Gentiva

“Upon patient record review 2 of 19 (Patient #6,12) 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 6: The record indicates that the psychosocial nor the spiritual assessment were completed within 5 calendar days following the election of hospice. Patient was admitted on 05/31/2024. Psychosocial assessment completed on 06/07/2024, 7 days after election. Spiritual assessment completed on 07/07/2024, 7 days after election. Patient 12: The record indicates that the spiritual assessment was not completed within 5 calendar days following the election of hospice. Patient was admitted on 06/14/2024. Spiritual assessment completed on 09/11/2024.”

“Upon patient record review 3 of 19 (Patient #4,5,13) 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 4: The record shows no evidence that a spiritual assessment was completed between the time admission and the time of survey. COS. Patient 5: The record shows no evidence that a spiritual assessment was completed between the time of admission and the time of survey. COS. Patient 13: The record shows no evidence that a spiritual assessment was completed between the time of admission and the time of survey. COS.”

“Upon patient record review, 5 of 19 (Patient #2,3,5,6,9) 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 2: No evidence that the bereavement risk assessment was completed within 5 days of election of hospice. Patient admitted on 11/01/2023, assessment completed on 12/14/2023. Patient 3: No evidence that the bereavement risk assessment was completed within 5 days of election of hospice. Patient admitted on 06/30/2022, assessment completed on 05/03/2023. Patient 5: No evidence that the bereavement risk assessment was completed within 5 days of election of hospice. Patient admitted on 05/01/2024, assessment completed on 05/07/2024. Patient 6: No evidence that the bereavement risk assessment was completed within 5 days of election of hospice. Patient admitted on 05/31/2024, assessment completed on 06/07/2024. Patient 9: No evidence that the bereavement risk assessment was completed within 5 days of election of hospice. Patient admitted on 02/29/2024, assessment completed on 04/01/2024.”

“Upon patient record review, 3 of 19(Patient #1,2,6) 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 1: No evidence that the comprehensive assessment was completed every 15 days. The record indicates that the RN has not completed a comprehensive assessment since 08/15/2024 and the start of survey. Patient 2: No evidence that the comprehensive assessment was completed every 15 days. The record indicates that the RN has not completed a comprehensive assessment since 08/13/2024 and the start of survey. Patient 6: No evidence that the comprehensive assessment was completed every 15 days. The record indicates that the RN had not completed a comprehensive assessment since 08/16/2024 and the start of survey.”

“Upon patient record review, 1 of 19 (Patient #8) 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 8: Patient has a diagnosis of depression that is listed as related to the hospice diagnosis. No evidence of problems, goals, and interventions related to depression included on the current plan of care. COS”

“Upon patient record review 3 of 19 (Patient #2,3,6) 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 2: No evidence that an aide supervisory visit was completed by the RN every 14 days. The record shows that the last supervised visit occurred on 08/13/2024. Patient 3: No evidence that an aide supervisory visit was completed by the RN every 14 days. The record shows that the last supervised visit occurred on 08/13/2024. Patient 6: No evidence that an aide supervisory visit was completed by the RN every 14 days. The record shows that the last supervised visit occurred on 08/16/2024.”