Enhabit Hospice

“Based on interview and record review, the hospice failed to ensure all hospice care and services furnished to patients and their families followed an individualized written plan of care established by the hospice IDG for 1 of 14 (Patient #10) patients reviewed in that the hospice failed to provide volunteer visits at the frequency ordered in the plan of care for Patient #10. This failure could result in the hospice failing to identify and meet the patients’ needs which could result in harm to patients. The findings included: Record review of the clinical record for Patient #10 included a recertification plan of care order, for the certification period of 05/19/25 – 07/15/25, which indicated the patient had a diagnosis of COPD (a medical disorder which results in difficulty breathing) and indicated volunteer phone visits were to be provided once a week. The recertification plan of care order indicated, “Volunteer Care Plan and Frequency: Weekly Tuck in Calls (phone calls made to check on the patient for any needs, such as need for medications or supplies or patient/family concerns prior to the weekend to prevent the patient having to contact the on-call line over the weekend).” Record review of the clinical record for Patient #10, for the week of 05/19/25 – 05/24/25 did not include documentation of a volunteer phone visit completed during that week. During an interview conducted on 07/30/25 at 12:33 p.m., the Administrator/Alternate Supervising Nurse said the Volunteer Coordinator was on leave and not available for interview. During an interview conducted on 07/31/25 at 11:51 a.m., the Alternate Administrator/Supervising Nurse said she was unable to locate the volunteer phone visit for the week of 05/19/25 – 05/24/25. The Alternate Administrator/Supervising Nurse said she had been unable to reach the Volunteer Coordinator to determine what had occurred. During an interview conducted on 07/31/25 at 4:38 p.m., the Administrator/Alternate Supervising Nurse said Volunteer G was the volunteer responsible for completing the volunteer phone visits to Patient #10. The Administrator/Alternate Supervising Nurse said Volunteer G made the calls and then turned the documentation of the calls into the Volunteer Coordinator who then reviewed them. The Administrator/Alternate Supervising Nurse said the volunteer phone visits for Patient #10 were ordered to be completed weekly and said she could only presume the visit was not completed for the week of 05/19/25 – 05/24/25 as they did not have documentation of a phone visit completed during that week. The Administrator/Alternate Supervising Nurse said she did not know the reason the visit was not completed. The Administrator/Alternate Supervising nurse said the volunteer phone visits were documented on the volunteer note form and uploaded into the patient’s clinical record. The Administrator/Alternate Supervising Nurse said the volunteer was responsible for completing the note and the Volunteer Coordinator was responsible for uploading the note into the clinical record. The Administrator/Alternate Supervising Nurse said she thought the volunteers had a couple of days to complete the note and have it uploaded to the record. The Administrator/Supervising Nurse said it was the responsibility of the Volunteer Coordinator to ensure the note was in the patient’s clinical record. When asked if there were any adverse outcomes to the patient related to the failure to provide the volunteer phone visit the week of 05/19/25 – 05/24/25, the Administrator/Alternate Supervising Nurse said, no. When asked if there were any potential adverse outcomes to patients related to a failure to complete the weekly volunteer phone visits, the Administrator/Alternate Supervising Nurse the hospice might not identify a patient need and the patient might have to call the on-call number for assistance. When asked the importance of providing care according to the frequency ordered on the written plan of care, the Administrator/Alternate Supervising Nurse said compliance and patient needs being met. During an interview conducted on 08/01/25 at 9:46 a.m., Volunteer G reviewed his phone call log records and said he did not see where he had made a phone call to Patient #10’s caregiver for the week of 05/19/25 – 05/24/25. During an interview conducted on 08/01/25 at 4:38 p.m., the Alternate Administrator/Supervising Nurse said Volunteer G was the volunteer responsible for completing the phone visit with Patient #10 during the week of 05/19/25 – 05/24/25. The Alternate Administrator/Supervising Nurse said the Volunteer Coordinator oversaw all volunteers, ensured care plans were updated, and that the hospice was meeting frequencies as ordered in the plan of care. The Alternate Administrator/Supervising Nurse said Volunteer G turned the documentation of the phone visits to patients into the Volunteer Coordinator. The Alternate Administrator/Supervising nurse said she went through all the Volunteer Coordinator’s documentation for the week of 05/19/25 – 05/24/25 but the documentation for the visit for Patient #10 for that week was missing. The Alternate Administrator/Supervising Nurse said the frequency of volunteer visits ordered for Patient #10 on the written plan of care was weekly and said there was no evidence that the frequency was followed for the week of 05/19/25 – 05/24/25. When asked the reason the visit was not completed, the Alternate Administrator/Supervising Nurse said her guess was that it was just an oversight. The Alternate Administrator/Supervising Nurse said the volunteer phone visits were documented on the volunteer visit note and uploaded into the patient’s clinical record and said there was a place for the volunteer to document on the note if they were unable to reach a patient or family member. The Alternate Administrator/Supervising Nurse said the volunteer was responsible for completing the note and the Volunteer Coordinator was responsible for co-signing and uploading the note once completed by the volunteer. The Alternate Administrator/Supervising Nurse said the volunteer usually completed the phone visits on Thursdays or Fridays and would usually turn the documentation into the Volunteer Coordinator the day the call was made. The Alternate Administrator/Supervising Nurse said the documentation of the visit was usually included in the patient’s clinical record by the Monday following the call. The Alternate Administrator/Supervising Nurse said the Volunteer Coordinator was responsible for ensuring the note was completed and uploaded into the patient’s clinical record. The Alternate Administrator/Supervising Nurse said there was no adverse outcome to the patient related to the failure to complete the visit. When asked if there was any potential adverse outcome to the patient, the Alternate Administrator/Supervising Nurse said the patient/family had the hospice’s phone number and this particular patient/family called her frequently and knew how to contact her but in general for patients the failure to complete volunteer phone visits at the frequency ordered in the plan of care could result in the hospice failing to identify a patient need. The Alternate Administrator/Supervising Nurse said the volunteer visit frequency was a physician’s order and must be followed. Record review of a hospice policy titled, “Physician’s Role,” dated 01/2000, last revised 06/03/25, indicated, “Care delivery follows the plan of care … The Agency uses the calendar week as the treatment week …” Record review of a hospice policy titled, “Volunteers,” dated 01/2013, last revised 08/06/23, indicated, “… All volunteers are required to provide timely … documentation of any patient related contact … The Volunteer … Uses the Volunteer progress note for documentation of any contact with the hospice client and their caregivers (via visit or telephone) … All volunteer documentation is to be submitted within 1 week of the client contact …””

“Based on interview and record review, the hospice RN failed to make an on-site visit to a patient’s home to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group met the patient’s needs no less frequently than every 14 days for 2 of 14 (Patient #3 and Patient #12) patients reviewed. This failure could result in the hospice failing to identify and address concerns with the hospice aide services and could result in the patient’s needs not being met. The findings included: Record review of the clinical record for Patient #3 included a plan of care, for the certification period of 04/16/25 – 07/14/25, which indicated the patient had a start of care date of 04/16/25 and a diagnosis of Sarcopenia (a loss of muscle tissue that occurs with aging). The plan of care indicated the patient was to receive skilled nurse and hospice aide visits. Record review of the clinical record for Patient #3, for the time-period of 06/03/25 – 06/19/25, did not include documentation of a hospice aide supervisory visit conducted during this time-period, indicating 17 days passed between hospice aide supervisory visits. Record review of the clinical record for Patient #3, for the time-period of 06/03/25 – 06/19/25, indicated hospice aide visits were provided on 06/06/25, 06/10/25, 06/13/25, and 06/16/25. Record review of the clinical record for Patient #3, for the time-period of 06/03/25 – 06/19/25, indicated RN O provided skilled nurse visits to Patient #3 on 06/05/25, 06/09/25, 06/12/25, and 06/16/25 and did not indicate RN O completed a hospice aide supervisory visit during the time-period reviewed. Record review of the clinical record for Patient #3, for the time-period of 06/03/25 – 06/19/25, indicated RN P provided a skilled nurse visit to Patient #3 on 06/15/25 and did not indicate RN P completed a hospice aide supervisory visit during the time-period reviewed. Record review of the clinical record for Patient #3, for the time-period of 06/03/25 – 06/19/25, did not indicate any skilled nurses other than RN O and RN P had provided skilled nurse visits to Patient #3 during the time-period reviewed. There was no documentation to indicate the hospice RN completed an on-site visit to Patient #3’s home to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group met the patient’s needs no less frequently than every 14 days during the time-period of 06/03/25 – 06/19/25. Record review of the clinical record for Patient #12 included a plan of care, for the certification period of 05/07/25 – 08/04/25, which indicated the patient had a start of care date of 05/07/25 and a diagnosis of senile degeneration of the brain (a medical condition that results in a progressive decline in thought processes, memory, and judgement). The plan of care indicated the patient was to receive skilled nurse and hospice aide visits. Record review of the clinical record for Patient #12, for the time-period of 06/25/25 – 07/17/25, did not include documentation of a hospice aide supervisory visit conducted during this time-period, indicating 23 days passed between hospice aide supervisory visits. Record review of the clinical record for Patient #12, for the time-period of 06/25/25 – 07/17/25, indicated hospice aide visits were conducted on 06/25/25, 06/30/25, 07/10/25, 07/11/25, and 07/14/25. Record review of the clinical record for Patient #12, for the time-period of 06/25/25 – 07/17/25, indicated RN visits were completed by RN O on 07/08/25 and 07/17/25. There was no documentation of other RN visits conducted during that time-period. There was no documentation of a hospice aide supervisory visit conducted during that time-period. There was no documentation to indicate the hospice RN completed an on-site visit to Patient #12’s home to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group met the patient’s needs no less frequently than every 14 days during the time-period of 06/25/25 – 07/17/25. During an interview conducted on 07/31/25 at 9:41 a.m., the Alternate Administrator/Supervising Nurse said the hospice aide supervisory visits were missed and said it was the same nurse (RN O) who had missed the supervisory visits in each case. The Alternate Administrator/Supervising Nurse said this was a newer nurse. The Alternate Administrator/Supervising Nurse said the hospice did not have a performance improvement plan in place regarding completion of hospice aide supervisory visits and said this was a newly identified issue. During an interview conducted on 07/31/25 at 11:21 a.m., the Alternate Administrator/Supervising Nurse said Patient #3 was not able to be interviewed but had family who could be contacted for an interview regarding his care. The Alternate Administrator/Supervising Nurse said Patient #12 had senile degeneration of the brain and was not able to be interviewed but said the patient had a family member who could be contacted to interview. Attempts were made to contact Patient #3’s Family Member #1 on 07/31/25 at 11:39 a.m., 07/31/25 at 2:54 p.m., and on 08/01/25 at 9:03 a.m. There was no answer to any attempts. Voicemail messages were left at each attempt, but no return call was received from Patient #3’s Family Member #1 prior to the end of the survey. During an interview conducted on 07/31/25 at 12:00 p.m., RN P said the visit she conducted with Patient #3 on 06/15/25 was a PRN (as needed) visit for a fall. RN P said she did not remember if the PRN skilled nurse visit not even included a place to document a hospice aide supervisory visit. RN P said if the hospice aide supervisory visit was not documented on the note, she did not complete a hospice aide supervisory visit during the visit on 06/15/25. During an interview conducted on 07/31/25 at 1:50 p.m., with RN O, when asked regarding the missing hospice aide supervisory visits for Patient #3 and Patient #12, RN O said there was a misunderstanding. RN O said the hospice was down to only one hospice aide and were prioritizing the patients who would receive the services and discontinuing the hospice aide services for patients who did not require the services at that time. RN O said Patient #3 resided in an ALF and the ALF staff confirmed they would be able to provide his personal care and Patient #12’s Family Member #1 confirmed she would provide the patient’s personal care. RN O said she thought the hospice office staff would create a physician’s order to discontinue the hospice aide services for Patient #3 and Patient #12, but they did not do so. RN O said she understood now that it was her responsibility to create the order to discontinue the hospice aide services and said she had failed to do so. RN O said she took responsibility for her failure to create the order. RN O said she believed the office would create the order, so she never checked the schedule to ensure the hospice aide visits for Patient #3 and Patient #12 were removed from the schedule. RN O said because the order was not written, the visits were not removed from the schedule and the hospice aide continued to make the visits. RN O said she believed the hospice aide visits had been discontinued and so she did not complete the hospice aide supervisory visits. During an interview conducted on 07/31/25 at 2:31 p.m. Patient #12’s Family Member #1 said she was satisfied with the hospice’s services and had no complaints or concerns. Family Member #1 said the hospice aide was very good and assisted the patient with bathing and changing her linens. During an interview conducted on 07/31/25 at 4:38 p.m., the Administrator/Alternate Supervising Nurse said the RN seeing the patient was responsible for completing the hospice aide supervisory visits every 14 days and said the hospice aide supervisory visit would be documented in the “RN 10” supervisory nurse visit note. The Administrator/Alternate Supervising Nurse said documentation of visits was to be completed the day of the visit and submitted to the patient’s clinical record by 10:00 p.m. on the day of the visit. When asked if the hospice aide supervisory visits for Patient #3 and Patient #12 had been completed every 14 days, the Administrator/Alternate Supervising Nurse said, “They seem to be missing.” The Administrator/Alternate Supervising Nurse said she did not know the reason the hospice aide supervisory visits had been missed. The Administrator/Alternate Supervising Nurse said there were no adverse outcomes to the patients related to the failure to provide the hospice aide supervisory visits every 14 days but said there could be a potential adverse outcome of patient’s needs not being met. When asked the importance of completing the hospice aide supervisory visits every 14 days, the Administrator/Alternate Supervising Nurse said, staying in compliance, ensuring needs were met, and ensuring staff were following the plan of care. During an interview conducted on 08/01/25 at 4:38 p.m., the Alternate Administrator/Supervising Nurse said the patient’s RN case manager was responsible for ensuring the hospice aide supervisory visits were completed every 14 days and said RN O was the RN case manager for both Patient #3 and Patient #12. The Alternate Administrator/Supervising Nurse said the hospice aide visits should be completed every 14 days and were documented in the “RN 10” nurse visit note. The Alternate Administrator/Supervising Nurse said the note should be completed and submitted to the patient’s clinical record by 10:00 p.m. the day the visit was completed. The Alternate Administrator/Supervising Nurse said the hospice aide supervisory visits were not completed every 14 days for Patient #3 or Patient #2 and said there seemed to be some miscommunication and RN O thought the hospice aide visits had been discontinued but they had not. The Alternate Administrator/Supervising Nurse said there were no adverse outcomes to the patients related to the failure and said she did not believe there would be a potential adverse outcome for Patient #3 or Patient #12 related to the failure to provide the hospice aide supervisory visits every 14 days but in general there could be a failure to identify an issue with hospice aide services for a patient if the hospice aide supervisory visits were not conducted every 14 days as required. When asked the importance of completing the hospice aide supervisory visits every 14 days, the Alternate Administrator/Supervising Nurse said staying in compliance, ensuring patient needs were met, and ensuring staff were following the plan of care. Record review of a hospice policy titled, “Home health/hospice aide competency & supervision,” dated 03/10/2000, last revised 06/28/24, indicated, “The Agency supervises home health/hospice aide services for compliance to established policies … rules and regulations … For patients receiving skilled nursing care … the Licensed Professional visits the patient’s residence at least once every two weeks, either when the aide is present or absent …””