Gentiva II

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

Rule L0530. Standard-level.

Content of plan of care (42 CFR 418.56(c)(2))

Rule L0547. Standard-level.

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

“Upon patient record review, 1 of 19 (Patient #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 14: During home visit medication reconciliation, the facility and hospice medication orders did not match. The facility had an order for levothyroxine daily that was not in the hospice record.”

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 #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 8: The medical record contained nursing documentation upon recertification assessment 6/16/26 identifying is a high risk for skin impairment. There was no evidence the plan of care was updated to include problems, goals, and interventions related to potential skin impairment.”

Rule L0553. Standard-level.

Coordination of services (42 CFR 418.56(e)(2))

“Upon client record review, 1 of 19 (Patient #7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 7: The medical record contained an order for spiritual care visits once monthly. There was no evidence of attempts for an August visit prior to 8/31/26 and frequency was not met with reason stating the chaplain was unable to coordinate visit for 8/31/26.”

Rule L0555. Standard-level.

Counseling services (42 CFR 418.64(d)(1))

Rule L0596. Standard-level.

Hospice aide assignments and duties (42 CFR 418.76(g)(2))

“Upon patient record review 1 of 19 (Patient #4) 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 4: The medical record contained an order for aide visits twice weekly. There was no evidence of a second visit completed the week of 7/19/26.”

Rule L0626. Standard-level.

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

“Upon patient client record review, 1 of 19 (Patient #1) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 1: The medical record contained documentation of a verbal certification of terminal illness upon admission received from a nurse practitioner instead of the patient’s elected attending physician. The physician did not sign the certification of terminal illness within two days to meet timeline for written acknowledgement as a substitute for the error in verbal received.”

Rule L0676. Standard-level.

Content (42 CFR 418.104(a)(6))

“Upon patient client record review, 2 of 19 (Patients #7,#8) did not have evidence that each patient record contains Advance Directives. Patient 7: The Michigan DNR order was incomplete with information empty regarding date form prepared, signing and collaborating physician phone numbers, and preparer’s organization and phone number. Patient 8: The Michigan DNR order was incomplete without identification of the signing physician’s name and phone number.”

Rule L0677. Standard-level.

Hospice plan of care (42 CFR 418.112(d)(1))

“Upon client record review, 1 of 19 (Patient #13) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 13: The medical record contained an order for catheter changes and maintenance that did not include identification of task responsibilities by the facility or hospice.”

Rule L0774. Standard-level.

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

“Upon patient record review, 2 of 19 (Patients #12,#14) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Hospice medication information specific to each patient Patients 12, 14: There was no evidence of updated plans of care and certifications of terminal illness in the hospice binders at the facilities.”

Rule L0781. Standard-level.