Gentiva II

“Upon patient record review, 1 of 14 (Patient #3) 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 3: The medication profile has an active order for MiraLAX oral powder 17 grams daily. No evidence that a diluent was included.”

“Upon patient record review, 1 of 14 (Patient #4) 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 4: The patient was admitted on 11/11/25. There was no evidence that a bereavement risk assessment was completed within 5 days of admission. Assessment completed on 11/17/2025.”

“Upon patient record review, 3 of 14 (Patient #2,6,10) 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 2: RN documentation indicated that the patient is legally blind. No evidence that goals and interventions related to visual impairment were added to the plan of care. Patient 6: Pre-bereavement risk assessment was completed by the MSW on 01/16/2026 and was scored as moderate. No evidence that a pre-bereavement care plan was added to reflect the caregivers needs. No evidence that the bereavement care plan was updated to reflect the caregivers needs. Patient 10: RN documentation indicated that patient is at high risk for falls due to altered mobility and continues to smoke with oxygen inside the home. No evidence that safety goals and interventions related to falls or oxygen was added to the plan of care.”

“Upon patient record review, 1 of 14 (Patient #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 2: RN documentation indicated that the patient has an active wound. No evidence that wound precautions were added to current aide plan of care.”

“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 Patient 7: Medical record indicated that the LPN added problems, goals, and interventions for anxiety and medication management to the plan of care. Patient is currently in his 9th benefit period and those problems, goals, and interventions remained active at the time the chart was surveyed. This is not within the LVN acceptable standards of practice.”

“Based on record review and interview, the agency failed to ensure the social worker completed their psychosocial assessment as ordered on the plan of care in 1 of 9 active clinical records reviewed with orders for the social worker to evaluate. (Patients: #1, 2, 3, 4, 6, 7, 10, 11, and 12) Findings Include: 1. An agency policy revised 08-30-2023 titled “;The Plan of Care, Policy No. 4-027” indicated but was not limited to, “; ... The care provided to the patient must be in accordance with the plan of care. ...” 2. During a review of Patient #1s clinical record, the record evidenced a plan of care with a start of care date of 12-22-2023 and a benefit period from 12-22-2023 to 03-20-2024. The plan of care evidenced the patient had the following diagnoses, Chronic systolic and diastolic heart failure (the heart muscle is weak and stiff causing the ventricles to be unable to relax appropriately) and chronic kidney disease (a condition where the kidneys are damaged and are unable to filter the blood appropriately). The plan of care indicated the patient had an order dated 12-22-2023 for a Medical Social Worker evaluation for the patient. The Interdisciplinary group meeting date on 12-27-2023 indicated the patient was new and a Medical Social Worker (MSW) evaluation had not been completed yet by MSW 1. The clinical record failed to evidence an MSW evaluation was completed in a timely manner. The clinical record evidenced a Registered Nurse (RN) start of care assessment on 12-22-2023. The assessment evidenced in the narrative note, Patient #1 had an order for MSW to assist with Healthcare Representative completion. Patient #1s clinical record evidenced a coordination note on 02-05-2024 by MSW 2, the MSW contacted the patient and the patient indicated they wanted an MSW evaluation. The MSW evaluation was completed on 02-19-2024, according to the patients request. An MSW evaluation failed to be completed less than 5 days after the start of care on 12-22-2023. 3. During an interview with the Administrator and Regional Director of Operations on 12-21-2024 at 12:45 PM, they indicated for Patient #1, there was a start of care order for the patient to receive an MSW evaluation. They indicated there was an order for MSW evaluation for the start of care. They indicated the record failed to evidence an MSW evaluation within 5 days of the start of care as ordered by the physician. 4. During an interview with MSW 2 on 02-21-2024 at 11:42 AM, they indicated Person 11, a previous MSW with the agency, had left the agency in December of 2023. They indicated they started at this agencys office on 01-29-2024. They indicated the only other MSW at the agency since Person 11 left was MSW 1 until MSW 2 came from the south office to work at this office. 5. During an interview with MSW 1 on 02-21-2024 at 3:01 PM, they indicated if MSW was ordered at the start of care, they were to set up an evaluation within the 5-day window. In December Person 11, former MSW, left the agency and the patients were seen by MSW 1 and MSW 2. 6. During an interview with MSW 1 on 02-22-2024 at 9:05 AM, they indicated they had never contacted or visited Patient #1 or their family. They confirmed Person 11 had left the agency the day the patient started on 12-22-2023, and the patients evaluation was not completed within the allotted 5-day window from the start of care date.”