Gentiva

EP Testing Requirements (42 CFR 418.113(d)(2))

“Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. The agency did not provide any emergency plan exercises or events.”

Rule E0039. Standard-level.

Timeframe for completion of assessment (42 CFR 418.54(b))

“Upon patient record review 1 of 19 (Patient #7) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual’s attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 7: The initial spiritual assessment was completed 3/4/25 with start of care 2/24/25.”

Rule L0523. Standard-level.

Content of comprehensive assessment (42 CFR 418.54(c)(6))

Rule L0530. Standard-level.

Content of comprehensive assessment (42 CFR 418.54(c)(7))

Rule L0531. Standard-level.

Plan of care (42 CFR 418.56(b))

“Upon patient record review, 1 of 19 (Patient #4) did not have evidence that the hospice follows the individualized plan of care developed in in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient’s needs if any of them so desire. Patient 4: There was no evidence of collaboration with the attending to develop the plan of care.”

Rule L0543. Standard-level.

Content of plan of care (42 CFR 418.56(c))

Rule L0545. Standard-level.

Content of plan of care (42 CFR 418.56(c)(5))

“Upon patient record review, 1 of 19 (Patient #1) 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: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, over bed table, and walker; and 12/30/24 identifying bedrails. There was no evidence of orders for the DME included in the plan of care. Corrected on site.”

Rule L0550. Standard-level.

Review of the plan of care (42 CFR 418.56(d))

“Upon patient record review, 4 of 19 (Patients #3,#4,#9,#11) 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 3,4,9,11: There was no evidence of IDG collaboration with the attending physician no less frequently then every 15 days”

Rule L0552. Standard-level.

Coordination of services (42 CFR 418.56(e)(2))

“Upon patient record review, 1 of 19 (Patient #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5: The medical record contained an order for social work visits once monthly. There was no evidence of a visit in February 2025.”

Rule L0555. Standard-level.

Counseling services (42 CFR 418.64(d)(1))

Rule L0596. Standard-level.

Hospice aide assignments and duties (42 CFR 418.76(g)(1))

Rule L0625. Standard-level.

Level of activity (42 CFR 418.78(e))

“Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The agency’s volunteer utilization rate was 0.07% for 2024.”

Rule L0647. Standard-level.

Governing body and administrator (42 CFR 418.100(b))

“Upon personnel record review, 1 of 15 (Personnel #2) did not have evidence the alternate administrator’s personnel record verifies that: • There is a signed job description for this role • The employee has been orientated to this role Personnel 2: There was no evidence of a signed job description as alternate administrator.”

Rule L0651. Standard-level.

Training (42 CFR 418.100(g)(2))

“Upon personnel record review, 2 of 15 (Personnel #2,#10) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel 2: There was no evidence of orientation to job role as DPCS and alternate administrator. Personnel 10: There was no evidence of orientation to job role as Volunteer Coordinator.”

Rule L0662. Standard-level.

Training (42 CFR 418.100(g)(3))

“Upon personnel record review, 1 of 15 (Personnel #11) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel 11: There was no evidence of a skills competency in the personnel file.”

Rule L0663. Standard-level.

Content (42 CFR 418.104(a)(2))

“Upon patient record review, 1 of 19 (Patient #9) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 9: The patient representative elected to receive the Notification of Hospice Non-Covered Items upon admission 10/30/24. The addendum was not issued until 11/8/24.”

Rule L0673. Standard-level.

Content (42 CFR 418.104(a)(6))

“Upon patient record review, 2 of 19 (Patients #2,#9) did not have evidence that each patient record contains Advance Directives. Patient 2,9: The plan of care identified the patient as DNR. There was no documentation to support code status.”

Rule L0677. Standard-level.

Content (42 CFR 418.104(a)(7))

“Upon patient record review, 1 of 19 (Patient #19) did not evidence that each patient record contains physician orders. Patient 19: There was no evidence of a physician order to discharge the patient due to extended prognosis.”

Rule L0678. Standard-level.

Authentication (42 CFR 418.104(b))

Rule L0679. Standard-level.

Personnel qualification (42 CFR 418.114(a))

“Upon personnel record review, 1 of 15 (Personnel #7) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at renewal or in accordance with specific state practice act requirements. Personnel 7: There was no evidence of current professional licensure. LCSW expired 2/28/25.”

Rule L0784. Standard-level.

Criminal background checks (42 CFR 418.114(d)(2))

“Upon personnel record review, 1 of 15 (Personnel #11) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel 11: There was no evidence of a criminal background check.”

Rule L0796. Standard-level.