Gentiva

“Upon patient record review 2 of 27 (Patient #16,19) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. Patient 16: Patient admitted on 03/01/2025. Chaplain services were declined at that time. There is no evidence that the RN or the SW completed this part of the comprehensive assessment at the time of survey. Mini spiritual assessment completed on day 3rd of the survey. Patient 19: Patient admitted on 01/15/2025. Chaplain services were declined. There is no evidence that the RN or the SW completed this part of the assessment. No evidence that the assessment has been completed at the time of survey. Mini spiritual assessment completed on day 3rd of the survey.”

“Upon patient record review, 2 of 27 (Patient #11,19) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient’s progress toward desired outcomes • Reassessment of the patient’s response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 11: No evidence that a comprehensive assessment was completed every 15 days between 05/26/2025 and 06/12/2025. 17 days between assessments. Patient 19: No evidence that a comprehensive assessment was completed every 15 days between 07/2/2025 and 07/18/2025. 16 days between assessments.”

“Upon patient record review, 1 of 27 (Patient #16) 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 16: The clinical documentation indicated that the patient developed a wound on 05/22/2025. No evidence that the wounds were measured for the weeks of May 26, 2025 and June 9, 2025. Wound was de-activated on 06/17/2025.”

“Upon patient record review, 1 of 27 (Patient #3) 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 3: The medical record indicated that the patient has an active diagnosis of Depression and currently take 2 medications for depression daily (Lexapro and Bupropion). There was no evidence of problems, goals, and interventions related to risk for depression included in the plan of care. COS- order written to add depression to the active plan of care during survey.”

“Upon client record review, 2 of 27 (Patient #18,20) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient’s condition requires but no less frequently then every 15 calendar days. Patient #18: No evidence of MSW contribution for IDGs that occurred on 04/01/25, 04/15/25, 04/29/25, 05/13/25, and 06/06/25. The MSW documented that “SW plans to see the patient before next IDG”. No patient specific information added to the basic psychosocial template. Patient #20: No evidence that the RN contributed to IDG for the initial IDG that occurred on 12/24/2024, and the following 3 IDGs that occurred on 01/07/2025, 01/21/2025, and 02/04/2025. RN signed those IDGs as being completed however Gentiva’s basic RN template within the body of the note was left blank with no patient specific information added. No evidence of MSW contribution for IDGs that occurred on 03/04/2025, 03/18/2025, and 04/01/2025. The MSW documented that “SW plans to see the patient before next IDG”. No patient specific information added to the basic psychosocial template.”

“Upon patient record review, 3 of 27 (Patient #13,15,16) 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 13: The medical record indicated that patient requested to end chaplain services on 03/19/2024. Problems, interventions, and goals related to spiritual care remain on the current the plan of care - new benefit period started on 06/22/2025. Also the current level of care listed on the active POC has the patient as respite care status. The medical record indicates that patient is currently receiving routine home care. No evidence that the patient received respite care since the time of admission, 10/31/2023. COS- new order written to remove the spiritual care plan and update the patient’s current level of care during survey. Patient 15: The medical record indicated that patient requested to end social worker services on 04/30/2025. Problems, interventions, and goals related to social services for companionship remain on the current the plan of care - new benefit period started on 06/08/2025. COS-new order written to remove social services from the plan of care during survey. Patient 16: The medical record indicated that the patient had a wound that was inactivated on June 17, 2025. Active wound care orders remain on the current plan of care. COS-new order written to remove wound care orders during survey.”

“Upon patient record review 1 of 27 (Patient #11) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient 11: No evidence that an RN completed a supervisory visit every 14 days between the following dates- 3/21/2025 and 4/30/2025 (40 days between visits), 04/30/2025 and 05/15/2025 (15 days between visits), and 05/15/2025 and 06/16/2025 (32 days between visits).”