Gentiva

“Upon patient record review, 3 of 19 (Patients #2,#8,#9) 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: Upon home visit medication reconciliation, the patient did not have donepezil in the home. Additionally there were several medications in the home that were not included in the hospice medication profile including Icy Hot, MiraLAX, milk of magnesia, aspirin, vit B12, Benadryl, cetirizine, Excedrin, meclizine, and Tums. Corrected on site with nurse education to the patient and reconciliation with the physician. Patient 8: Upon home visit medication reconciliation, the patient’s daughter responsible for medication administration stated the patient was no longer taking aspirin and it had been discontinued. The medication profile listed the aspirin as current. Corrected on site. Patient 9: Upon home visit medication reconciliation, the facility medication profile contained acetaminophen, milk of magnesia, sennosides and tramadol PRNs that were not on the hospice profile. The facility and hospice doses for quetiapine also differed with facility instructions for 75 mg three times daily and hospice instructions for 50 mg three times daily. Corrected on site.”

“Upon patient record review, 1 of 19 (Patient #3) 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 3: The initial bereavement assessment was completed 3/7/25 with start of care 2/27/25.”

“Upon patient record review, 1 of 19 (Patient #1) 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 1: The medical record contained nursing documentation upon admission identifying patient had a history of recent fall with abrasion to head and documentation 2/28/25 identifying need for assistance with standing. There was no evidence of problems, goals, and interventions related to fall safety. Corrected on site.”

“Upon patient record review, 2 of 19 (Patient #2,9) 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: Upon home visit medication reconciliation, there were several medications in the home not ordered on hospice plan of care including Icy Hot, MiraLAX, milk of magnesia, aspirin, vit B12, Benadryl, cetirizine, Excedrin, meclizine, and Tums. Corrected on site with nurse education to the patient and reconciliation with the physician. Patient 9: Upon home visit medication reconciliation, the facility medication profile contained acetaminophen, milk of magnesia, sennosides and tramadol PRNs that were not ordered on hospice plan of care. The facility and hospice doses for quetiapine also differed with facility instructions for 75 mg three times daily and hospice instructions for 50 mg three times daily. Corrected on site.”

“Upon patient record review, 3 of 19 (Patients #2,#7,#10) 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 2: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair. There was no evidence of an order for the DME included in the plan of care. Corrected on site. Patient 7: The medical record contained nursing documentation 2/17/25 identifying patient use of oxygen and a Hoyer lift. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 10: The medical record contained nursing documentation 12/16/24 identifying patient use of bedrails, commode and over bed table. There was no evidence of orders for the DME included in the plan of care. Corrected on site.”

“Upon patient record review, 3 of 19 (Patients #10,#12,#13) 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 10: The plan of care contained active problems, goals, and interventions to be addressed by the chaplain. Chaplain services were discontinued 3/2/25. Corrected on site. Patient 12: The plan of care contained active problems, goals, and interventions to be addressed by the chaplain. Chaplain services were discontinued 10/30/24. Corrected on site. Patient 13: The plan of care contained active problems, goals, and interventions to be addressed by the social worker. There was no evidence or social work services except an initial assessment. Corrected on site.”