Gentiva

“Upon patient record review, 5 of 19 (Patient #1,#3,#4,#5,#9) 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: Miconazole was on the facility medication profile, but not on the hospice medication profile. COS Patient #3: The patient indicated she was taking Flonase and using Systane daily; there was no evidence of either on the medication profile. COS Patient #4: The patient’s sister indicated the patient was taking Magnesium Glycinate, but there was no evidence this was on the medication profile. COS Patient #5: On 08-28-25 and 09-11-25, the SN documented the patient was using medicated mouthwash that was helping with dental sores and fever blisters, however medicated mouthwash was not on the medication profile. In addition, on 09-11-25 the SN documented the patient “will use mag Citrate for constipation”, however, there was no evidence that mag Citrate was on the medication profile. COS Patient #9: On 09-02-25, the NP and the RN documented the patient was “currently on antibiotics” and on 09-04-25, the MD documented the patient was taking Keflex for a UTI. However, Keflex was not on the medication profile.”

“Upon patient record review, 1 of 19 (Patient #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 #6: At admission, the SN indicated the patient had a foley catheter and the MD documented the patient had a foley catheter on the CTI signed 08-04-25. However, there was no evidence the initial plan of care included the foley catheter or related care.”

“Upon patient record review, 4 of 19 (Patient #1,#3,#4,#5) 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: Miconazole was on the facility medication profile, but no evidence of order. COS Patient #3: The patient indicated she was taking Flonase and using Systane daily; there was no evidence of orders. COS Patient #4: The patient’s sister indicated the patient was taking Magnesium Glycinate, but there was no evidence orders. COS Patient #5: The SN visit notes dated 08-28-25 and 09-11-25 indicated the patient was using medicated mouthwash and Mag Citrate, but there was no evidence of a physician’s order. COS”

“Upon patient record review, 2 of 19 (Patient #11,#13) 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 #11: On the recert CTI dated 06-04-25, the MD indicated the patient had decided to no longer check his blood sugar daily and he had discontinued anti-glycemics. However, there was no evidence the care plan interventions were updated after 06-04-25 for daily glucose monitoring via FSBS. COS Patient #13: Upon admission, the MSW reached out to the patient to schedule an evaluation on 08-22-25 and 08-25-25 with no response. The plan of care dated 09-02-25 indicated the social work frequency was one time for eval, however there was no evidence of further contacts or documentation the patient declined a social work visit.”

“Upon patient record review, 1 of 19 (Patient #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 • 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 #6: The aide was ordered 3 x week beginning 07-28-25, but the aide completed 15 missed visit notes dated 08-01-25, 08-04, 08-08, 08-11, 08-15, 08-18, 08-25, 08-29, 09-01, 09-03, 09-10, 09-12, 09-15, and 09-17-25. However, there was no evidence the aide care plan was updated by the responsible RN during this time.”

“Upon patient client record review, 3 of 19 (Patient #3,#5,#8) 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 #3; A supervisory visit was completed on 07-10-25, but there was no evidence of a CNA visit until 07-14-25. Patient #5: An aide supervisory visit was documented on 03-26-25, but there was no evidence of a CNA visit until 05-13-25. Patient #8: An aide supervisory was completed on 08-21-25 and 08-28-25 and the SN documented “yes” the aide had visited in the last 14 days. However, the last evidence of an aide visit was 07-31-25.”