Gentiva

“Based on review of policy titled “Durable Medical Equipment and Supplies,” review of records, family and staff interview, it was determined the agency failed to provide medical supplies based on the health care needs of the patient. Specifically, the agency failed to provide supplies for one patient (P)(P1) of three patients reviewed. Findings included: Review of the policy titled “Durable Medical Equipment and Supplies,” revised 12/23/2025, reveals the following:PurposeTo ensure that equipment and supplies are provided for Hospice patients based on assessed health care needs.Procedure:1. As part of the Comprehensive assessment, the patient will be assessed as to the medical equipment being used within the home. Included in the assessment is the identification of the Durable Medical Equipment (DME) company providing the equipment. Review of clinical record for P1 revealed a Hospice certification and Plan of Care dated 10/29/2025 with an order for management of tracheostomy (a surgical procedure that creates an opening in the neck to facilitate breathing), inner cannula (removable tube inside a tracheostomy tube that helps maintain a clear airway) size 6.5 to be changed daily. Review of supply orders failed to reveal the delivery of inner cannulas from 10/29/2025. The first documentation for delivery of inner cannulas is on 11/18/2025. Delivery confirmation noted delivery of 30-8.0 mm Shiley inner cannulas. Chart review for P1 revealed nurse note dated 01/15/2026, nurse narrative stating ” Pt [family member] states that respiratory therapist has not been to their house nor have they received any respiratory supplies from (the facility) since admission.” A phone interview was conducted on 06/02/2026 at 9:44 AM with the family of P1 who stated ”The issue I have with (the facility) is that they could not get the inner cannula for the trach, and every time I called to check on the status of the trach supplies, they always had an excuse.” An in-person interview was conducted on 06/03/2026 at 9:30 AM with the Executive Director who confirmed that tracheostomy supplies were ordered for P1 on 11/14/2026 and delivered on 11/18/2026. The Executive Director stated that the agency had to add the tracheostomy supplies to the Durable Medical Equipment (DME) contract prior to being able to order the inner cannulas.”

“Upon patient record review 1 of 19 (Patient #1) 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 1: Patient elected to receive SC evaluation at the time of admission. The record indicates that the spiritual assessment was not completed within 5 calendar days following the election of hospice. Patient was admitted on 10/07/2024. Spiritual assessment completed on 10/16/2024, 9 days after election.”

“Upon patient record review, 1 of 19 (Patient #5) 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 5: Duplicate drug therapy: The medication profile contained 2 listings of Nystatin 100,000 units/ml dated 08/20/23 and 01/05/25 that were active in the profile. Corrected on site.”

“Upon patient record review, 2 of 19 (Patient #1,8) 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 1: No evidence that a bereavement risk assessment was completed within 5 days of the election of hospice. Patient admitted on 10/07/2024, assessment completed on 01/28/2025. Patient 8: No evidence that a bereavement risk assessment was completed within 5 days of the election of hospice. Patient admitted on 08/18/2024, assessment completed on 10/16/2024.”

“Upon patient record review, 2 of 19 (Patient #11,12) 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 an RN assessed the patient as the condition required but no less frequently than every 15 days. The record indicates that there were 17 days between RN assessments 12/23/2024 and 01/09/2025. Patient 12: No evidence that an RN assessed the patient as the condition required but no less frequently than every 15 days. The record indicates that there were 17 days between RN assessments 12/10/2024 and 12/27/2024.”

“Upon patient record review, 1 of 19 (Patient #7) 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 7: The record indicates that patient developed a DTI on 10/09/2024. No evidence that the wound has been measured since 12/13/2024. Wound remains active in the wound chapter, the plan of care has active wound care orders. Gentiva policy is for wounds to be measured weekly.”

“Upon patient record review, 3 of 19 (Patient #8,9,13) 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 current takes Phenobarbital and Dilantin for seizures. Seizures listed as related diagnosis. There was no evidence of problems, goals, and interventions related to seizures included in the plan of care. Corrected on site. Patient 9: Patient has type 2 diabetes listed as a related diagnosis. There was no evidence of problems, goals, and interventions related to diabetes included in the plan of care. Corrected on site. Patient 13: Plavix 75mg as a blood thinner and has a history of GI hemorrhage. There was no evidence of problems, goals, and interventions related to safety for risk for bleeding included in the plan of care. Corrected on site.”

“Upon patient record review, 2 of 19 (Patient #1,13) 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 record indicates that patient had a wound at the time of admit that was deactivated in the wound chapter on 10/28/2024. No evidence that an order was received to take the wound care supplies off the current POC supply list. Corrected on site. Patient 13: Wound supplies were listed on the patient active plan of care supply list. No evidence that the patient had a wound at the time of admit or at any time during the current benefit period. Corrected on site.”

“Upon patient record review 4 of 19 (Patient #1,4,6,13) 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 1: The record indicated that the aide plan of care has orders for the aide to provide nail care and shampoo weekly with the visit frequency of 3 visits a week. Aide documentation showed that those task were performed at multiple visits for the following weeks: Twice for the weeks of 12/15/24 (12/16 and 12/18), 12/22/2024 (12/23 and 12/26), and 01/13/2024 (01/13 and 01/15). Three times for the week of 01/05/2024 (01/06, 01/08, and 01/10). Also for this patient the record indicated that the aide plan of care has visit frequency ordered 3 times a week. No evidence that 3 visits occurred for the week of 12/23/24. Documentation shows visits were completed on 12/23 and 12/26. No missed visit noted or an order to decrease the visits for that week. Patient 4: Aide plan of care has visit frequency ordered as 3 times a week. No evidence that 3 visits occurred for the week of 12/2/24. Documentation shows visits were completed on 12/5 and 12/6. No evidence that the missed visit was at the request of the patient/caregiver or physician order entered to decrease visits for that week. Patient 6: Aide plan of care has visit frequency ordered as 3 times a week. No evidence that 3 visits occurred for the week of 11/10/24. No documentation to support that any aide visits were provided for that week. No evidence that 3 visits occurred for the week of 11/17/24. Documentation shows visits were completed on 11/21 and 11/22. No evidence that the missed visit was at the request of the patient/caregiver or physician orders entered to decrease visits for those weeks. Patient 13: The record indicated that the aide plan of care has orders for the aide to provide nail care and shampoo weekly with the visit frequency of 3 visits a week. Aide documentation showed that those task were performed at multiple visits for the following weeks: Twice for the weeks of 11/04/24 (11/5 and 11/8), 11/11/24 (11/11 and 11/15), 11/18/24 (11/25 and 11/27), 12/01/24 (12/02 and 12/06), 12/08/24 (12/09 and 12/13), 12/15/24 (12/16 and 12/20), 01/05/25 (01/06 and 01/10) and 01/12/25 (01/13 and 01/17).”

“Upon patient record review 1 of 19 (Patient #3) 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 3: The record indicated that patient has been receiving aide services since the time of admission. No evidence that a registered nurse made supervised visits every 14 days between 10/13/2024 and 11/02/2024 - 20 days between supervised visits.”

“Upon patient record review, 1 of 19 (Patient #4) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 4: The record indicated that the aide entered a missed visit note on 10/16/2024 that was not completed, had no evidence of which physician/RN was notified that the visit was missed. The record indicated that the SC entered a missed visit note on 08/20/2024 that was not completed, did not include a reason why the visit was missed in the note.”

“Upon patient record review, 1 of 19 (Patient #2) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 2: Plan of care has chaplain frequency as once a month. No evidence that the patient received a visit for the month of August, September, and October 2024. No evidence that the missed visits were at the request of the patient/caregiver or physician orders entered to skip visits for those month.”