Gentiva II

“Upon patient record review, 2 of 14 (Patients #1, #5) 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 Patient 1: The admission note charts that patient requires oxygen, this is not included on the medication profile. Corrected Patient 5: Patient was ordered Oxygen therapy upon admit, patient would refuse delivery of oxygen concentrator, per nurse visit charting. Oxygen remained on the medication profile. Corrected on site”

“Upon patient record review, 2 of 14 (Patients #1, #8) 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 1: Patient was admitted on 02/17/25, the bereavement risk assessment was not performed until 02/27/25. Patient 8: Patient was admitted on 12/20/24, the bereavement risk assessment was not performed until 12/26/24.”

“Upon patient record review, 1 of 14 (Patient #6) 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 6: The wound to greater trochanter that was initiated on 3/20/25 only has one measurement charted on 3/27/25 and the wound to left patellar initiated on 4/7/25- has no wound care measurements since onset, company policy is for wounds to measured weekly.”

“Upon patient record review, 1 of 14 (Patient #2 ) 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 2: The admission noted that patient has dysphagia, there are no goals, plans, or interventions for identified problem.-Corrected on site”

“Upon patient record review, 3 of 14 (Patients #1, #5, #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. Patient 1: The admission note charts that patient requires oxygen, there is no orders written of oxygen therapy. Corrected on site Patient 5: Patient was ordered Oxygen therapy upon admit, she would refuse delivery of oxygen concentrator charted in nurse visit. No order written to remove oxygen from plan of care. Corrected on site Patient 7: The facility profile is missing lorazepam 0.5 tablet. Also, methadone is listed as oral solution on hospice chart, on the facility chart, methadone order is in tablet form, there is no evidence in the hospice chart of an order for the discontinuation of medications or changes.-Corrected on site”

“Upon patient record review, 5 of 14 (Patients #1, #2, #4, #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 equipment and supply needs. Patient 1 The admitting nurse note charts that a hospital bed, bedside table nebulizer, oxygen concentrator is in patient’s home. There are no orders written for this listed medical equipment.-Corrected on site Patient 2 The admitting nurse note charts that a nebulizer is in use. There is no order written for this.-Corrected on site Patient 4 A bedside commode was added in the nurse recertification note, there is no order written for this medical equipment.-Corrected on site Patient 6 The nurse recertification note, charts that a raised toilet seat added, there is no order written to supply this medical equipment-Corrected on site. Patient 7 The patient has breathing treatment medications ordered since admission, there is no nebulizer order written-Corrected on site”

“Upon patient record review, 3 of 14 (Patients #8, #11, #12) did not have evidence the hospice offers bereavement counseling that includes: • 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 8: Upon review of medical record, the bereavement plan of care requires that a sympathy card, a 1 month letter, and 3 month letter be delivered to the identified bereavement contacts, there is no evidence that these tasks have been completed. Bereavement phone call was documented but was not on bereavement care plan to perform. Patient 11: The bereavement plan of care, there is no evidence that the Holiday letter was sent out. Patient 12: The bereavement plan of care, there is no evidence that the Holiday letter was sent out.”

“Upon patient record review, 2 of 14 (Patient #3, #6) 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 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 Patient 3: The patient developed a wound on 3/29/25, the aide care plan was not updated to reflect care or maintenance of wound sites during bathing.-Corrected on site Patient 6: The patient developed wounds on 03/20/25 and 04/07/25, the aide care plan was not been updated to reflect care or maintenance of wound sites during bathing. Corrected on site”