Gentiva II

Content of comprehensive assessment (42 CFR 418.54(c)(6))

Rule L0530. Standard-level.

Content of comprehensive assessment (42 CFR 418.54(c)(7))

Rule L0531. Standard-level.

Approach to service delivery (42 CFR 418.56(a)(1))

Rule L0540. Standard-level.

Content of plan of care (42 CFR 418.56(c)(4))

Rule L0549. Standard-level.

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

Rule L0550. Standard-level.

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

“Upon client record review, 1 of 19 (Patient #3) 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 3: There was no evidence of collaboration with the attending physician for review of the plan of care since 6/2/26.”

Rule L0552. 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 client record review, 1 of 19 (Patient #10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 10: The medical record contained nursing documentation 4/24/26 regarding indwelling catheter being removed. There was no evidence of an order to remove the catheter.”

Rule L0555. Standard-level.

Program activities (42 CFR 418.58(c)(2))

“Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient 12: The medical record contained documentation by the social worker 5/11/26 that the facility reported the patient had a fall. There was no evidence of hospice investigation of the incident.”

Rule L0569. Standard-level.

Counseling services (42 CFR 418.64(d)(1))

Rule L0596. Standard-level.

Hospice aide assignments and duties (42 CFR 418.76(g)(1))

“Upon patient record review, 1 of 19 (Patient #9) did not have evidence in the patient record that hospice aide assignments and duties are specific to patient needs. Patient 9: The aide care plan did not contain instructions that the patient requires thickened liquids.”

Rule L0625. Standard-level.

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

“Upon patient record review 1 of 19 (Patient #10) 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 10: There was no evidence of an aide supervisory visit from 5/5/26 to 6/15/26.”

Rule L0629. Standard-level.

Recertification of the terminal illness (42 CFR 418.102(c))

“Upon client record review, 1 of 19 (Patient #1) did not have evidence that the physician provides a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the recertification form, or as an addendum to the recertification form. Patient 1: The Recertification of Terminal Illness for benefit period 3 starting 9/24/25 did not contain a physician narrative regarding patient eligibility.”

Rule L0668. Standard-level.

Content (42 CFR 418.104(a)(6))

“Upon patient client record review, 3 of 19 (Patients #6,#13,#16) did not have evidence that each patient record contains Advance Directives. Patient 6,16: The plan of care identified the patient as DNR. There was no evidence of advanced directives such as a living will, POLST form, or DNR in the medical record. Patient 13: The plan of care identified the patient as DNR. The DNR order form was incomplete and unsigned by a physician.”

Rule L0677. Standard-level.

Hospice plan of care (42 CFR 418.112(d))

“Upon client record review, 1 of 19 (Patient #6) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 6: The medical record contained an order for nursing visits twice weekly. There was no evidence of a second visit completed the week of 4/19/26.”

Rule L0773. Standard-level.

Hospice plan of care (42 CFR 418.112(d)(1))

“Upon client record review, 1 of 19 (Patient #5) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 5: The medical record contained orders for peg tub insertion site care that does not specify facility and hospice responsibilities.”

Rule L0774. Standard-level.

Coordination of services (42 CFR 418.112(e)(3))

“Upon patient record review, 1 of 19 (Patient #6) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient Patient 6: During home visit review of hospice documentation, the facility did not have an election form, CTI, or plan of care updates since 5/5/26.”

Rule L0781. Standard-level.