Providence Hospice

“Based on clinical records review and staff interview, in 3 of 19 (Pt’s. #5, 10, and 13) clinical records, the Hospice failed to ensure an initial Bereavement assessment was completed upon admission. Findings include:1. The clinical records were reviewed on 07/15/26 and 07/16/26. The records lacked documentation the Hospice completed the initial Bereavement assessment for the following Pts.:Pt. #5 SOC 02/26/26Pt.#10 SOC 07/06/26Pt.#13 SOC 02/06/262. During interviews with the Director of Quality, Administrator, and Hospice Clinical Supervisor on 07/16/26 at 1:15 PM and 2 :15 PM, the above findings were confirmed.”

“Based on a review of clinical records and staff interviews, in 11 of 19 (Pts. # 4, 5, 6, 7, 1, 2, 15, 16, 3, 14 and 17) clinical records reviewed, the Hospice failed to ensure the entire IDG supervised services to meet the medical, and counseling needs of the Hospice Pts. and their families. 9. Pt. # 3 was admitted for Hospice Services on 01/05/26 with the Diagnosis of but not limited to Progressive Supranuclear Ophthalmoplegia. The clinical record was reviewed on 07/15/26. The IDG meeting dated 05/14/26 and 06/11/26, lacked documentation that the Medical Director/ Physician participated in the meeting, as required by the Hospice’s IDG form. 10. Pt. # 14 was admitted for Hospice Services on 09/04/24 with the Diagnosis of but not limited to Cerebrovascular Disease. The clinical record was reviewed on 07/15/26. The IDG meeting dated 06/11/26, lacked documentation that the Medical Director/ Physician participated in the meeting, as required by the Hospice’s IDG form. 11. Pt. # 17 was admitted for Hospice Services on 10/30/25 with the Diagnosis but not limited to Cerebrovascular Disease. The clinical record was reviewed on 07/15/26. The IDG meeting dated 05/24/26 and 05/21/26, lacked documentation that the Medical Director/ Physician participated in the meeting, as required by the Hospice’s IDG form. 12. The above findings were confirmed during interviews with the Hospice Administrator and Quality Director on 07/16/26 between 1:15PM and 2:30 PM. 5. Pt. #1 was admitted to hospice 05/01/26 with diagnosis of Senile degeneration of the brain. The record was reviewed on 7/16/26. The IDG meetings on 05/14/26 and 06/11/26 lacked documentation the Medical Director participated in the IDG meetings.6. Pt. #2 was admitted to hospice 06/05/25 with diagnosis of Corticobasal degeneration. The record was reviewed on 7/16/26. The IDG meetings on 05/14/26 and 06/18/26 lacked documentation the Medical Director participated in the IDG meetings.7. Pt. #15 was admitted to hospice 04/20/26 with Hypertensive heart disease with heart failure. The record was reviewed on 7/16/26. The IDG meeting on 05/14/26 lacked documentation the Medical Director participated in the IDG meetings.8. Pt. #16 was admitted to hospice 06/27/25 with Malignant neoplasm of prostate. The record was reviewed on 7/16/26. The IDG meetings on 07/10/25, 07/17/25, and 07/31/25 lacked documentation the Medical Director participated in the IDG meetings. Findings include:1. Pt. # 4 was admitted for Hospice Services on 06/20/24 with the Diagnosis of but not limited to Chronic Systolic (Congestive) Heart Failure. The clinical record was reviewed on 07/15/26. The IDG meeting dated 06/18/26, lacked documentation that the Medical Director/ Physician participated in the meeting, as required by the Hospice’s IDG form.2. Pt. # 5 was admitted for Hospice Services on 02/26/26 with the Diagnosis of but not limited to End Stage Renal disease. The clinical record was reviewed on 07/15/26. The IDG meeting dated 06/18/26, lacked documentation that the Medical Director/Physician participated in the meeting, as required by the Hospice’s IDG form.3. Pt. # 6 was admitted for Hospice Services on 09/13/25 with the Diagnosis of but not limited to Senile Degeneration of Brain. The clinical record was reviewed on 07/15/26. The IDG meeting dated 06/18/26, lacked documentation that the Medical Director/Physician participated in the meeting, as required by the Hospice’s IDG form.4. Pt. # 7 was admitted for Hospice Services on 05/01/26 with the Diagnosis of but not limited to Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 07/16/26. The IDG meeting dated 06/18/26, lacked documentation that the Medical Director/Physician participated in the meeting, as required by the Hospice’s IDG form.”

“Based on Hospice staff list review and staff interviews, the Hospice failed to have an alternate Chaplain (Spiritual Counselor) available to cover duties in the absence of the Chaplain. Findings include:1. The Hospice staff list was reviewed on 07/16/26. The staff list only includes 1 Chaplain (Spiritual Counselor).2. During an interview with E#1 (Chaplain) on 07/15/26 at 3:30 PM. E#1 stated and confirmed she is the only Chaplain on staff. During the same interview, when asked, who covers as Chaplain in the event she is not available, E#1 stated, “we can look at community churches and get some assistance”.3. During an interview with E#2 (Hospice Administrator) on 07/16/26 at 10:45 AM. The Administrator stated and confirmed the Hospice only has 1 Chaplain on staff. During the same interview the Administrator confirmed the Hospice has no alternate staff to cover the duties in the absence of E#1.”