Gentiva Birmingham

“Upon patient record review, 1 of 23 (Patient #21) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient 21: Order on 1/16/25 to discontinue Norco and start oxycodone as needed due to poor pain control, however there was no evidence of follow up by nurse to assess medication effectiveness until 1/20/25. Nursing documentation from visit on Monday, 1/20/25 states patient had no pain relief since last Friday, 1/17/25. During the visit on 1/20/25, oxycodone was discontinued and new order to start Morphine ER and Morphine IR for breakthrough pain. No evidence of nursing follow up to assess effectiveness until visit on 1/23/25.”

“Upon patient record review, 6 of 23 (Patient #2,#5,#6,#10,#13,#17) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 2: Medication profile contained an order for Gavi lax, however there was no diluent instructions. Also, Ibuprofen was ordered as PRN, however order contained no frequency instructions. Both were corrected on site with orders received. Patient 5: During medication reconciliation, the facility and hospice medications did not match. The hospice medication profile contained the medications Loperamide and Trazadone, but the facility medication profile did not. Medical record also contains order for oxygen with no rate or delivery method. Oxygen corrected on site with orders received. Patient 6: Medication profile contained an order for MiraLAX, however there was no diluent instructions. Medication profile also contained oxygen with no delivery method. Both were corrected on site with orders received. Patient 10,13: Medication profile contained oxygen with no delivery method. Corrected on site with orders received. Patient 17: Documented use of DuoNeb treatments on 12/2/25 and 12/4/25, however no evidence on medication profile. Medication profile also contained oxygen with no delivery method. Both were corrected on site with orders received.”

“Upon patient record review, 1 of 23 (Patient #18) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 18: Admission on 2/13/25. There was no evidence of an initial bereavement assessment being completed. Corrected on site.”

“Upon patient record review, 2 of 23 (Patient #14,#21) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 14: No evidence of weekly wound measurements and wound assessments per agency policy 11/20/25 through 12/2/25. Patient 21: Order on 1/16/25 to discontinue Norco and start oxycodone as needed due to poor pain control, however there was no evidence of follow up by nurse until 1/20/25. Nursing documentation from visit on Monday, 1/20/25 states patient had no pain relief since last Friday, 1/17/25. During the visit on 1/20/25, oxycodone was discontinued and new order to start Morphine ER and Morphine IR for breakthrough pain. No evidence of nursing follow up until visit on 1/23/25.”

“Upon patient record review, 14 of 23 (Patient #2,#3,#4,#5,#6,#7,#8,#9,#12,#14,#15,#16,#17,#18)did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 2: On admission, documented high risk for falls, however there is no plan of care for safety/fall prevention. Also, documented risk for aspiration, however the plan of care was not updated to include problems, goals and interventions related to aspiration precautions. Admitting diagnosis is a neurocognitive disorder and documented dementia, however there is no plan of care for neuro dysfunction. Corrected on site with plan of care updates. Patient 3: Documented dementia on admission, however there is no plan of care for neuro dysfunction. Patient 4: Documented high risk for falls, however there is no plan of care for safety/fall prevention. Corrected on site with plan of care update. Patient 5: Documented high risk for falls on admission, however there is no plan of care for safety/fall prevention. Patient 6: High risk for falls documented from admission, however there is no plan of care for safety/fall prevention. Corrected on site by updating plan of care. Patient 7: Documented high risk for falls, respiratory and cardiac dysfunction from admission, however there is no evidence of problems, goals and interventions. Corrected on site. Patient 8: Documented high risk for falls on admission, however there is no plan of care for safety/fall prevention. Corrected on site by updating plan of care. Patient 9: High risk for falls and respiratory dysfunction documented on admission, however there is no evidence of plan of care for either. Patient 12: Admission documentation identifies high risk for falls and neuro dysfunction, however there is no plan of care for safety/fall prevention or neuro dysfunction. Corrected on site. Patient 14: Documented high risk for falls from admission, however there is no plan of care for safety/fall prevention. Patient 15: Bleeding precautions documented on admission, however there is no plan of care for risk for bleeding. Corrected on site by updating plan of care. Patient 16: Documented high risk for aspiration, endocrine and neuro dysfunction from admission, however there is no evidence of problems, goals and interventions. Corrected on site by updating plan of care. Patient 17: Documented nausea/vomiting, oxygen use, risk for falls, risk for bleeding and anxiety from admission, however there is no evidence of problems, goals and interventions. Corrected on site by updating plan of care. Also, plan of care open for DuoNeb treatments, however no evidence of DuoNeb order. Corrected on site with plan of care updates. Patient 18: Risk for skin breakdown and risk for aspiration were documented on admission, however there was no evidence of plan of care for either issue. Corrected on site by updating plan of care.”

“Upon patient record review, 6 of 23 (Patient #2,#5,#6,#10,#13,#17) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 2: An order for Gavi lax with no diluent instructions. Also, Ibuprofen was ordered as PRN, however order contained no frequency instructions. Both were corrected on site with orders received. Patient 5: Medical record also contains order for oxygen with no rate or delivery method. Oxygen corrected on site with orders received. Patient 6: An order for MiraLAX with no diluent instructions. Order for oxygen with no delivery method. Both were corrected on site with orders received. Patient 10,13: Order for oxygen with no delivery method. Corrected on site with orders received. Patient 17: Documented use of DuoNeb treatments on 12/2/25 and 12/4/25, however no evidence of medication order. Order for oxygen with no delivery method. Both were corrected on site with orders received.”

“Upon patient record review, 13 of 23(Patients #1,#2,#5,#6,#7,#8,#10,#11,#12,#13,#14,#15,#17) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 1,2: Documented on admission patient use of a wheelchair, but there was no evidence of an order for the DME included in the plan of care. Corrected on site with orders received. Patient 5: Admission identified patient use bed and oxygen, however no evidence of an order for the DME included in the plan of care. Corrected on site with orders received. Patient 6: Nursing documentation upon admission identified patient use of a commode and shower chair, however no evidence of an order for the DME included in the plan of care. Patient 7: Nurse identified on admission patient use of oxygen, however no evidence of an order for the DME included in the plan of care. Patient 8: Admission nurse documents patient use of a bed rails and Geri chair, however no evidence of an order for the DME included in the plan of care. Corrected on site with orders received. Patient 10: Nursing documentation upon admission identified patient use of a bedside commode, however no evidence of an order for the DME included in the plan of care. Corrected on site with orders received. Patient 11: Documented on admission patient use of a bed. Also, on 12/9/25, there was documented use of rollator, however no evidence of DME orders for bed or rollator included in the plan of care. Corrected on site with order received. Patient 12: Documented on admission patient use of bed and shower chair, however there was no evidence of an order for the DME included in the plan of care. Corrected on site with orders received. Patient 13: Nursing documentation identified patient use of wheelchair, nebulizer, walker and bed. There was no evidence of an order for the DME included in the plan of care. Corrected on site with orders received. Patient 14: Nursing documentation upon admission identified patient use of a commode, however no evidence of an order for the DME included in the plan of care. Corrected on site with orders received. Patient 15: Documented on admission patient use of a walker, but there was no evidence of an order for the DME included in the plan of care. Corrected on site with orders received. Patient 17: Nursing documentation identified patient use of oxygen and nebulizer, however no evidence of an order for the DME included in the plan of care. Corrected on site with orders received.”

“Upon patient record review, 5 of 23 (Patients #1,#3,#9,#10,#14) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient 1: Plan of care contained active problems, goals, and interventions to be completed by the chaplain; however, chaplain services were discontinued on 11/13/25. Corrected on site by updating plan of care. Patient 3: Plan of care contained active SN task to obtain copy of advance directives, however, the document was received upon admission with paperwork but plan of care was not updated. Patient 9: Plan of care contained active respite problems, goals and interventions from October but had not been updated with level of care change. Patient 10: Plan of care open to obtain copy of advance directives, however copy of advance directives was provided upon admission. Plan of care was not updated. Corrected on site with plan of care update. Patient 14: Dysphasia documented since recert assessment on 10/21/25, however there is no plan of care related to dysphagia. Corrected on site by updating plan of care.”

“Upon patient record review, 2 of 23 (Patient #22,#23) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 22,23: Documentation in bereavement activity report states bereaved was receiving mailings. Personnel documented coordination notes that mailings were not being sent due to lack of address. No evidence of attempts to obtain address.”

“Upon patient record review, 6 of 23 (Patient #3,#5,#7,#8,#9,#12) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 3: Aide care plan task for hair care with frequency of per patient request. Patient unable to make needs known due to dementia. Also, RN documented axilla wound care with dressing in place. There was no evidence of dressing instructions on the aide care plan. Patient 5: Nursing documentation and plan of care identify patient is a fall risk, however there is no evidence of instructions for fall risk on the aide care plan. Corrected on site. Patient 7: Aide care plan task for transfers with frequency of per request and no evidence patient is cognitively able to make decisions and there was no evidence of instructions for max assist with transfers. Corrected on site. Patient 8: Medication profile contains order for an anticoagulant, however there is no evidence of instructions for bleeding risk on the aide care plan. Corrected on site. Patient 9: Documentation since 11/26/25 states patient is bedbound and no longer able to transfer, however aide care plan task for ambulation and shower provide instructions of standby assist. No evidence of care plan update. Patient 12: Nursing documentation since admission identified patient as a fall risk, however there is no evidence of instructions for fall risk on the aide care plan. Corrected on site.”

“Upon patient record review 3 of 23 (Patient #3,#4,#5) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 3: Order for aide visit once weekly. There was no evidence of visit made week of 11/23/25. Patient 4: Order for aide visits three times weekly. There was only evidence of one visit made week of 11/23/25. Patient 5: Order for aide visit twice weekly. There was no evidence of second visit made week of 11/30/25.”