Gentiva I

Timeframe for completion of assessment (42 CFR 418.54(b))

“Upon patient record review 1 of 19 (Patient #3) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual’s attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 3: No evidence that the spiritual assessment was completed within 5 days of admission. The patient was admitted on 5/2/25. The spiritual care assessment was completed on 5/8/25.”

Rule L0523. Standard-level.

Update of comprehensive assessment (42 CFR 418.54(d))

Rule L0533. Standard-level.

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

Rule L0545. Standard-level.

Content of plan of care (42 CFR 418.56(c)(5))

“Upon patient record review, 1 of 19 (Patient #1) 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 indicated that the patient was admitted with a foley catheter. Foley catheter removed on 02/21/2025. Foley catheter supplies remained active on the current plan of care that started on 07/29/2025.”

Rule L0550. Standard-level.

Review of the plan of care (42 CFR 418.56(d))

Rule L0553. Standard-level.

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

“Upon patient record review, 1 of 19 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: The RN documentation on 05/01/25 indicated that the patient acquired a skin tear on the elbow and that the nurse changed the bandage during the visit. No evidence that an order was received that contained specific wound care orders for the skin tear.”

Rule L0555. Standard-level.

Prevention (42 CFR 418.60(a))

“Upon observation and home visit 1 of 4 (Patient #2), there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #2: During the home visit, the hospice aide placed her electronic tablet onto the counter in the patients room without a barrier of any sort.”

Rule L0579. Standard-level.

Control (42 CFR 418.60(b)(1))

“Upon observation, there was no evidence in QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the hospice’s Quality Assessment and Performance Improvement program. Patient 1: Medical record indicated that the patient had a UTI in June 2025. No evidence that a surveillance report was completed at the time of survey.”

Rule L0580. Standard-level.

Supervision of hospice aides (42 CFR 418.76(h)(1))

“Upon patient record review 1 of 19 (Patient #5) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient 5: No evidence that a registered nurse made an aide supervisory visit every 14 days between 08/19/25- 09/11/25 (23 days).”

Rule L0629. Standard-level.

Services (42 CFR 418.100(c))

“Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Nursing services • Medical social services • Physician services • Counseling services, including spiritual counseling, dietary counseling and bereavement counseling • Hospice aide, volunteer, homemaker services • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care • Medical supplies (including drugs and biologicals) and medical appliance Patient #10: Medical record indicated that the LPN had edited an intervention in the respiratory chapter of the plan of care.”

Rule L0652. Standard-level.