Providence Hospice, Inc.

“Based on record review and interview, the hospice failed to ensure 1 of 1 active clinical record reviewed patient, with a private residence home visit observed, was fully informed about all Medicare covered hospice services (Patient #4). Findings include: During the observation, of a home visit with Patient #4, on 07/24/2026, beginning at 9:00 AM, the patient indicated he/she medications included but not limited to Lantus insulin daily for the last 3 years, and Breo and Spiriva inhaler daily for the last 6 years. The patient indicated he/she paid $100 per month for each inhaler. A POC for 1st benefit period 06/22/2026 to 09/19/2026, indicated Patient #4 had a primary diagnosis of malignant neoplasm of the right main bronchus and other pertinent diagnosis of chronic obstructive pulmonary disease (chronic lung disease), and medications listed failed to evidence the Lantus, Breo and Spiriva inhalers. An Advanced Beneficiary Notice of Non-coverage, dated 06/29/2026, indicated if Medicare doesn’t pay for the medications listed the patient would be responsible for payment. The list of medications failed to include the Lantus, Breo, and Spiriva. During an interview, on 07/27/2026, beginning at 10:45 AM, the Administrator indicated the nurse documents medications upon the patient’s admission to hospice, and the social worker will review with the patient what medications would be covered by hospice. The Administrator indicated all of the patient’s medications were not reconciled upon admission to hospice and the social worker would not be able to review a complete list of medications with the patient that would or would not be covered by hospice. The Administrator indicated hospice covered medications were based on the patient’s terminal diagnosis and the patient’s complete list of medications would need to be reviewed to determine if the inhalers would be covered by hospice based on the diagnosis.”

“Based on observation, record review, and interview, the hospice failed to ensure the POC included all medications and treatments to meet the needs of the patient in 1 of 1 active clinical record reviewed with an observed home visit (Patient #4), and in 1 of 1 active clinical record reviewed with a patient with a gastrostomy tube (tube into the stomach for nutrition) (Patient #12). Findings include: 1. During the observation, of RN 3’s home visit with Patient #4, on 07/24/2026, beginning at 9:00 AM, the patient indicated he/she medications included but not limited to Lantus insulin daily, Breo and Spiriva inhaler daily, and a Fentanyl Patch every 3 days. A POC for 1st benefit period 06/22/2026 to 09/19/2026, indicated Patient #4 had a primary diagnosis of malignant neoplasm of the right main bronchus, and medications listed failed to evidence the Lantus, Breo and Spiriva inhalers. A Skilled Nursing Visit Note, dated 07/21/2026, indicated prescriptions were reviewed for new or changed medications and no evidence of change since last review was documented. During an interview, on 07/24/2026, beginning at 9:00 AM, RN 3 indicated medication reconciliation was to be completed every month. RN 3 indicated the Fentanyl Patch was ordered through the prescribing platform and should have been added on to the patient’s medication list. During an interview, on 07/24/2026, beginning at 1:00 PM, the Administrator indicated the POC medications are to be current and updated. 2. A POC for 2nd benefit period 07/23/2026 to 10/20/2026, indicated Patient #12 had a primary diagnosis of senile degeneration of the brain, and had a gastrostomy tube (tube into the stomach for nutrition), was to have nothing by mouth, and received tube feedings. The POC failed to evidence how the tube feeding was administered, the frequency, or the type of tube feeding. During an interview, on 07/28/2026, beginning at 2:20 PM, the Administrator indicated the type of tube feeding, amount, frequency and water flushes should have been and was not included on the POC.”

“Based on record review and interview, the hospice failed to ensure reconciliation of medications with a skilled nursing facility in 1 of 1 active clinical record reviewed with an observed visit at Entity A, a skilled nursing facility (Patient #1). Findings include: A revised policy, dated 05/2013, titled, “Medication Profile,” indicated the clinician wound obtain and document a complete list of the patient’s medications upon the patient’s admission, and when updates to the comprehensive assessment were performed. An Entity A’s Order Summary Report, dated 07/23/2026, indicated Patient #1’s medications included but not limited to Humalog Insulin per sliding scale three times per day with a start date of 07/14/2026. A POC, for 1st benefit period 07/02/2026 to 09/29/2026, indicated medications included but not limited to Saxagliptin (oral hypoglycemic) daily with a start date of 07/02/2026, and Olanzapine (antipsychotic) twice per day with a start date of 07/02/2026. Entity A’s Order Summary Report failed to evidence the patient was on Saxagliptin nor Olanzapine. The hospice’s POC failed to evidence the patient was on Humalog Insulin. A Hospice Patient Care Verbal Order, dated 07/23/2026, indicated Saxagliptin, and Olanzapine were discontinued on 07/23/2026, and Humalog Insulin sliding scale order was started on 07/23/2026. During an interview, on 07/23/2026, beginning at 9:00 AM, RN 1 indicated the patient’s Humalog Insulin should have been and was not added to the hospice’s medication list. RN 1 indicated medication reconciliation with a skilled nursing facility should be completed weekly by reviewing the facility’s medication list.”

“Based on record review and interview, the hospice failed to ensure 1 of 1 active patient’s clinical record reviewed with an observation visit at Entity A, a skilled nursing facility, had a urinary tract infection (infection in the urinary tract that could include the kidneys, ureters, bladder, and urethra) tracked for quality improvement (Patient #1); 1 of 2 active clinical records reviewed that resided in a private residence, in their 2nd benefit period, had a urinary tract infection tracked for quality improvement (Patient #9); and 1 of 1 active patient’s clinical record reviewed with an observation visit at Entity B, a skilled nursing facility, had a fall tracked for quality improvement (Patient #3). Findings include: 1. A revised policy, dated 08/2025, titled, “Quality Assurance Performance Improvement Plan,” indicated the quality assurance performance improvement program would collect and analyze data in all areas of operations for the purpose of improving patient care and services. The policy indicated data would be collected on topics to prevent adverse events. 2.During an interview, on 07/23/2026, beginning at 9:00 AM, during the observation of a visit at Entity A, RN 1 indicated Patient #1, with a hospice election date of 07/02/2026, had a recent urinary tract infection and was on antibiotics. A Skilled Nursing Visit Note, dated 07/20/2026, indicated the patient was started on Macrobid (anti-infective) for a suspected urinary tract infection. A Current POC, dated 07/22/2026, indicated Macrobid was started for 5 days on 07/17/2026. An Infection Report, for August 2025 to July 24, 2026, failed to evidence documentation of Patient #1’s urinary tract infection. During an interview, on 07/24/2026, beginning at 11:30 AM, Administrative Staff 3 indicated Patient #1’s urinary tract infection was not and should have been on the hospice’s infection report and the hospice nurses are to complete an infection report as soon as the urinary tract infection was noted. 3.A Skilled Nursing Visit Note, dated 06/18/2026, indicated Patient #9, with a hospice election date of 03/15/2026, was started on an antibiotic for a suspected urinary tract infection. A Patient Care Verbal Order, dated 06/18/2026, indicated antibiotic Doxycycline was ordered. An Infection Report, for August 2025 to July 24, 2026, failed to evidence documentation of Patient #9’s urinary tract infection. During an interview, on 07/28/2026, beginning at 12:00 PM, the Administrator indicated Patient #9’s urinary tract infection should have been and was not on the hospice’s infection report, and the hospice nurses are to complete an infection report when they are made aware of an infection and the visit note allowed the nurses to enter the infection report from the skilled nursing visit note. The Administrator indicated infections are documented on the infection log report when a suspected infection was noted or an antibiotic was initiated. 4.A Skilled Nursing Visit Note, dated 06/30/2026, indicated Patient #3, with a hospice election date of 03/22/2026, had yellow and purple discoloration to the left cheek under their glasses due to a fall the prior week, and Entity B’s facility nurse notified the RN of patient’s fall. An Adverse Event Report, from May 2025 to July 2026, failed to evidence documentation of Patient #3’s fall. During an interview, on 07/24/2026, beginning at 1:00 PM, the Administrator indicated Patient #3’s fall was not and should have been documented by the hospice nurses when they are made aware of the fall, and the hospice nurses are able to document a fall report in the skilled nursing visit that will generate an adverse event report.”

“Based on record review and interview, the hospice’s performance improvement activities failed to evidence focus on high risk, high volume, nor problem prone areas related to patients’ falls in 1 of 1 agency. Findings include: 1.A revised policy, dated 08/2025, titled, “Quality Assurance Performance Improvement Plan,” indicated the hospice’s quality assurance performance improvement plan (QAPI) would identify areas for opportunities for improvement and implement improvement activities, the program would address safety and quality with clinical interventions, and the performance improvement process intent would be to prevent or decrease the likelihood of problems by identifying areas of opportunity to fix underlying causes of persistent and or systemic problems. 2. Adverse Events Logs and Average Daily Census Reports for May 2025 to May 2026 evidenced the following related to patients’ falls: A. May 2025 average daily census 35, 7 (20%) unduplicated patients’ falls B. June 2025 average daily census 35, 4 (11%) unduplicated patients’ falls C. July 2025 average daily census 36, 4 (11%) unduplicated patients’ falls D. August 2025 average daily census 44, 6 (14%) unduplicated patients’ falls E. September 2025 average daily census 47, 10 (21%) unduplicated patients’ falls F. October 2025 average daily census 44, 11 (25%) unduplicated patients’ falls G. November 2025 average daily census 46, 5 (11%) unduplicated patients’ falls H. December 2025 average daily census 42, 3 (7%) unduplicated patients’ falls I. January 2026 average daily census 38, 3 (6%) unduplicated patients’ falls J. February 2026 average daily census 35, 2 (6%) unduplicated patients’ falls K. March 2026 average daily census 33, 2 (6%) unduplicated patients’ falls L. April 2026 average daily census 31, 5 (16%) unduplicated patients’ falls M. May 2026 average daily census 31, 5 (16%) unduplicated patients’ falls 3. During an interview, on 07/24/2026, beginning at 12:00 PM, Administrative Staff 3 indicated the hospice’s performance improvement program did not include interventions for improvement activities related to patients’ falls. 4. During a follow up interview, on 07/27/2026, beginning at 11:45 AM, Administrative Staff 3 indicated the hospice identified patients’ falls as being a concern, however, did not have documentation the quality performance improvement program implemented interventions.”

“Based on observation, record review, and interview, the hospice’s POC for patients that resided in skilled nursing facilities failed to identify the care and services that patients required and specifically identify which provider was responsible for performing the respective functions that were agreed upon in 4 of 4 active clinical records reviewed of patients residing in skilled nursing facilities (Patient #1, Patient #3, Patient #7, Patient #12). Findings include: 1.A revised policy, dated 12/2025, titled, “Care Coordination,” indicated care coordination would include but not limited to clearly outlining each clinician’s responsibilities to avoid duplication of services. 2. A POC, for 1st benefit period 07/02/2026 to 09/29/2026, indicated Patient #1 resided in Entity A, a skilled nursing facility, had a primary diagnosis of senile degeneration of the brain, was incontinent of bowel and bladder, was disoriented, had fall precautions, required 24 hour supervision, had hospice skilled nursing visits 2 times per week for 12 weeks beginning the week of 07/07/2026, hospice aide services 2 times per week for 12 weeks beginning the week of 07/07/2026 for assistance with transfers, incontinent care, and bath or shower, hospice chaplain visits 1 time per month for 2 months, and hospice social worker visits 1 time per month for 3 months. The POC indicated the patient’s right arm skin tears required dressing changes every Monday, Wednesday, and Friday, with a start date of 07/02/2026, per the hospice and as needed per the skilled facility staff. The POC failed to evidence the hospice staff was to provide nursing visits 3 times per week for skin tear dressing changes, and failed to identify the provider responsible for the patient’s needs in the absence of the hospice staff. During an observation of a RN visit at Entity A, on 07/23/2026, beginning at 9:00 AM, the skilled nursing facility’s hospice binder failed to evidence a delineation of care between Entity A and hospice. 3.A POC for 2nd benefit period 06/20/2026 to 09/17/2026, indicated Patient #2 resided in Entity B, a skilled nursing facility, had a primary diagnosis of moderate protein – calorie malnutrition, was incontinent of bowel and bladder, required 24 hour supervision, had fall and aspiration precautions, had hospice skilled nursing visits 2 times per week for 12 weeks beginning the week of 06/20/2026, hospice aide services 2 times per week for 13 weeks beginning the week of 06/20/2026 for assistance with transfers, incontinent care, assistance with dressing, and showering, and hospice chaplain visits 1 time per month for 3 months. The POC failed to identify the provider responsible for the patient’s needs in the absence of the hospice staff. During the observation of RN 2’s visit at Entity B on 07/23/2026, beginning at 10:50 AM, the hospice’s skilled nursing facility binder failed to evidence a delineation of care between Entity B and the hospice. During an interview, on 07/23/2026, beginning at 10:50 AM, RN 2 indicated he/she was unaware if Entity B had a delineation of care documented with hospice. 4.A POC for 1st benefit period 07/11/2026 to 10/08/2026, indicated Patient #7 resided in Entity C, a skilled nursing facility, had a primary diagnosis of senile degeneration of the brain, was incontinent of bowel and blader, was disoriented, had fall and aspiration precautions, had hospice skilled nursing visits 3 times per week for 12 weeks beginning the week of 07/13/2026, hospice aide visits 2 times per week for 12 weeks beginning the week of 07/13/2026 for assistance with dressing, incontinent care, bed bath, had wound care to left heel wound. The POC failed to identify the provider responsible for the patient’s needs in the absence of the hospice staff. During an interview, on 07/28/2026, beginning at 2:00 PM, the Administrator indicated the POC did not include the specific provider responsible for the patient’s needs. 5. A POC for 2nd benefit period 07/23/2026 to 10/20/2026, indicated Patient #12 resided in entity D, a skilled nursing facility, had a primary diagnosis of senile degeneration of the brain, required 24 hour supervision, was disoriented, had hospice skilled nursing visits 2 times per week for 12 weeks beginning the week of 07/23/2026, hospice aide visits 2 times per week for 12 weeks beginning the week of 07/23/2026 for incontinent care and bed bath, had tube feedings through a gastrostomy tube (tube into the stomach for nutrition), and weekly gastrostomy tube site assessment. An Interdisciplinary Group Meeting Note, dated 07/08/2026, indicated patient had deep tissue injury to the left leg wound care every Monday, Wednesday, and Friday with an onset date of 05/06/2026, left abdomen wound care daily with an onset date of 05/06/2026, back wound care with an onset date of 05/06/2026, and left and right arm wound care daily with an onset date of 05/06/2026. The POC failed to evidence the delineation of care for the patient’s care needs in the absence of the hospice staff to include wound and gastrostomy tube feedings. During an interview, on 07/28/2026, beginning at 2:20 PM, the Administrator indicated the POC did not include a delineation of care with Entity D to include the provider responsible for the patient’s gastrostomy and wound care needs. The Administrator indicated a delineation of care should have included documentation and coordination with the skilled nursing facility of the patient’s gastrostomy tube placement and residual assessments.”

“Based on observation, record review, and interview, the hospice failed to ensure Entity A and Entity B, skilled nursing facilities were provided with hospice information to include the most recent POC, hospice election form, advanced directives, and physician certification of terminal illness in 2 of 2 skilled nursing facility observed patients visits (Patient #1, Patient #3). Findings include: 1. A POC, for 1st benefit period 07/02/2026 to 09/29/2026, indicated Patient #1 resided at Entity A with a hospice election date of 07/02/2026. A Physician Orders for Scope of Treatment, dated 06/17/2026, indicated the patient’s power of attorney elected for the patient not to be resuscitated if the patient had no pulse or was not breathing. A Hospice Certification of Terminal Illness, for benefit period 07/02/2026 to 09/29/2026, indicated the patient had a terminal illness with a life expectancy of six months or less if the disease followed the normal course for a terminal diagnosis of senile degeneration of the brain. During the observation of RN 1’s visit, on 07/23/2026, beginning at 9:00 AM, the hospice’s binder at the skilled nursing facility failed to evidence a delineation of care between the facility and hospice, do not resuscitate documentation, certificate of terminal illness nor the patient’s hospice election consent. During an interview, on 07/23/2026, beginning at 9:00 AM, RN 1 indicated the hospice binder at Entity A did not include the patient’s do not resuscitate documentation, certification of terminal illness, delineation of care, nor the patient’s hospice election form and the hospice’s social worker was responsible for ensuring the patients’ advanced directives and hospice election form were in the facility’s hospice binder. 2. A POC, for 2nd benefit period 06/20/2026 to 09/17/2026, indicated Patient #3 resided at Entity B with a hospice election date of 03/22/2026. A Hospice Certification of Terminal Illness for benefit period 03/22/2026 to 06/19/2026, indicated the patient had a terminal illness with a life expectancy of six months or less if the disease followed the normal course for a terminal diagnosis of moderate protein – calorie malnutrition. During the observation of RN 2’s visit, on 07/23/2026, beginning at 10:50 AM, the hospice’s binder at the skilled nursing facility failed to evidence a delineation of care between the facility and hospice nor a certification of terminal illness. 3. During an interview, on 07/23/2026, beginning at 2:00 PM, the Administrator indicated the hospice’s binder at skilled nursing facilities should include patients’ consents, advanced directives, certification of terminal illness, POC and updates to the POC.”

“Based on record review and interview, the hospice failed to ensure orientation related to the hospice philosophy to include hospice policies and procedures regarding methods of comfort, pain control, symptom management, principles about death and dying, patient rights, and appropriate forms were provided to skilled nursing facilities’ staff that provided care to patients, to include 2 of 2 skilled nursing facilities where observation patients’ visits were completed. (Entity A, Entity B). Findings include: A Hospice POC, for Patient #1, indicated the patient resided at Entity A, with a hospice election date of 07/02/2026. A Hospice POC, for Patient #3, indicated the patient resided at Entity B, with a hospice election date of 03/22/2026. A Hospice Contract with Skilled Nursing Facilities indicated the hospice would provide orientation to the hospice philosophy to the long term care facility staff, including hospice policies and procedures regarding methods of comfort, pain control, symptom management, as well as principles of death and dying, individual responses to death, patient rights, appropriate forms, and record keeping requirements. A Palliative Care versus Hospice Education for Skilled Nursing Facilities Form, indicated by the hospice Administrator as the education presented to skilled nursing facilities, failed to evidence hospice policies and procedures regarding methods of comfort, pain control, symptom management, principles about death and dying, patient rights, appropriate forms, and record keeping requirements. During an interview, on 07/23/2026, beginning at 2:00 PM, the Administrator indicated the hospice’s social worker and marketer provided in-services at skilled nursing facilities. During a follow up interview, on 07/24/2026, beginning at 1:00 PM, the Administrator indicated the hospice marketer and social worker do not document skilled nursing facility’s in-services nor have a sign in sheet. During an interview, on 07/27/2026, beginning at 10:45 AM, Marketer 1 indicated hospice training was presented to skilled nursing facility’s leadership team to include directors of nursing, unit managers, and social services, and did not include the nurses nor aides. Marketer 1 indicated sign in sheets are not completed, and the in services would include hospice and palliative care benefits, and would present identifiers for who would benefit from hospice and palliative care services.”