Gentiva

“Upon patient record review, 8 of 27 records (Patient #2,#3,#4,#9,#10,#11,#12,#20) 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 #2: The medication profile contained duplication of Ipratropium 0.5%/Albuterol 3mg/ml nebulizer. One dated 5/1/24 stating q8h prn and 1 dated 5/8/24 stating every 4h prn. Corrected on site. Patient #3: The medication profile contained a duplicate medication for Lorazepam 0.5 mg tab, q4h prn anxiety or agitation. Corrected on site. Patient #4: The medication profile contains oxygen 2L/min prn SOB. There was not evidence of a route. Corrected on site. Patient #9: The medical record contained nursing documentation 5/21/24 identifying patient has nitroglycerin in the home for chest pain. There was no evidence of the nitroglycerin listed on the medication profile. Corrected on site. Patient #10: The medication profile contained all oral medications but listed alternate routes of under the tongue including Ativan, carvedilol, clonidine, gabapentin, hydrocodone-acetaminophen, oxcarbazepine, pantoprazole, sen-o-tab, Seroquel, and trazadone. Corrected on site. Patient #11: Ativan, Morphine scheduled and prn, and Venlafaxine all have the route as oral and should be via PEG tube. Patient #12: Several medications listed route as oral and not via PEG tube including Allopurinol, Baclofen, Citalopram, Duloxetine, Gabapentin, Seroquel and Morphine. The Miralax had a route of O2 Nasal and did not include directions for mixing. Patient 20: During medication review for the home visit, the hospice medication profile did not match the facility medication profile. The hospice identified a Senna-S PRN and the facility identified Senna without the docusate as a PRN. Corrected on site.”

“Upon patient record review, 1 of 27 records (Patient #18) 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 #18: The medical record contained an initial bereavement assessment completed 4/10/24 with a start of care 4/2/24.”

“Upon patient record review, 2 of 27 records (Patient #19, #20) did not have evidence that a Registered Nurse ensured continuous assessment of the patient and family’s needs and coordinated 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 #19: The medical record contained left heel wound measurements 4/7/24, 5/10/24, 5/30/24, and 6/10/24, and right heel measurement 4/7/24 with inactivation 4/24/24 without additional assessments. There was no evidence of weekly wound measurements completed as required per agency policy. Patient #20: The medical record contained nursing documentation since admission identifying patient has a wound to left hip. There was no evidence of a weekly wound measurement completed between 5/20/24 and 6/3/24 as required per agency policy.”

“Upon patient record review, 1 of 27 (Patient #18) 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 #18: The medical record contained nursing documentation since admission identifying patient issues with bradycardia and peripheral edema. There was no evidence of problems, goals, and interventions related to cardiovascular dysfunction in the plan of care. Corrected on site.”

“Upon patient record review, 2 of 27 records (Patient #12, #13) 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. Patient #12 order on 5/28/24 to increase visits to 2x month for caregiver support and did not include the discipline that would be making the visits. Patient #13 initial plan of care included frequencies for MSW and SC as 1 prn eval.”

“Upon patient record review, 5 of 27 records (Patient #4, #9, #10, #11, #12) 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 #4: The record indicated an order for oxygen 2L/min prn SOB. There was not evidence of a route. Corrected on site. Patient #9: The medical record contained nursing documentation 5/21/24 identifying patient has nitroglycerin in the home for chest pain. There was no evidence of an order for nitroglycerin. Corrected on site. Patient #10: The medical record contained orders for all oral medications have alternate routes of under the tongue including Ativan, carvedilol, clonidine, gabapentin, hydrocodone-acetaminophen, oxcarbazepine, pantoprazole, sen-o-tab, Seroquel, and trazadone. Corrected on site. Patient #11: Nursing visits on 6/15/24 and 6/17/24 document tube feedings being held, there is no evidence of an order to hold tube feedings. Ativan, Morphine scheduled and prn, and Venlafaxine all have the route as oral and should be via PEG tube. Patient #12: RN visit 4/3/24 documents the use of a trilogy, no orders for the trilogy settings, use, management. Nursing visits document the presence of a PEG tube with tube feedings of Kate Farms 1-2 cans/day, no evidence of an order for the tube feedings. Several medications listed route as oral and not via PEG tube including Allopurinol, Baclofen, Citalopram, Duloxetine, Gabapentin, Seroquel and Morphine. The Miralax had a route of O2 Nasal and did not include directions for mixing.”

“Upon patient record review, 2 of 27 records (Patient #17,#19) 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 #17: The medical record contained nursing documentation since admission identifying patient use of a walker. There was no evidence of an order for the walker included in the plan of care. Corrected on site. Patient #19: The medical record contained nursing documentation since admission identifying patient use of a wheelchair, and during home visit, it was observed the patient has a low air loss mattress. There was no evidence of orders for the wheelchair and mattress included in the plan of care. Corrected on site.”

“Upon patient record review, 3 of 27 (Patient #7, #9, #19) 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 #7: The spiritual care counselor had been visiting the patient and had established outcome/goals in the plan of care. The patient declined the spiritual care counselor , dated 3/28/24, and the service was discontinued. The specific goals and interventions related to the patient’s spiritual well being, with goals specific to the spiritual care provider remained on the care plan. Corrected on site. Patient #9: The medical record contained nursing documentation 5/21/24 identifying patient has nitroglycerin in the home for chest pain. There was no evidence of problems, goals, and interventions related to cardiovascular dysfunction included in the plan of care. Corrected on site. Patient #19: The plan of care contained active problem of caregiver strain and goals of facility placement for the patient. Social worker documentation identified the patient moved into a nursing facility 3/19/24. Corrected on site.”

“Upon client record review, 2 of 27 records (Patient #4,#5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4: The volunteer orders for the certification period beginning on 5/6/24 indicated encouragement cards and cookie delivery. The records contained visit documents for the dates of 5/23/24 and 5/28/24. Patient #5: The skilled nurse visit frequency was 2x/week. For the weeks of 5/12/24 - 5/18/24 and 6/2/24 - 6/8/24, the record indicated only 1 visit each of these weeks. In addition, oxygen was ordered at 4.5L/min continuously. The Certification of terminal illness for the benefit period beginning on 4/11/24 also stated that oxygen was increased to 4.5L. Nursing documentation indicated that the oxygen was at 4L/min”

“Upon patient record review, 1 of 27 records (Patient #27) 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 #27: There was no evidence of bereavement care plan tasks of sending a 9 month letter, a memorial service invitation, or holiday letter being completed as assigned.”

“Upon patient record review, 2 of 27 records (Patient #13, #14) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide including alerts and precautions that must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • 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 #13 has dysphagia and aspiration precautions on the care plan however the aide care plan did not include aspiration precautions. Patient #14 has aspiration precautions on the care plan, however the aide care plan did not include aspiration precautions.”

“Upon patient record review 4 of 27 records (Patient #8, #11, #14, #17) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #8: The aide plan of care indicated to provide shampoo 1x/week. Aide visit frequency was 2x/week. The documentation revealed that a shampoo was completed at most of the visits. Patient #11 aide care plan included nail care and shave weekly. Aide completed nail care on 5/14/24, 5/17/24, 5/21/24, 5/24/24, 5/28/24, 5/30/24, 6/11/24, 6/13/24. Shave was refused on 5/30/24 and not performed on the 5/28/24 visit. Patient #14: during the visit with the surveyor on 6/20/24 the aide removed the dressing on the patient’s foot. The aide care plan has for the aide to leave the dressing in place. Patient #17: The medical record contained an ordered aide frequency of once weekly. There was no evidence of a visit completed the week of 5/5/24. After agency investigation, it was discovered a missed visit explanation was entered as a nursing visit instead of the aide visit.”

“Upon client record review, 3 of 27 records (Patient #2, #11, #13) 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 #2: The skilled nurse visit frequency was 3x/week. For the week of 5/26/24-6/1/24, the record indicated only 2 visits (5/29/24 and 5/30/24) Patient #11: Order for SW on 4/22/24 effective 4/20/24 2every2m2, 2m1, 1m1, and 3 prn. MSW visits completed on 4/22/24, 5/3/24 and 5/21/24. SC order on 4/22/24 effective 4/20/24 for 2every2m2, 2m2, and 3prn. SC visits completed on 4/22/24, 5/2/24, and 5/16/24. Patient #13: order on 5/6/24 for a PT eval, no evidence of documentation that evaluation occurred. Volunteer order on 4/2/24 for weekly tuck in calls and an order on 6/3/24 for volunteer visits to start monthly on 6/3/24 for companionship. Volunteer visits documented on 4/12/24, 4/25/24, 5/10/24, and 5/21/24 all without an order for these visits. Order on 3/25/24 for SW effective 3/22/24 2every2m2, 2m2 and 3prn. SW visits completed on 3/25/24, 4/8/24, 4/26/24. SC order on 3/26/24 effective 3/22/24 1m1, 4m1, 5m1, 2m1 and 3prn. SC visits completed on 3/26/24 and 3/29/24. SC order on 4/30/24 effective 4/1/24 2m1, 3m1, 1m1. SC visit completed on 4/4/24, no evidence of a second visit for April.”

“Upon client record review, 2 of 27 records (Patient #2,#11) 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 #2: The record indicated a wound care order, ‘Hospice nurse or facility nurse to provide wound care 3x/week...’. There was not evidence that the plan of care specifically identified which provider was to perform the wound care. Patient #11 order on 6/16/24 for 16fr Foley with 10cc balloon change every 30 days, order does not include who is managing the Foley the hospice or the SNF.”

“Upon patient record review, 5 of 27 records (Patient #1, #11, #13, #15, #20) did not have evidence that the hospice provided the following information to the SNF: • 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 • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice’s 24-hour on-call system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient Patient #1: There was not evidence of the Hospice election form. Corrected on site. Patient #11, #13, #15 no evidence of documentation in the EMR of the documents provided to the SNF, the agency has a process and they are hand delivered but not documented. Patient #20: During observation of home visit, the facility hospice binder did not contain a signed CTI with the physician’s explanation of eligibility and a signed election form.”