Gentiva

“Upon patient record review, 6 of 19 (Patients #1,#6,#7,#10,#11,#14) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 1: Upon medication reconciliation during home visit, the facility and hospice medication profiles did not match. The facility profile contained tamsulosin and tramadol that was not on the hospice profile. Patient 6: The medical record contained nursing documentation 3/17/25 identifying oxygen was delivered. There was no evidence of oxygen listed on the medication profile. Corrected on site. Patient 7: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. The medication profile also contained latanoprost eye drops with no instruction of which eye or eyes identified for administration. Corrected on site. Patient 10: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. Upon medication reconciliation during home visit, the facility and hospice medication profiles did not match. The facility profile did not contain lorazepam, melatonin, and morphine that was on the hospice profile. Corrected on site. Patient 11: Upon medication reconciliation during home visit, the facility and hospice medication profiles did not match. The facility profile contained atorvastatin and valproate acid solution at bedtime that was not on the hospice profile. Patient 14: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. Corrected on site.”

“Upon patient record review, 1 of 19 (Patient #3) 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 3: The initial bereavement assessment was completed 3/19/25 with start of care 3/13/25.”

“Upon patient record review, 2 of 19 (Patients #2,#3) 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 2: There was no evidence of an RN assessment from 3/20/25 to 4/10/25. Patient 3: There was no evidence of an RN assessment from 3/18/25 to 4/14/25.”

“Upon patient record review, 3 of 19 (Patients #3,#10,#11) 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 contained nursing documentation upon admission identifying patient unresolved issues with nausea. There was no evidence of problems, goals, and interventions related to nausea included in the plan of care. Corrected on site. Patient 10: The medical record contained nursing documentation upon admission identifying patient unresolved issues with high risk for skin impairment and dysphagia. There was no evidence of problems, goals, and interventions related to skin and dysphagia included in the plan of care. Corrected on site. Patient 11: The medical record contained nursing documentation upon admission identifying patient is a high risk for skin impairment. There was no evidence of problems, goals, and interventions related to skin included in the plan of care. Corrected on site.”

“Upon patient record review, 6 of 19 (Patients #1,#6,#7,#10,#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 medications and treatments. Patient 1: Upon medication reconciliation during home visit, the facility and hospice medication profiles did not match. Hospice did not have orders for tamsulosin and tramadol that were listed on the facility medication profile. Patient 6: The medical record contained nursing documentation 3/17/25 identifying oxygen was delivered. There was no evidence of an order for oxygen rate, frequency, and delivery method. Corrected on site. Patient 7: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen rate, frequency, and delivery method. The record also contained an order for latanoprost eye drops with no specification on which eye or eyes are appropriate for administration. Corrected on site. Patient 10: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen rate, frequency, and delivery method. Upon medication reconciliation during home visit, the facility and hospice medication profiles did not match. The facility profile did not contain lorazepam, melatonin, and morphine that was on the hospice profile. Hospice did not have orders to discontinue the medications. Corrected on site. Patient 11: Upon medication reconciliation during home visit, the facility and hospice medication profiles did not match. Hospice did not have orders for atorvastatin and valproate acid solution at bedtime that were listed on the facility medication profile. Patient 14: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen rate, frequency, and delivery method. Corrected on site.”

“Upon patient record review, 7 of 19 (Patients #2,#4,#7,#8,#10,#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 2: The medical record contained nursing documentation 4/1/25 identifying patient use of a wheelchair and commode. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 4: The medical record contained nursing documentation upon admission identifying patient use of a nebulizer and walker. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 7: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for the DME included in the plan of care. Corrected on site. Patient 8: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair. There was no evidence of an order for the DME included in the plan of care. Corrected on site. Patient 10: The medical record contained nursing documentation 4/15/25 and 4/22/25 identifying patient use of a Hoyer lift and hospital bed. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 11: The medical record contained nursing documentation identifying patient use of a hospital bed and over bed table since admission, and a Hoyer lift since 3/6/25. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 14: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair, and hospital bed. There was no evidence of orders for the DME included in the plan of care. Corrected on site.”

“Upon patient record review, 2 of 19 (Patients #9,#13) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 9: The aide care plan did not contain instructions regarding wound management during bathing. Corrected on site. Patient 13: The aide care plan contained bathing tasks for a shower twice weekly and bed bath weekly. The patient was receiving two aide visits a week per orders. Corrected on site.”

“Upon patient record review, 2 of 19 (Patients #1,#5) 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 1: The medical record contained an order 4/23/25 to obtain a UA that did not specify which provider is responsible for performing the duty. Patient 5: The initial plan of care order for foley size, change frequency, and maintenance did not specify which provider is responsible for performing the duties. Corrected on site.”