Gentiva

“Upon patient record review, 7 of 30 (Patients #1,#2,#4,#5,#6,#11,#13) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 1: The medication profile contained duplicative polyethylene glycol listings and oxygen not listed. The medical record contained nursing documentation 5/2/24 identifying patient use of oxygen. Corrected on site. Upon observation during the home visit medication reconciliation, the facility medication profile did not contain bisocodyl suppositories, dextromethorphan-guaifenesin and albuterol inhaler orders that were on the hospice medication profile. Patient 2: The medication profile contained duplicative Miralax listings. Corrected on site. Patient 4: The medication profile contained differing oxygen listings for PRN and continuous. Corrected on site. Patient 5: The medication profile contained Biofreeze topical gel with no area defined for administration. Corrected on site. Patient 6: The medication profile contained duplicative lorazepam PRN orders for oral tablets and concentrate. There was no evidence of instructions to differ when administration appropriate or if allowed together. Corrected on site. Patient 11: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of the oxygen listed on the medication profile. Corrected on site. Patient 13: The medication profile contained duplicative Tylenol PRN listings. Corrected on site.”

“Upon patient record review, 1 of 20 (Patient #13) 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 13: The medical record contained an initial bereavement assessment completed 7/5/23 with a start of care 6/28/23.”

“Upon patient record review, 2 of 20 (Patients #4,#15) 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 4: The medical record contained nursing documentation 4/23/24 identifying patient issues with constipation and nausea. There was no evidence of problems, goals, and interventions related to constipation and nausea included in the plan of care. Corrected on site. Patient 15: The medical record contained nursing documentation upon recertification 3/18/24 identifying patient has episodes of chest pain relieved by nitro. There was no evidence of problems, goals, and interventions related to the chest pain. Corrected on site.”

“Upon patient record review, 4 of 20 (Patients #1,#5,#6,#11) 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: The medical record contained nursing documentation 5/2/24 identifying patient use of oxygen. There was no evidence of an order for oxygen. Corrected on site. Patient 5: The medical record contained nursing documentation upon admission identifying patient had a wound to the left hip. There was no evidence of an order for wound care to the left hip wound. Corrected on site. Patient 6: The medical record contained duplicative lorazepam PRN orders for oral tablets and concentrate. There was no evidence of instructions to differ when administration appropriate or if allowed together. Corrected on site. Patient 11: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen. Corrected on site.”

“Upon patient record review, 8 of 20 (Patients #1,#4,#7,#8,#11,#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 admission and recertification identifying patient use of a hospital bed, bedside table, and oxygen equipment. There was no evidence of orders for the equipment included in the plan of care. Corrected on site. Patient 4: The medical record contained nursing documentation upon admission identifying patient use of a shower chair. There was no evidence of an order for the equipment included in the plan of care. Corrected on site. Patient 7: The medical record contained nursing documentation upon recertification 4/4/24 identifying patient use of a commode. There was no evidence of an order for the equipment included in the plan of care. Corrected on site. Patient 8: The medical record contained nursing documentation upon recertification 4/29/24 identifying patient use of bedrails. There was no evidence of an order for the equipment included in the plan of care. Corrected on site. Patient 11: The medical record contained nursing documentation upon recertification 4/30/24 identifying patient use of a Hoyer lift and the medication profile contained an albuterol prescription requiring a nebulizer. There was no evidence of orders for the equipment included in the plan of care. Corrected on site. Patient 12: The medical record contained nursing documentation 4/29/24 identifying patient use of a wheelchair. There was no evidence of an order for the equipment included in the plan of care. Corrected on site. Patient 13: The medical record contained nursing documentation upon recertification 4/10/24 identifying patient use of bedrails and bedside table. There was no evidence of orders for the equipment included in the plan of care. Corrected on site. Patient 15: The medical record contained nursing documentation upon admission identifying patient use of a walker and catheter supplies. There was no evidence of an order for the equipment included in the plan of care. Corrected on site.”

“Upon patient record review, 7 of 20 (Patients #1,#2,#6,#7,#8,#11,#14) did not have evidence in the patient record that hospice aide assignments and duties are specific to the patient needs. whether personal care or non-personal care tasks, are not acceptable Patient 1: The aide care plan did not contain instructions on transfer assistance needed. Corrected on site. Patient 2: The aide care plan did not contain instructions on transfer assistance needed. Corrected on site. Patient 6: The aide care plan did not contain instructions on transfer assistance needed. Corrected on site. Patient 7: The aide care plan did not contain instructions on transfer assistance needed. Corrected on site. Patient 8: The aide care plan did not contain instructions on transfer assistance needed. Corrected on site. Patient 11: The aide care plan did not contain instructions on need for 2 person assist with Hoyer lift. Corrected on site. Patient 14: The aide care plan did not contain instructions on transfer assistance needed. Corrected on site.”

“Upon patient client record review, 1 of 20 (Patient #20) 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 20: The medical record contained an order for patient to discharge due to going to non-contracted facility, however the discharge summary states transfer to another hospice. Agency confirmed the patient was a discharge and not a transfer and that the discharge reason was coded inaccurately resulting in the conflicting information.”