Gentiva

“Upon patient record review, 2 of 5 (Patient #3,4) 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: Current supply list has wound care supplies listed. No evidence that the patient has had a wound during the time on service. Patient 4: Current DME supply list has an oxygen concentrator listed. The medical record indicated that oxygen was discontinued on 05/12/26. No evidence oxygen concentrator was removed from the DME supply list at that time.”

“Upon patient record review, 8 of 27 (Patients #4,#5,#8,#9,#12,#14,#16,#18) 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 facility and hospice medication profiles did not match. The facility profile contained Miralax as a PRN medication instead of scheduled on hospice profile, did not contain scheduled donepazil that was on hospice profile, contained acetaminophen, ondansetron and Mylanta PRNs that were not on hospice profile, and contained scheduled Aricept and docusate that were not on hospice profile. Patient 5: Upon home visit medication reconciliation, the facility and hospice medication profiles did not match. The facility profile did not contain scheduled olanzapine that was on hospice profile. Patient 8: The medication profile contained glucose tablets without a specification for when administration is appropriate, and duplicate listings of morphine and naproxen. Upon home visit medication reconciliation, the facility and hospice medication profiles did not match. The facility profile contained oxygen at 2 LPM and hospice had 2-4 LPM. Patient 9,18: The medication profile contained nitroglycerin tablet every 5 minutes without instructions for a maximum amount of consecutive doses. Patient 12: The medication profile contained duplicate listings of senna. Patient 14: Upon home visit medication reconciliation, the facility and hospice medication profiles did not match. The facility profile did not contained scheduled acidophilus that was on hospice profile. Patient 16: Upon home visit medication reconciliation, the facility and hospice medication profiles did not match. The facility profile contained Ativan scheduled twice daily instead of once daily at bedtime on hospice profile, and contained a scheduled Linzess and PRN senna that were not on hospice profile.”

“Upon patient record review, 2 of 27 (Patients #15,#17) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 15: The medical record contained documentation identifying patient wound on bilateral buttocks. There was no evidence of weekly wound measurements and assessments since 3/23/26 as required per agency policy. Patient 17: The medical record contained documentation identifying patient wound on left calf. There was no evidence of weekly wound measurements and assessments since 3/20/26 as required per agency policy.”

“Upon patient record review, 2 of 27 (Patients #8,#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 8: The medical record indicated the patient was on services for heart disease and had use of oxygen since admission. There was no evidence of problems, goals, and interventions related to cardiac and respiratory dysfunctions included in the plan of care. Patient 13: The medical record contained diagnoses of bradycardia and hypertension that were supported with vitals documentation. There was no evidence of problems, goals, and interventions related to cardiac dysfunction included in the plan of care.”

“Upon patient record review, 9 of 27 (Patients #4,#5,#8,#9,#10,#11,#14,#16,#18) 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 facility and hospice medication orders did not match. The facility orders contained Miralax as a PRN medication instead of scheduled on hospice profile, did not contain scheduled donepazil order that was on hospice medical record, contained acetaminophen, ondansetron and Mylanta PRN orders that were not on hospice record, and contained scheduled Aricept and docusate orders that were not on hospice record. The record also contained nursing documentation identifying the patient had a feeding tube since admission. There was no evidence of an order for the tube insertion site care, and flushing or maintenance. Patient 5: Upon home visit medication reconciliation, the facility and hospice medication orders did not match. The facility record did not contain a scheduled olanzapine order that was on hospice profile. Patient 8: The medical record contained an order for glucose tablets without a specification for when administration is appropriate. Upon home visit medication reconciliation, the facility and hospice medication orders did not match. The facility profile contained an oxygen order at 2 LPM and hospice had 2-4 LPM. Patient 9,18: The medical record contained an order for nitroglycerin tablet every 5 minutes without instructions for a maximum amount of consecutive doses. Patient 10: The medical record contained nursing documentation 2/27/26 identifying patient had a g-tube placed. There was no evidence of an order for the tube insertion site care, and flushing or maintenance. Patient 11: The medical record contained nursing documentation since admission identifying patient has a colostomy. There was no evidence of an order for colostomy maintenance. Patient 14: Upon home visit medication reconciliation, the facility and hospice medication orders did not match. The facility profile did not contain an order for scheduled acidophilus that was on hospice record. Patient 16: Upon home visit medication reconciliation, the facility and hospice medication orders did not match. The facility contained an order for Ativan scheduled twice daily instead of once daily at bedtime on hospice record, and the facility contained orders for scheduled Linzess and PRN senna that were not on hospice record.”

“Upon patient record review, 6 of 27 (Patients #1,#2,#8,#12,#13,#15) 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 1: The medical record contained nursing documentation upon recertification assessment 2/24/26 identifying patient use of a wheelchair. There was no evidence of an order for the DME included in the plan of care. Patient 2: The medical record contained nursing documentation 4/3/26 identifying patient use of a sit to stand mechanical lift. There was no evidence of an order for the DME included in the plan of care. Patient 8: The medical record contained nursing documentation upon recertification assessment 2/16/26 identifying patient use of an APP mattress. There was no evidence of an order for the DME included in the plan of care. Patient 12: The medical record contained nursing documentation since admission identifying patient use of a wheelchair, and bedrails since recertification assessment 3/18/26. There was no evidence of orders for the DME included in the plan of care. Patient 13: The medical record contained nursing documentation upon recertification assessment 3/2/26 identifying patient use of a wheelchair. There was no evidence of an order for the DME included in the plan of care. Patient 15: The medical record contained an order for nebulized medications. There was no evidence of an order for the nebulizer included in the plan of care.”

“Upon client record review, 2 of 27 (Patients #2,#19) 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 2: The election form identified the patient elected a community physician as their attending. There was no evidence of collaboration with the attending for review of the plan of care since 2/25/26. Patient 19: The election form identified the patient elected a community physician as their attending. There was no evidence of collaboration with the attending for review of the plan of care since 3/5/26 until start of survey 4/6/26.”

“Upon patient record review, 2 of 27 (Patients #4,#15) 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 4: The medical record contained an order for the patient to receive Jevity tube feedings three times daily if the patient consumes less than 50% of each meal. There was no evidence the plan of care was updated to reflect the change in nutrition interventions from scheduled every four hours, to as needed. Patient 15: The medical record contained nursing documentation upon recertification assessment 2/9/26 identifying patient had multiple medication changes for agitation. There was no evidence the plan of care was updated to include problems, goals, and interventions related to agitation.”

“Upon client record review, 3 of 27 (Patients #7,#11,#20) 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 weekly. There was no evidence of a visit completed the week of 3/1/26. Patient 11: The medical record contained an order for nurse visits twice weekly. There was no evidence of a second visit completed the week of 3/8/26. Patient 20: The medical record contained an order for social worker visits once monthly. There was no evidence of visits completed in February and March 2026.”

“Upon patient record review, 5 of 27 (Patients #2,#6,#10,#11,#20) did not have evidence in the patient record that hospice aide assignments and duties are: • Specific to patient needs. • 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. Patient 2: The medical record contained nursing documentation 4/3/26 identifying patient use of a sit to stand mechanical lift. There was no evidence of instructions for transfer assistance required on the aide care plan. Patient 6: The aide care plan contained bathing tasks for bed baths every visit and showers every visit. Patient 10: The medical record contained nursing documentation since admission identifying patient use of a Purwick external catheter. There was no evidence of instructions for catheter use or care included on the aide care plan. Patient 11: The medical record contained nursing documentation since admission identifying patient has a colostomy. There was no evidence of instructions regarding the colostomy included on the aide care plan. Patient 20: The aide care plan contained task for routine catheter care. Nursing documentation 12/17/25 identified the catheter was removed.”

“Upon patient client record review, 1 of 27 (Patient #1) 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: The medical record contained nursing documentation upon recertification assessment 2/24/26 identifying patient has dyspnea with minimal exertion. After agency investigation, the documentation was in error and did not reflect patient condition.”

“Based on agency policy, clinical record review, and staff interviews, the agency failed to include oxygen and suctioning in the plan of care for 1 of 1 patient with suctioning (patient #1).Finding included: A policy, The Plan of Care (revised 12/31/2025) received on 01/12/2026 at 2:20 PM from the administrator stated, “The written plan of care will contain, but not limited to, the following: … DME [durable medical equipment] and medical supplies necessary to meet the patient needs…”Patient #1 was admitted on 09/19/2025 with a diagnosis of malignant neoplasm of colon (colon cancer). The plan of care or 09/19/2025-12/17/2025 included orders for skilled nurse (SN) visits 2 times a week for 1 week, 3 times a week for 2 weeks for 10 weeks, 1 time a week for 1 week, and 3 PRN (as needed). Review of the clinical record revealed that on 09/24/2025 Registered nurse (RN) #5 documented, “PT [patient] breathing is labored … Daughter removes phlegm [thick mucus] with use of suctioning… suction machine ordered…” Further review revealed that a physician’s order for oxygen and suctioning were not included in the plan of care.During an interview conducted on 01/12/2026 at 1:28 PM RN #5 stated, “There should be an order in there if she has it… Yes, it should be added to the plan of care.”During an interview conducted on 01/12/2026 1:39 PM the administrator stated, “Always get an order from the physician and add it to the plan of care.””

“Based on agency policy, clinical record review, and staff interviews, the agency failed to document providing instructions for proper use of durable medical equipment (DME) for 1 of 3 patients with DME (patient #1).Findings included: A policy, Clinical Record (revised 12/3/12025) received on 01/12/2026 at 2:17 PM from the agency administrator stated, “A clinical/service record will be initiated and maintained for each patient… and will include at a Minimum: … Documentation of any/all education provided to the patient/caregiver…”Patient #1 was admitted on 09/19/2025 with a diagnosis of malignant neoplasm of colon (colon cancer). The plan of care or 09/19/2025-12/17/2025 included orders for skilled nurse (SN) visits 2 times a week for 1 week, 3 times a week for 2 weeks for 10 weeks, 1 time a week for 1 week, and 3 PRN (as needed). Review of the clinical record revealed that on 09/24/2025 Registered nurse (RN) #5 documented, “PT [patient] breathing is labored … Daughter removes phlegm [thick mucus] with use of suctioning… suction machine ordered…” Further review revealed that no education to the patient/caregiver was documented on how to use the suction machine.An interview with RN #5 on 01/12/2026 at 1:28 PM revealed that interventions on education should be included in the plan of care.An interview with the administrator on 01/12/2026 at 1:39 PM revealed that when an order is added to the plan of care education to the patient/family should be added.”

“Based on agency policy, clinical record review, and staff interviews, the agency failed to document caregiver problems for 1 of 1 patient with a discharge for cause (patient #1)Findings included: A policy, Clinical Record (revised 12/12/2025), received on 12/15/2025 at 2:23 PM from the agency director stated, “A clinical/service record will be initiated and maintained for each patient receiving care… and will include at a minimum… Patient/family response to care/services provided… Entries into the clinical record will be clear, concise, and specific statements of fact.”A policy, Live Discharge and Discharge Planning Process (revised 11/05/2025) received on 12/15/2025 at 12:52 PM from the agency director stated, “Document the problem(s)…”Patient #1 was admitted on 04/19/2024 with a diagnosis of dysphagia (difficulty swallowing) following a cerebral infarction (brain tissue death following a blood clot). The plan of care for 08/15/2025-10/13/2025 included orders for skilled nurse (SN) visits 1 time a week for 8 weeks with 4 PRN (as needed) and home hospice aid (HHA) visits 1 time a week for 1 week, 5 times a week for 8 weeks, and 1 time a week for 1 week. A review of the clinical record revealed that registered nurse #4 documented that the patient was discharged due to, “CG [caregiver] using inappropriate language with staff.” Further review revealed that there was no documentation of the caregiver using inappropriate language with the staff.An interview with the agency director on 12/15/2025 at approximately 1:45 PM revealed that the caregiver was using inappropriate language with HHA #5. 26 of 26 HHA visits conducted between 08/15/2025 and 10/02/2025 were documented with no indication of problems with the caregiver.An interview conducted on 12/15/2025 at 2:00 PM with HHA #5 revealed that they failed to document the caregiver problems and failed to document notifying the registered nurse. HHA #5 stated that sometimes they document aggression.An interview conducted on 12/15/2025 at 2:04 PM with the agency director revealed that caregiver problems and conversations with the registered nurse should be documented in the clinical record.”