Gentiva

“Upon patient record review, 1 of 14 (Patient #1) 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: During the home visit, the patients caregiver stated that the patient does not take Dulcolax suppository, Eliquis, famotidine, Geri-knot, loratadine, or mirtazapine which are all listed on the active medication profile. Reports that the patient only takes Losartan 50mg, Lexapro 20mg, Lactulose 10grams, acetaminophen 500mg PRN. The patient also uses MiraLAX PRN daily. No evidence that MiraLAX was included on the active medication list. Corrected on site. New orders received to remove medications that are not being taken from the active medication list and add MiraLAX.”

“Upon patient record review, 5 of 14 (Patient #2,3,6,10,13) 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 2: The patient was admitted on 08/24/25. There was no evidence of a bereavement risk assessment completed within 5 days of admit. Assessment completed on 09/25/2025. Patient 3: The patient was admitted on 09/20/25. There was no evidence of a bereavement risk assessment completed within 5 days of admit. Assessment completed on 10/2/2025. Patient 6: The patient was admitted on 08/26/25. There was no evidence of a bereavement risk assessment completed within 5 days of admit. Assessment completed on 09/09/2025. Patient 10: The patient was admitted on 07/31/25. There was no evidence of a bereavement risk assessment completed within 5 days of admit. Assessment completed on 08/06/2025. Patient 13: The patient was admitted on 11/15/24. There was no evidence of a bereavement risk assessment completed within 5 days of admit. Assessment completed on 02/13/2025.”

“Upon patient record review, 5 of 14 (Patient #2,3,4,6,9) 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 indicated that the patient has an unsteady gait and increased weakness. No evidence of problems, interventions, and goals related to altered mobility included in the plan of care at the time that the chart was surveyed. Corrected on site. New order written to update the plan of during survey. Patient 3: The medical record indicated that the patient is a risk for falls, risk for aspirations due to dysphagia, depression (takes medications daily), and is incontinent of bowel and bladder. No evidence of problems, interventions, and goals related to falls, dysphagia, depression, or incontinent problems at the time the chart was surveyed. Corrected on site. New order written to update the plan of during survey. Patient 4: The medical record indicated that the patient has a related diagnosis of depression and currently takes 2 medication daily for depression. No evidence of problems, interventions, and goals related to depression included in the plan of care at the time that the chart was surveyed. Corrected on site. New order written to update the plan of during survey. Patient 6: Pre-bereavement risk assessment was completed by the nurse on 09/09/2025 and was scored as moderate. Another bereavement risk assessment was completed by the chaplain on 04/10/2025 that also scored high. No evidence that the bereavement care plan was updated to reflect the caregivers needs. Patient 9: Pre-bereavement risk assessment was completed by the nurse on 09/09/2025 and was scored as moderate. Another bereavement risk assessment was completed by the chaplain on 04/10/2025 that also scored high. No evidence that the bereavement care plan was updated to reflect the caregivers needs.”

“Upon patient record review, 3 of 14 (Patient #3,4,5) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 3: SW and SCP frequency was PRN only without a standing order on the initial evaluation order, order corrected once the disciplines completed their evaluations. Patient 4: SW and SCP frequency was PRN only without a standing order on the initial evaluation order, order corrected once the disciplines completed their evaluations. Patient 5: SCP frequency was PRN only without a standing order on the initial evaluation order, order corrected once the disciplines completed their evaluations.”

“Upon patient record review, 3 of 14 (Patient #3,4,6) 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 indicated that the patient used a high-back wheelchair daily. No evidence that the high-back wheelchair was placed on the current supply list. Corrected on site. New order written to update the supply list during survey. Patient 4: The medical record indicated that patient had wound while on services that was discontinued on 07/14/2025. No evidence that the current supply list was updated to remove wound care supplies from the supply list. New order written to update the supply list during survey. Patient 6: The medical record indicated that patient used a bedside commode. No evidence that the bedside commode was placed on the current supply list. New order written to update the supply list during survey.”

“Upon patient record review 2 of 14 (Patient #6,9) 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 6: Pre-bereavement risk assessment was completed by the nurse on 09/09/2025 and was scored as moderate. Another bereavement risk assessment was completed by the chaplain on 04/10/2025 that also scored high. No evidence that a follow-up was completed or that anything was done to start supporting the caregiver. Patient 9: Pre-bereavement risk assessment was completed by the nurse on 09/09/2025 and was scored as moderate. Another bereavement risk assessment was completed by the chaplain on 04/10/2025 that also scored high. No evidence that a follow-up was completed or that anything was done to start supporting the caregiver.”

“Upon patient record review, 1 of 14 (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 RN documentation indicated that the patient requires 2 aide per visit for bath/transfer. No evidence that the aide plan of care was updated to include the 2 person assist at the time that the chart was surveyed. Also the current aide plan of care included diabetic precautions. No evidence that the patient has diabetes. Corrected on site. Aide plan of care updated during survey.”

“Upon patient record review 1 of 14 (Patient #3) 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 3: Plan of care has aide frequency ordered as 3 times weekly. No evidence that the patient received 3 visits for the week of 12/10/25. No evidence that the visit was missed at the request of the patient/CG or that an order was received to decrease visits for the week. Missed visit documentation stated that the visit was missed due to ‘other”.”