Gentiva

“Upon patient record review, 5 of 19 (Patients #4,#5,#6,#7,#9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 4: Upon home visit medication reconciliation, the patient denied taking chlorthalidone for edema that was listed on the profile as a medication scheduled daily. Patient 5: Upon home visit medication reconciliation, the facility medication profile contained a dose of Depakote 500mg compared to hospice 125mg, and senna plus 2 tablets twice daily instead of 1 capsule twice daily. The hospice medication profile contained potassium chloride oral packets with no instructions to mix with a diluent. Patient 6: The medication profile contained multiple medications with conflicting route of oral and instructions to administer via peg tube. Patient 7: Upon home visit medication reconciliation, the facility medication profile contained vitamin B12 daily that was not on the hospice profile, and diclofenac topical gel four times daily as needed instead of twice daily as needed as profiled by the hospice. Patient 9: The medication profile contained differing oxygen PRNs for 2-4L dated 5/16/26 and 2L dated 5/18/26. There was no evidence the previous instructions were removed from the medication profile when the order changed.”

“Upon patient record review, 3 of 19 (Patients #2,#6,#7) 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: The medical record contains nursing documentation upon admission identifying patient has COPD and dyspnea with minimal exertion. There is no evidence of problems, goals, and interventions related to respiratory dysfunction included in the plan of care. Patient 6: The medical record contained nursing documentation upon admission identifying patient has COPD requiring oxygen, and a seizure disorder. There is no evidence of problems, goals, and interventions related to respiratory dysfunction and seizure precautions included in the plan of care. Patient 7: The medical record contained nursing documentation upon admission identifying patient has dyspnea with minimal exertion. There is no evidence of problems, goals, and interventions related to respiratory dysfunction included in the plan of care.”

“Upon patient record review, 5 of 19 (Patients #4,#5,#6,#7,#13) 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 4: Upon home visit medication reconciliation, the patient denied taking chlorthalidone for edema. There was no evidence the hospice agency discussed with the physician to receive an order to discontinue the medication due to patient not taking. Patient 5: Upon home visit medication reconciliation, the facility medication orders contained a dose of Depakote 500mg compared to hospice 125mg, and senna plus 2 tablets twice daily instead of 1 capsule twice daily. The hospice medical record contained an order for potassium chloride oral packets with no instructions to mix with a diluent. Patient 6: The medication orders contained multiple medications with conflicting route of oral and instructions to administer via peg tube. Patient 7: Upon home visit medication reconciliation, the facility medication orders contained vitamin B12 daily that was not on the hospice record, and diclofenac topical gel four times daily as needed instead of twice daily as needed as per hospice order. Patient 13: The medical record contained nursing documentation since admission identifying patient has an indwelling catheter. There was no evidence of an order for catheter balloon size, change frequency, and maintenance.”

“Upon patient record review, 4 of 19 (Patients #5,#6,#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 equipment and supply needs. Patient 5: The medical record contained nursing documentation upon admission identifying patient use of half rails on hospital bed. There was no evidence of an order for the rails included in the plan of care. Patient 6: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, bed rails, commode, tube feeding supplies, over bed table, oxygen and nebulizer. There was no evidence of orders for the DME included in the plan of care. Patient 11: The medical record contained nursing documentation upon admission identifying patient use of a shower chair. There was no evidence of an order for the chair included in the plan of care. Patient 14: The medical record contained nursing documentation since admission identifying patient use of a cane for ambulation. there was no evidence of an order for the cane included in the plan of care.”

“Upon patient record review, 2 of 19 (Patients #15,#17) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. • Ensuring that bereavement services reflect the needs of the bereaved Patient 15: The bereavement care plan contained tasks to send a holiday letter and memorial service invitation. There was no evidence of those tasks being completed. Patient 17: The bereavement care plan contained tasks to send a sympathy card, holiday letter and memorial service invitation. There was no evidence of those tasks being completed.”

“Upon personnel record review, 2 of 15 (Personnel #4,#6) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel 4,6: There was no evidence each of the required tasks observed through demonstration and assessed as competent by an RN.”

“Upon patient record review, 2 of 5 (Patient #3,4) 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 3: The medical record indicated that the patient started treatment for a UTI on 12/31/2025. There was no evidence of problems, goals, and interventions related UTI or infection included in the current plan of care. Corrected on site, plan of care updated during the survey. Patient 4: The medical record indicated that the patient admitted on treatment for a chronic UTI. Patient is currently prescribed Cipro 250mg daily prophylactically. There was no evidence of problems, goals, and interventions related to the genitourinary chapter, chronic UTI, or infections included in the current plan of care. Corrected on site, plan of care updated during the survey.”

“Upon client record review, 2 of 5 (Patients #4,#5) did not have evidence that the plan of care included IDG’s documentation of the patient’s or families level of understanding, involvement and agreement with the plan of care. Patient 4: The medical record contained nursing documentation identifying patient fall 8/30/25 resulting in patient report of soreness to bottom. There was no evidence of family involvement with developing a plan of care related to the fall. Agency completed an internal investigation regarding the incident and completed nursing education to staff 10/28/25. Patient 5: The medical record contained nursing documentation identifying patient fall 10/27/25 resulting in patient report of leg pain, inability to bear weight on left leg, and skin tear with bruising to right arm. There was no evidence of family involvement with developing a plan of care related to the fall.”

“Upon patient record review, 1 of 5 (Patients #4) did not have evidence in the patient record that as part of the patient-specific comprehensive assessment the hospice may determine the need for a referral and/or further evaluation by other appropriate health professionals. Patient 4: The medical record contained a nursing visit 8/30/25 in response to a fall with reports of some soreness to patient’s bottom. There was no evidence of a comprehensive assessment with examination of potentially injured area with report to physician to determine if further evaluation needed. Fall report stated there was no injury however nursing visit 8/31/25 did indicate pain and swelling to right hip resulting from fall 8/30/25 and patient was sent to the emergency room. Agency completed an internal investigation of incident and provided education to nursing staff on 10/28/25.”

“Upon patient record review, 2 of 5 (Patients #4,#5) did not have evidence that the hospice follows the individualized plan of care developed in in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient’s needs if any of them so desire. Patient 4: The medical record contained nursing documentation identifying patient fall 8/30/25 resulting in patient report of soreness to bottom. There was no evidence of physician notification regarding the fall. Agency completed an internal investigation regarding the incident and completed nursing education to staff 10/28/25. Patient 5: The medical record contained nursing documentation identifying patient fall 10/31/25 resulting in patient sustaining bumps to left side and back of head. There was no evidence of physician notification regarding the fall.”

“Upon patient record review, 2 of 5 (Patients #4,#5) 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 4: The medical record contained nursing documentation identifying patient fall 8/30/25 resulting in patient report of soreness to bottom. There was no evidence of family education related to the fall. Agency completed an internal investigation regarding the incident and completed nursing education to staff 10/28/25. Patient 5: The medical record contained nursing documentation identifying patient fall 10/27/25 resulting in patient report of leg pain, inability to bear weight on left leg, and skin tear with bruising to right arm. There was no evidence of family education related to the fall.”

“Upon patient record review, 2 of 5 (Patients #2,#3) 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: The medical record contained a prescription for Eliquis. There was no evidence of problems, goals, and interventions related to risk for bleeding included in the plan of care. Corrected on site with plan of care update. Patient 3: The medical record contained a prescription for Plavix. There was no evidence of problems, goals, and interventions related to risk for bleeding included in the plan of care.”