Gentiva

“Upon patient record review, 3 of 14 (Patients #2,#4,#7) 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 2: The medical record contained an initial bereavement assessment 8/6/26 with admission 7/28/26. Patient 4: The medical record contained an initial bereavement assessment 7/7/26 with admission 6/26/26. Patient 7: The medical record contained an initial bereavement assessment 6/11/26 with admission 6/2/26.”

“Upon patient record review, 1 of 14 (Patient #8) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient’s progress toward desired outcomes • Reassessment of the patient’s response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 8: The social worker documentation for updated plan of care 8/12/26 and the RN’s documentation 8/12/26 and 8/26/26 did not contain information on the patient’s progress toward goals and changes in assessments.”

“Upon client record review, 2 of 14 (Patients #1,#2) 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. Patients 1,2: There was no evidence of collaboration with the attending physicians to develop the plan of care. Per agency policy number 4-027, the agency must provide the attending physicians with a copy of the plan of care for approval of verbal orders and receive signatures.”

“Upon patient record review, 2 of 14 (Patients #8,#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 8: During home visit medication reconciliation, the facility and hospice medication orders did not match. The facility had regular Senna scheduled and as needed and hospice had Senna plus with docusate. Patient 10: The medical record contained an incomplete order 8/19/26 for catheter to be changed every 30 days. The order did not contain the catheter size to be utilized.”

“Upon patient record review, 5 of 14 (Patients #3,#6,#7,#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 equipment and supply needs. Patient 3,6,7: The medical record contained nursing documentation upon admission identifying patient use of a shower chair. There was no evidence of an order for the DME included in the plan of care. Patient 9: During home visit observation, the patient had a raised toilet seat and shower chair. There was no evidence of orders for the DME included in the plan of care. Patient 10: The medical record contained nursing documentation upon admission identifying patient use of a suction machine and walker. There was no evidence of orders for the DME included in the plan of care.”

“Upon client record review, 4 of 14 (Patients #3,#4,#9,#10) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient’s condition requires but no less frequently then every 15 calendar days. Patient 3,4: There was no evidence of collaboration with the attending between 7/31/26 and 8/17/26. Patient 9: The medical record contained nursing documentation 7/28/26 identifying patient had potential seizure activity. There was no evidence of collaboration with the attending physician regarding the patient’s condition. Patient 10: There was no evidence of collaboration with the attending between the date attending was elected 7/22/26 and 8/17/26.”

“Upon patient record review, 2 of 14 (Patient #9,#10) 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 9: The medical record contained nursing documentation 7/28/26 identifying patient had potential seizure activity. There was no evidence the plan of care was updated to include problems, goals, and interventions related to seizure precautions. Patient 10: The plan of care included inappropriate interventions related to restraint safety measures. There was no evidence of restraints utilized in the home and the POC was never updated when reviewed.”

“Upon client record review, 4 of 14 (Patients #2,#5,#9,#10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: The medical record contained an order for volunteer visits twice monthly. There was no evidence of a second volunteer visit in August. Patient 5: The medical record contained an order for nurse visits twice weekly. There was no evidence of a second visit completed the week of 8/16/26. Patient 9: The medical record contained an order for volunteer visits twice monthly. There was no evidence of a second volunteer visit in August. Patient 10: The medical record contained an order for nurse visits three times the first week, then twice weekly after. There was no evidence of a third visit the week of 7/20/26.”

“Upon patient record review, 1 of 14 (Patient #12) 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. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 12: The medical record contained documentation of a bereaved daughter receiving mailings. There was no evidence of a bereavement plan of care developed.”

“Upon patient record review, 3 of 14 (Patients #1,#5,#10) did not have evidence in the patient record that hospice aide assignments and duties are specific to patient needs. Patient 1: The aide care plan did not contain instructions on how to transport patient to shower. Patient required Hoyer for transfer. Patient 5: The aide care plan contained instructions regarding multiple wound dressings in place. All wounds were documented as healed 5/12/26, but the aide care plan was not updated to reflect the change. Patient 10: The medical record contained nursing documentation since admission identifying patient use of a walker. The aide care plan did not contain instructions regarding patient need for walker with ambulation.”

“Upon patient record review 3 of 14 (Patients #5,#6,#9) 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 5: The medical record contained an order for aide visits three times weekly. There was no evidence of a third visit completed the week of 8/23/26. Patient 6: The medical record contained an order for aide visits three times weekly. There was no evidence of a third visit completed the week of 8/9/26. Patient 9: The medical record contained an order for aide visits three times weekly. There was no evidence of a third visit completed the week of 8/23/26.”

“Upon patient client record review, 9 of 14 (Patients #1,#2,#3,#4,#6,#7,#8,#10,#11) did not have evidence that each patient record contains Advance Directives. Patient 1: The medical record contained an incomplete POLST that did not identify the primary care physician and phone number or the signing physician with license type and phone number. Patient 2: The medical record contained an incomplete POLST that did not contain the primary care physician and phone number or the patient’s date of birth. Patient 3,4,7,10: The medical record contained an incomplete POLST that did not identify signing physician with printed name, license type and phone number. Patient 6: The medical record contained an incomplete POLST that did not identify the primary care physician and phone number or the signing APRN’s phone number. Patient 8: The plan of care identified the patient as a DNR. There was no evidence of an Advance Directive to support the code status. Patient 11: The medical record contained an incomplete POLST that did not identify the primary care physician’s phone number and was not signed by a physician.”