Gentiva

“Upon patient record review, 2 of 15 (Patients #1,#10) 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 1: The medication profile contained duplicative Colace listings. Corrected on site. Patient 10: The initial care plan order contained an order for oxygen equipment. There was no evidence of oxygen included in the medication profile. Corrected on site.”

“Upon patient record review, 1 of 15 (Patient #1) 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: The medical record contained an initial bereavement assessment completed 12/14/23 with a start of care 12/8/23”

“Upon patient record review, 4 of 15 (Patients #2,#3,#5,#6) 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 medical record contained nursing documentation upon admission identifying patient is a high risk for falls. There was no evidence of problems, goals, and interventions related to safety included in the plan of care. Corrected on site. Patient 3: The medical record contained nursing documentation upon recert visit 12/7/23 identifying patient is a high risk for falls. There was no evidence of problems, goals, and interventions related to safety included in the plan of care. Corrected on site. Patient 5: The medical record identified patient was on hospice services for dysphagia following a CVA. There was no evidence of problems, goals, and interventions related to the risk for aspiration included in the plan of care. Corrected on site. Patient 6: The medical record contained nursing documentation upon admission identifying patient is a high risk for skin impairment. There was no evidence of problems, goals, and interventions related to skin included in the plan of care. Corrected on site.”

“Upon patient record review, 3 of 15 (Patients #3,#5,#6) 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 upon admission identifying patient use of walker for ambulation. There was no evidence of the walker included as DME in the plan of care. Corrected on site. Patient 5: The medical record contained nursing documentation 12/15/23 identifying patient use of a walker for ambulation. There was no evidence of the walker included as DME in the plan of care. Corrected on site. Patient 6: The medical record contained IDT documentation 12/27/23 identifying patient use of a hospital bed. There was no evidence of the bed included as DME in the plan of care. Corrected on site.”

“Upon patient record review, 6 of 15 (Patients #1,#2,#5,#6,#9,#10) 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 • 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 1,2,5,9: The aide care plans did not contain instructions for transfer assist needed. Corrected on site. Patient 6,10: The aide care plans contained task for shower with no task for transfers and instructions for transfer assist needed. Corrected on site.”