Gentiva Hospice

“Upon patient record review, 3 of 14 (Patient #1, 5, 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: The patient was admitted on 3-10-26. The record indicated that the bereavement risk assessment was completed on 3-23-26 which is greater than the 5 day requirement. Patient #5: The patient was admitted on 3-26-26. The record indicated that the bereavement Risk assessment was completed on 4-3-26 which is greater than the 5 day requirement. Patient #8: The patient was admitted on 10-24-25. The record indicated that the bereavement risk assessment was completed on 10-30-25 which is greater than the 5 day requirement.”

“Upon patient record review, 1 of 14 (Patient #9) 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 #9 The patient record had documented the patient had a diagnosis of anxiety. There was no evidence of a problem statement with goals and interventions and progress toward outcomes related to the management of anxiety.”

“Upon patient record review, 2 of 14 (Patient #3,8) 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 #3: The record indicated that the patient had a wheelchair, raised toilet seat and bed alarm. There was not evidence that this was in the plan of care. Patient #8: The clinical record indicates the patient has a shower chair in the home. There was not evidence that this was in the plan of care.”

“Upon client record review, 2 of 14 (Patient #7,9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #7: The record indicated a new order was received on 5-25-26 to replace the current foley catheter with a 16 Fr. with a 10cc. balloon. The RN documented in the clinical record that the foley catheter was replaced with 16Fr 5cc balloon. This incorrect verbiage was also carried over into the patients plan of care which did not match the current physician order. Patient #9: The record indicated the patient has orders to change the indwelling foley catheter as needed for occlusion, infection or if problems noted. Documentation noted in the clinical record on 5-20-26 RN states the patients foley is due to be changed without noting a reason in her documentation. During a home visit patient states his foley catheter is changed on a regular basis. There was not evidence that scheduled foley catheter changes were a part of the care plan.”

“Upon patient record review, 2 of 14 (Patient #11,12) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #11: A post bereavement risk assessment was completed on 12-17-25 and a care plan was created for the bereavement personnel to follow. There is no evidence stated in the bereavement coordination notes that the sympathy card or holiday letter were mailed to the bereaved. Patient #12: A post bereavement risk assessment was completed on 11-20-2025 which generated a care plan for the bereavement personnel to follow. There is no evidence stated in the bereavement coordination notes that the sympathy card or holiday or memorial service invitation was mailed to the bereaved.”

“Upon patient record review, 2 of 14 (Patient #1,2) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1:The aide plan of care indicated the patient to transfer with use of walker. Order written on 4-8-26 to discontinue the patients walker. No Evidence found that the aide care plan was updated to reflect the change. Patient #2: Documentation indicated the patient had orders for bilateral heel protectors. This was not reflected in the current aide plan of care.”