Gentiva

“Upon patient record review, 2 of 19 (Patients #4,#8) 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 4: The medication profile contained active Paxlovid instructions for an order 12/21/25 that was for 5 days only. Corrected on site with medication profile updated. Patient 8: The medical record contained nursing documentation since admission identifying patient use of oxygen. There was no evidence of oxygen included on the medication profile. Corrected on site with medication profile updated.”

“Upon patient record review, 1 of 19 (Patient #13) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • Changes that have taken place since the initial assessment • Information on the patient’s progress toward desired outcomes • Reassessment of the patient’s response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 13: There was no evidence of a comprehensive physical assessment by an RN between 12/23/25 and 1/13/26.”

“Upon patient record review, 3 of 19 (Patients #2,#3,#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 2: There was no evidence of a wound assessment and measurement prior to receiving wound care orders 1/16/25 as required per agency policy. Patient 3: The medical record contained nursing documentation upon admission identifying patient had a peritoneal wound. There was no evidence of weekly wound assessments and measurements as required per agency policy. Patient 6: The medical record contained nursing documentation identifying patient had wounds to bilateral heels. There was no evidence of weekly wound assessments and measurements between 12/31/25 and 1/14/26 as required per agency policy.”

“Upon patient record review, 4 of 19 (Patients #3,#9,#12,#14) 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 3: The medical record contained nursing documentation upon admission identifying patient history of a CVA and seizures. There was no evidence of problems, goals, and interventions related to neurological dysfunction and seizure precautions included in the plan of care. Corrected on site with plan of care update. Patient 9: The medical record contained nursing documentation upon admission identifying patient history of a CVA and seizures. There was no evidence of problems, goals, and interventions related to neurological dysfunction included in the plan of care. Corrected on site with plan of care update. Patient 12: The medical record contained nursing documentation upon admission identifying patient history of falls. There was no evidence of problems, goals, and interventions related to fall safety included in the plan of care. Corrected on site with plan of care update. Patient 14: The medical record contained nursing documentation upon admission identifying patient history of CVA and varices related to liver disease. There was no evidence of problems, goals, and interventions related to neurological dysfunction and risk for bleeding included in the plan of care. Corrected on site with plan of care update.”

“Upon patient record review, 2 of 19 (Patients #2,#8) 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 2: The aide care plan identified patient had an indwelling catheter. There was no evidence of an order for catheter type, size, change frequency and maintenance. Corrected on site with order clarifications. Patient 8: The medical record contained nursing documentation since admission identifying patient use of oxygen. There was no evidence of an order for oxygen rate, frequency, and delivery method. Corrected on site with order clarifications.”

“Upon patient record review, 5 of 19 (Patients #3,#4,#7,#8,#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 medical record contained nursing documentation upon admission identifying patient use of a shower chair. There was no evidence of an order for the DME included in the plan of care. Corrected on site with order received. Patient 4: The medical record contained nursing documentation upon recertification assessment 12/17/25 identifying patient use of a cane. There was no evidence of an order for the DME included in the plan of care. Corrected on site with order received. Patient 7: The medical record contained nursing documentation upon admission identifying patient use of a shower chair. There was no evidence of an order for the DME included in the plan of care. Patient 8: The medical record contained nursing documentation upon recertification assessment 11/19/25 identifying patient use of a lift for transfers. There was no evidence of an order for the DME included in the plan of care. Corrected on site with order received. Patient 14: The medical record contained nursing documentation upon admission identifying patient use of a walker and shower chair, and 1/7/26 identifying use of trapeze bar. There was no evidence of orders for the DME included in the plan of care. Corrected on site with order received.”

“Upon patient record review, 2 of 19 (Patients #7,#18) 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 plan of care included two active code statuses of both full code and DNR. The plan of care was not updated to remove the full code status when DNR form was signed. Corrected on site with plan of care update. Patient 18: The patient was discharged from hospice 12/17/25. There was no evidence the plan of care was updated to included problems, goals, and interventions related to discharge planning.”

“Upon client record review, 2 of 19 (Patient #10, 11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 10: The medical record contained an order for a PT assessment 12/10/25. There was no evidence the agency arranged for the PT evaluation to be completed. Corrected on site with agency communication with contracted agency. Patient 11: The medical record contained an order for spiritual care visits once weekly. There was no evidence of a visit completed the week of 12/7/25. Corrected on site with late data entry of reason for missed visit.”

“Upon patient record review, 1 of 19 (Patient #17) 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 Patient 17: The medical record contained a bereavement care plan with task for monthly contact with the bereaved unless refused and evaluated as low risk, due to initial bereavement assessment as high risk. There was no evidence of any contact with the bereaved after death.”

“Upon patient record review, 2 of 19 (Patients #6,#7) 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 medical record contained wound care orders 12/25/25 and 1/14/26. There was no evidence of instructions for the aide regarding treatment of wounds during showers on the aide care plan. Corrected on site with aide care plan update. Patient 7: The medical record contained nursing documentation upon admission identifying patient is a max assist for transfers. There was no evidence of transfer instructions on the aide care plan. Corrected on site with aide care plan update.”