procedures” tab, revealed a diagnosis of “personal history of nicotine dependence” and “Dependence of supplemental oxygen.” Review of P13’s “Client Coordination Note Report” found in the EMR under the “Visit Notes” tab, revealed that on nursing visits made on 08/19/24, 08/21/24, and 08/22/24, there was no documentation indicating that the Registered Nurse (RN) provided education to the patient or the patient’s caregivers on the dangers of smoking with or near supplemental oxygen when in use. Review of P13’s “Hospice Plan of Care (POC) Report” found in the EMR under the “Plan of Care” tab, indicated RN started P13’s care plan on 08/19/24; however, the POC did not include the need to educate the patient or the patient’s caregivers on the dangers of smoking with or near supplemental oxygen when in use. In addition, Review of P13’s “Client Coordination Note Report” found in the EMR under the “Notes” tab, indicated that during the nursing visit made on 08/22/24, the “patient’s [grandchild] said that they were giving the patient the MS ER (morphine sulphate extended release tablet used for severe pain) 30 milligram (mg.) as ordered but it was sedating patient and [he/she] was not eating because [he/she] was sleeping too much. The [grandchild] said that they started cutting the tablets in half, and that seems to be working better for the patient.” There was no documentation indicating that education was provided to the caregiver on the dangers of cutting an extended-release morphine tablet in half. Review of the “NIH” website https://dailymed.nlm.nih.gov, indicated “Morphine sulfate extended-release tablets are to be swallowed whole and are not to be broken, chewed, dissolved, or crushed. Taking broken, chewed, dissolved, or crushed morphine sulfate extended-release tablets leads to rapid release and absorption of a potentially fatal dose of morphine.” During an interview on 8/28/24 at 11:30 AM, the Administrator confirmed the following: 1) there was no documentation on educating P13 or P13’s caregivers on the dangers of smoking with supplemental oxygen in use; 2) education on the dangers of smoking should be reinforced at each patient visit when there is evidence of smoking in the home where there is oxygen in use; and 3) education should have been provided by the RN after P13’s caregiver stated that he/she was cutting the extended-release morphine tablets in half. The Administrator stated that the agency does not have a policy on the dangers of smoking with supplemental oxygen in the home, or the dangers of cutting extending release tablets in half. Review of the agency’s undated policy titled “Medications” revealed “ ... If the patient is self-administering medications, staff will provide training and supervision and allow for the teach-back method to be implemented to ensure they are safely administering these medications. ...” 2. Review of P6s “Medication List” dated 08/06/24, located in P6s EMR under the “Medications” tab revealed P6 was to receive Jevity 1.5 continuously at 40 ml/hr. (milliliters per hours) with 250 ml of water every six hours via peg tube. Review of P6s “Plan of Care (POC)” dated 08/06/24, provided by the facility revealed, “;...provide teaching/reinforcement related to appetite, dehydration, diet modifications, S/S [signs and symptoms] aspiration, and safe feeding strategies to reduce aspiration...” Review of P6s “Skilled Nursing” visit documentation for 08/06/24, 08/07/24, 08/09/24, 08/13/24, 08/20/24, and 08/27/24 did not reflect education to the responsible party/caregiver of the patient potentially decreasing nutritional needs as the patients condition declines and how to prevent aspiration associated with tube feedings along with the signs and symptoms of aspiration. During an interview on 08/28/24 at 5:20 PM, the Administrator confirmed there was no documentation of the nurse providing education on safe feeding strategies to prevent aspiration or the signs and symptoms of aspiration to P6s caregiver, and there should have been.”

“Based on record review, interview, and policy review, the Hospice Agency failed to provide appropriate symptom management for two of 14 (Patients (P) 3 and (P)7) sampled patients reviewed. This deficient practice had the potential to affect both patients quality of life. 1. Review of P3’s “Visit Note Reports,” dated 06/13/24, 07/12/24, and 07/15/24, in the Electronic Medical Record (EMR) under the “Visit Notes” tab indicated that P3’s diagnosis was stomach cancer. P3 reported a pain rating of seven out of 10 to the Registered Nurse (RN) and described the pain in the abdomen and “aching” and “shooting.” On the pain scale, zero indicates no pain and 10 indicates the worst pain possible. P3’s pain goal was a five out of 10. There was no documentation indicating that the RN notified the Medical Director to report the unresolved symptoms or that a medication change was made. Review of P3’s “Visit Note Reports,” dated 07/22/24 and 08/21/24 found in the EMR under the “Visit Notes” tab indicated that P3 reported a pain rating of six out of 10 to the RN and described the pain in the abdomen as “shooting.” There was no documentation indicating that the RN notified the Medical Director to report the unresolved symptoms or that a medication change was made. 2. Review of P7’s “Visit Note Report,” dated 08/06/24, found in the EMR under the “Visit Notes” tab indicated that P7 was diagnosed with pancreatic cancer and reported to the RN that “[he/she] has constant generalized pain ... and chronic nausea and vomiting.” P7’s pain medications consisted of oxycodone and morphine. Review of P7’s “Visit Note Report,” dated 08/07/24, found in the EMR under the “Visit Notes” tab indicated that P7’s caregiver reported to the RN that “patient is having a very hard time sleeping at night, only sleeping one – two hours on and off during the night. Patient said that the pain, nausea, and generalized stress is what’s keeping [him/her] up at night. Also said that [he/she] doesn’t feel like the morphine concentrate is helping with patient’s pain.” There was no documentation indicating that the RN notified the Medical Director to report the unresolved symptoms or that a medication change was made. Review of P7’s “Visit Note Report,” dated 08/19/24, found in the EMR under the “Visit Notes” tab indicated that P7 rated his/her pain an eight out of 10 and described the pain as “aching”, “burning”, and “stabbing.” P7’s pain goal was a two to three out of 10. During the visit, the RN administered pain medications, and the pain decreased to a four out of 10 which was still not within the patient’s pain goal. There was no documentation indicating that the RN notified the Medical Director to report the unresolved symptoms or that a medication change was made. Review of P7’s “Visit Note Report,” dated 08/23/24, found in the “Visit Notes” tab indicated that P7’s caregiver reported the patient “needed oxycodone approximately six times and morphine twice in the past 24 hours for break through pain.” The RN received new orders to increase the Fentanyl patch; however, there was no follow-up visit made to ensure the increased Fentanyl dosage was effective. The patient passed away on 08/26/24. During an interview on 08/28/24 at 5:00 PM, the Administrator confirmed that symptoms were not appropriately managed for P3 and P7. Review of the agency’s undated policy titled “Coordination of Services” indicated “ ... Coordination of services describes the Agency’s methods for cooperation and communication to confirm liaison between team members and physician(s) to support objectives outlines in the plan of care. 3.1 Professional staff coordinate services with the physician. Staff 3.1.2 Promptly alert the physician to any changes which suggest a need to modify the plan of care. ...””

“Based on record review, interview, and policy review, the Hospice Agency failed to ensure that patient care plans incorporated measurable data elements to assess if progress toward expected outcomes of care plan goals were being met for 14 of 14 sampled patients (Patient (P) 1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14) reviewed for care plan development. This deficient practice had the potential to affect all 39 patients receiving services from the Hospice Agency. 1. Review of P3’s “Hospice POC (Plan of Care) Report,” found in P3’s Electronic Medical Record (EMR) under the “Care Plan” tab, indicated the Registered Nurse (RN) started P3’s “POC” on 12/16/23 that included altered nutrition/hydration, altered home safety, self-care deficits, altered gastrointestinal system, altered comfort, and altered genitourinary system. The Medical Social Worker (MSW) started P3’s “POC” on 12/18/23 that included altered home safety. The “POCs” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 2. Review of P7’s “Hospice POC Report,” found in P7’s EMR, indicated the RN started P7’s “POC” on 08/06/24 that included altered comfort, altered nutrition/hydration, altered respiratory status, altered skin integrity, altered gastrointestinal system, altered home safety, and self-care deficits. The MSW started P7’s “POC” on 08/19/24 that included alterations in coping. The “POCs” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 3. Review of P9’s “Hospice POC Report,” found in P9’s EMR, indicated the RN started P9’s “POC” on 04/17/24 that included altered comfort, altered cardiac/circulatory system, and altered sensory/neurological status. The MSW started P9’s “POC” on 04/20/24 that included alterations in coping. The Chaplain started P9’s “POC” on 04/18/24 that included alterations in spiritual issues and life value. The “POCs” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 4. Review of P10’s “Hospice POC Report,” found in P10’s EMR, indicated the RN started P10’s “POC” on 06/12/24 that included altered comfort, self-care deficits and altered sensory/neurological status. The “POC” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 5. Review of P12’s “Hospice POC Report,” found in P12’s EMR, indicated the RN started P12’s “POC” on 06/21/24 that included altered comfort, altered cardiac/circulatory system, altered sensory/neurological status, altered skin integrity, and altered nutrition/hydration. The care plan did not include measurable data elements to monitor progress toward the expected outcomes and goals. 6. Review of P13’s “Hospice POC Report,” found in P13’s EMR, indicated the RN started P13’s “POC” on 08/19/24 that included altered comfort, altered cardiac/circulatory system, altered respiratory status, and altered gastrointestinal system. The MSW started P13’s “POC” on 08/21/24 that included altered comfort. The “POCs” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 7. Review of P14’s “Hospice POC Report,” found in P14’s EMR, indicated the RN started P14’s “POC” on 03/13/24 that included altered comfort, altered respiratory status, and altered home safety. The MSW started P14’s “POC” on 03/16/24 that included alterations in coping. The Chaplain started P14’s “POC” on 3/15/24 that included alterations in spiritual issues and life values. The “POCs” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 8. Review of P1’s hospice “Plan of Care (POC)” provided by the facility, indicated the RN, SW, and Chaplin, started P1’s “POC” on 02/06/24 that included altered comfort, altered cardiac/circulatory system, altered sensory/neurological status, need for skilled care related to risk of falls, altered home safety, need for observation/evaluation of signs and symptoms of the anticipatory grieving process, and spiritual issues and life values. The “POC” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 9. Review of P2’s hospice “Plan of Care (POC)” provided by the facility, indicated the RN, SW, and Chaplin, started P2’s “POC” on 10/04/23 that included altered comfort, need for skilled teaching of altered comfort, altered cardiac/circulatory status, altered respiratory status, identification of responsible party for administering medications, potential for constipation related to opioid use, need for skilled care related to risk for falls, altered home safety, need for observation/evaluation of psychosocial symptoms related to anxiety and depression affecting quality of life, need for observation/evaluation of signs and symptoms of the anticipatory grieving process, and spiritual issues and life values. The “POC” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 10. Review of P4’s hospice “Plan of Care (POC)” provided by the facility, indicated the RN, SW, and Chaplin, started P4’s “POC” on 07/19/24 that included altered comfort, need for skilled teaching of altered comfort, need for observation/assessment of psychosocial/spiritual factors affecting pain, altered cardiac/circulatory system, altered respiratory status, altered skin integrity, identification of responsible party for administering medications, altered home safety, coping, and spiritual issues and life values. The “POC” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 11. Review of P5’s hospice “Plan of Care (POC)” provided by the facility, indicated the RN, SW, and Chaplin, started P5s “POC” on 07/27/24 that included altered comfort, need for skilled teaching of altered comfort, need for skilled care related to risk of falls, altered cardiac/circulatory system, altered respiratory status, altered skin integrity, need for skilled teaching of altered comfort, potential for constipation related to opioid use, need for observation/evaluation of psychosocial symptoms related to anxiety and depression affecting quality of life, need for observation/evaluation of signs and symptoms of the anticipatory grieving process, and spiritual issues and life values. The “POC” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 12. Review of P6’s hospice “Plan of Care (POC)” provided by the facility, indicated the RN, SW, and Chaplin, started P6s “POC” on 08/06/24 that included altered comfort, need for skilled teaching of altered comfort, need for skilled care related to risk of falls, altered respiratory status, altered nutrition/hydration, need for skilled teaching on proper mouth care, altered skin integrity, altered gastrointestinal, need for wound care, altered home safety, need for skilled care related to risk for falls, self-care deficits, observation/evaluation of psychosocial symptoms related to anxiety and depression affecting quality of life, and spiritual issues and life values. The “POC” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 13. Review of P8’s hospice “Plan of Care (POC)” provided by the facility, indicated the RN and SW started P8s “POC” on 07/19/24 that included altered comfort, need for skilled teaching of altered comfort, need for skilled care related to risk of falls, altered cardiac/circulatory status, need for assessment and hospice nursing interventions of psychosocial, cognitive, and behavioral symptoms affecting quality of life, altered respiratory status, altered skin integrity, identification of responsible party for administering medications, altered home safety, need for skilled teaching related to patients risk for falls and safety to prevent falls, and altered comfort. The “POC” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 14. Review of P11’s hospice “Plan of Care (POC)” provided by the facility, indicated the RN, SW, and Chaplin, started P11s “POC” on 03/06/24 that included altered comfort, need for skilled teaching of altered comfort, need for skilled administration of pain medications, altered cardiac/circulatory system, altered respiratory status, oxygen safety and respiratory supporting device education and monitoring, identification of responsible party for administering medications, potential for constipation related to opioid use, need for skilled teaching related to risk for falls, altered home safety, altered nutrition/hydration, need for skilled administration of indwelling catheter, increased risk/declining status/imminent death, coping, and spiritual issues and life values. The “POC” did not include measurable data elements to monitor progress toward the expected outcomes and goals. During an interview on 08/28/24 at 2:00 PM, the Administrator confirmed that the agency staff including the RN’s, MSW’s and Chaplains were not creating “POCs” that were measurable and included data elements to monitor progress toward the expected outcomes and goals. Review of the agency’s undated policy titled “Admission Process & Patient Assessment” revealed “ ... A plan of care will be established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient’s needs if any of them desire. The hospice will ensure that each patient and the primary caregiver(s) receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care. The plan of care will reflect patient and family goals and interventions based on the problems identified. ...””