Gentiva II

“Upon patient record review 2 of 19 records (Patient #6, #11) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual’s attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #6: The record indicated that the Start of Care was 01/25/24 there was no evidence of the Spiritual Comprehensive Assessment was completed until 2/5/24. Patient #11: The record indicated that the Start of Care was on 12/5/23 there was no evidence of the Spiritual Comprehensive Assessment was completed until 2/27/24.”

“Upon patient record review, 6 of 19 records (Patient #1, #2, #4, #5, #6, #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 #1: The medication profile indicated Lidocaine Topical patch daily for pain apply 12 hours, off 12 hours. There was not evidence of a specific location. Corrected on site. Patient #2: The medication profile indicated Oxygen @ 1.5 to 2.5 liters prn, there was no evidence of a route of administration. Corrected on site. Patient #4: The medication profile indicated there were no OTC supplements, there was evidence the patient was being given Vitamin D3 400IU BID. Corrected on site. Patient #5: The medication profile indicated Humalog Kwikpen(U-100) Insulin 100U/ml SQ per instructions, Sliding Scale notify MD if BS > 400 or <70. There was no evidence of a sliding scale. Corrected on site. Patient #6: The medication profile indicated Ciprofloxacin 0.3% dexamethasone 0.1% ear drop suspension, there was not evidence of which ear the drops needed to go in. Corrected on site. In addition, Acetaminophen 500mg two tabs po Q4hours prn. There was no evidence of a max allowable dose for 24 hours. Also, Acetaminophen Hydrocodone 5/325 one tab po Q6hours prn and there was no evidence of a max allowable dose for 24 hours. Corrected on site. Patient #8: The medication profile indicated Nitroglycerin 0.4mg SL by mouth/under the tongue every 5 minutes as needed. There was no evidence of the number of doses to take before taking another action. Corrected on site.”

“Upon patient record review, 1 of 19 records (Patient #2) 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 record indicated the patient was on Eliquis 2.5mg po BID. There was no evidence in the plan of care regarding bleeding precautions. Corrected on site.”

“Upon patient record review, 6 of 19 records (Patient #1, #2, #4, #5, #6, #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 #1: The record indicated an order for Lidocaine Topical patch daily for pain apply 12 hours, off 12 hours. There was not evidence of a specific location. corrected on site. In addition: The record indicated an order dated 12/21/23 for Vaseline Gauze with Stretch wrap or gauze wrap to left leg. There was not evidence of a specific location. Corrected on site. Patient #2: The record indicated an order for Oxygen @ 1.5 to 2.5 liters prn, there was no evidence of a route of administration. Corrected on site. Patient #4: The there were no orders for OTC supplements, there was evidence upon home visit the patient was being given Vitamin D3 400IU BID. Corrected on site. Patient #5: The record indicated an order for Humalog Kwikpen (U-100) Insulin 100U/ml SQ per instructions, Sliding Scale notify MD if BS > 400 or <70. There was no evidence of a sliding scale. Corrected on site. In addition, there was no evidence of a complete order for the foley catheter on 3/27/24 as it was written Catheter 18 French, 10 ml balloon, patient and family agreed to placement. There was no evidence in the order to include irrigation and or when to change out the catheter. Corrected on site. Patient #6: The record indicated an order for Ciprofloxacin 0.3% dexamethasone 0.1% ear drop suspension, there was not evidence of which ear the medication needed to go in. Corrected on site. In addition, Acetaminophen 500mg two tabs po Q4hours prn. There was no evidence of a max allowable dose for 24 hours. Also, Acetaminophen Hydrocodone 5/325 one tab po Q6hours prn and there was no evidence of a max allowable dose for 24 hours. Corrected on site. Patient #8: The record indicated an order for Nitroglycerin 0.4mg SL by mouth/under the tongue every 5 minutes as needed. There was no evidence of the number of doses to take before taking another action. Corrected on site. In addition: The record indicated foley catheter supplies were given on 4/1/24 with a plan to insert a foley catheter with a 10cc balloon inflation. There was no evidence in the record for an order for the foley catheter. Corrected on site.”

“Upon client record review, 5 of 19 records (Patient #2, #3, #6, #10, #12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: The record indicated the visit frequency for the Chaplain was for an evaluation then 2M2, 1M1. The Chaplain completed the evaluation on 12/20/23 with routine visits on 1/24/24 and 2/3/24. There was no evidence of the second visit in January or February 2024. There was no evidence of a visit in March 2024. In addition, the visit frequency for the Social Worker was for an evaluation then 2M2, 1M1. The Social Worker completed the evaluation on 12/20/23 with routine visits on 1/29/24 and 2/26/24. There was no evidence of the second visit in January or February 2024. There was no evidence of a visit in March 2024. Patient #3: The record indicated the visit frequency for the Social Worker was four every 2M2. The record indicate the Social Worker made four visits in February 2024 and four visits in March 2024. Patient #6: The record indicated there was skilled nursing visit frequency orders on 1/25/24 for 3W1. There was no evidence of 3 visits being made between 1/25/24 to 1/27/24. Patient #10: The record indicated a social worker frequency of 1M3 on 1/11/24. The record had no evidence of the scheduled visit in January 2024 and no visit made in February 2024. Patient #12: The record indicated nurse frequency of 2W13 effective starting on 3/5/24. There was no evidence of nursing visits from 3/5/24 to 3/9/24.”

“Upon patient client record review, 1 of 19 records (Patient #3) 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: This patient was on hospice for COPD, the record indicated in the Social Workers initial assessment that this patient was on service for Parkinson and Dementia. Corrected on site.”