Gentiva

“Upon patient record review, 5 of 19 (Patient #1, #2, #3, #4, #12) 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 hospice medication profile indicates this patient is on continuous oxygen. However, there is no evidence of continuous oxygen on the facility MAR. Patient#2: The hospice medication profile states patient is taking lorazepam 0.5mg 1 every 4 hours PRN anxiety and restlessness, geri-tussin 100mg/5ml every 6 hours PRN cough, Ipratropium 0.5 albuterol 3mg nebulizer solution, oxygen 1-3 lpm nasal cannula PRN SOB, and benzonatate 100mg 1 every 6 hour PRN for cough. There is no evidence of these medication on the facility MAR. Patient#3: The hospice medication profile indicates patient is taking hydromorphone 1 tice a day. It also indicates patient has an order for hydromorphone 1 every 4 hours PRN for breakthrough pain. In the home the only instruction on the hydromorphone if for 1 every 4 hours PRN. The order for the scheduled hydromorphone to help control pain was dated 1/16/26. The bottle in the home was filled on 02/17/26. Patient#4: During home visit, it was noted the facility MAR contained zinc oxide 10% apply three times a day and hydrocortisone 1% apply every 12 hours PRN itching. There is no evidence of these on the hospice medication profile. Additionally, the hospice medication profile list acetaminophen 325mg take 2 every 6 hours PRN. There is no evidence of this medication on the facility MAR. Patient#12: The record indicates there was an order on medication profile dated 1/15/26 for oxygen 7-10 lpm by trach at night. However, on 1/22/26 on 1/22/26 the nurse documents the patient was on 10L when she arrived for her afternoon visit. She educated the caregiver and moved patient down to 6Lpm. On 1/28/26 the nurse documents that the patient reported being comfortable at 2 lpm. There is no evidence of oxygen ordered at these levels for daytime or PRN usage on the medication profile.”

“Upon patient record review, 1 of 19 (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 aide plan of care list the patient have vision as a functional limitation and requires visual precautions. There is no evidence of goals and interventions related to these issues on the plan of care.”

“Upon patient record review, 2 of 19 (Patient #4, #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: During home visit, it was noted the facility MAR contained zinc oxide 10% apply three times a day and hydrocortisone 1% apply every 12 hours PRN itching. There is no evidence of an order for these in the hospice medical record. Patient#12: The record indicates there was an order on medication profile dated 1/15/26 for oxygen 7-10 lpm by trach at night. On 1/28/26 the nurse documents that the patient reported being comfortable at 2 lpm. There is no evidence of an order for oxygen ordered at this level for daytime or PRN usage in the hospice medical record.”

“Upon patient record review, 3 of 19 (Patient #3, #5, #14) 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 nurse documents for IDG 1/22/26 that suction was delivered due to patient issues with increased mucous production. There is no evidence of an order for suction machine include in the plan of care. Patient#5:The record indicates the patient has wound care and pressure relieving boots. There is no evidence of an order including these items on the plan of care. Patient#14:The record indicates wound care supplies are listed on the plan of care. There is no evidence in the record indicating the patient requires wound care supplies.”

“Upon patient record review, 3 of 19 (Patient #1, #5, #7) 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#1:The patient currently takes medication for insomnia. The nurse documents on 1/12/26 that the patient has continued issues with insomnia. The doctor has an order on 2/22/26 to add insomnia as a diagnosis. There is no evidence of problems with goals and interventions related to insomnia on the plan of care. Patient#5:The record indicates the nurse documented on visit 2/2/26 that patient received pressure relieving boots. She also documents that she told the spouse she would be educating the facility staff on appropriate use of this item. There is no evidence of goals of interventions related to this on the plan of care. Patient#7: The record indicates MSW services were discontinued on 1/3/26. However, the MSW goals and interventions are still active on the plan of care. The record also indicates that from 1/1/26 till 2/3/26 the patient had a nephrostomy tube. There is no evidence of problems, goals, or interventions related to the nephrostomy tube care.”

“Upon client record review, 3 of 19 (Patient #3, #9, #12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#3: The record indicates the frequency order for MSW states effective 2/1/26. However, there is an MSW visit documented on 1/16/26. There is no evidence of a frequency order for this visit. Patient#9: The record indicates the frequency for skilled nurse is ordered for 1 time per week. There is no evidence of a documented visit or a missed visit for the week of 2/8/26. Patient#12: The record indicates there was an order on medication profile dated 1/15/26 for oxygen 7-10 lpm by trach at night. However, on 1/22/26 the nurse documents the patient was on 10L when she arrived for her afternoon visit. She educated the caregiver and moved patient down to 6Lpm, there was no evidence of an order for this liter flow.”

“Upon patient record review 1 of 19 (Patient #7) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient#7:During record review, the POC indicated chaplain services were discontinued 2/10/26. IDG on 1/22/26 written by female chaplain indicates that chaplain visits are to be moved to a male chaplain per patient preference. The female chaplain documents speaking to the male chaplain on 1/20/26 about this. She then documents that chaplain visits should be removed from this chaplain. There is a doctor order stating to discontinue all chaplain visits. There is no evidence that chaplain services have continued with the male chaplain.”

“Upon patient client record review, 2 of 19 (Patient #7, #16) 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#7: During record review it was noted that the plan of care indicates patient is a full code. However, the MSW documents during IDG 1/8/26 and on visit 1/2/26 that patient is a DNR. There is no evidence of a DNR in the patient record. Conflicting information. Patient#16: The discharge summary states “discharge to home or self-care;live discharge out of service area- No GIP contract (symptom management reason related to prognosis).” It is unknown if the patient was admitted to hospital or to the hospice GIP unit at hospital.”