Enhabit Hospice

“Based on interview, record review, and policy review, the Hospice Agency failed to meet the Condition of Participation (CoP): Core Services. The agency’s Registered Nurse (RN) failed to follow acceptable nursing standards of practice. This deficient practice had the potential to cause serious harm to this patient.Findings include: The Hospice Agency failed to ensure a physician’s order was obtained for the RN to insert a straight catheter on 01/13/2025 and place a foley catheter on 01/14/2025 for one of 14 sampled patients (Patient (P) 1). Additionally, the RN failed to obtain physician’s order for a mechanical soft diet with thickened liquids for P1 who had swallowing problems. (Refer to L591).”

“Based on document review, interview, and policy review, the Hospice agency failed to ensure the patient Plan of Care (POC) for one of 14 patients (Patient (P)1) had the correct dietary order based on the assessment of swallowing difficulties. This failure had the potential to cause aspiration as a result of liquids not being thickened.Findings include: Review of the agency’s policy titled, “Interdisciplinary Group,” dated 11/10/2025, revealed “The Interdisciplinary Group [IDG] ensures each plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions including … Interventions to manage pain and symptoms.”Review of P1’s initial “Skilled Nursing (SN) Assessment,” with a Start of Care (SOC) dated 10/30/2024 revealed Mechanical Soft and Thickened Liquids.”Review of P1’s “Hospice Certification and Plan of Care,” dated from 10/30/2024 to 01/27/2025 revealed the “Nutritional Requirements: Cardiac Diet.” The POC did not include mechanical soft diet and thickened liquids.Review of P1’s “Recertification Plan of Care Update,” dated 01/24/2025 revealed the sections labeled “Diet/Nutritional Requirements” were blank. On 12/15/2025 at 4:15 PM, the Director of Operations confirmed the initial POC and the Recertification POC did not include mechanical soft diet and thickened liquids.”

“Based on document review, interview, and policy review, the Hospice agency failed to ensure the plan of care (POC) included patient/caregiver goals that incorporate data elements to assess progress toward expected outcomes for three of 14 sampled patients (Patient (P) 1, P6, and P12. The deficient practice had the potential to affect the comfort and safety of all patients receiving services from the Hospice agency. Findings include: Review of the agency’s policy titled, “Interdisciplinary Group,” dated 11/10/2025, revealed, “The Interdisciplinary Group [IDG] ensures each plan of care includes … Measurable outcomes anticipated from implementing and coordinating the plan of care.”1. Review of P1’s “Hospice Recertification Plan of Care Update,” dated 01/24/2025 revealed goals which included:”Patient’s acceptable pain level will be achieved through pharmacological and non-pharmacological interventions.””Patient’s respiratory status will be stabilized within constraints of disease.””Patient will have an effective bowel program.”The POC did not include measurable data elements to monitor progress toward achieving the goal.2. Review of P6’s “Hospice Recertification Plan of Care Update,” dated 12/15/2025 revealed the POC did not include any identified patient or caregiver goals or measurable data elements to monitor progress toward achieving the goals. Under the “Goals” section in the POC only staff interventions are identified. 3. Review of P12’s “Hospice Recertification Plan of Care Update,” dated 10/17/2025 revealed goals that included:”Patient/Caregiver(s) demonstrate knowledge of anorexia, and/or dehydration and aspiration risk in the dying patient and demonstrate comfort the plan of care as evidenced [blank].””Patient’s respiratory status will be stabilized with constraints of disease as evidenced by [blank].The goals did not include measurable data elements to monitor progress toward achieving the goal.During an interview on 12/17/2025 at 12:30 PM, the Director of Operations confirmed that the patient/caregiver goals identified in the POC did not include measurable outcomes.”

“Based on interview, record review, and policy review, the agency failed to ensure physician orders were obtained prior to the implementation of medical interventions for one of 14 sampled patients (Patient (P) 1). 1. The Hospice Agency’s Registered Nurse (RN) inserted an indwelling catheter in P1 without a physician’s order for the placement of the indwelling catheter, an order to indicate the size of the catheter, instructions for catheter care, and how often the catheter was to be changed; 2. The RN implemented a modified diet for P1 without a physician order for the modified diet; and 3. The RN failed to ensure P1’s Plan of Care (POC) included the patient’s catheter and modified diet. These failures had the potential to cause serious harm to P1.Findings include: 1. Review of the agency’s policy titled, “Indwelling urinary catheter (Foley) care and management, home care,” dated 12/14/2025, indicated, documentation associated with indwelling urinary catheter care and management includes teaching to the patient and family (if appropriate). Review of P1’s initial “Skilled Nursing (SN) Assessment,” revealed the Start of Care (SOC) date was 10/30/2024. Review of P1’s “Physician Order,” dated 12/15/2025 and located in the patient’s Electronic Medical Record (EMR) revealed an order for an indwelling urinary catheter due to urinary retention, and the catheter was placed. The order did not identify the size of catheter to be used, instructions for catheter care, or instructions for changing the catheter.Review of P1’s “Visit Note,” dated 12/17/2024 revealed the indwelling catheter was removed on 12/17/2024 (two days after it was placed) related to hematuria (blood in the urine). Review of P1’s “Physician Orders revealed no order for the indwelling catheter to be removed. Review of P1’s “Visit Note” dated 01/13/2025 revealed the patient was experiencing foul smelling, cloudy, and brown urine. It was recorded a urine specimen was obtained via “straight cath [catheter],” and the patient was placed on an antibiotic medication.Review of P1’s “Physician Orders revealed no order for the patient to has a straight catheter inserted to obtain a urine specimen.Review of P1’s “Visit Note” dated 01/14/2025 revealed that on 01/14/2025, the patient was provided with an indwelling urinary catheter. There was no order recorded for the urinary catheter at that time. Review of P1’s entire EMR from 01/14/2025 through 02/27/2025 revealed no documented evidence P1’s catheter was changed, that the family was provided education related to catheter care, or catheter care was provided by hospice staff. Review of the EMR revealed a physician order dated 02/27/2025 for an indwelling urinary catheter to be changed every 30 days as needed for urinary retention. During an interview on 12/15/2025 at 1:08 PM, a family member stated asking repeatedly for the catheter to be changed due to P1’s discomfort and ongoing signs of infection; however, staff would either ignore the request or state they did not have the supplies necessary to change the catheter. The family member stated on 03/02/2025, a staff member changed the catheter using supplies from multiple catheter care kits. At this time, P1 had developed a fever and was sent to the hospital and died eight days later from kidney failure and left lung pneumonia.During an interview on 12/16/2025 at 10:50 AM, the Administrator confirmed there was no physician’s order for the placement of the indwelling urinary catheter which included the catheter size and care instructions until 02/27/2025. The Administrator assumed the former leadership had identified there was no order at that time and wrote the order. Review of P1’s “Nursing Note,” dated 03/02/2025 indicated P1 had a fever of 99.9 degrees Fahrenheit (F), increased confusion and tremors with signs of early sepsis. The nursing note indicated the family decided to transport P1 to the hospital for treatment. 2. Review of the agency’s policy titled, “Aspiration precautions, home care,” dated 02/23/2025, indicated, “The primary goal of a patient with dysphagia in the home is to maintain adequate nutrition while minimizing the risk of aspiration . . . by modifying the consistency of food and drink (as ordered). . . documentation associated with aspiration precautions includes: . . . contact with the practitioner or other healthcare provider, information conveyed, orders received . . .”Review of P1’s “Hospice Start of Care” nursing assessment, dated 10/30/2024 revealed P1 was identified to be dysphasic with aspiration precautions, only tolerating thick liquids and soft chopped foods. A mechanical soft diet with thickened liquids was recommended. Review of P1’s Interdisciplinary Group (IDG) meeting note dated 11/14/2024 and provided by the Administrator, indicated P1 was receiving thickened liquids.Review of P1’s”Nursing Note,” dated 01/13/2025 indicated P1 was to have thickened liquids. During an interview on 12/16/2025 at 11:53 AM, the family member stated that on 02/06/2025 a Certified Nurse Aide (CNA) left a glass of unthicken liquid within reach of P1. The family member walked in the room and observed P1 drinking the water. The nurse was notified about the incident and indicated an x-ray would be ordered. Several days later an x-ray was obtained. P1 continued to cough, with a low-grade fever, so the family member decided to have P1 transported to the hospital for treatment. P1 was diagnosed with left lung pneumonia and expired 8 days later. Review of P1’s EMR revealed there were no orders in the POC to address the swallowing difficulties, the Hospice Aide POC did not address swallowing problems. There were no physician orders for thickened liquids.3. Review of P1’s “Hospice Certification and Plan of Care,” dated from 10/30/2024 to 01/27/2025 revealed the patient’s POC did not include P1’s indwelling catheter nor the patient’s modified diet. During an interview on 12/17/2025 at 4:01 PM, the Administrator confirmed P1’s hospice aide care plan did not include thickened liquids P1’s POC did not address the mechanical soft diet, the thickened liquids, and there were no physician orders for thickened liquids. The Administrator stated nursing would have been expected to check and verify all orders and confirm the correct POC was in place.”

“Based on document review, interview, and policy review, the Hospice agency failed to meet the minimum volunteer activity level of five percent of the total patient care hours. This failure had the potential to result in unmet needs for 40 of 40 active patients.Findings include: Review of the agency’s policy titled, “Volunteers” dated 11/11/2025, 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 agency document titled, “Hospice Volunteer Requirement Report” revealed the agency’s monthly volunteer hour percentages for 2025 were:January – 2.08%February – 2.51%March – 2.36%April – 2.11%May – 4.53%June – 3.95%July – 5.59%August – 3.13%September – 3.37%October – 3.15%November – 3.09 %December – 2.64%The average volunteer percentage for January 2025 through December 2025 was 3.19%.Review of the agency’s “Performance Improvement Project (PIP) “ dated 04/15/2025 revealed the agency identified three actions to be completed to increase the volunteer hours by 09/30/2025. The form was blank and did not indicate if the Volunteer Coordinator completed the actions or not. The form did not indicate that the goal was extended or what steps the Volunteer Coordinator did take to increase volunteer participation. During an interview on 12/15/2025 at 3:15 PM, the Director of Operations stated the PIP documentation form was blank because the goal was not met and would have been ongoing. During an interview on 12/16/2025 at 1:45 PM, the Volunteer Coordinator confirmed the agency’s volunteer hours fell below the minimum requirement of 5% for 11 out of 12 months and stated, “The orientation is very time consuming and that is what seems to be a barrier for some people who expressed interest.””