Every finding on record at Entera Hospice Inc

Upon patient record review, 3 of 14 (Patient # 3, 4, 5) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 3: The family choice for attending doctor and the choice of attending provider is left blank on Election of Benefits at SOC on 08/18/2025. Patient 4: There is no indication of patient choice for attending physician at SOC 8/13/25. The form is left blank under right to choose an attending physician. Patient 5: There is no indication of patient choice for attending provider and the choice of attending is left blank on Election of Benefits at SOC on 07/24/25.

Upon patient record review, 1 of 14 (Patient # 2) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 2: Comprehensive assessment 8/11/25 does not assess for imminence of death.

Upon patient record review, 3 of 14 (Patient # 1, 3, 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: Patient 1: Upon visit, the facility medication record contains orders nystatin powder, seroquel and benadryl every 6 hours PRN and agency medication list did not contain nystatin powder and seroquel and had benadryl listed for once daily PRN. The medication profile contains orders for aromatherapy orders for lavender, peppermint,wild orange apply 1 application topically with gloved hands TID prn for anxiety, nausea, somnolence, poor appetite with no specific dose indicated and where to apply. Corrected on site with updated orders. Patient 3: Upon home visit, daughter reports only home medications include atorvastatin and hydrochlorothiazide. Medications listed at SOC 08/18/2025 do not contain orders for atorvastatin and hydrochlorothiazide. Only medications listed on medication profile include comfort care kit medications and daughter is unaware of these medications and denies any medications have been delivered to home since admission. Corrected on site with updated orders. Patient 8: The medication profile 08/12/25 contains orders from 12/23/24 for aromatherapy orders for lavender, peppermint,wild orange apply 1 application topically with gloved hands TID prn for anxiety, nausea, somnolence, poor appetite with no specific dose indicated and where to apply.

Upon patient record review, 2 of 14 (Patient # 6 and 7) 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 6: The initial POC 7/03/25 does not contain evidence of identified issues, interventions, goals and timelines being developed addressing patient needs at SOC. Initial POC 7/3/25 does not indicate any care of G tube, nutrition, or medication management via g-tube. SN documents g-tube dressing changes daily with no problems/goals/interventions for g-tube care, nutrition or medication management via g-tube. Patient 7: SN documents RN visits for foley and wound care three times weekly with no problems/goals/interventions for foley and wound care.

Upon patient record review, 5 of 14 (Patient # 1,2,3,6,8) 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: POC 6/27/25 contains wound care orders to cleanse buttock stage 2 wound with soap/water and cover with hydrocolloidal dressing every 3 days and prn. The order does not specify who will complete wound care memory care staff or agency SN. In addition, the facility treatment plan contains orders for aromatherapy for lavender, peppermint, wild orange apply 1 application topically with gloved hands TID prn for anxiety, nausea, somnolence, and poor appetite. The agency POC orders for aromatherapy do not contain specific dose or instructions to apply to wrist. Corrected on site with updates to POC. Patient 2: The initial POC 08/11/25 does not contain orders for wound care and Foley catheter details including size, balloon, care of foley, when and who will change and irrigation of catheter. Corrected on site with updates to POC. Patient 3: Upon home visit, daughter reports only at home medications include atorvastatin and hydrochlorothiazide. Initial POC 08/18/2025 does not contain orders for atorvastatin and hydrochlorothiazide. Only medications listed on POC include comfort care kit medications and daughter is unaware of these medications and denies any medications have been delivered to home since admission. Corrected on site with obtaining medication orders and update to POC. Patient 6: There are no routine medications listed on POC besides comfort kit medications and no wound care directions on POC. Patient 8: The POC 08/12/25 contains orders from 12/23/24 for Aromatherapy orders for lavender, peppermint,wild orange apply 1 application topically with gloved hands TID prn for anxiety, nausea, somnolence, poor appetite with no specific dose indicated and where to apply.

Upon patient record review, 5 of 14 (Patient # 6, 7, 8, 9, 10) 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 6: The updated POC on 8/12/25 only contains one issue, goal and intervention on psychosocial written by MSW. There is no evidence of nursing POC interventions, goals and timelines. Updated POC 08/12/25 remains with no evidence of Nutrition supplementation via Peg tube, no orders for care of g-tube dressing changes, no equipment listed on POC for administration of tube feeding . Patient 7: The updated POC on 7/29/25 and 8/12/25 show evidence of RN visits 3 times weekly for foley and wound care. There remains no evidence of foley and wound care orders or instructions of care noted on the updated POC. Patient 8: The updated POC 8/12/25 does not show evidence of updates to timelines and goals dated with target dates 3/25/25. Patient 9: The updated POC 8/12/25 contains evidence of issues, interventions, goals and timelines containing target dates of resolving by 6/9/25. Patient 10: The updated POC 8/12/25 contains evidence of issues, interventions, goals and timelines containing target dates of resolving by 4/8/25.

Upon patient record review, 6 of 14 (Patient # 1, 4, 6, 7, 8, 10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: There is evidence of Music Therapy visits being completed with no order for music therapy. Patient 4: The initial POC 8/13/25 contains visit frequency for RN visits 3x/week for wound care. The visit record does not show evidence of RN visits completed 3x weekly. Patient 6: The initial POC 7/3/25 does not indicate any care of G tube, nutritional supplementation, or medication management via g-tube. SN documents g-tube dressing changes daily. Patient 7: The initial POC contains orders for RN visits 3 times weekly for foley and wound care. There is no evidence of orders for care of foley and wound care. There is evidence documented of foley and wound care being provided by skilled nurse in consecutive assessments. In comprehensive assessment on 8/5/25 SN documents "suprapubic cath checked patency, patient tolerated well." 8/13/25 SN documents "L buttocks wound clean with normal saline, pat dry, santyl to affected area three times a week" providing care for suprapubic and wound without an order noted on the POC. In addition, there are no orders on POC for visits for medical social worker or spiritual care being provided. Patient 8: There is evidence of Music Therapy visits being completed with no order for music therapy. Patient 10: There is evidence of Music Therapy visits on 8/1/25 and 8/15/25 being completed with no order for music therapy.

Upon patient record review, 1 of 14 (Patient #1) 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 1: There is an order at the facility to apply ice pm right foot for 20 min three times daily ordered by Gentiva Hospice. Agency was not aware facility obtained an order from a different hospice agency.

Upon patient record review 1 of 14 (Patient #4) 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 4: Aide POC 8/13/25, the aide is ordered 3 times weekly. There is no evidence of aide visits as of 8/20/25. Medical record does not contain evidence of an aide being assigned to patient yet.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. No evidence that the agency utilized volunteers for at least 5% of the total patient care hours in 2024. The total usage of volunteers for 2024 was 4.6%.

Upon personnel record review, 1 of 14 (Personnel # 14) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel 14: The nurse practitioner does not show evidence of receiving orientation on specific job requirements.

Condition of Participation: Clinical Records.

Upon patient record review, 7 of 14 (Patient #3, 4, 5, 6, 8, 9 and 10) did not have evidence that each patient record contains: Patient 3: The family choice for attending doctor and the choice of attending provider is left blank on Election of Benefits at SOC on 08/18/2025. Patient 4: The Election of Benefits form does not contain patient signature and date of SOC on 08/13/25. Patient 5: There is no indication of patient choice for attending provider and the choice of attending is left blank on Election of Benefits at SOC on 07/24/25. Patient 6: The Election of Benefits form does not contain patient signature and date of SOC on 07/24/25. Patient 8: The Election of Benefits form was completed 5/30/24 indicating both request and refusal to receive Non-covered items. The non-covered addendum is blank and there was no evidence of patient/caregiver receiving a copy. A completed addendum was scanned into Medical record on 8/20/25 after start of survey, edited and signed by son on 5/29/24. Agency reports family was notified during survey and verbally agreed to edits on the EOB. Patient 9: The Election of Benefits form at SOC on 3/12/25 remains blank on line to authorize Medicare hospice coverage to be provided by agency and effective date is blank. Form is Signed and dated by patient. The non-covered addendum is blank and there is no evidence of patient/caregiver receiving a copy. A completed addendum is scanned into EMR 8/21/25 with edits made to complete EOB for 3/12/25. Agency reports contacted family and were agreeable to edits on the EOB. Patient 10: The Election of Benefits form does not contain patient/caregivers signature and date at SOC on 02/08/25.

Upon patient record review, 2 of 14 (Patient # 4, 7) 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 4: Aide supervisory visit are being completed by the SN on 8/18/25. The hospice aide has not made a visit to the patient. Agency reports aide is still being trained on documentation in EMR. Patient 7: Medical records review, indicate code status is DNR but no DNR/POLST forms are present in medical record. MSW documents on the POC 7/4/25 problem, intervention and goal for working with patient to understand full code status and MD documents Full Code in F2F encounter on 8/20/25. The code status is unclear. In addition, the Initial Consent form at SOC on 7/2/25 indicate both a request and refusal to receive Non-Covered Items, Services, and Drugs is marked.

Upon patient record review, 1 of 6 records (Patient #1) 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 plan of care contained Therahoney, Antiseptic spray and Povidone Iodine all topical for 3 different wounds and did not specify the location or which wound for each topical application. The patient has 3 wounds; Left heel, Right ankle and sacrum. The POC did not include specific goals for the wounds.

Upon client record review, 2 of 6 records (Patient #2, #3) 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 patient was admitted on 6/28 with nursing visits ordered 2 times a week. The patient was only seen once during week one. Patient #3: Medical Social Worker frequency is ordered for 1 time a week; however is only visiting 1 time a month. On 6/15 Physical Therapy was ordered for evaluation and treat. The physical therapist visits 2 times a week. There is no order or care plan update that the PT is visiting twice weekly.

Upon patient record review 1 of 4 applicable records (Patient #2) 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 #2: Upon admission on Tuesday 6/28, the aide frequency was ordered 3 times a week for 13 weeks; however aide did not see patient until 7/2, no evidence of additional visits this week. On 7/2, the aide documented that there was a bedsore to buttocks and "wound care done". There was no wound care noted on the aide care plan.