Gentiva

“Upon patient record review, 4 of 14 (Patient #2,3,5,9) 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 uses a wheelchair and Hoyer lift due to altered mobility and muscle weakness. No evidence of problems, interventions, and goals related to altered mobility included in the plan of care. Corrected on site. New order written to update the plan of during survey. Patient 3: The medical record indicated that the patient uses a wheelchair, has contractures in her neck and spine. No evidence of problems, interventions, and goals related to altered mobility included in the plan of care. Corrected on site. New order written to update the plan of during survey. Patient 5: Pre-bereavement risk assessment was completed by the nurse at the time of admit (04/10/2025) and was scored as high. 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. No evidence that the admitting nurse or chaplain communicated the high pre-bereavement risk with the rest of the team. 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 at the time of admit and was scored as moderate. Another bereavement risk assessment was completed by the chaplain on 08/04/2025 that also scored moderate. No evidence that a follow-up was completed or that anything was done to start supporting the caregiver. No evidence that the admitting nurse or chaplain communicated the high pre-bereavement risk with the rest of the team. No evidence that the bereavement care plan was updated to reflect the caregivers needs.”

“Upon client record review, 3 of 14 (Patient #6,8,9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 6: RN documentation on 10/06/2025 indicated that she removed 6 staples from the patients head. No evidence that an order was received to remove the staples. Patient 8: The current plan of care has orders for volunteer visits to be completed 4 times a month starting in October 2025. No evidence that 4 visits occurred for the month of November 2025. Patient 9: The plan of care has orders for SN at 2 times a week. No evidence that 2 visits occurred for the week of 12/21/2025. One documented visits noted for the week.”

“Upon patient record review 2 of 14 (Patient #5,9) 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 5: Pre-bereavement risk assessment was completed by the nurse at the time of admit (04/10/2025) and was scored as high. 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. No evidence that the admitting nurse or chaplain communicated the high pre-bereavement risk with the rest of the team and that care and services were being addressed to meet patient/family needs. Patient 9: Pre-bereavement risk assessment was completed by the nurse at the time of admit and was scored as moderate. Another bereavement risk assessment was completed by the chaplain on 08/04/2025 that also scored moderate. No evidence that a follow-up was completed or that anything was done to start supporting the caregiver. No evidence that the admitting nurse or chaplain communicated the high pre-bereavement risk with the rest of the team and that care and services were being addressed to meet patient/family needs.”

“Upon patient record review 2 of 14 (Patient #6,8) 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 6: Plan of care has aide frequency ordered as 2 times weekly. No evidence that the patient received 2 visits for the week of 10/12/25. No evidence that the visit was missed at the request of the patient/CG or that an order was received to decrease the amount of visits for the week. Patient 8: Plan of care has aide frequency ordered as 2 times weekly. No evidence that the patient received 2 visits for the week of 10/12/25 and the week10/26/2025. No evidence that these visits were missed at the request of the patient/CG or that an order was received to decrease visits for the week.”

“Upon patient record review 1 of 14 (Patient #2) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient 2: No evidence that a registered nurse made a supervised visit every 14 days between 11/18/2025-12/09/2025 (21 days) and again between 12/09/2025 and 01/02/2025 (23 days).”

“Upon client record review, 2 of 14 (Patient #1,2) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. accordance with this hospice plan of care. Patient 1: The plan of care has orders for SN at 3 times a week. No evidence that 3 visits occurred for the week of 12/21/2025. Two documented visits noted for the week. Patient 2: The current plan of care has orders for volunteer visits to be completed 4 times a month for the month of October, twice a month for the month of November, then once for the month of December. No evidence that 4 visits were completed for the month of October, 2 visits for the month of November, nor one visit for the month of December.”