Gentiva

“Upon patient record review, 2 of 19 (Patient #2,#3) 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#2:Upon home visit observation, it was identified that lorazepam 0.5mg was listed as active medications on the agency medication profile. There was no evidence of this medication on the facility profile. Patient#3: Upon home visit observation, it was identified that the medication atropine 0.75 place 2 drops under tongue every 2 hours PRN for secretions was present in the home. There is no evidence of this medication on the agency medication profile.”

“Upon patient record review, 1 of 19 (Patient #8) 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#8: Upon review of record, there was documentation indicating the person to be a moderate risk on 10/21/25. No evidence that a follow-up was completed or that anything was done to start supporting the person at the time that the need was identified. No evidence that the bereavement care plan was updated to reflect the persons needs. There is documentation that prior to 10/21 a mock survey was completed on 10/02/25 and a plan of correction was put in place on 10/02.”

“Upon client record review, 3 of 19 (Patient #3,#11,#13) 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 skilled nurse frequency is ordered at 2 times per week. On the week of 1/7/26 there is only evidence of 1 visit completed. There was no evidence of missed visits. Patient#11: The skilled nurse frequency is ordered at 2 times per week. On the week of 01/01/26 there is only evidence of 1 visit being completed. There was no evidence of missed visits. Patient#13: The skilled nurse frequency is ordered at 2 times per week. On the week of 12/04/25 there is only evidence of 1 visit being completed. There was no evidence of missed visits.”

“Upon patient record review 1 of 19 (Patient #8) 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#8: There was documentation indicating the person to be a moderate risk on 10/21/25. No evidence that a follow-up was completed or that anything was done to start supporting the person at the time that the need was identified. No evidence that the bereavement care plan was updated to reflect the persons needs. There is documentation that prior to 10/21 a mock survey was completed on 10/02/25 and a plan of correction was put in place on 10/02.”

“Upon patient record review, 1 of 19 (Patient #14) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Patient#14:There was documentation in the chaplain visit on 12/15/25 stating that a non-facility vascular nurse was giving the patient an IV infusion. There is no evidence in the record that this was coordinated between the facility and the hospice agency. Upon the administrator inquiring about this occurrence, the facility indicated that this infusion was scheduled prior to the hospice admit and they did not cancel nor communicate it with the hospice.”

“Upon patient record review 5 of 19 (Patient #1,#2,#5,#6,#14) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient#1: The Plan of Care indicates aide frequency is ordered at 3 times per week. On the week of 1/27/26 only 1 in person visit is documented. There was no evidence of missed visits. Patient#2: The Plan of Care indicates aide frequency is ordered at 3 times per week. On the week of 11/23/25 only 1 in person visit is documented. There was no evidence of missed visits. Patient#5: The Plan of Care indicates aide frequency is ordered at 5 times per week. On the week of 01/19/26 only 2 in person visits are documented. There was no evidence of missed visits. Patient#6: The Plan of Care indicates aide frequency is ordered at 5 times per week. On the week of 11/25/25 only 2 in person visits are documented. There was no evidence of missed visits. Patient#14: The Plan of Care indicates aide frequency is ordered at 5 times per week. On the week of 12/01/25 only 1 in person visit is documented. There was no evidence of missed visits.”