Providence Home Health & Hospice

“Based on policy review, record review, and interview, the hospice provider failed to complete a fall assessment during the initial comprehensive assessment in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all the patients served by the provider.Findings included:Review of the provider’s policy titled, “Comprehensive Assessment,” dated 10/2025, showed during the comprehensive patient assessment, all baseline data and other relevant information was to be documented in the patient’s clinical record including: - A physical assessment that included relevant data related to pertinent physical findings and the patient’s terminal illness; - The patient’s functional status that included, but was not limited to, the degree of self-care and the amount and level of assistance needed; and - Complications and risk factors that affect care planning. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 10/16/2025 with a terminal diagnosis of stage 3a (three) chronic kidney disease (a condition where kidneys are mildly to moderately damaged). The patient resided in a long-term care facility (LTCF). Review of the initial comprehensive assessment, dated 10/16/2025, showed the patient was admitted to a LTCF for a rehabilitation stay for hip repair, due to a fall, that resulted in a fracture in the right femur (thigh bone). The registered nurse (RN) failed to complete a fall assessment.During an interview on 11/13/2025 at 10:00 AM, the administrator and administrator designee stated that they would expect a fall assessment to be completed on a patient who had recovered from a hip fracture that was due to a fall.”

“Based on policy review, record review, observation, and interview, the hospice provider failed to ensure staff maintained an accurate and updated medication profile in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Medication Profile,” updated 07/2024, showed in part: - A drug regimen review would be performed by a registered nurse at the time of the initial assessment, when updates to the comprehensive assessments are performed, and with the addition of a new medication; - During subsequent home visits, the medication profile would be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians understood the medication regimen. This includes, but will not be limited to: * Using the medication profile to evaluate the use of the drugs in the home setting. The medication profile includes, but is not limited to all current medications, dates prescribed, name and medication, dose, frequency, drug classification, and date discontinued; - Based on review of the medication profile as well as the written material, changes in the plan of care may be required; and - Deviations from taking medications as ordered would be documented in clinical notes, and the physician (or other authorized independent practitioner) would be notified. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 09/15/2025 with a terminal diagnosis of chronic combined systolic and diastolic (congestive) heart failure (a decrease in the ability of the heart to pump blood). The patient resided at his/her own home with their spouse. Observation and interview on 11/12/2025 showed the following discrepancies between the provider’s current medication profile, dated 09/15/2025 to 12/13/2025, and the patient’s home medication bottles:- The provider’s profile showed levothyroxine (thyroid hormone) 75 micrograms (mcg) take one daily (order received 09/23/2025). The patient was taking 50 mcg daily;- The provider’s profile showed Mucus Relief 400 milligram (mg) take one every four hours as needed for congestion (order received 10/01/2025). The patient was not taking the medication and did not have it in the home;- The provider’s profile showed aspirin, chewable, 81 mg take one daily for clot prevention (order received 09/23/2025). The patient stated that he/she was not taking the aspirin and that he/she never received the medication;- The provider’s profile showed vitamin D3 (supplement) 25 mcg take one daily. The patient was taking 125 mcg (5,000 international units) daily; - The patient was taking Eliquis 5 mg, take one twice a day (order to discontinue on 09/23/2025). He/she stated he/she never stopped taking the Eliquis. The provider’s profile failed to include Eliquis; and - The patient was using over the counter (OTC) CBD (topical cannabidiol is a natural compound derived from the hemp plant) cream for lower back pain with good results (noted on skilled nurse note 10/02/2025 and interdisciplinary group meeting 10/14/2025). The provider’s profile failed to include the OTC CBD cream. During an interview on 11/13/2025 beginning at 2:02 PM, the administrator stated that the medications in the home should match the medication profile”

“Based on policy review, record review, and interview, the plan of care (POC) failed to include measurable outcomes in, but not limited to, two of five full records reviewed (Records/Patients #3 and #4). This deficient practice has the potential to affect all the patients served by the provider.Findings included:Review of the provider’s policy titled, “The Plan of Care,” dated 10/2025, showed, in part, the POC was to contain measurable outcomes anticipated from implementing and coordinating the POC. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 08/07/2025 with a terminal diagnosis of stage 4 (four) chronic kidney disease (a serious condition where kidneys are moderately to severely damaged). The patient resided in a long-term care facility (LTCF). Review of the POC, dated 11/11/2025, showed the following goals/interventions: - Patient’s pain was to be maintained at a comfortable level throughout the end of life; - Skin integrity was to be maintained during care; - Patient/caregiver were to receive optimal teaching and support as cardiac functions changed during care; and - The POC failed to include measurable outcomes anticipated from implementing and coordinating the POC.RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 10/16/2025 with a terminal diagnosis of stage 3a (three) chronic kidney disease (a condition where kidneys are mildly to moderately damaged). The patient resided in a LTCF. Review of the plan of care, dated 11/11/2025, showed the following goals/interventions: - Patient’s pain was to remain at a comfortable level during care; - Patient was to receive optimal level of pain and/or symptom management on a short-term basis; - Patient/caregiver was to receive optimal teaching and support as cardiac functions change during care; - Skin integrity was to be maintained during care; and - The POC failed to include measurable outcomes anticipated from implementing and coordinating the POC.During an interview on 11/13/2025 at 10:00 AM, the administrator and administrator designee stated that they would expect the goals on the POC to be measurable.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure a complete, individualized written plan of care (POC) was developed that included all of the patient’s medical equipment in, one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “The Plan of Care,” revised 10/2025, showed in part: - The POC will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group (IDG) and will be reviewed on a regular basis but no less than every 15 days;- The POC will include all services necessary for the palliation and management of the terminal illness and related conditions;- The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the POC; and- The written plan of care may contain, but not be limited to, the durable medical equipment (DME) and medical supplies necessary to meet the patient’s needs. Review of the provider’s undated policy titled, “Comprehensive Assessment,” showed in part, during the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient’s clinical record, including but not limited to, equipment presently in home and potentially needed by (the) patient. Review of the provider’s undated policy titled, “Interdisciplinary Group Plan of Care,” showed in part, the interdisciplinary group, (in collaboration with the attending physician, if any) will conduct assessments, develop and update the POC. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 09/15/2025 with a terminal diagnosis of chronic combined systolic (congestive) and diastolic (congestive) heart failure (a decrease in the ability of the heart to pump blood) and obstructive sleep apnea (OSA) (sleep-related breathing disorder). The patient resided at his/her own home with their spouse. Review of the referral history and physical (H&P), dated 08/25/2025, showed:- The patient’s past medical history included OSA and used a continuous positive airway pressure (CPAP) machine (a machine that uses mild air pressure to keep the airway open while sleeping) with oxygen at 3 (three) liters per a minute (lpm); and- The assessment/plan included obstructive sleep apnea syndrome (OSAS) using CPAP. Review of the initial POC (IPOC) dated 09/15/2025, showed the following interventions under the shortness of breath problem:- Administer supplemental oxygen as ordered; and- Educate patient and/or caregiver on oxygen safety and equipment maintenance. Review of the clinical record failed to show oxygen and CPAP listed on the DME section on the initial POC (IPOC) dated 09/15/2025 and the POC dated 09/16/2025. During an interview on 11/13/2025 beginning at 2:09 PM, the administrator stated that the POC should be completed within five days of admission and should include the DME.”

“Based on policy review, clinical record review, and interview, the hospice provider failed to ensure the interdisciplinary group (IDG) updated/revised the plan of care (POC) with new assessment findings/orders in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. Review of the provider’s policy titled, “The Plan of Care,” dated/revised 10/2025, showed, in part: - Purpose: To ensure that an individualized POC is completed that complies with accepted standards of care and regulatory issues;- A written individualized patient and family/caregiver POC will be established and maintained for each individual admitted to the hospice program;- The POC will meet the documentation requirements of the physician-directed medical orders and the care planning process;- The POC will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group (IDG) and will be reviewed on a regular basis but no less than every 15 days;- The POC will include all services necessary for the palliation and management of the terminal illness and related conditions;- The POC will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort, and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregivers needs, goals and outcome achievement;- The POC will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the IDG, with input from the attending physician, the patient, and the family/caregiver, based on ongoing comprehensive assessments of the patient and family/caregiver; - Review of the POC will be documented in the clinical record; and- Revision dates will be noted on the plan of care. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 09/25/2025 with a terminal diagnosis of chronic diastolic, congestive heart failure (a decrease in the ability of the heart to pump blood). He/she resided in a long-term care facility (LTCF).Review of the registered nurse (RN) initial assessment visit note dated 09/25/2025, showed “right foot pinky toe- 1.2 by 1.8 (failed to specify the unit of measurement) wound, treatment in place skin tear LFA (left forearm), buttocks with shearing (a skin injury that occurs when skin and underlying tissues are pulled in the opposite direction) area- tx (treatment) in place”. Review of the POC dated 09/25/2025 to 12/23/2025 showed:- Provide/educate on wound care as ordered; and- The POC failed to contain specific wound care orders. Review of a physician order dated 09/25/2025, showed:- Buttocks: cleanse, apply hydrogel/collagen to wound and cover with foam dressing daily until healed;- Right foot pinky toe: cleanse, apply betadine to wound and cover with dry dressing daily until healed; and- Left forearm skin tear: contact layer every seven (7) days until healed. Review of the IDG meeting/updated POCs dated 09/30/2025,10/14/2025, 10/28/2025, and 11/11/2025, showed;- Provide/educate on wound care as ordered; and- The IDG/POC updates failed to identify the specific wound care orders for the pinky toe. During an interview on 11/12/2025 at 11:15 AM, the administrator designee stated that he/she:- Thought the initial plan of care order, dated 09/25/2025, followed throughout the patient’s stay;- Thought the “provide/educate on wound care as ordered” was sufficient for updating the POCs since there was an order; and- Voiced understanding that the POCs needed to be individualized with the patient’s specific orders.”

“Based on standards of practice, record review, observation, and interview, the hospice provider failed to ensure nursing care and services were provided to meet the nursing needs of the patient as identified in the patient’s initial assessment, comprehensive assessment, and updated assessment in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. Findings included:Review of the provider’s policies showed the provider failed to have a wound care/measurement policy.Review of the article by Karen S. Clay, RN, BSN, CWCN Copyright 2008 titled, “Evidence-Based Pressure Ulcer Prevention: A Study Guide for Nurses,” showed the following: “The standard of practice requires at least weekly measurement of the wound. In addition, every time you change the dressing, assess peri-wound skin, wound margins, wound tissue, drainage, odor, pain, and any other relevant issues. On a weekly basis, assess those macroscopic (i.e., visible to the naked eye) indices, measure the wound, assess the effectiveness of the treatment, and determine any treatment plan changes.” (http://www.hcpro.com/content/76944.pdf Chapter 9-Wound Healing-Page 95) RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 09/25/2025 with a terminal diagnosis of chronic diastolic, congestive heart failure (a decrease in the ability of the heart to pump blood). He/she resided in a long-term care facility (LTCF).Review of the registered nurse (RN) initial assessment visit note dated 09/25/2025 showed “right foot pinky toe- 1.2 by 1.8 wound (failed to specify the unit of measurement), treatment in place skin tear LFA (left forearm), buttocks with shearing area (a skin injury that occurs when skin and underlying tissues are pulled in the opposite direction) - tx (treatment) in place”. Review of the subsequent skilled nurse (SN) visit notes, dated 09/26/2025, 09/30/2025, 10/02/2025, 10/07/2025, 10/09/2025, 10/14/2025, 10/16/2025, 10/21/2025, 10/23/2025, 10/28/2025, 10/30/2025, 11/04/2025, 11/06/2025, and 11/11/2025, showed the SN failed to document measurements of the right pinky toe.Observation on 11/12/2025 at 10:22 AM showed the patient continued to have a measurable black scabbed area on the top of the right pinky toe.During an interview on 11/13/2025 at 10:26 AM, the administrator stated that:- He/she could find no further measurements of the pinky toe wound in the clinical record;- He/she would expect the RN to assess wounds every visit and measure wounds weekly; and- The RN had told her that “you really couldn’t measure that wound”.”

“Based on policy review, record review, and interview, the hospice provider failed to forward the discharge summary to the patient’s attending physician, in but not limited to, one of four applicable records reviewed (Record/Patient #8). This deficient practice has the potential to affect all live discharge patients served by the provider. Findings included:Review of the provider’s policy titled, “Discharge Summary,” dated/updated 07/2024, showed all patients discharged from a service and from hospice will have a discharge summary completed and filed in the clinical records.Review of the provider’s undated policy titled, “Discharge from Hospice Program,” showed a copy of the discharge summary will be sent to the attending physician.RECORD/PATIENT #8:Review of the clinical record showed the patient was admitted to hospice services on 07/03/2025. The patient revoked the hospice benefit and was discharged 07/31/2025.Further review of the clinical record showed the record failed to include a discharge summary.During an interview on 11/12/2025 at 3:35 PM, the administrator stated that, unfortunately, he/she did not have a written discharge summary, therefore it was not sent to the attending physician.”

“Based on policy review, record review, and interview, the provider failed to ensure the long-term care facility (LTCF) had the necessary information to assure the patient received the necessary care and services in, but not limited to, two of three home visits conducted in a LTCF (Records/Patients #3 and #4). This deficient practice has the potential to affect all patients served by the provider who reside in a LTCF.Findings included:Review of the provider’s policy titled, “Provision of Care to Residents of Skilled Nursing Facility (SNF)/Nursing facility (NF) or Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID),” dated 07/2024, showed the [provider] was to provide the SNF/NF and ICF/IID the following information: - The most recent plan of care; - Hospice election form and advance directives; - Physician certification and recertification of the terminal illness; - Names and contact information for the hospice personnel involved in hospice care; - Instruction on how to access the hospice 24-hour on-call system; - Hospice medication information; and - Hospice physician and attending physician (if any) orders. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 08/07/2025 with a terminal diagnosis of stage 4 (four) chronic kidney disease (a serious condition where kidneys are moderately to severely damaged). The patient resided in a LTCF. Review of the hospice binder located in the LTCF failed to include the following: - Current hospice plan of care; - Hospice election form; - Current medication profile; and - Hospice physician and attending physician orders.RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 10/16/2025 with a terminal diagnosis of stage 3a (three) chronic kidney disease (a condition where kidneys are mildly to moderately damaged). The patient resided in a LTCF. Review of the hospice binder located in the LTCF failed to include the following: - Current hospice plan of care; - Hospice election form; - Advance directive; - Physician certification and recertification; - Current medication profile; and - Hospice physician and attending physician orders.During an interview on 11/11/2025 at 2:45 PM, the hospice care unit manager, at the LTCF, stated that the provider always provided the necessary documents in the binder. The information had never been missing in the binder and he/she did not know why it was not there.During an interview on 11/13/2025 at 10:00 AM, the administrator and administrator designee stated that once the documents were created, they were printed and set aside for a volunteer to insert in the binder when he/she volunteered on the following Saturday. The provider was not aware that the volunteer did not come. The provider changed their process during the survey and the hospice aides were directed to file the documents in the hospice binders in the LTCF.”