Providence Care

“Based on review of the volunteer documentation binder, review of policy “Volunteer Services,” and staff interview, it was determined that the hospice failed to maintain a volunteer program that utilizes volunteers in administrative and/or patient care roles, failed to document ongoing efforts to recruit and retain volunteers and failed to ensure that volunteer activity in the provision of day-to-day administrative and/or direct patient care services was equal to at least 5 percent of the total patient care hours of paid staff. The cumulative effects of these systemic problems resulted in the hospice’s inability to ensure the availability and accessibility of volunteer services for the patients and families. Findings include: Review of the policy titled “Volunteer services” revised date of 4/2011 reveals the following:PolicyHospice uses volunteers in administrative or direct patient care roles under the supervision of Volunteer Coordinator.Procedure:1.Hospice will document active and ongoing efforts to recruit and retain volunteers.2. Hospice will document the cost savings achieved through the use of volunteers.6.The coordinator is responsible for planning, organizing, documenting and directing the comprehensive volunteer services program. Review of the volunteer documentation binder revealed that the agency failed to maintain a volunteer program that utilizes volunteers in administrative and/or patient care roles , failed to document ongoing efforts to recruit and retain volunteers and failed to ensure that volunteer activity in the provision of day-to-day administrative and/or direct patient care services was equal to at least 5 percent of the total patient care hours of paid staff. On 7/8/25 at approximately 11:32 am, an interview was conducted with the Area Vice President (AVP), who revealed that the hospice agency did not have a volunteer coordinator and did not have an active volunteer program.”

“Based on review of policies and procedures, record reviews, and staff interviews, it was determined that the hospice governing body failed to organize, manage, and administer its resources as evidenced by failure to:1. Maintain a volunteer program that utilizes volunteers and documents ongoing efforts to recruit and retain volunteers.2. Provide bereavement services as care planned for three of three patients sampled.3. Provide medical supplies for one patient (P) (P#15) of 19 sampled patients.4. Ensure a hospice administrator is responsible for day-to-day operations and supervision of hospice staff.These systemic failures impact the agency’s ability to provide care and services necessary for the management of the hospice patients’ terminal illness and related conditions. Findings include: 1. On 7/8/25 an interview was conducted with the Area Vice President of Operations (AVPO), who revealed that the hospice agency does not have a volunteer coordinator and does not have an active volunteer program. AVPO also confirmed that the agency does not have documentation of efforts to recruit or retain volunteers. 2. On 7/8/2025 at approximately 1:50 p.m., a telephone interview was conducted with Chaplain EE, who explained that if care plans were not up to date, it was an “oversight” on his part. 3. Review of the clinical record revealed that P#15 was admitted with an indwelling pleural catheter (small tube inserted in the chest cavity to drain fluid) which requires the use of a catheter kit to drain the fluid. The last catheter kit was used on 4/26/25, and agency staff did not obtain a correct catheter kit until 5/3/25. 4. On 7/7/2025 at approximately 1:00 p.m., an interview was conducted at the agency with the Clinical Nurse Manager (CNM), who verbalized that the AVPO is the administrator and that her position is CNM over the Monroe and Gainesville offices. The CNM further explained that she also serves as the Gainesville office Nurse Case Manager. On 7/8/2025 at approximately 10:30 a.m., an interview was conducted at the agency with the AVPO, who revealed that the Clinical Nurse Manager (CNM) is the Administrator for both offices. Cross refer to L0651 relating to the governing body and administrator. Cross refer to L0658 relating to multiple locations line of authority and administrative control.”

“Based on review of records, review of policy “Plan of Care,” and staff interviews, it was determined that the agency failed to ensure the requirements for care planning and management of patient care services were met for one patient (P) (P#15) of 19 sampled patients. Findings include: Review of policy titled “IDG Care Planning Process,” revised February 2022, revealed the following:Policy: In order to assure that care is appropriately planned to meet each patient’s specific need and problems8. The plan of care is written to include all services necessary for the palliation and management of the terminal illness and related conditions, including:• medical supplies and appliances necessary to meet the needs of the patient Review of the clinical record revealed that P#15 was admitted to services on 4/22/25 with a indwelling pleural catheter (small tube inserted in the chest cavity to drain fluid) which requires the use of catheter drainage kits to drain the fluid. P#15 last catheter kit was used by the agency nurse on 4/26/25 and the agency staff was unable to obtain a correct catheter kit until 5/3/25. During this time the agency staff were using the family’s personal medical supplies for the patient. The agency staff failed to coordinate with team members to ensure the supplies were readily available to assist in the management of the patient’s care. During an in-office interview with the Team Coordinator on 7/8/25 at 1:30 p.m., the Team Coordinator did confirm she does all the patient supply ordering for the agency. It was also confirmed that the agency ran out of drainage kits for the patient on 4/26/25 and the Team Coordinator placed an order for the drainage kits on 4/29/25, three days after last kit was used. An interview with the Area Vice President of Operations (AVPO) on 7/8/25 at 3:00 p.m., it was confirmed the agency failed to order the drainage kits in a timely manner to ensure supplies were available for the patient as needed. The AVPO stated that the family should not have to order supplies for the patient. It was also confirmed that the agency had not reimbursed the family for monies spent on supplies and they would ensure the family received all monies spent.”

“Based on review of records, review of policy “Coordination of Patient Care,” and staff interviews, it was determined the agency failed to coordinate with members of the Interdisciplinary Group (IDG), to ensure supplies were readily available for one patient (P) (P#15) of 19 sampled patients. · Findings include: Review of policy titled “Coordination of Patient Care,” revised June 2019 revealed the following:Policy: Hospice staff members regularly communicate to ensure that their efforts are coordinated effectively and ultimately support the objectives outlined in the interdisciplinary group (IDG) plan of care. Review of the clinical record revealed that P#15 was admitted to services on 4/22/25 with an indwelling pleural catheter (small tube inserted in the chest cavity to drain fluid) which requires the use of catheter kits to drain the fluid. P#15 last catheter kit was used by the agency nurse on 4/26/25 and the agency staff was unable to obtain a correct catheter kit until 5/3/25. During this time the agency staff were using the family’s personal medical supplies for the patient. The agency staff failed to coordinate with team members to ensure the supplies were readily available to assist in the management of the patient’s care. The record failed to reveal documentation that the physician was notified of the staffs’ inability to acquire a drainage kit to drain the PleurX (draining catheter placed within the patient’s chest to drain fluid) as scheduled. During an in-office interview with the Team Coordinator on 7/8/25 at 1:30 pm, the Team Coordinator did confirm she does all the patient supply ordering for the agency. It was also confirmed agency ran out of drainage kits for the patient on 4/26/25 and the Team Coordinator placed an order for the drainage kits on 4/29/25. The Team Coordinator provided a medical supply form to indicate five drainage catheters were ordered on 4/29/25 and delivered to the home on 5/1/25. However, according to the Team Coordinator the catheters received were not the correct ones, according to the family, and were unable to be used to drain the PleurX. Another order was placed on 5/1/25 for the correct catheter kits and delivered 5/3/25. A medical supply form was presented to show the order and delivery date of the kits. The Team Coordinator reported all information had been provided for the ordering of supplies. During a telephone interview with Registered Nurse (RN) HH on 7/8/25 at 2:00 p.m., it was confirmed that the agency used the last catheter kit on 4/26/25 and the agency did not have any more drainage catheters available at that time. RN HH visited the patient on 4/28/25 however, did not have the correct catheter kits to drain the PleurX. On 4/30/25, agency staff attempted to obtain drainage bags from local facilities but was unable to find available drainage bags. RN HH visited the patient on 5/1 and 5/3/25 and had to use the family’s catheter supply. The agency catheter kits arrived on 5/5/25 and RN HH reports an attempt to see the patient. However, the family refused the visit at the door, gave RN HH all catheter kits ordered by the agency as the family had initiated a transfer to another hospice agency. An interview with the Area Vice President of Operations (AVPO) on 7/8/25 at 3:00 pm, it was confirmed the agency failed to order the drainage kits in a timely manner to ensure supplies were available for the patient as needed. The AVPO also confirmed that the family should not have to order supplies for the patient. It was also confirmed that the agency had not reimbursed the family for monies spent on supplies and they would ensure the family received all monies spent.”

“Based on review of the policy “Bereavement Services,” record reviews and staff interview, it was determined the agency failed to follow the bereavement plan of care for three patients (P) (P#17, P#18, P#19) of three sampled bereavement records. Findings include: Review of the policy titled “Bereavement Services,” Policy number 4.26.1, revised February 2022, revealed the following:Procedure3. Within two weeks of the patient death, a condolence card will be mailed to the family. Within a month of death, a twelve-month bereavement-mailing program will be initiated for designated family members.9. Bereavement assessment and clinical notes are documented in the patient’s permanent clinical record. 1. Review of records revealed P#17 expired on 6/8/2025. Document titled “Bereavement Care Plan Details,” revealed that a bereavement letter was to be sent on 6/22/2025. Further review of the clinical record failed to indicate that a letter was sent. 2. Review of records revealed P#18 expired on 4/19/2025. Document titled “Bereavement Care Plan Details,” revealed a bereavement letter was due on 5/3/2025 and a phone call was due on 6/18/2025. Further review of the clinical record failed to indicate that a letter was sent, or phone calls were made. 3. Review of records revealed P#19 expired on 5/6/2025. Document titled “Bereavement Care Plan Details,” revealed a bereavement letter was due on 5/20/2025 and a phone call was due on 7/5/2025. Further review of the clinical record failed to indicate that a letter was sent, or phone calls were made. On 7/8/2025 at approximately 1:50 p.m., a telephone interview was conducted with Chaplain EE, who acknowledged responsibility for the bereavement program. He explained that if the care plans were not up to date, it was an “oversight” on his part. He further revealed that the bereavement process is transitioning to email contacts, and that may account for a lapse in documentation.”

“Based on review of the volunteer documentation binder, review of policy “ Volunteer Services,” and staff interview, it was determined that the hospice failed to document ongoing efforts to recruit and retain volunteers. The hospice failed to document and demonstrate viable and ongoing efforts to recruit and retain volunteers. Findings include: On 7/8/25 an interview was conducted with the Area Vice President (AVP), who revealed that the hospice agency did not have a volunteer coordinator and did not have an active volunteer program. AVP revealed that the agency does not have documentation of efforts to recruit volunteers and efforts to retain volunteers. AVP was unable to provide documentation of ongoing efforts to recruit and retain volunteers. Cross Refer to L641 relating to Volunteers.”

“Based on review of policy “Administrator: Defined,” and staff interviews, it was determined the hospice governing body failed to ensure a hospice Administrator is responsible for day-to-day operations and supervision of hospice staff. The agency is without day-to-day supervision of the hospice staff and program. Findings include: Review of the policy titled “Administrator: Defined,” Policy number 7.1.2, revised February 2022, revealed the following:Responsibilities5. The Administrator of Hospice has the following responsibilities:• Planning, organizing, directing and evaluating operations to ensure the provision of adequate and appropriate care and services to patients, families and caregivers necessary for the palliation and management of the terminal illness and related conditions.• Assuring appropriate staff supervision during all operating hours.• Appointing a similarly qualified alternate to be available at all times during operating hours in the absence of the Administrator. On 7/7/2025 at approximately 11:10 a.m., surveyors entered the agency and asked for the administrator. The Admission Nurse and Team Coordinator revealed that the Administrator is out on medical leave. On 7/7/2025 at approximately 11:20 a.m., an interview was conducted at the agency with the Admission Nurse, who was unable to name who was in charge while the Administrator is on leave. On 7/7/2025 at approximately 11:25 a.m., an interview was conducted at the agency with the Team Coordinator, who was unable to name who was in charge during the Administrator’s absence. The Team Coordinator verbalized that the Area Vice President of Operations (AVPO) had been called and was driving to the agency from South Carolina. The Clinical Nurse Manager (CNM) arrived at the agency on 7/7/2025 at approximately 1:00 p.m. During an interview, the CNM verbalized that the AVPO is the administrator and that her position is CNM over the Monroe and Gainesville offices. The CNM further explained that she also functions as the nurse case manager for the Gainesville office patients. On 7/8/2025 at approximately 10:30 a.m., an interview was conducted at the agency with the AVPO, who revealed the CNM is the Administrator for both offices. The AVPO confirmed that there would have been no staff supervision on 7/7/2025 if the surveyors had not come.”

“Based on policy “Administrator: Defined,” facility documents, and staff interviews, it was determined the hospice agency failed to clearly define lines of authority and administrative control over the agency and (one) branch office. Findings include: Review of the policy titled “Administrator: Defined,” Policy number 7.1.2, revised February 2022, revealed the following:Responsibilities4. If Hospice has branches, appropriate administrative records are maintained for each branch.5. The Administrator of Hospice has the following responsibilities:•Assuring appropriate staff supervision during all operating hours.•Appointing a similarly qualified alternate to be available at all times during operating hours in the absence of the Administrator. Review of a document presented as the agency’s organizational chart failed to reveal lines of authority for the branch office or identify an Administrator or alternate. The document failed to reveal names for the “Governing Body,” “CEO,” or “CCO.” On 7/7/2025 at approximately 11:10 a.m., the Admission Nurse and Team Coordinator were in the office and revealed that the Administrator is out on medical leave and unavailable. On 7/7/2025 at approximately 11:20 a.m., an interview was conducted at the agency with the Admission Nurse, who was unable to reveal who was in charge while the Administrator is on leave. On 7/7/2025 at approximately 11:25 a.m., an interview was conducted at the agency with the Team Coordinator, who was unable to name who was in charge during the Administrator’s absence. The Team Coordinator verbalized that the Area Vice President of Operations (AVPO) had been called and was driving to the agency from South Carolina. The Clinical Nurse Manager (CNM) arrived at the office at approximately 1:00 p.m. During an interview on 7/7/2025 at 1:00 p.m., the CNM verbalized that her position is CNM over the Monroe and Gainesville offices and that she functions as the nurse case manager for the Gainesville office patients. The CNM additionally verbalized that the AVPO is the administrator. Review of an email from agency leadership by the AVPO dated June 13, 2025, revealed that the CNM is named as administrator with the AVPO as alternate.”

“Based on policy titled “;Providence Care IDG Care Planning Process,” , policy titled “;Providence Care After Hours Accessibility,”, clinical record reviews, review of document titled “;Statement of Event”, and staff interviews, it was determined the agency failed to organize, manage, and administer its resources to provide the hospice care and services necessary for the palliation and management of the terminal illness and related conditions for patients as evidenced by agencys failure to provide and manage appropriate end of life care for one patient (P) (P#2) of five sampled patients. Findings include: Review of policy titled “;Providence Care IDG Care Planning Process,” revised June 2019, reveals the following: PROCEDURE3. The IDG works together to meet the physical, medical, psychosocial, emotional and spiritual needs of Hospice patients and families facing terminal illness and bereavement. IDG members provide the care and services offered by Hospice. IDG supervises the care and services.• Supervision of care by the IDG members is accomplished by face-to-face or telephone conferences, evaluations, discussions and general oversight, as well as by direct observations. Review of policy titled, “;Providence Care After Hours Accessibility”, revised June 2019 reveals the following: 8. The Director and/or Manager of Patient Services is on-call 24 hours per day on a rotating basis. Review of clinical record of P#2 revealed a skilled visit note, dated 1/1/2025 and signed by RN AA on 3/10/2025, revealed RN AA visited P#2 at 5:45 p.m. and left at 6:06 p.m. P#2 was moaning with pain and had increased respirations during assessment and RN AA administered one dose of morphine. Further review of the clinical records failed to reveal P#2s response to morphine or that RN AA notified the physician of the change in condition. The record failed to reveal interventions to address P#2s respiratory distress and ongoing symptoms despite interventions already provided. Review of document titled “;Statement of Event” revealed Clinical Manager (CM) received a call on 1/1/25 at approximately 4:05 p.m. that P#2 had a change in condition with breathing difficulty. CM documented she sent a message to RN AA of the need for the skilled nurse visit for P#2 and instructed RN AA to give the first dose of morphine. The CM further revealed that RN AA sent a message at 6:06 p.m. to report that she was leaving P#2, who was in distress and that she gave morphine, but the respirations were still elevated, and O2 SAT was 83% (amount of oxygen in your blood). The CM did not see the text until after 8:00 pm. On 3/10/25 at 2:45 pm, an interview was conducted at the office conference room with the Clinical Manager (CM).The CM revealed RN AA is a new hospice nurse who was hired less than six months ago. CM confirmed she received a call from the facility on 1/1/25 around 4:00 p.m. stating P#2 had a change in condition and was having difficulty in breathing. CM stated that she texted RN AA and advised her to go and administer the first dose of morphine to P#2. CM explained that she received a message from RN AA at around 6 or 6:15 p.m. on 1/1/2025, stating that she assessed P#2 and gave morphine, but patients respirations were still high and O2 saturation was 83%. CM stated that she received the text after 8:00 p.m., because the volume on her phone was low, and she didnt hear the phone. CM further revealed RN AA reported that RN BB spoke to the family of P#2, who was very upset. CM confirmed receiving a call from the agencys marketer on 2/2/2025, reporting the family of P#2 was very upset and trying to reach the CM. CM stated she advised the marketer she was busy seeing patients until 12:15 p.m. CM stated that she texted the family member of P#2 later that evening. On 3/10/2025 at 3:20 p.m., a phone interview with RN AA revealed RN AA arrived at the facility around 4:45 p.m. and administered the first dose of morphine to P#2. RN.AA stated that she reassessed the patient after giving morphine and the patient was still in distress, “;breathing heavy,” and that respirations were still high. RN AA further revealed she called the nurse manager and RN BB without response before leaving the facility. RN AA explained there was no return call from CM until after she reached home. RN AA stated that after further advice from the CM and RN BB, she returned to the facility, arriving at 9:02 p.m. RN AA confirmed she was informed by facility staff that another hospice provider was providing care for P#2.RN AA stated that she was not aware that she could call the physician to update on patients condition and obtain orders to administer more morphine as per physician orders. On 3/11/25 at 9:10 a.m., a phone interview was conducted with the family of P#2, who stated that the nurse who came to see her mother did not know what to do. The family of P#2 further revealed that the nurse gave P#2 one syringe of morphine and then left with P#2 still in distress. The family member of P#2 arrived at the facility around 6:30 p.m. The family member of P#2 further revealed calling another hospice provider around 6:30 p.m. to transfer P#2 and reported that P#2 received five doses of morphine between 7:30 p.m., and midnight and the new hospice agency provided continuous care with a nurse who stayed with the patient. On 3/11/25 at 9:32 a.m., a phone interview was conducted with RN BB. On 1/1/25, between 5:00 and 6:00 p.m., RN BB revealed receiving several messages from RN AA. RN BB reported that she could not call RN AA back until after 8:00 p.m. RN BB confirmed that RN AA reported that she gave morphine to P#2 and left the patient in distress.RN BB stated she advised RN AA to go back and assess P#2 and give medications as needed. RN BB stated RN AA was advised that Medical Doctor (MD) needs to be notified of patients condition and get orders to give more morphine and titrate oxygen. RN BB further stated that she went to see P#2 around 8:00 a.m., on 1/2/25 and found patient was pronounced (nurse confirms that there is no signs of life) by another hospice provider.”

“Based on record reviews, staff and family interview, signed statements, and document, “;Statement of Event,” it was determined that the agency failed to effectively manage the patients pain and symptoms related to the terminal illness. Specifically, the Registered Nurse (RN) (RN AA) failed to administer the medication as per physicians order to make the patient comfortable in a timely manner for one patient (P) (P#2) of five patients reviewed. Findings include: Review of signed statement of RN BB dated 1/14/25, revealed the following: On a nurse visit on 12/30/25, it was reported to RN BB that P#2 had a decrease in food intake, difficulty swallowing her morning medications in applesauce, and experiencing congested lung sounds with a cough. It was documented that the family member of P#2s was also concerned of an elevated Blood Sugar (BS) of 301 that had been recorded of P#2. RN BB documented to family member of P#2, that the BS would not be covered with insulin since P#2 is not eating. RN BB and facility staff discussed there was a decline in P#2, and it could be the flu. RN BB wrote, “;will have to continue to assess to know for sure.” RN BB also ordered oxygen (O2) for P#2. Further review of signed statement of RN BB, revealed orders were called in for P#2 to a pharmacy on 12/31/25 and delivered the same evening. The following medications were ordered; Morphine-opioid, (used to relieve pain and shortness of breath) 0.5ml po/sl q2 prn 10 syringes, lorazepam (Ativan) (used to treat anxiety)1mg po q4 prn 10 tablets, hyoscyamine (Levsin) (used to treat excessive oropharyngeal secretions) 0.125mg po q4 prn 6 tablets, promethazine (used to treat nausea and vomiting) 25mg po q4 prn 4 tablets. Review of clinical record of P#2 failed to reveal documentation that a nurse visit was made for P#2 on 12/31/24 to address the change(s) in condition observed by RN BB on 12/30/25. RN BB further reported in her signed statement that CM informed RN BB on 1/1/25, that the facility had called and stated P#2 needed a visit to assess patients change(s) in condition. RN BB responded she was not available. Review of skilled visit note dated 1/1/25, revealed that RN AA received a call on 1/1/25 at 4:46 p.m., she was notified that P#2 needed the first dose of morphine. Further review of skilled visit note revealed RN AA arrived on 1/1/25 at 5:45 p.m. to assess P#2 from call received. Further review of the visit note RN AA documented the following: P#2 respirations were increased and moaning during the assessment. Review of document titled Grievance/Complaint Report dated 1/8/25 revealed the following: Family member of P#2 notified other hospice provider to provide services for P#2. She requested a transfer of services without notification to Providence or the facility. Family member of P#2 was very upset and felt that the nurse left her mother in distress and there were not enough meds. On 3/10/25 at 3:20 p.m., a phone interview was conducted with RN AA who revealed that she left the facility after giving the first dose of morphine. On 3/11/25 at 9:10am. a phone interview was conducted with family member of P#2 who revealed after nurse (RN AA) left on 1/1/25, with P#2 in distress, she called another hospice provider around 6:30 p.m., to transfer P#2 to their services.”

“Based on review of policy titled “;Providence Care IDG Care Planning Process,” clinical record review, and staff interview, it was determined the hospice failed to ensure the plan of care included interventions to manage pain and symptoms for one patient (P) (P#2) of five patients sampled. Findings include: Review of policy titled “;Providence Care IDG Care Planning Process,” revised February 2022, reveals the following: POLICYIn order to assure that care provided is appropriately planned to meet each patient’s specific needs and problems, Hospice will utilize data/information gathered during the comprehensive assessment, updates to the comprehensive assessment and reassessments, in the care planning process to provide care that is consistent with the patient and family needs, with patient’s needs and goals as a priority. PROCEDURE3. The IDG works together to meet the physical, medical, psychosocial, emotional and spiritual needs of Hospice patients and families facing terminal illness and bereavement. IDG members provide the care and services offered by Hospice. IDG supervises the care and services.4. A registered nurse that is a member of the IDG is designated to provide coordination of care, coordinating and implementing the plan of care and to ensure continuous assessment of each patient’s and family’s needs and implementation of the IDG plan of care. The RN ensures that the plan of care is individualized, updated and relevant to the needs of patient/family by:• Ensuring the continuous assessment of each patient’s/family’s needs.• Documenting and revising patient care goals/objectives in a timely manner under the direction of the IDG.• Communicating with the IDG any changes in the delivery of services from the established plan of care.• Easing exchange of information among IDG staff and patient/caregiver.• Developing and revising patient care goals/objectives in coordination with other members of the IDG.• Monitoring for successful implementation of the plan of care.8. An individualized written plan of care is developed for each patient. The plan of care reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments. The plan of care is written to include all services necessary for the palliation and management of the terminal illness and related conditions, including: • Interventions to manage pain and other symptoms.Effective pain and symptom management includes the ongoing assessment of the patient’s physical, psychosocial, emotional and spiritual needs and reassessing the effectiveness of the current plan of care in order to address those needs. Review of document titled “;Plan of Care Effective 12/3/2024,” The Plan of Care (POC) revealed P#2 was admitted to hospice on 12/3/2024. P#2s family chose hospice with the goal of making the patient comfortable and managing symptoms as the disease progresses. Further review of the POC revealed the POC failed to reveal interventions to manage pain or respiratory distress and was last updated on 12/6/2024. On 3/10/25 at 2:45 p.m., an interview was conducted at the office conference room with the Clinical Manager (CM). CM confirmed she received a text message from RN AA at 6 or 6:15 p.m. on 1/1/2025, stating that P#2 had been assessed and administered morphine, but patients respirations were still high and O2 saturation (percentage of oxygen in the blood) was 83%. CM reported she did not see the text until after 8:00 p.m. due to her phone volume turned down and she did not hear it. The CM confirmed all documentation for P#2 had been provided. On 3/10/2025 at 3:20 pm, a phone interview with RN AA revealed RN AA arrived at the facility around 4:45 p.m. and administered the first dose of morphine to P#2. RN AA stated that she reassessed the patient after giving morphine and the patient was still in distress, “;breathing heavy,” and that respirations were still high. RN AA stated that she was not aware that she could call the physician to update on patients condition and obtain orders to administer more morphine as per physician orders.”

“Based on policy titled “;Providence Care Assessment and Reassessment Guidelines,” clinical record reviews, review of facility documents, and staff interviews, it was determined the hospice failed to ensure that services provided are based on assessment of the patient and family needs for one patient (P) (P#2) of five patients sampled. Findings include: Review of unnumbered policy titled “;Providence Care Assessment and Reassessment Guidelines,” revised June 2019, reveals the following: PROCEDURE4. Communication:• Pertinent assessment and reassessment data will be communicated to team members, the IDG, patient and the patient’s physician by IDG meetings, case conference, telephone, in person or in writing. Review of clinical record of P#2 revealed a skilled visit note, dated 1/1/2025 and signed by Registered Nurse (RN) AA on 3/10/2025, and revealed RN AA visited P#2 at 5:45 p.m. and left at 6:06 p.m. P#2 was moaning with pain and had increased respirations during assessment and RN AA administered one dose of morphine. Further review of the clinical records failed to reveal P#2s response to morphine or that RN AA notified the physician of the change in condition. The record failed to reveal interventions addressing P#2s respiratory distress and ongoing symptoms despite interventions already provided. Review of document titled “;Statement of Event” revealed Clinical Manager (CM) received a call on 1/1/25 at approximately 4:05 p.m., reporting that P#2 had a change in condition and breathing difficulty. CM sent a message to RN AA of the need for the skilled nurse visit for P#2 and informed RN AA to give the first dose of morphine. The CM further revealed that RN AA sent a text message to the CM at 6:06 p.m., to report that she was leaving P#2, who was in distress and that she gave morphine, but the respirations were still elevated, and O2 SAT was 83%. On 3/10/25 at 2:45 pm, an interview was conducted at the office conference room with the Clinical Manager (CM).CM confirmed she was sent a text message from RN AA at 6 or 6:15 p.m., on 1/1/2025 stating that she assessed P#2 and gave morphine, but patients respirations were still high and O2 saturation was 83%. CM did not see the text until after 8:00 p.m. On 3/10/2025 at 3:20 p.m., a phone interview with RN AA revealed RN AA arrived at the facility around 4:45 p.m. and administered the first dose of morphine to P#2. RN AA stated that she reassessed the patient after giving morphine and the patient was still in distress, “;breathing heavy,” and that respirations were still high. RN AA stated that she was not aware that she could call the physician to update on patients condition and obtain orders to administer more morphine as per physician orders. On 3/11/25 at 9:10 a.m., a phone interview was conducted with the family of P#2, who stated that the nurse who came to see her mother did not know what to do. The family member of P#2 revealed that the nurse gave P#2 one syringe of morphine and then left with P#2 still in distress.The family of P#2 further revealed calling another hospice provider around 6:30 p.m., to transfer P#2 and reported that P#2 received 5 doses of morphine between 7:30 p.m., and midnight. On 3/11/25 at 9:32 a.m., a phone interview was conducted with RN BB. On 1/1/25 between 5:00 and 6:00 p.m., RN BB revealed receiving several messages from RN AA. RN BB revealed that RN AA told RN BB that she gave morphine to P#2 and left the patient in distress.RN BB further stated that she went to see P#2 around 8:00 a.m., on 1/2/25 and found patient was pronounced (nurse confirms that there is no signs of life) by another hospice provider.”

“Based on clinical record reviews, signed statements of staff, review of document titled “;Statement of Event,” and staff interviews, it was determined the agency failed to ensure that nursing needs of the patients were met as identified in the updated assessments for one patient (P) (P#2) of five patients reviewed. Findings include: Review of document titled “;Statement of Event” revealed Clinical Manager (CM) received a call on 1/1/25 at approximately 4:05 p.m. that P#2 had a change in condition. The facility requested a skilled nurse visit due to their rules that the first dose of morphine (an analgesic and narcotic drug obtained from opium and used medicinally to relieve pain) cannot be administered by the facility staff. CM documented she instructed facility staff to administer Ativan (benzodiazepine used to treat anxiety disorders or anxiety associated with depression) and she would reach out to a nurse for a visit. CM documented she sent a message to RN AA of the need for the skilled nurse visit for P#2 and informed RN AA to give the first dose of morphine. Review of the on-call visit note dated 1/1/25 revealed that RN AA assessed the patient having increased respirations and moaning out in pain. RN AA administered morphine as per orders and reassessed patient for any changes. The RN AA visit note revealed that patient appears to be in an exacerbation which has possibly been going on for several hours. RN AA documents that nurse reassessed patient and will need another round of morphine to alleviate at next scheduled time. Review of statement signed by RN AA dated 1/20/25, revealed that RN AA reassessed the patient and respirations were still increased and the RN AA decided that P#2 might be in an exacerbation due to length of time without any medications. Review of “;Statement of Event” note, CM documented that RN AA sent a message at 6:06 p.m. to report that she was leaving P#2, who was in distress and that she gave morphine, but the respirations were still elevated, and O2 SAT (percentage of oxygen in the blood) was 83%. RN AA asked CM, who was to give the next dose of morphine. CM further documented that later RN AA spoke with RN BB, and she informed RN AA that she should have stayed with P#2. RN AA further reported she called back to the facility after she got home, and it was reported P#2 was resting and respirations and blood pressure had decreased. RN AA called the family member to report the update reported by the facility and the family member informed RN AA that was incorrect information. RN AA called CM and CM informed RN AA she needed to go back to the facility and make a visit. RN AA arrived at the facility at 9:33 p.m., P#2 was comfortable and resting with man at bedside. On 3/10/25 at 3:20 p.m., a phone interview was conducted with RN AA who revealed that she left the facility after giving the first dose of morphine. RN AA stated that she is new to hospice, and this is the first time she has encountered patient in crisis event, and she didn’t know what to do so she called CM and RN BB for further instructions. RN AA stated that since she didn’t hear back from CM and RN BB, she left the facility leaving the patient alone in distress. RN AA stated that after reaching home, she called patient’s daughter and patient’s daughter told RN AA that P#2 is in distress and ask RN AA to come back for a visit.RN AA stated that she received a call back from CM and CM advised RN AA to go back to the facility and assess P#2. Upon arrival to the facility, RN AA stated that the facility advised RN AA that another hospice agency has been caring for the patient. On 3/10/25 at 4:00 p.m., an interview was conducted at the agency office with Clinical Manager (CM) and Executive Director (ED). Both CM and ED revealed that RN AA did leave P#2 while patient was in distress and did not meet the immediate needs of P#2. ED and CM revealed that after RN AA left the facility around 6:00 p.m., on 1/1/25, another hospice agency intervened and provided care for P#2.”

“Based on record review, policy titled “ Providence Care IDG Care Planning Process,” staff and family interviews, it was determined that the agency failed to ensure that hospice services and treatment were provided as per patient and family needs to optimize comfort and dignity for one patient (P) (P#2) of five patients reviewed. Findings include: Review of policy titled, “;Providence Care IDG Care Planning Process,” revised June 2019, reveals the following: POLICY: To assure that care provided is appropriately planned to meet each patient’s specific needs and problems, Hospice will utilize data/information gathered during the comprehensive assessment, updates to the comprehensive assessment and reassessments, in the care planning process to provide care that is consistent with the patient and family needs, with patient’s needs and goals as a priority. PROCEDURE8. An individualized written plan of care is developed for each patient. The plan of care reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments. The plan of care is written to include all services necessary for the palliation and management of the terminal illness and related conditions, including: • Interventions to manage pain and other symptoms.Effective pain and symptom management includes the ongoing assessment of the patient’s physical, psychosocial, emotional and spiritual needs and reassessing the effectiveness of the current plan of care to address those needs. Review of document titled “;Statement of Event,” revealed (Clinical Manager) CM received a call on 1/1/25 at approximately 4:05 p.m., that P#2 had a change in condition with breathing difficulty. The facility requested a skilled nurse visit to assess the patient for patient discomfort. RN AA was nurse on call and made the visit to assess P#2 and provide comfort measures as needed. RN AA arrived at P#2 residence to assess the patient. RN AA administered the first dose of morphine. RN AA sent a message at 6:06 p.m., to supervisor to report that she was leaving P#2, who continued to present in distress after morphine had been given as evidenced by increased respirations and decreased oxygen saturation (measure of oxygen in the blood). P#2 oxygen saturation was measured at 83%. The clinical record failed to indicate RN AA notified the physician of the decline in the patient status to provide further medical intervention. Review of statement note signed by RN AA further revealed later that RN AA spoke with RN BB, and she informed RN AA that she should have stayed with P#2. RN AA further reported she called back to the facility after she got home, and it was reported P#2 was resting and respirations and blood pressure had decreased. RN AA called family member to report the update reported by the facility and the family member informed RN AA that was incorrect information. CM informed RN AA she needed to back to the facility and make a visit. The document further revealed RN AA arrived at the facility at 9:33 p.m., P#2 was comfortable and resting with man at bedside. Review of signed statement by RN BB revealed RN BB was going to follow up first thing in the morning. RN BB reported on arrival at facility the morning of 1/2/25, the facility informed her P#2 had expired. On 3/11/25 at 9:10 a.m., a phone interview was conducted with family member of P#2 who revealed after nurse left on 1/1/25 with P#2 in distress, she called another hospice provider around 6:30 p.m. to transfer patient. She reported the admitting nurse was there at approximately 7:10 p.m. and discovered there was not enough medication for P#2 at the facility therefore, had to order more medication to ensure P#2 was comfortable and without pain.”

“Based on record review, staff and family interviews, it was determined that the agency failed to ensure that a governing body (or designated persons so functioning) assumes full legal authority and responsibility the management of the hospice, the provision of all hospice services, and continuous quality assessment and performance improvement. The agency failed to ensure that the governing body is responsible for the day-to-day operations of the hospice. Findings include: Review of the on-call visit note dated 1/1/25 revealed that RN AA assessed the patient having increased respirations and moaning out in pain. RN AA administered morphine as per orders and reassessed patient for any changes. The RN AA visit note revealed that patient appears to be in an exacerbation which has possibly been going on for several hours. RN AA documents that nurse reassessed patient and will need another round of morphine to alleviate at next scheduled time. Further review of the visit note revealed that RN AA failed the notify the physician of the change in condition of P#2. Cross reference L0648 relating to Organization and Administration of Services”

“Based on record reviews, and staff interviews, it was determined that agency failed to ensure that clinical records were clear, correct and precise for one patient (P) (P#2) of five patients reviewed. Specifically, the verbal order for medication was not clarified and updated as per physician orders. Findings include: Review of the Physician Order dated 12/31/24 at 11:00 a.m., for P#2 revealed the following: Morphine sulfate 20mg/5ml; Give 0.5 ml oral every 4 hours as needed for pain and shortness of breath. Review of an on-call visit note dated 1/1/25, RN AA documents the following: Morphine given per orders. Morphine ordered every two hours. Further Review of signed E-script prescription signed and dated on 12/31/24 at 2:29 p.m., by Medical Director (MD), received from pharmacy, reveals the following order: Morphine 100mg/ml (20mg/ml) oral solution; give 0.5ml oral every 2 hours as needed for pain and agitation. please put in prefill syringes. On 3/10/25 at 3:20 pm, a phone interview was conducted with RN AA who revealed that she gave the first dose of morphine. RN AA further stated that morphine comes in a syringe and there were 10 syringes in the lock box, and she administered one syringe of morphine. RN AA reported she was not sure how much morphine is in that syringe. RN AA failed to clarify the morphine order to ensure the right frequency was ordered for P#2. On 3/10/25 at 9:49 am, a phone interview was conducted with a pharmacy technician at the pharmacy. Pharmacy technician stated that on 12/31/24 at 2:29 p.m., pharmacy received an E-script Prescription order from patient’s MD for the following: Morphine sulfate 20mg/ml; take 0.5ml by mouth every 2 hours as needed for pain and agitation. On 3/12/25 at 11:28 a.m., an office interview was conducted with the Executive Director (ED), who revealed that verbal order for Morphine was not clear, and RN AA did not clarify the current morphine order with the physician and transcribe the new current order onto the clinical record for P#2.”