Enhabit Hospice

“Based on record review and interview, the hospice failed to ensure emergency preparedness disaster declaration, table-top exercises, drills, community drills or plan activation events were conducted as required for 05/12/2023 to 12/31/23, and 01/01/24 to 12/31/24 for 49 patients, seven volunteers, and 26 employees. Findings: A review of emergency preparedness records showed winter weather advisories were emailed out to staff on 01/14/24 and again on 02/17/25. Documentation showed no after action summary reporting, table-top exercises, drills, community drills or plan activation events for 05/12/23 to 12/31/23, and 01/01/24 to 12/31/24.On 04/03/25 at 3:00 p.m., Staff B stated the hospice had no emergency preparedness disaster declarations, table-top exercises, drills, community drills or plan activation events for 05/12/23 to 12/31/23, and 01/01/24 to 12/31/24.”

“Based on record review and interview, the hospice failed to ensure it completed an initial assessment within 48 hours of election of the hospice benefit for five (Patients #1, 6, 8, 10, and 11) of 14 patients. Findings: Patient #1A review of the clinical record showed a referral date of 09/13/24 with election of the hospice benefit and SOC on 09/19/24 (6 days later). Documentation showed no declined visits, no physician notifications, and no changes in orders. On 04/03/25 at 2:56 p.m., Staff B stated the initial comprehensive assessment was not completed within five days for patient #1. Patient #6A review of the clinical record showed a referral date of 06/03/24 with election of the hospice benefit and SOC on 08/23/24 (81 days later). Documentation showed no declined visits, no physician notifications, and no changes in orders. On 04/03/25 at 3:55 p.m., Staff B stated the initial comprehensive assessment was not completed within five days for patient #6. Patient #8A review of the clinical record showed a referral date of 03/14/25 with election of the hospice benefit and SOC on 03/20/25 (6 days later). Documentation showed no declined visits, no physician notifications, and no changes in orders. On 04/03/25 at 4:05 p.m., Staff B stated the initial comprehensive assessment was not completed within five days for patient #8. Patient #10A review of the clinical record showed a referral date of 06/14/24 with election of the hospice benefit and SOC on 07/20/24 (36 days later). Documentation showed no declined visits, no physician notifications, and no changes in orders. On 04/03/25 at 4:15 p.m., Staff B stated the initial comprehensive assessment was not completed within five days for patient #10. Patient #11A review of the clinical record showed a referral date of 11/15/24 with election of the hospice benefit and SOC on 11/21/24 (6 days later). Documentation showed no declined visits, no physician notifications, and no changes in orders. On 04/03/25 at 4:20 p.m., Staff B stated the initial comprehensive assessment was not completed within five days for patient #11.”

“Based on record review and interview, the hospice failed to ensure initial psychosocial assessments were conducted by the MSW within the five-day for two (Patients #1 and #6) of 14 patients. Findings: Patient #1A review of the clinical record showed an election of the hospice benefit and SOC on 09/19/24. Documentation showed no psychosocial assessment conducted and showed no follow up care and services were offered or provided by an MSW. Documentation showed no declined MSW visits, no physician notifications, and no changes in orders. On 04/03/25 at 2:56 p.m., Staff B stated:1. The MSW had not conducted the initial psychosocial assessment for patient #1 within the five-day timeframe and2. The hospice didn’t have a MSW available at that time and was utilizing a social worker out of Denton, Texas that was licensed in Oklahoma. Patient #6A review of the clinical record showed an election of the hospice benefit and SOC on 08/23/24. Documentation showed no psychosocial assessment conducted and showed no follow up care and services were offered or provided by an MSW. Documentation showed no declined MSW visits, no physician notifications, and no changes in orders. On 04/03/25 at 3:55 p.m., Staff B stated:1. On 04/03/25 at 2:56 p.m., Staff B stated:1. The MSW had not conducted the initial psychosocial assessment for patient #1 within the five-day timeframe and2. The hospice didn’t have a MSW available at that time and was utilizing a social worker out of Denton, Texas that was licensed in Oklahoma.”

“Based on record review and interview, the hospice failed to ensure development of a bereavement POC for four (Patients #2, 4, 6 and #13) of 14 patients. Findings: Patient #2A review of the clinical record showed an election of the hospice benefit/SOC on 02/27/25. Documentation showed a spiritual assessment on 03/03/25, and a psychosocial assessment was conducted 03/04/25. Documentation showed a bereavement POC dated 04/03/25 (35 days later). Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #4A review of the clinical record showed an election of the hospice benefit/SOC on 03/26/25. Documentation showed a spiritual assessment on 03/27/25, and a psychosocial assessment was conducted 03/28/25. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #6A review of the clinical record showed an election of the hospice benefit/SOC on 08/23/24. Documentation showed a spiritual assessment on 08/26/24, and showed no psychosocial assessment was conducted. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #13A review of the clinical record showed an election of the hospice benefit/SOC on 03/03/23. Documentation showed a spiritual assessment on 03/07/23, and a psychosocial assessment was conducted 03/06/24. Documentation showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. On 04/03/25 at 4:40 p.m., Staff C stated patients #2, 4, 6 and #13 had no bereavement POCs.”

“Based on record review and interview, the hospice failed to ensure the IDG developed and updated the plans of care four (Patients #4, 5, 8 and #12) of 14 patients. Findings: Patient #4A review of the clinical record showed no POC for the certification period of 03/26/25 to 05/24/25. IDG update meetings on 03/17/25 and on 03/31/25 showed no documentation of an identified wound care site on the POC for subsequent recertification period starting on 03/26/25. Documentation showed no IDG communications and no physician notifications for wound site care. On 04/03/25 at 3:33 p.m., Staff B stated the recertification plan of care for patient #4 was not updated with an identified wound care site prior to the beginning of the patient’s subsequent recertification period. Patient #5A review of the clinical record showed no POC for the certification period of 03/04/25 to 05/02/25. IDG update meetings on 03/03/25, 03/17/25 and on 03/31/25 showed no interventions and goals related to the hospice diagnosis of sarcopenia on the POC for the subsequent recertification period starting on 03/04/25. Documentation showed no IDG communications, no IDG review of the patients care and services provided by the hospice and no physician notifications for wound site care. On 04/03/25 at 3:50 p.m., Staff B stated the recertification plan of care for patient #5 did not include interventions and goals for the hospice diagnosis of sarcopenia. Patient #8A review of the clinical record showed no POC for the certification period of 03/20/25 to 06/17/25. IDG update meetings on 03/17/25 and on 03/31/25 showed no interventions and goals related to the hospice diagnosis of heart failure on the POC for the subsequent recertification period starting on 03/04/25. Documentation showed no IDG communications, no IDG review of the patients care and services provided by the hospice and no physician notifications for wound site care. On 04/03/25 at 3:50 p.m., Staff B stated the recertification plan of care for patient #8 did not include interventions and goals for the hospice diagnosis of heart failure. Patient #12A review of the clinical record showed no POC for the certification period of 08/25/24 to 10/23/24. IDG update meetings on 08/19/24, 09/02/24, 09/16/24, 09/30/24, 10/14/24 showed no interventions and goals related to the hospice diagnosis of heart failure on the POC for the certification period starting on 08/25/24. Documentation showed no IDG communications, no IDG review of the patients care and services provided by the hospice and no physician notifications for wound site care. On 04/03/25 at 4:35 p.m., Staff B stated the recertification plan of care for patient #12 did not include interventions and goals for the hospice diagnosis of heart failure.”

“Based on record review and interview, the hospice failed to ensure urinary catheter management was included in the POC for one (Patient #9) of 14 patients. Findings: Patient #9A review of a POC dated 02/10/25 to 05/10/25 showed IDG updates during the weeks of 02/17/25, 03/03/25, 03/17/25 and 03/31/25. SN visit notes dated 02/26/25, 03/04/25, 03/11/25, 03/18/25, 03/25/25 and 04/01/25 showed the patient had an indwelling Foley catheter in place but showed no orders for SN to perform urinary catheter management monthly. Documentation showed no communications between the IDG and showed no changes in the POC. On 04/03/25 at 4:12 p.m., Staff B stated there were no orders SN to perform urinary catheter management monthly.”

“Based on record review and interview, the hospice failed to ensure continued review and update of the hospice aide care plan for six (Patients #3, 5, 7, 9, 10 and #12) of 14 patients. Findings: Patient #3A recertification plan of care dated 03/19/25 to 06/16/25 and IDG updates to the POC on 03/17/25 and 03/31/25 showed no physician orders for hospice aide visits. Documentation showed a hospice aide care plan dated 03/19/25 with an aide visit frequency and duration of two times a week for six weeks, then one time a week for one week effective 12/22/24 (prior certification period) and showed no review or update to the hospice aide care plan for the 03/19/25 to 06/16/25 certification period. Documentation showed no communication between the IDG, no physician notifications and showed no ordered aide visit frequency. Patient #5A recertification plan of care dated 03/04/25 to 05/02/25 and IDG update meetings on 03/03/25, 03/17/25 and on 03/31/25 showed no physician orders for hospice aide visits. Documentation showed a hospice aide care plan dated 03/04/25 with an aide visit frequency and duration of one time a week for one week, three times a week for eight weeks, then one time a week for one week effective 01/03/25 (prior certification period) and showed no review or update to the hospice aide care plan for the 03/04/25 to 05/02/25 certification period. Documentation showed no communication between the IDG, no physician notifications and showed no ordered aide visit frequency. Patient #7A recertification plan of care dated 03/23/25 to 06/20/25 and IDG updates to the POC on 03/17/25 and 03/31/25 showed no physician orders for hospice aide visit. A hospice aide care plan dated 03/23/25 showed no aide visit frequency and showed no review or update to the hospice aide care plan for the 03/23/25 to 06/20/25 certification period. Documentation showed no communication between the IDG, no physician notifications and showed no ordered aide visit frequency. Patient #9A recertification plan of care dated 02/10/25 to 05/10/25 and IDG updates to the POC on 02/17/25, 03/03/25, 03/17/25 and 03/31/25 showed no physician orders for hospice aide visits. Documentation showed a hospice aide care plan dated 02/10/25 with an aide visit frequency and duration of one time a week for 13 weeks, effective 11/12/24 (prior certification period) and showed no review or update to the hospice aide care plan for the 02/10/25 to 05/10/25 certification period. Documentation showed no communication between the IDG, no physician notifications and showed no ordered aide visit frequency. Patient #10A recertification plan of care dated 03/17/25 to 05/15/25 and IDG updates to the POC on 03/17/25 and 03/31/25 showed no physician orders for hospice aide visits. Documentation showed a hospice aide care plan dated 03/17/25 with an aide visit frequency and duration of two times a week for 12 weeks, then one time a week for one week effective 07/21/24 (prior certification period) and showed no review or update to the hospice aide care plan for the 03/17/25 to 05/15/25 certification period. Documentation showed no communication between the IDG, no physician notifications and showed no ordered aide visit frequency. Patient #12A recertification plan of care dated 08/25/24 to 10/23/24 and IDG updates to the POC on 08/19/24, 09/02/24, 09/16/24, 09/30/24, 10/14/24 documented no physician orders for hospice aide visits. The documentation showed a hospice aide care plan dated 08/25/24 which showed no aide visit frequency and duration and showed no review or update to the hospice aide care plan for the 08/25/24 to 10/23/24 certification period. Documentation showed no communication between the IDG, no physician notifications and showed no ordered aide visit frequency. On 04/03/25 at 3:30 p.m., Staff B stated the clinical record documentation for patients #3, 5, 7, 9, 10 and #12 showed no review or update to the hospice aide care plans.”