Gentiva

“Upon patient record review, 3 of 14 (Patient #8, #9, 10) 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 #8: As observed during a home visit the instructions on the Humulin N box said it was to be taken in the AM and the Lorazepam bottle said 1mg po every 2 hours prn. Review of the hospice medication profile said Humulin N 18U SQ daily and Lorazepam 1mg oral every 2 hours. The caregiver who was the grandson also revealed during the visit that the patient was taking Milk of Magnesia prn and High Fiber Liquid 30ml daily at lunch which was not on the hospice medication profile. In addition, the medication profile revealed that Claritin 10mg po daily was a duplicate on the med profile. Corrected on site. Patient #9: As observed during a home visit the facility medication profile revealed orders for Lorazepam 0.5mg every 12h prn and Neurontin 300mg at HS. The hospice medication profile said Lorazepam 1mg every 6h prn and Neurontin 300mg AM. Corrected onsite. The hospice medication profile also had Milk of Magnesia 400mg/5ml 30ml daily and Senna 8.6 1 tablet daily and those medications were not on the facility medication profile. The Senna was corrected onsite. In addition, the medication profile revealed that Bisacodyl was a duplicate on the medication profile. Corrected on site. Patient #10: As observed during a home visit the SNF medication profile said Antifungal (Clotrimazole) External Cream 1% topical apply to right big toe topically daily. There was no evidence that the hospice medication profile contained this medication. There were 9 medications (Abilify, Bisacodyl, Fleets Enema, Omeprazole, Ondansetron, Oxybutynin, Senna, Sertraline, Tums) and oxygen that were on the hospice medication profile but not on the facility medication profile.”

“Upon patient record review, 1 of 14 (Patient #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 #8: Upon review of the record there is no evidence an initial bereavement risk assessment was completed for the grandson Ryan, who is the primary hands-on caregiver in the home.”

“Upon patient record review, 1 of 14 (Patient #1) 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 #1: Upon review of the record the nurse documented on 8/8/2025 “there is a small abrasion on the right knee” which is not a complete assessment of the new wound. In the 8/14/2025 nurse visit it is documented “abrasion to right knee scabbed” which is not a complete assessment of the wound. There was also no evidence that a dressing change was completed during the visits by the hospice nurse or that a dressing had been in place as per the order.”

“Upon patient record review, 1 of 14 (Patient #8) 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: Upon review of the record the care plan had wound care interventions and goals but documentation didn’t reveal that the patient had any wounds. Corrected on site.”

“Upon patient record review, 1 of 14 (Patient #2) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #2: Upon review of the record it revealed an order on 6/8/2025 for the SN visit frequency of 2wk2, 1wk1, 4prn. There was a new SN visit frequency order on 6/11/2025 with an additional 8prn visits. Another order was written on 7/7/2025 which included 12 prn visits. The record indicated there were additional prn visit orders without an increase in routine visits.”

“Upon patient record review, 4 of 14 (Patient #1, #8, #9, #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 medications and treatments. Patient #1: Upon review of the documentation wound care was being provided by the family however the order stated the hospice nurse was to do the wound care. Patient #8: Upon record review there were orders for Humulin N 18U SQ daily and Lorazepam 1mg oral every 2 hours. During the home visit the box for the Humulin N was ordered as every AM and the Lorazepam was 1mg po every 2 hours prn. Corrected onsite. There was no order in the hospice record for Milk of Magnesia and High Fiber Liquid that the patient’s caregiver said he was giving the patient. Corrected onsite. Patient #9: Upon record review the orders were Lorazepam 1mg every 6h prn and Neurontin 300mg AM. During the home visit the facility medication profile revealed orders that were different than the hospice orders Lorazepam 0.5mg every 12h prn and Neurontin 300mg at HS. Corrected onsite. Patient #10: Upon review of the SNF medication profile it said Antifungal (Clotrimazole) External Cream 1% topical apply to right big toe topically daily. There was no evidence of an order for the Clotrimazole in the patient’s hospice record.”

“Upon patient record review, 6 of 14 (Patient #1, #3, #4, #5, #6 and #8) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient #1: Upon review of the record it was documented that the patient had a new wound on right knee on 8/8/2025 but there was no evidence that the care plan was updated with wound interventions and goals. Patient #3: Upon review of the record on 7/18/2025 wound care interventions and goals were still on the care plan even though the documentation revealed the wound healed 7/28/2025. Corrected onsite. Patient #4: Upon review of the documentation revealed that the 7/29/2025 left proximal forearm wound was healed on 8/12/2025, the 8/12/2025 right eyebrow wound was healed on 8/12/2025 and the 6/17/2025 left distal forearm wound was healed on 6/24/2025. There no evidence that the 3 wounds had interventions and goals in the care plan. Patient #5: Upon review of the record it indicated that the patient had a UTI diagnosed on 8/4/2025 but there is no evidence that infection interventions and goals were added to the care plan. Patient #6: Upon review of the record it is documented that the patient was on respite care from 8/13/2025 through 8/17/2025. There is no respite interventions or goals added to the care plan. Patient #8: Upon review of the record there were SW interventions and goals on the care plan even though additional SW services were refused by the patient and family after the evaluation visit. Corrected on site.”

“Upon patient record review, 4 of 14 (Patient #1, #4, #5, #8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: Upon review of the record the nurse documented on 8/8/2025 “there is a small abrasion on the right knee”, there was no evidence that a dressing change was completed during the visits by the hospice nurse or that a dressing had been in place as per the order. Patient #4: Upon review of the record the 7/3/2025 order was to increase SN visits to daily effective 6/29/2025. The record revealed that there were no SN visits made on 6/29/2025, 7/1/2025 and 7/2/2025. The record indicated that the SC did an evaluation on 6/19/2025 with a subsequent visit frequency effective 7/7/2025 2every2m2, 1m1, 2prn. No evidence that the SC followed the visit frequency and record revealed visits on 7/7/2025, 7/24/25 and 8/6/2025. Patient #5: Upon review of the record it indicated that the SC did the evaluation on 6/23/2025 with a visit frequency effective 6/19/2025 2every2m2, 2m1, 1m1, 3prn. There is no evidence in the record that the SC followed the ordered visit frequency due to making visits on 7/9/2025, 7/31/2025 and 8/14/2025. Patient #8: Upon review of the record there was an order on 7/9/2025 for a “PT eval for passive and active ROM. Restorative program.” There is no evidence that the PT eval had been completed.”

“Upon observation, and record review, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient #1: Upon record review it was documented the patient had a fall on 8/8/2025. There is no evidence in the record that a fall incident report was completed. Patient #4: Upon record review it is documented the patient had a fall on 7/21/2025 and 8/13/2025. There is no evidence in the record that a fall incident report was completed.”

“Upon patient record review 1 of 14 (Patient #5) 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 #5: Upon review of the record the aide care plan said the patient was to be shaved the 2nd visit of each week. The documentation revealed that the aide shaved the patient on the 1st visit of the week on the following dates: 6/24/2025, 7/8/2025, 7/15/2025, 7/22/2025, 7/28/2025, 8/12/2025 and 8/19/2025.”

“Upon patient client record review, 1 of 14 (Patient #6) 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 #6: Upon review of the record the nurse documented on 6 visits (7/21/2025, 7/25/2025, 7/28/2025, 8/1/2025, 8/4/2025 and 8/8/2025) “Wound care performed per Dr. orders” instead of the specific wound care that was completed during the visit by the nurse.”

“Upon patient record review, 1 of 14 (Patient #10) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice’s 24-hour on-call system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient Patient #10: Upon review of the SNF clinical record there was no evidence of the names and contact information for hospice personnel involved in hospice care of the patient.”