Gentiva I

“Upon patient record review, 5 of 19 (Patient #1,#2,#3,#13,#14) 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#1: Medication profile indicates albuterol 1.25/3ml for nebulizer is a routine scheduled medication. However, instructions state every 4 hours as needed. During visit to facility it was noted that facility medication profile list glucagon emergency kit and Lantus 100u/ml 5 units at HS. However, these are not on the agency medication profile. Also, the agency list sertraline 100mg 1 daily on their profile but this is not found on facility medication profile. Patient#2: The agency medication profile list acetaminophen 500mg 2 tabs at bedtime. However, it also notes in instructions to take every 4 hours as needed. During facility visit it was noted that facility medication profile shows acetaminophen 1000mg at bedtime for moderate pain and another listing for acetaminophen 650mg 1 every 4 hours for moderate pain. Patient#3: During home visit caregiver indicates lactulose has not been given for over a week due to causing loose stools. Lactulose currently shows as an active medication on medication profile. The medication profile also indicates patient has oxygen in home for PRN use; however per caregiver there is no oxygen in home. Caregiver also states patient taking AZO cranberry 1 daily. There is no evidence of this on the medication profile. Patient#13: The medication profile indicated Mucinex 600 ER 1 twice a day is a routine scheduled medication; however, the instructions state take as needed. Patient#14: The medication profile indicated morphine 100/5ml take 20mg every 2 hours is a routine scheduled medication; however, the instructions state give as second line for SOB if no relief from oxygen after 15 min.”

“Upon patient record review, 1 of 19 (Patient #8) 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#8: There is no evidence of an RN making visits or completing an assessments between 7/1/26-7/30/26. The LVN is making comprehensive assessment visits which is outside the scope of practice for a LVN. The Illinois Nurse Practice Act (225 ILCS 65) and administrative rules (Ill. Admin. Code tit. 68, § 1300.250), a Licensed Practical Nurse (LPN) may perform focused nursing assessments and collect data, but cannot perform the comprehensive, initial nursing assessment reserved for a Registered Professional Nurse (RN). The LVN was the only nurse making visits during this time and there was no evidence of documentation that the RN was collaborating with the LVN, nor did the LVN attend IDG meetings during this time.”

“Upon patient record review, 1 of 19 (Patient #8) 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#8: There is no evidence of an RN making visits or completing an assessment between 7/1/26-7/30/26. The LVN was making comprehensive assessment visits which is outside the scope of practice for a LVN. The Illinois Nurse Practice Act (225 ILCS 65) and administrative rules (Ill. Admin. Code tit. 68, § 1300.250), a Licensed Practical Nurse (LPN) may perform focused nursing assessments and collect data, but cannot perform the comprehensive, initial nursing assessment reserved for a Registered Professional Nurse (RN). The LVN was the only nurse making visits during this time and there was no evidence of documentation that the RN was collaborating with the LVN, nor did the LVN attend IDG meetings during this time.”

“Upon patient record review, 3 of 19 (Patient #1,#2,#12) 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 #1: During the home visit it was noted, per facility, patient is taking insulin daily and ordered glucagon PRN. There is no evidence of problems, interventions, or goals related to insulin and monitoring of patient blood sugar on plan of care. Patient#2: Per record on 3/3/26 it was noted patient has pacemaker. There are no related problems, interventions, and goals in plan of care. The patient is admitted with terminal diagnosis of heart failure. Patient#12: The record indicates chaplain has not made a visit since initial evaluation, although he has made calls and put in missed visits. He documents on 8/12/26 coordination note confirming that services are declined for chaplain but remains available for needs. However, problems, goals, and interventions on plan of care remain active for chaplain.”

“Upon patient record review, 4 of 19 (Patient #1,#3,#6,#9) 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 medications and treatments. Patient#1: During facility visit it was noted that facility shows patient ordered glucagon emergency kit and Lantus 100u/ml 5 units at HS. However, there is evidence of an order for these medications for in agency record. Patient#3: During home visit the care giver indicates lactulose has not been given for over a week due to causing loose stools, however this medication is still an active order. The medication order also indicates patient has oxygen in home for PRN use. Per caregiver there is no oxygen in home. Caregiver also states patient taking AZO cranberry 1 daily. There is no evidence of an order for this. Patient#6: The record indicates patient was ordered a regular diet on admit. However, on nurse visit 6/22/26,7/6, and 7/30 nurse documents patient now requires mechanical soft diet. The regular diet in still active on POC. There is no evidence of an order to update the diet to mechanical soft. Patient#9: The face sheet on chart and the 6/18/26 plan of care indicate terminal diagnosis as diabetes. However, the 7/2/26 visit note and 7/1 IDG note state terminal diagnosis is heart failure. There is no evidence of an order updating the terminal illness.”

“Upon patient record review, 5 of 19 (Patient #1,#2,#3,#4,#6) 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 patient is a diabetic. Plan of care includes intervention for hospice nurse/Facility nurse to perform fasting blood sugar checks. However, there is no evidence of glucometer on supply order. Patient#2: The record indicates per plan of care that patient is having blood sugar monitored at the facility. There is no evidence of glucometer/diabetic equipment on supply order. Patient #3: The CTI 7/7/26 mentions patient having bilateral foot drop and requires use of foot hugger. There is no evidence of this on supply/DME order. Patient#4: The record indicates patient was ordered nectar thick liquids on 8/12/26. However, there is no evidence of thickener on supply order. Patient#6: The record indicates patient is on continuous oxygen and is chair/bed bound. The aide plan of care indicates he takes a shower. However, there is no evidence of any shower safety equipment on supply order.”

“Upon patient record review, 4 of 19 (Patient #1,#3,#5,#6) 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: There is no evidence of skin precautions on the aide plan of care; however, there is evidence this is on the main plan of care. The record also indicates patient is incontinent, bedbound, and has a wound. Patient#3: The record indicates per CTI 7/7/26 that patient requires use of foot huggers/brace due to bilateral foot drop. There is no evidence of this on the aide plan of care. Patient#5: The active aide plan of care indicates patient requires contact precautions. However, these precautions were removed from the main plan of care after patient had a negative lab report 7/24/26. Patient#6: The aide pan of care indicates patient is being given a shower. However, there is no evidence of any shower DME or equipment for patient safety. The record indicates patient is on continuous oxygen and is chair/bedbound.”

“Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Nursing services • Medical social services • Physician services • Counseling services, including spiritual counseling, dietary counseling and bereavement counseling • Hospice aide, volunteer, homemaker services • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care • Medical supplies (including drugs and biologicals) and medical appliance LVN is not following consistent with accepted standards of practice within the LVN scope of practice as evidenced by Patient#8: There is no evidence of an RN making visits or completing an assessments between 7/1/26-7/30/26. The LVN is making comprehensive assessment visits which is outside the scope of practice for a LVN. The Illinois Nurse Practice Act (225 ILCS 65) and administrative rules (Ill. Admin. Code tit. 68, § 1300.250), a Licensed Practical Nurse (LPN) may perform focused nursing assessments and collect data, but cannot perform the comprehensive, initial nursing assessment reserved for a Registered Professional Nurse (RN).”

“Upon patient client record review, 2 of 19 (Patient #1,#12) 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#1: Coordination note in patient chart indicates aide had a missed visit on 7/11/26. However, this date was typed in error and was actually 7/9/26. Patient#12: Nurse documented on 7/14/26 that questions were answered by POA and on 7/27 reviewed bowel regime with POA. This patient does not have POA.”

“Upon client 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: The plan of care indicates hospice nurse and facility nurse to perform fasting blood sugars and report to MD is under 50 or over 400. There is no evidence documentation of coordination or collaboration in the chart to evidence blood sugars being monitored as there are no results documented.”