Enhabit Hospice

“Based on interview and review of the facility’s Emergency Preparedness Plan (EPP), the agency failed to ensure the EPP policies addressed the use of federal and/or state healthcare volunteers to meet staffing requirements during an emergency event. This failure had the potential to affect the current 19 patients receiving care from the hospice agency. Findings include:Review of the facility’s EPP, last reviewed on 06/02/23, with the Director of Operations (DOO) revealed no policy inclusion regarding the integration of State and/or Federal healthcare professional volunteers in an emergency or other emergency staffing strategies.During an interview on 05/14/25 at 4:33 PM, the DOO remarked, “I know that we don’t have this.””

“Based on interview and review of the facility’s Emergency Preparedness Plan (EPP), the Hospice failed to maintain a current list of names and contact information in the “Emergency Preparedness Communication Plan” that included other hospices. This failure had the potential to affect any of the current 19 patients receiving care from the organization and could delay the facility’s ability to respond to an emergency. Findings include:Review of the agency’s EPP Communication Plan, last reviewed on 06/02/23, with the Director of Operations (DOO) revealed no inclusion of a list of other hospices and their respective contact information.In an interview on 05/15/25 at 5:01 PM, the DOO confirmed the hospice employees and physicians were included, but “We do not have other hospices.””

“Based on interview and review of the facility’s Emergency Preparedness Plan (EPP), the facility failed to maintain a current list of contact information that included the Federal, State, Regional, Tribal, and Local emergency preparedness staff and/or agencies in their Emergency Preparedness Communication Plan. This failure had the potential affect any of the 19 current patients receiving care from the facility and would delay the facility’s ability to respond to an emergency; and the potential to prevent first responders and other sources of assistance from providing care and services to the facility and its patients or staff during an emergency event. Findings include:Review of the facility’s EPP Communication Plan, last reviewed on 06/02/23, with the Director of Operations (DOO) did not show the contact information for the Federal, State, Regional, Tribal, and Local emergency preparedness agencies. The Communication Plan listed the local fire department. During the review on 05/14/25 at 5:02 PM, the DOO reviewed the emergency plan, pointed out the fire department and stated, “No, it’s not in there.””

“Based on interview, record review, and policy review, the Hospice agency failed to ensure that the plan of care contained measurable goals for three of 14 patients (Patients (P) 2, P11, and P12) whose records were reviewed. This failure had the potential to affect the patient’s receipt of necessary care and determination if care plan goals had been met or if a plan of care revision was required. Findings include:In response to a request for a facility policy regarding the plan of care development, the agency provided a policy titled, “Physician’s Role,” revised 02/18/25, that revealed, “. . . 2.0 Plan of care is a written plan developed with the participation of professional staff and the patient, in consultation with and authorized by the physician that supports the patient’s medical, nursing and psychosocial needs in the home setting and serves as the basis of care delivery . . .” The policy did not address having measurable goals for identified problems.1. Review of P2’s “Patient Information Report,” provided by the agency, revealed a referral date of 12/20/24; with the last recertification period beginning on 03/20/25 and a terminal diagnosis of chronic obstructive pulmonary disease.Review of P2’s “Hospice POC [Plan of Care] Report,” provided by the agency, revealed a problem regarding observation and assessment of altered comfort that had a goal of “Patient’s pain will remain at an acceptable level to patient/caregiver.” No acceptable pain level was identified to ensure the pain relief goal was measurable or achieved. 2. Review of P11’s “Patient Information Report,” provided by the agency, revealed a referral date of 04/14/25 and a terminal diagnosis of heart failure.Review of P11’s “Hospice POC Report,” provided by the agency, revealed a problem regarding observation and assessment of altered comfort that had a goal of “Patient’s pain will remain at an acceptable level to patient/caregiver.” No acceptable pain level was identified to ensure the pain relief goal was measurable or achieved.3. Review of P12’s “Patient Information Report,” provided by the agency, revealed a referral date of 05/03/25 and a terminal diagnosis of liver cirrhosis and hepatic encephalopathy.Review of P12’s “Hospice POC Report,” provided by the agency, revealed a problem regarding observation and assessment of altered comfort that had a goal of “Patient’s pain will remain at an acceptable level to patient/caregiver.” No acceptable pain level was identified to ensure the pain relief goal was measurable or achieved.During an interview on 05/14/25 at 2:45 PM, the Branch Director expressed an expectation stating, “Care plans should have measurable goals. The one I did last night I made sure of.””

“Based on interview and review of the agency documentation, the agency failed to ensure volunteers provided day-to-day administrative and/or direct patient care services equaling a minimum of five percent of the total patient care hours of all paid hospice employees and contract staff. Findings include:Review of the facility’s policy titled, “Volunteers,” reviewed on 10/29/24 revealed:”. . . Volunteers will provide day to day administrative and/or direct client care services in an amount that at a minimum equals 5% of the total patient care hours of all paid hospice employees and contract staff . . .”Review of the “Hospice Volunteer Requirement Report,” provided by the agency, revealed for 10/2024 through 04/2025, the monthly volunteer hour percentages were:Month Total: October 2024Hospice Hours 238.39Volunteer Hours 8.22Percentage 3.45%Month Total: November 2024 Hospice Hours 274.24Volunteer Hours 3.63Percentage 1.32%Month Total: December 2024Hospice Hours 292.18Volunteer Hours 0.75Percentage 0.26%For Year 2025Month Total: JanuaryHospice Hours 297.34Volunteer Hours 4.0Percentage 1.35%Month Total: FebruaryHospice Hours 233.06Volunteer Hours 1.42Percentage 0.61%Month Total: MarchHospice Hours 336.28Volunteer Hours 2.83Percentage 0.84%Month Total: AprilHospice Hours 327.22Volunteer Hours 6.58Percentage 2.01%”During an interview on 05/14/25 at 4:59 PM, the Director of Operations stated the expectation was for the agency to have volunteer hours of 5% of the agency’s yearly hours. The Director of Operations stated, “We’re not meeting that.””

“Based on interview, record review, and agency policy review, the agency failed to ensure that copies of a patient’s advance directive and/or healthcare power of attorney (HCPOA) were contained in the medical record for three of 14 patients (Patient (P) 1, P3, and P14) whose records were reviewed. This failure had the potential to affect patient care by not having the designated person making medical decisions and having the patient’s expressed medical preferences followed. Findings include:Review of the facility’s policy titled, “Advance Directives,” reviewed 11/26//24, revealed, “. . . During the initial visit, in advance of furnishing care, the appropriate admitting licensed professional . . . Obtains a copy of the advance directives, if possible, to file in the patient’s clinical record . . .”1. Review of P1’s “Patient Information Report,” provided by the agency, revealed a hospice referral date of 02/27/25 and a terminal diagnosis of hemiparesis with cerebrovascular disease.During an interview and record review on 05/13/25 at 12:49 PM, review of P1’s “Informed Consent for Hospice Services” form revealed the form was checked that P1 had a HCPOA and a living will. The Branch Director (BD) reviewed the record and stated the clinical record did not contain copies of either the HCPOA or living will. 2. Review of P3’s “Patient Information Report,” provided by the agency, revealed a hospice referral date of 03/04/25 and a terminal diagnosis of senile degeneration of the brain.During an interview and record review on 05/14/25 at 10:49 AM, review of P3’s “Informed Consent for Hospice Services” form revealed the form was marked that P3 had a HCPOA. The BD reviewed the record and stated a copy of the HCPOA was not included in the clinical record. 3. Review of P14’s “Patient Information Report,” provided by the agency, revealed a hospice recertification referral date of 12/20/24 and a terminal diagnosis of colon cancer.During an interview and record review on 05/14/25 at 3:31 PM, review of P14’s “Informed Consent for Hospice Services” form revealed the form was marked that P14 had a HCPOA. The BD reviewed the file for a copy of the HCPOA and stated the clinical record did not contain a copy of the HCPOA.”

“Based on observation, interview, and policy review, the Hospice Agency failed to ensure that supplies kept for patient use were not expired. This had the potential to negatively affect 19 of 19 current patients. Expired products may not perform as intended, leading to ineffective treatment, and/or increase the risk of infection. Findings include:A tour of the hospice agency’s stock rooms on 05/13/25 at 8:00 AM revealed one box containing 144 three-gram packages of McKesson lubricating jelly that had an expiration date of 04/14/25 and two sterile McKesson Indwelling Catheter Trays with an expiration date of 12/28/24 available for patient use. During an interview on 05/13/25 at 8:10 AM, the Branch Director (BD) confirmed the expiration dates as printed on the packages. During an interview on 05/13/24 at 8:39 AM, the BD confirmed the products were available for patient use and stated an expectation that the nurse would check the expiration dates prior to using. Review of the agency’s policy titled, “Medical Supply Management,” reviewed 10/11/24, revealed, “. . . It is the policy of the Agency to adhere to the following guidelines with regard to managing medical supplies for the office and Individual patients . . . The Administrative Specialist is responsible for maintaining medical supply stock levels . . . The Administrative Specialist via periodic visual inspections evaluates/maintains office stock levels . . .” The policy did not address expired products.”

“Based on interview, record review, and policy review, the facility failed to ensure the Skilled Nursing Facility (SNF) received the hospice plan of care documentation for one of one patient (Patient (P) 2) reviewed who lived at a SNF out of a total sample of 14. This had the potential to affect the care and services provided to the patient. Findings include:Review of P2’s “Patient Information Report,” revealed P2’s last recertification period began on 03/20/25 for a primary terminal diagnosis of chronic obstructive pulmonary disease.During a home visit to the SNF on 05/13/25 at 4:05 PM, R2’s Hospice three ring binder, located at the SNF Nurse’s Station, was reviewed with the SNF Administrator. There was no hospice plan of care located in the binder. At 4:50 PM, the Hospice Social Worker reviewed the binder and confirmed it did not contain the hospice plan of care. At 4:55 PM, the SNF Licensed Nurse reviewed the electronic medical record and confirmed the hospice plan of care was not included in other hospice documentation.During an interview on 05/14/25 at 2:45 PM, the Branch Director (BD) stated the fax that should have gone to the SNF with P2’s plan of care did not go through. The BD stated that the SNF should have the hospice plan of care.Review of the facility policy’s titled, “Clinical Records,” revised 05/03/24, revealed, “. . . The Agency maintains a record in the patient’s home, as needed, to confirm appropriate and coordinated care when there are multiple care givers, multiple disciplines, and/or frequent or complex services which necessitate access to current information regarding the patient and his/her care . . .””