Gentiva

“Upon patient record review 3 of 19 (Patients #1,#2,#10) 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: The initial comprehensive spiritual assessment was completed 9/26/24 with start of care 9/20/24. Patient 2: The initial comprehensive spiritual assessment was completed 9/27/24 with start of care 9/20/24. Patient 10: The initial comprehensive spiritual assessment was completed 10/17/24 with start of care 10/10/24.”

“Upon patient record review, 7 of 19 (Patients #2,#3,#4,#7,#9,#11,#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 2: The medication profile contained acetaminophen 650mg with instructions identifying to be administered for pain or fever listed as scheduled every four hours in error instead of as needed. Corrected on site. Patient 3: The medication profile contained Miralax oral powder with no instructions to mix with a diluent and active diflucan listed that was ordered for 3 days on 11/8/24. Corrected on site. Patient 4,14: The medication profile contained oxygen with no delivery method. Corrected on site. Patient 7: Upon medication reconciliation during home visit, the facility medication profile contained narcan and baclofen that were not on the hospice profile. The hospice medication profile contained Celebrex 200mg capsules stating dose was 1 mg in error. Corrected on site. Patient 9: The medication profile contained Miralax oral powder with no instructions to mix with a diluent and oxygen with no delivery method. Corrected on site. Patient 11: Upon medication reconciliation during home visit, the facility medication profile contained narcan that was not on the hospice profile and had oxygen as needed instead of continuous as ordered by hospice. The hospice medication profile contained morphine with instructions identifying to be administered for pain or air hunger listed as scheduled every 2 hours in error instead of as needed. Corrected on site.”

“Upon patient record review, 7 of 19 (Patients #2,#3,#4,#7,#9,#11,#14) 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 2: The medical record contained an order for acetaminophen 650mg with instructions identifying to be administered for pain or fever listed as scheduled every four hours in error instead of as needed. Corrected on site. Patient 3: The medical record contained an order for Miralax oral powder with no instructions to mix with a diluent. The record also contained nursing documentation since admission identifying patient has an indwelling catheter. There was no evidence of an order for the catheter type, size, change frequency, and maintenance. Corrected on site. Patient 4,14: The medical record contained an order for oxygen with no delivery method. Corrected on site. Patient 7: The hospice medical record contained and order for Celebrex 200mg capsules stating dose was 1 mg in error. Corrected on site. Patient 9: The medical record contained orders for Miralax oral powder with no instructions to mix with a diluent and oxygen with no delivery method. Corrected on site. Patient 11: The medical record contained an order for morphine with instructions identifying to be administered for pain or air hunger listed as scheduled every 2 hours in error instead of as needed. Corrected on site.”

“Upon patient record review, 2 of 19 (Patients #7,#10) 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 7: The medical record contained nursing documentation 11/21/24 identifying patient use of a fall alarm. There was no evidence of an order for the alarm included in the plan of care. Corrected on site. Patient 10: The medical record contained nursing documentation upon admission identifying patient use of a low air loss mattress and Hoyer lift. There was no evidence of an order for the mattress and lift included in the plan of care. Corrected on site.”

“Upon patient record review 2 of 19 (Patients #10,#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 Patient 10: The medical record contained an ordered aide frequency of twice weekly. There was no evidence of a second visit completed the week of 11/10/24. Corrected on site with late entry of missed visit data. Patient 13: The medical record contained an ordered aide frequency of twice weekly. There was no evidence of a second visit completed the week of 11/3/24. Corrected on site with late entry of missed visit data.”

“Upon patient record review, 1 of 19 (Patient #10) 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 10: The medical record contained nursing documentation upon admission mistakenly identifying the patient as using intermittent oxygen. There was no further evidence of oxygen use and the agency verified the patient does not have oxygen in the home.”