Gentiva I

“Upon patient record review, 5 of 19 (Patients #5,#6,#7,#12,#13) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 5: Upon home visit medication review, the facility and hospice medication profiles did not match. The facility had an albuterol inhaler and lidocaine patch daily as needed that were not on the hospice profile, the facility had gabapentin 400mg three times daily listed with hospice dose at 100mg twice daily, the facility listed lorazepam every 2 hours as needed with hospice every 8 hours as needed, the facility listed melatonin scheduled with hospice listed as needed, and facility listed ondansetron every 6 hours as needed with hospice every 8 hours as needed. Corrected on site. Patient 6: The medical record contained nursing documentation since admission identifying patient use of oxygen. There was no evidence of oxygen included in the medication profile. Corrected on site. Patient 7: Upon home visit medication review, the facility and hospice medication profiles did not match. The facility had an albuterol inhaler and guaifenesin that were not on the hospice medication profile. Corrected on site. Patient 12: Upon home visit medication review, the patient did not have citalopram that was listed on the medication profile, and had divalproex as needed that was not on the profile. Corrected on site. Patient 13: The medical record contained nursing documentation since admission identifying patient use of oxygen. There was no evidence of oxygen included in the medication profile. Upon home visit medication review, the facility medication profile did not contain ondansetron as needed. Corrected on site.”

“Upon patient record review, 2 of 19 (Patients #5,#9) 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 5: The initial bereavement assessment was completed 2/25/25 with start of care 2/19/25, not meeting the five day timeline. Patient 9: The initial bereavement assessment was completed 2/7/25 with start of care 2/1/25, not meeting the five day timeline.”

“Upon patient record review, 2 of 19 (Patients #5,#11) 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 5: The medical record contained nursing documentation 2/19/25 upon admission, identifying the patient had a coccyx wound that was unable to be examined during the initial assessment. There was no evidence of a skin assessment completed until 3/4/25. Patient 11: The medical record contained wound care orders 1/30/25 for right and left buttocks. There was no evidence of measurements of the left buttock wound from 1/30/25 to 2/24/25, and no assessments of the left buttock wound from 2/3/25 to 2/24/25.”

“Upon patient record review, 3 of 19 (Patients #9,#11,#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 9: The medical record contained documentation of the patient’s primary diagnosis of Alzheimer’s disease. There was no evidence of problems, goals, and interventions related to neurological dysfunction included in the plan of care. Corrected on site. Patient 11: The medical record contained nursing documentation upon admission identifying the patient as a high risk for falls. There was no evidence of problems, goals, and interventions related to fall safety. Corrected on site. Patient 14: The medical record contained nursing documentation upon admission identifying patient is a high risk for falls and has pitting edema. There was no evidence of problems, goals, and interventions related to fall safety and edema included in the plan of care. Corrected on site.”

“Upon patient record review, 3 of 19 (Patients #3,#6,#13) 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 3: The medical record contained nursing documentation since admission identifying patient use of a Bipap at night. There was no evidence of an order for Bipap parameters. Corrected on site. Patient 6,13: The medical record contained nursing documentation since 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, 6 of 19 (Patients #3,#5,#7,#9,#12,#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 3: The medical record contained nursing documentation since admission identifying patient use of a Bipap at night. There was no evidence of an order for the equipment. Corrected on site. Patient 5: The medical record contained nursing documentation upon admission identifying patient use of a nebulizer. There was no evidence of an order for the equipment. Corrected on site. Patient 7: The medical record contained nursing documentation upon admission identifying patient use of half rails, and 12/20/24 identifying use of an over the bed table and low air loss mattress. There was no evidence of an order for the equipment. Corrected on site. Patient 9: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, over the bed table, wheelchair, and oxygen. There was no evidence of an order for the equipment. Corrected on site. Patient 12: The medical record contained nursing documentation upon recertification 1/13/25 identifying patient use of a fall mat. There was no evidence of an order for the equipment. Corrected on site. Patient 14: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, low air loss mattress, and over the bed table; and 2/24/24 identifying use of a wheelchair. There was no evidence of an order for the equipment. Corrected on site.”

“Upon patient record review, 4 of 19 (Patients #5,#7,#8,#13) 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 5: The plan of care contained active wound care orders. The wound was documented as healed 3/4/25. Corrected on site. Patient 7: The medical record contained nursing documentation 11/4/24 identifying patient relocation to a facility. The plan of care contained active problems, goals, and interventions identifying caregiver strain with the patient’s need for long-term placement. Corrected on site. Patient 8: The plan of care was not updated with DNR code status, signed 2/4/25. Patient admitted as full code that was still the identified code status on the plan of care. Corrected on site. Patient 13: The medical record contained nursing documentation upon admission identifying patient was receiving fluids via an IV. There was no evidence of current IV fluid administration and the plan of care contained active problems, goals, and interventions for IV use. Corrected on site.”

“Upon patient record review, 1 of 19 (Patient #5) did not have evidence in the patient record that hospice aide assignments and duties are: • 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 5: The aide care plan contained tasks to turn and reposition per patient request as needed; and transfer as needed. Corrected on site.”