Gentiva

“Upon patient record review, 3 of 19 (Patient #1,2,8) 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 1: Clonazapam/Klonipine 1mg twice a day listed on the current medication profile at the SNF. No evidence that medication was added to the hospice active medication profile. COS. Patient 2: Robitussin and Lorazepam listed on the hospice active medication profile . No evidence that those medications were being taken by the patient or listed on the active medication profile for the SNF. COS. Patient 8: The record indicates duplicate drug therapy for Ferosul and Lantanopost on the current medication profile. Ferosul 325mg (65mg iron) daily one ordered for 05/24/2024 and the other ordered on 09/16. Latanopost 0.005% eye drops 1 drop for each eye at bedtime daily one ordered for 05/24/2024 and the other ordered on 09/16. Corrected on site”

“Upon patient record review, 5 of 19 (Patient #3,4,6,10,13) 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: Patient currently takes Wellbutrin and Cymbalta as anti-depressants. There was no evidence of problems, goals, and interventions related to depression included in the plan of care. COS. Patient 4: Patient currently takes Keppra 250mg daily for seizures, Remeron and Seroquel 25mg for anti-depressant. There was no evidence of problems, goals, and interventions related to seizures and depression included in the plan of care. COS. Patient 6: The record indicates that the patient has a current diagnosis of Diabetes, blood sugar checks 3 times a day, and currently takes insulin/metformin. No evidence that problems, goals, and interventions related to endocrine/blood sugars on the current POC. COS. Patient 10: Patient currently takes Xarelto 20mg and has a related diagnosis of heart failure and currently suffers from anxiety. There was no evidence of problems, goals, and interventions related to anxiety, cardiac status, and risk for bleeding included in the plan of care. COS. Patient 13: Patient currently has Major depressive disorder listed as a related diagnosis. There was no evidence of problems, goals, and interventions related to depression included in the plan of care. COS.”

“Upon patient record review, 5 of 19 (Patient #1,2,3,5,7) 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 1,2,3,5,7: The plan of care has volunteer orders for weekly tuck in visits and PRN visits. No evidence that a number was added to the specify the amount of PRN visits. Corrected on site.”

“Upon patient record review, 3 of 19 (Patient #2,5,6) 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 2: RN documentation stated that the patient uses a hoyer lift to get patient out of the bed to the chair. No evidence that a hoyer lift was added on the equipment plan of care. Patient 5: RN documentation stated that the patient uses a wheelchair for mobility. No evidence that a wheelchair was added to the equipment plan of care. Patient 6: RN documentation stated that the patient uses a rollator/walker to help with mobility and a nebulizer was used for oxygen treatments. No evidence that a nebulizer or the rollator/walker was added on the equipment plan of care.”

“Upon patient record review 3 of 19 (Patient #1,4,14) 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 1: Aide plan of care indicates for linens to be changed and shampoo to be completed weekly. The aide documentation shows that the hospice aide provided hair care at both visits for the week of 09/08/24. Aide plan of care has orders to complete 3 visits weekly. No evidence that patient received 3 visits during the week of 07/14, 09/01, 09/15, and 10/06. Patient 4: Aide plan of care has orders to complete 3 visits weekly. No evidence that patient received 3 visits during the week of 09/01/24 and 09/15/24. For the week of 09/01, only 2 visits occurred, on 09/04 and 09/06. For the week of 09/15, only 2 visits occurred on 09/16 and 09/18. Patient 14: Aide plan of care indicates hair care to be completed weekly. Aide documentation shows that the hospice aide provided hair care at every visit instead of weekly as ordered for the following weeks: 8/4/24, 8/11/24,8/18/24, 8/25/24, 9/15/24, 9/22/24, & 10/6/24.”

“Upon patient record review, 3 of 19 (Patient #1,3,11) 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 1: Missed visit note entered on 10/07/2024 by the RN. No evidence that the date of the visit included in the note. Patient 3: Missed visit note entered on 10/09/2024 by the aide. No evidence that the date of the visit or who was notified of the missed visit was included in the note. Patient 11: Mississippi Physician Orders for Sustaining treatment missing the required signature date for the signing MD. Corrected on site.”