Gentiva

Content of comprehensive assessment (42 CFR 418.54(c)(6))

Rule L0530. Standard-level.

Content of comprehensive assessment (42 CFR 418.54(c)(7))

“Upon patient record review, 1 of 19 (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 bereavement assessment was completed on 5/7/25 with SOC 4/21/25.”

Rule L0531. Standard-level.

Plan of care (42 CFR 418.56(b))

“Upon patient record review, 1 of 19 (Patient #19) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient 19: There was no evidence of patient and family education surrounding need to transfer to another hospice agency due to agency inability to continue services.”

Rule L0544. Standard-level.

Content of plan of care (42 CFR 418.56(c))

Rule L0545. Standard-level.

Content of plan of care (42 CFR 418.56(c)(4))

Rule L0549. Standard-level.

Content of plan of care (42 CFR 418.56(c)(5))

Rule L0550. Standard-level.

Review of the plan of care (42 CFR 418.56(d))

“Upon patient record review, 1 of 19 (Patient #19) 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 19: There was no evidence the plan of care was updated to include need for patient to transfer to another hospice due to agency inability to continue services.”

Rule L0553. Standard-level.

Program activities (42 CFR 418.58(c)(2))

“Upon observation, 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 2: The medical record contained social worker documentation 10/28/25 identifying patient was reported as having taken double doses of blood pressure medication for two nights. There was no evidence of an incident report completed and investigation conducted.”

Rule L0569. Standard-level.

Hospice aide assignments and duties (42 CFR 418.76(g)(1))

“Upon patient record review, 1 of 19 (Patient #5) did not have evidence in the patient record that hospice aide assignments and duties are specific to patient needs. Patient 5: There was no evidence of instructions to utilize a lift for transfers included in the aide care plan. Corrected on site with aide care plan update.”

Rule L0625. Standard-level.

Supervision of hospice aides (42 CFR 418.76(h)(1))

“Upon patient record review 1 of 19 (Patient #5) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient 5: There was no evidence of aide supervision completed between 10/1/25 and 10/21/25.”

Rule L0629. Standard-level.

Level of activity (42 CFR 418.78(e))

“Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Agency annual volunteer utilization rate was 2.8% for 2024. Year to date rate is at 3.9%”

Rule L0647. Standard-level.

Content (42 CFR 418.104(a)(5))

“Upon patient record review, 1 of 19 (Patient #3) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 3: There was no evidence a verbal certification was received from the attending physician upon admission. Verbal certification was documented as received from a PA and written certification was not received until 2/5/25 with admission 1/17/25.”

Rule L0676. Standard-level.

Authentication (42 CFR 418.104(b))

“Upon patient record review, 1 of 19 (Patient #3) 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 3: Orders for O2 DME in error, patient did not have O2. Corrected”

Rule L0679. Standard-level.

Coordination of services (42 CFR 418.112(e)(3))

“Upon patient record review, 2 of 19 (Patients #3,#8) did not have evidence that the hospice provided the following information: • Physician certification and recertification of the terminal illness specific to each patient Patient 3: Upon observation during the home visit, the facility binder did not have any CTIs previous to benefit period started 9/14/25. Patient 8: Upon observation during the home visit, the facility binder did not contain physician narrative and signature for benefit period 5/30/25 and no CTI for benefit period 7/29/25.”

Rule L0781. Standard-level.