Every finding on record at Providence Home Health LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: The effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, it was revealed that the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient's current prescription and OTC drugs. CLINICAL RECORD 13: The patient elected hospice care on 11/27/2024 with a diagnosis of Malignant Neoplasm of the esophagus. A skilled nursing visit was completed on 12/04/2024 and included documentation that read in part, "Patient utilizing oxygen intermittently, but daughter reports its more often now. Humidifier filled with water. Oxygen level was 97 percent on 4 liters." The clinical record included a physician order for Oxygen obtained on 11/27/2024. The medication profile did not include the documentation of oxygen. During a joint record review and interview on 06/12/2025, the Director of Nursing [Personnel Record 5] confirmed that oxygen was not documented on the medication profile.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene, use of gloves, mask, eye protection, or face shield depending on anticipated exposure. This standard was not met as evidenced by document review, interview and observation. In 1 of 3 (33%) home visit observations, it was revealed that the agency did not ensure that hand hygiene was performed when indicated per the agency's policy. DOCUMENT 1: Policy titled, Hand Washing Policy-In Patient's Home, date: 2024, read in part, "Thorough hand washing/hand antisepsis is required of all employees. Handwashing/Hand Hygiene Procedure: c. after removing gloves." HOME VISIT 2: The patient elected hospice care on 12/27/2024 with a diagnosis of Atherosclerotic Heart Disease. During the home visit with the Licensed Practical Nurse (LPN) [Personnel Record 2] on 06/12/2025, the LPN donned gloves and provided pericare. After pericare was completed, the LPN removed gloves, donned new gloves, obtained vital signs (blood pressure, temperature, pulse, and respiration), and completed a skin inspection. The LPN did not perform hand hygiene after removing the gloves per agency policy. During an interview on 06/12/2025, the Director of Nursing confirmed the findings and that hands should be cleansed between and after glove removal per the agency's policy.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. and written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 3 of 13 (23%) clinical records reviewed of patients who received Hospice Aide (HA) services, it was revealed that the agency did not ensure that the HA received written care instructions to meet the patient's needs. CLINICAL RECORD 2: The patient elected hospice care on 12/27/2024 with a diagnosis of Atherosclerotic Heart Disease. The hospice plan of care ordered HA services two (2) times weekly beginning the week of 12/27/2024. The HA care plan, effective 12/27/2024, assigned the HA the relevant task: Hygiene-Bath-Shower Chair. The HA care plan was updated on 01/16/2025, and the relevant task, Hygiene-Bath-Bed, was added. The HA care plan, effective 03/27/2025 through 06/24/2025, included the relevant tasks (active interventions) of bed bath and shower. The HA care plan did not include specific care instructions, including when the patient was to receive a shower or bed bath (patient unable to refuse due to cognitive abilities). CLINICAL RECORD 4: The patient elected hospice care on 03/18/2024 with a diagnosis of Alzheimer's Disease. The hospice plan of care and updated plans of care ordered HA services two (2) times weekly beginning the week of 03/18/2024 through the date of review. The HA care plan, effective 03/18/2024, assigned the HA the relevant task: Hygiene-Bath-Shower Chair. The HA care plan was updated on 05/13/2025, and the relevant task, Hygiene-Bath-Bed, was added. The HA care plan, updated 05/13/2025 and effective through 06/24/2025, included the relevant tasks (active interventions) of bed bath and shower. The HA care plan did not include specific care instructions, including when the patient was to receive a shower or bed bath (patient unable to refuse due to cognitive abilities). CLINICAL RECORD 12: The patient elected hospice care on 08/26/2024 with a diagnosis of Senile degeneration of the brain. The hospice plan of care ordered HA services two (2) times weekly beginning the week of 08/26/2024. The HA care plan, effective 08/26/2024, assigned the HA the relevant task: Hygiene-Bath-Shower Chair. The HA care plan was updated on 11/24/2024, and the relevant task, Hygiene-Bath-Bed, was added. The HA care plan, effective 11/24/2024 through 02/20/2025, included the relevant tasks (active interventions) of bed bath and shower. The HA care plan did not include specific care instructions, including when the patient was to receive a shower or bed bath (patient unable to refuse due to cognitive abilities). During a joint record review and interview on 06/13/2025, the Director of Nursing [Personnel Record 5] confirmed the HA care plan did not include instructions from the Registered Nurse delineating when the patient was to receive a shower or a bed bath.

It is required that the individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program. The hospice maintains documentation that each hospice aide has met the requirements. This standard was not met as evidenced by document review, interview and personnel record review. In 1 of 1 (100%) personnel record of a hospice aide, the hospice did not ensure that a competency assessment was documented as completed upon hire according to hospice policy. Agency policy, “Hospice Competencies,” stated in part: “Before any field staff member may conduct an unsupervised patient visit, he or she must pass a skills competency evaluation. Items that are not observed cannot be performed independently until an RN is able to observe the aide performing the tasks. If an aide is not competent in 2 or more areas, the aide cannot perform patient visits independently." Record 1: The record for this Hospice Aide, hired on 1/19/2023, did not include documented evidence that a skills competency evaluation was completed according to hospice policy. The Director of Nursing was interviewed on 3/20/2023 and stated, "I took her to the facility to introduce her, watched her bathe two patients and showed her how to document." Additionally, the Director of Nursing stated, "I did not complete a competency (checklist) and did not observe any other tasks". The Director of Nursing confirmed the hospice aide had been making independent visits that started the week of 1/29/2023 and included patient showering and other skills that were not documented as observed by the RN. The Administrator was interviewed on 3/20/2023 and stated that hospice aides are required to have a competency skills checklist completed before completing visits on their own. Agency policy, “Hospice Competencies,” stated in part, “Before any field staff member may conduct an unsupervised patient visit, he or she must pass a skills competency evaluation. Items that are not observed cannot be performed independently until an RN is able to observe the aide performing the tasks. If an aide is not competent in 2 or more areas, the aide cannot perform patient visits independently." Record 1 (Hospice Aide): hire date 1/19/2023. There was no documented evidence that a skills competency evaluation was completed according to hospice policy. The Director of Nursing was interviewed on 3/20/2023 and stated, "I took her to the facility to introduce her, watched her bathe two patients and showed her how to document." Additionally during interview on 3/20/2023, the Director of Nursing stated, "I did not complete a competency and did not observe any ather tasks" The Director of Nursing confirmed the hospice aide had been making independent visits that started by the week of 1/29/2023 and included showering and other skills not observed. The Administrator was interviewed on 3/20/2023 and stated, the hospice aides are required to have a competency skills checklist completed before completing visits on their own.

It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group; included in the plan of care; permitted to be performed under state law and regulation; and consistent with the hospice aide training. THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 3 of 4 (75%) records of patients who received hospice aide services it was revealed the hospice did not ensure the hospice aide followed the plan of care as ordered. Record 1: The patient elected the hospice benefit on 7/14/2021 with a primary diagnosis of Alzheimer's disease. A physician’s order, effective 1/23/2023, ordered hospice aide visits to be provided "2 x weekly". During the week of 2/19/2023 - 2/25/2023, a hospice aide visit was documented as provided on 2/20/2023 and there was no documented evidence of a second visit or reason for the missed visit. Additionally, the hospice aide documentation on aide visit notes dated 2/20/2023 and 3/6/2023 stated the hospice aide shaved the patient. The hospice aide care plan dated 1/23/2023 did not include shaving as an assigned task. Record 3: The patient elected the hospice benefit on 7/8/2022 with a primary diagnosis of Chronic Obstructive Pulmonary Disease. A physician’s order, effective 10/9/2022, ordered hospice aide visits to be provide "2 x weekly". During the weeks of 11/20/2022 - 11/26/2022 and 11/27/2022 - 12/3/2022, there was no documented evidence of hospice aide visits provided or documented reasons for the missed visits. Record 5: The patient elected the hospice benefit on 7/28/2022 with a primary diagnosis of Senile Degeneration of Brain. A physician’s order, effective 10/26/2022, ordered hospice aide visits to be provided "2 x weekly". During the weeks of 12/4/2022 - 12/10/2022, 12/11/2022 - 12/17/2022, 12/18/2022 - 12/24/2022 and 12/25/2022 - 12/31/2022, there was no documented evidence of hospice aide visits provided or documented reasons for the missed visits. The Director of Nursing was interviewed on 3/20/2023 and agreed, the hospice aide did not follow the plan of care as ordered. Additionally, the Director of Nursing stated, the expectation was the RN was to complete the bathing if the aide was out but there was no documentation that described the RN as completing these tasks during the dates identified. The Director of Nursing stated, “We had trouble getting the nurses to bathe the patients.” Record 1: The patient elected the hospice benefit on 7/14/2021 with a primary diagnosis of Alzheimer's disease. A physician’s order effective 1/23/2023 ordered a hospice aide 2 x weekly. During the week 2/19/2023-2/25/2023, a hospice aide visit was documented on 2/20/2023. There was no documented evidence of a second visit or reason for the missed visit. Additionally, the hospice aide documentation on 2/20/2023 and 3/6/2023 revealed the hospice aide shaved the patient. The hospice aide care plan dated 1/23/2023 did not include shaving as an assigned task. Record 3: The patient elected the hospice benefit on 7/8/2022 with a primary diagnosis of Chronic obstructive pulmonary disease. A physician’s order effective 10/9/2022 ordered a hospice aide 2 x weekly. During the weeks 11/20/2022-11/26/2022 and 11/27/2022-12/3/2022, there was no documented evidence of hospice aide visits or documented reasons for the missed visits. Additionally, there was no documented evidence the hospice aide services ordered were provided to the patient during the two weeks. Record 5: The patient elected the hospice benefit on 7/28/2022 with a primary diagnosis of Senile degeneration of brain. A physician’s order effective 10/26/2022 ordered a hospice aide 2 x weekly. During the weeks 12/4/2022-12/10/2022, 12/11/2022-12/17/2022, 12/18/2022-12/24/2022 and 12/25/2022-12/31/2022, there was no documented evidence of hospice aide visits or documented reasons for the missed visits. Additionally, there was no documented evidence the hospice aide services ordered were provided to the patient during the two weeks. The Director of Nursing was interviewed on 3/20/2023 and agreed, the hospice aide did not follow the plan of care as ordered. Additionally during interview on 3/20/2023, the Director of Nursing stated, the expectation was the RN was to complete the bathing if the aide was out but there are none documented during the dates identified. The Director of Nursing stated, “we had trouble getting the nurses to bathe the patients.”

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: A summary of the patient’s hospice stay, including treatments, symptoms, and pain management. THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 1 (100%) record reviewed of a patient who was a live discharge from the hospice agency it was revealed that the hospice did not ensure the documented discharge summary included a summary of the patient's hospice stay, as described in the agency's policy. Agency policy, "PC.D20 Discharge from Hospice", stated in part under the subtitle, "Procedure": (7) the discharge summary... includes... (e) significant health history, (f) discharge orders, instructions... (g) status of patient at time of discharge, (h) brief description of services provided and ongoing needs that cannot be met." Record 5: The patient elected the hospice benefit on 7/8/2022 and elected discharge from the agency by revocation of their hospice benefit effective 1/18/2023 to seek treatment at a local hospital. A review of the discharge summary that was sent to the physician and facility revealed it was incomplete with blank areas and did not include a documented summary of the patient’s hospice stay. The Director of Nursing was interviewed on 3/20/2023 and agreed, the discharge summary was incomplete. Agency policy, "PC.D20 Discharge from Hospice", stated in part under the subtitle, "Procedure": (7) the discharge summary... includes... (e) significant health history, (f) discharge orders, instructions... (g) status of patient at time of discharge, (h) brief description of services provided and ongoing needs that cannot be met. Record 5: The patient elected the hospice benefit on 7/8/2022 and elected discharge from the agency by revocation effective 1/18/2023 to seek treatment at a local hospital. A review of the discharge summary revealed it was incomplete with blank areas and without a documented summary of the patient’s hospice stay. There was no documented evidence a discharge summary was completed with all the required elements and sent to the attending and/or hospital. The Director of Nursing was interviewed on 3/20/2023 and agreed, the discharge summary was incomplete.

It is required that the hospice informs and distributes to the patient written information about its policies on advance directives, including a description of applicable state law. It is the patient’s right to formulate an advance directive should she or he wish to do so. The hospice maintains written policies and procedures concerning advance directives with respect to all adult individuals receiving care by or through the hospice. The hospice provides written information to patients about their rights under state law to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives at the individual’s option. This standard was not met as evidenced by document review and interview. Review of the hospice's sample admission packet revealed the admission packet contained a patient and family handbook with a state specific do not resuscitate (DNR) form and a living will form. The handbook did not contain the agency's policy on advance directives or education. Agency policy, "PC.A35 Advance Directives", stated in part that the agency: "... informs and distributes written information to the patient on his or her right to formulate advance directives... Procedure (1)… the written information given to the patient and/or legal representative includes (a) the hospice's policies on the implementation of the patient's advance directives including any limitations; and (b) a description of the patient's rights under State law, including the patient's right to formulate an advance directive and the right to accept or refuse medical or surgical treatment, including do not resuscitate (DNR) orders. Interview with the Administrator on 8/24/2022 confirmed the agency's policy on advance directives was missing from the admission packets distributed to patients and families. The Administrator stated the policy will be included in the packet.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan: As frequently as the patient's condition requires; but no less frequently than every 15 calendar days. A revised plan of care includes: Information from the patient’s updated comprehensive assessment; and record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 3 of 3 (100%) records reviewed where the patient expired on the agency's service, the agency failed to follow their bereavement policy of discussing the patient's death and bereavement care planning at the first interdisciplinary group (IDG) meeting following the patient's death. Agency policy,"PC.B10 Bereavement-Care Planning", stated in part: "(4) The bereavement coordinator... initiates the bereavement discussion and care planning at the first IDG meeting following the patient's death. At this time, the bereavement plan of care is developed...". Clinical Record 4 - The record for this patient with an election of hospice benefit dated 1/18/2020, did not include evidence of discussion regarding the patient's death and bereavement plan of care during the IDG meeting on 3/16/2022, which was the first meeting conducted after patient's date of death on 3/3/2022. Clinical Record 6 - The record for this patient with an election of hospice benefit dated 4/4/2021, did not include evidence of discussion regarding the patient's death and bereavement plan of care during the IDG meeting on 7/6/2022, which was the first meeting conducted after patient's date of death on 7/1/2022. Clinical Record 3 - The record for this patient with an election of hospice benefit dated 6/14/2021, did not include evidence of discussion regarding the patient's death and bereavement plan of care during the IDG meeting on 2/16/2022, which was the first meeting conducted after patient's date of death on 2/15/2022. Interview with the Director of Nursing on 8/24/2022 stated and confirmed that patients' deaths and bereavement care plans were not discussed or documented during the IDG meeting after the patient's death.

It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group; Included in the plan of care; Permitted to be performed under state law and regulation; and Consistent with the hospice aide training. This standard was not met as evidenced by a review of clinical records, document reviews, interviews and observations. Review of 1 of 7 (14%) clinical records of patients who received hospice aide services revealed aide services were not provided in accordance with duties assigned on the aide care plan. This was confirmed during 1 of 1 (100%) home visit where the hospice aide was observed performing care that was not assigned on the aide care plan. Record 0/Home Visit 3 - The hospice aide was observed performing care on 8/23/2022 during a consented home visit for a patient with a hospice election of benefit dated 8/12/2022. The hospice aide care plan dated 8/12/2022, had four (4) documented assigned instructions for the aide to complete during the visit: bath-shower, shower chair, oral care, and shampoo. The hospice aide performed the following additional unassigned activities that were not documented on the aide care plan: assisted patient with dressing; standby assist with ambulation with seated walker; and skin care with lotion. Interview with the Administrator and the Director of Nursing on 8/23/2022 confirmed the hospice aide did adhere to the duties as assigned on the aide plan.

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination: the primary terminal condition; related diagnosis(es), if any; current subjective and objective medical findings; current medication and treatment orders; and information about the medical management of any of the patient's conditions unrelated to the terminal illness. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 11 of 11 (100%) records reviewed, the narrative for certification or recertification of the patients' terminal illness status of 6 months or less was not directly developed by the medical director based on their direct review of the patients' clinical status [Clinical Record 4, Clinical Record 3, Clinical Record 8, Clinical Record 5, Clinical Record 7, Clinical Record 1, Clinical Record 0, Clinical Record 10, Clinical Record 6, Clinical Record 9, Clinical Record 2]. Face to Face documents were completed and documented, and all certifications of the terminal illness documents were completed and signed timely by the physician for all the episodes of care. However, the physician narratives did not contain clinical findings that were directly written by the physician/medical director. The documentation present in the summaries included documentation of the patients' primary terminal condition and related diagnoses, and report scores extracted from nursing clinical notes completed for Palliative Performance Scale scores (PPS), Karnofsky Performance Scale scores, Functional Assessment Staging Tool scores (FAST) and/or the New York Heart Association (NYHA) functional class scores. During interview, the process for development of the certification of terminal illness was described as completed by a hospice staff member who extracted information from the clinical record to develop the necessary summaries, which were then presented to the medical director for signature. The physician narratives did not contain physician composed clinical findings but inserted notes and/or scores from nursing staff of Palliative Performance Scale scores (PPS), Karnofsky Performance Scale scores, Functional Assessment Staging Tool scores (FAST) and/or New York Heart Association (NYHA) functional class scores.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid-certified facility, the hospice forwards to the receiving facility a copy of: The hospice discharge summary described in HCDT 40.I. This standard was not met as evidence by review of clinical records and interview. Review of 1 of 1 (100%) records of a patient who was transferred to another hospice revealed the summary was incomplete and did not include all of the required elements. Clinical Record 5 – The patient with a hospice election of benefit dated 5/4/2022 was transferred due to the request for a transfer to another hospice effective 8/12/2022. The summary completed at the time of transfer was incomplete with several blank areas and without a documented summary of the patient's hospice stay. Interview with the Director of Nursing on 8/24/2022 confirmed the summary was incomplete during a joint review of the record.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by a review of clinical records, document review and interviews. In 1 of 1 (100%) records reviewed where the patient was a live discharge from the hospice agency, the documented discharge summary did not include a summary of the patient's hospice stay, per the agency's policy.. Agency policy, "PC.D20 Discharge from Hospice", stated in part under the subtitle, "Procedure": (7) the discharge summary... includes... (e) significant health history, (f) discharge orders, instructions... (g) status of patient at time of discharge, (h) brief description of services provided and ongoing needs that cannot be met... ". Clinical Record 9 - The patient with a hospice election of benefit dated 2/11/2022 was discharged by the hospice agency due to an extended prognosis, effective 8/8/2022. The discharge summary was incomplete with several blank areas and without a documented summary of the patient's hospice stay. Interview with the Director of Nursing on 8/24/2022 confirmed the discharge summary was incomplete during a joint record review.

It is required that all hospice professionals who provide services directly, under an individualized contract, or under arrangements with a hospice are legally authorized (licensed, certified or registered) in accordance with local, state, and federal law and regulation, and act only within the scope of their state license or state certification or registration. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 3 of 3 (100%) records reviewed of patients who expired while on the agency's service, licensed practical nurses (LPN) performed the patients' death pronouncements, which exceeds the scope of practice for LPNs as defined by state regulations. The state law effective 2006, stated in part: "... allow an Advanced Registered Nurse Practitioner, registered professional nurse, or a licensed physician assistant who is employed by an adult care home or hospice facility to make the determination and pronouncement of the death of a patient, in the absence of a physician." Clinical Record 6 - Documentation on the visit note dated 7/1/22, was completed by the LPN who performed the pronouncement of death during the site visit. Clinical Record 3 - Documentation on the visit note dated 2/15/2022, was completed by the LPN who performed the pronouncement of death during the site visit. Clinical Record 4 - Documentation on the visit note dated 3/3/2022, was completed by the LPN who performed the pronouncement of death during the site visit. Interview with the Administrator confirmed the agency allowed LPNs to complete pronouncements of death for hospice patients, stating they would call the registered nurse and hospice physician.