Family Hospice, Ltd D/B/A Gentiva

“Upon patient record review 3 of 19 (Patient #6,10,14) 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 6: No evidence that the initial spiritual comprehensive assessment was completed within 5 days of admission. The patient was admitted on 03/20/25. The spiritual care assessment was completed on 3/31/25, 11 days after admission. Patient 10: No evidence that the initial spiritual comprehensive assessment was completed within 5 days of admission. The patient was admitted on 03/21/25. The spiritual care assessment was completed on 3/27/25, 6 days after admission. Patient 14: No evidence that the initial spiritual comprehensive assessment was completed within 5 days of admission. The patient was admitted on 03/05/25. The spiritual care assessment was completed on 3/11/25, 6 days after admission.”

“Upon patient record review, 4 of 19 (Patient #1,5,6,7) 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: The RN documentation indicated that patient has oxygen at 2L at bedtime. No evidence that oxygen was added to the current medication list. COS- new order placed for oxygen at 2LNC PRN during survey. Patient 5: The RN documentation indicated that patient uses a BIPAP at 7L continuously. No evidence that BIPAP orders were added to the current medication list. COS - new order placed for CPAP during survey. Patient 6: The RN documentation indicated that patient has oxygen at 2L as needed at bedtime. No evidence that oxygen was added to the current medication list. COS - new order placed for oxygen at 2LNC PRN during survey. Patient 7: The current plan of care includes orders for Lorazepam 1mg tab PRN as needed for seizures. No evidence active medication profile included a frequency for the medication to be given. The RN documentation indicated that the patient used oxygen at 3-5L NC. The current medication profile has the oxygen flow rate ordered at 5-10L via NC. No evidence that the an order was received for 3LNC. COS - new order placed to update oxygen flow during survey.”

“Upon patient record review, 1 of 19 (Patient #6) 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 6: The patient was admitted on 03/20/2025. No evidence that the initial bereavement risk assessment was completed within 5 days of admission. Assessment completed on 04/22/2025.”

“Upon patient record review, 2 of 19 (Patient #9,13) 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 9: No evidence that a RN comprehensive assessment was completed every 15 days between 06/26/2025 and 07/17/2025. 21 days between assessments. Patient 13: No evidence that a RN comprehensive assessment was completed every 15 days between 06/27/2025 and 07/19/2025. 22 days between assessments.”

“Upon patient record review, 1 of 19 (Patient #3) 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. policy is for wounds to be measured weekly. Patient 3: The record indicates that patient developed cellulitis on 02/13/2025 that healed on 03/13/2025. No evidence that the wound was measured since the day it was first assessed by the RN. The record indicates that patient developed a wound to the left buttock on 04/23/2025. No evidence that the wound was assessed. The documentation reflects that the wound was active from 04/23/2025 - 05/27/2025. Gentiva policy is for wounds to be measured weekly.”

“Upon patient record review, 2 of 19 (Patient #8,14) 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 documentation indicated that the patient has trouble swallowing and is a risk for aspiration. No evidence of problems, interventions, and goals related to safety/risk of aspiration. COS - Plan of care order written to add aspiration to the active plan of care during survey. Patient 14: The documentation indicated that the patient has trouble swallowing and is a risk for aspiration. No evidence of problems, interventions, and goals related to safety/risk of aspiration. COS - Plan of care order written to add aspiration to the active plan of care during survey.”

“Upon patient record review, 1 of 19 (Patient #5) 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. use. Physician order updated during the survey. Patient 5: The initial visit frequency for both the social worker and the spiritual care counselor was 1 PRN without a standing order on the initial evaluation order, order corrected once the disciplines completed their evaluations.”

“Upon patient record review, 4 of 19 (Patient #1,5,6,7) 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. medications and treatments. Patient 1: The RN documentation indicated that patient has oxygen at 2L at bedtime. No evidence that an order was received for oxygen. COS- new order placed for oxygen at 2LNC PRN during survey. Patient 5: The RN documentation indicated that patient uses a BIPAP at 7L continuously. No evidence that an order was placed for BIPAP. COS - new order placed for CPAP during survey. COS - new order placed for CPAP during survey Patient 6: The RN documentation indicated that patient has oxygen at 2L as needed at bedtime. No evidence that an order was received for oxygen. COS- new order placed for oxygen. COS - new order placed for oxygen at 2LNC PRN during survey. Patient 7: The current plan of care includes orders for Lorazepam 1mg tab PRN as needed for seizures. No evidence that the order included a frequency for the medication to be given. The RN documentation indicated that the patient used oxygen at 3-5L NC. The plan of care has the oxygen flow rate ordered at 5-10L via NC. No evidence that the an order was received for 3LNC. COS - new order placed to update oxygen flow during survey.”

“Upon patient record review, 2 of 19 (Patient #1,5) 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 the patient has oxygen PRN available in the home. No evidence that oxygen was included on the current DME supply list. The current supply list included wound care supplies. No evidence that the patient has ever had a wound during time of service. COS - New order written to update the current DME and supply list during survey. Patient 5: The clinical documentation indicated that the patient uses a Hoyer lift due to altered mobility that is used for transfers. No evidence that a Hoyer lift was included on the current DME list. COS- New order written to update the current DME list.”

“Upon patient record review, 1 of 19 (Patient #14) 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 14: The medical record indicated that patient requested to end chaplain services on 05/28/2025. Problems, interventions, and goals related to spiritual care remain on the current the plan of care - new benefit period started on 07/12/2025. COS - new order written to remove the spiritual care plan from the plan of care during survey.”

“Upon patient record review, 3 of 19 (Patient #17,18,19) 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 #17: No evidence that the bereavement plan of care was being followed. No evidence of post-death 2 week mailing was mailed within 2 weeks of the date of death. Patient died on 11/05/2024, sent on 12/23/2024. Patient #18: No evidence that the bereavement plan of care was being followed. Patient had 2 bereavement contacts. One was mailed a unable to contact letter. The other had a care plan for letters to be sent. No evidence of post-death 2 week mailing was mailed within 2 weeks of the date of death. Patient died on 10/04/2024, sent on 12/23/2024. No evidence that the 6 month letter was sent. Patient #19: No evidence that the bereavement plan of care was being followed. No evidence of post-death 2 week mailing was mailed within 2 weeks of the date of death. Patient died on 12/27/2024, no evidence that the mailing was sent.”