Every finding on record at Vistacare USA, LLC

Based on review of policy titled “Governing Body,” review of records, family and staff interview, it was determined the governing body failed to assume authority and responsibility for the management and day-to-day operation of the agency. Specifically, the governing body failed to provide supplies for one patient (P)(P1) of three patients reviewed. --- Findings included: Cross refer to L0652 relating to Services.

Based on review of policy titled “Durable Medical Equipment and Supplies,” review of records, family and staff interview, it was determined the agency failed to provide medical supplies based on the health care needs of the patient. Specifically, the agency failed to provide supplies for one patient (P)(P1) of three patients reviewed. --- Findings included: Review of the policy titled “Durable Medical Equipment and Supplies,” revised 12/23/2025, reveals the following:PurposeTo ensure that equipment and supplies are provided for Hospice patients based on assessed health care needs.Procedure:1. As part of the Comprehensive assessment, the patient will be assessed as to the medical equipment being used within the home. Included in the assessment is the identification of the Durable Medical Equipment (DME) company providing the equipment. Review of clinical record for P1 revealed a Hospice certification and Plan of Care dated 10/29/2025 with an order for management of tracheostomy (a surgical procedure that creates an opening in the neck to facilitate breathing), inner cannula (removable tube inside a tracheostomy tube that helps maintain a clear airway) size 6.5 to be changed daily.  Review of supply orders failed to reveal the delivery of inner cannulas from 10/29/2025. The first documentation for delivery of inner cannulas is on 11/18/2025. Delivery confirmation noted delivery of 30-8.0 mm Shiley inner cannulas. Chart review for P1 revealed nurse note dated 01/15/2026, nurse narrative stating ” Pt [family member] states that respiratory therapist has not been to their house nor have they received any respiratory supplies from (the facility) since admission.” A phone interview was conducted on 06/02/2026 at 9:44 AM with the family of P1 who stated  ”The issue I have with (the facility) is that they could not get the inner cannula for the trach, and every time I called to check on the status of the trach supplies, they always had an excuse.”  An in-person interview was conducted on 06/03/2026 at 9:30 AM with the Executive Director who confirmed that tracheostomy supplies were ordered for P1 on 11/14/2026 and delivered on 11/18/2026. The Executive Director stated that the agency had to add the tracheostomy supplies to the Durable Medical Equipment (DME) contract prior to being able to order the inner cannulas.

Upon patient record review 1 of 19 (Patient #1) 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 1: Patient elected to receive SC evaluation at the time of admission. The record indicates that the spiritual assessment was not completed within 5 calendar days following the election of hospice. Patient was admitted on 10/07/2024. Spiritual assessment completed on 10/16/2024, 9 days after election.

Upon patient record review, 1 of 19 (Patient #5) 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 5: Duplicate drug therapy: The medication profile contained 2 listings of Nystatin 100,000 units/ml dated 08/20/23 and 01/05/25 that were active in the profile. Corrected on site.

Upon patient record review, 2 of 19 (Patient #1,8) 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 1: No evidence that a bereavement risk assessment was completed within 5 days of the election of hospice. Patient admitted on 10/07/2024, assessment completed on 01/28/2025. Patient 8: No evidence that a bereavement risk assessment was completed within 5 days of the election of hospice. Patient admitted on 08/18/2024, assessment completed on 10/16/2024.

Upon patient record review, 2 of 19 (Patient #11,12) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 11: No evidence that an RN assessed the patient as the condition required but no less frequently than every 15 days. The record indicates that there were 17 days between RN assessments 12/23/2024 and 01/09/2025. Patient 12: No evidence that an RN assessed the patient as the condition required but no less frequently than every 15 days. The record indicates that there were 17 days between RN assessments 12/10/2024 and 12/27/2024.

Upon patient record review, 1 of 19 (Patient #7) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 7: The record indicates that patient developed a DTI on 10/09/2024. No evidence that the wound has been measured since 12/13/2024. Wound remains active in the wound chapter, the plan of care has active wound care orders. Gentiva policy is for wounds to be measured weekly.

Upon patient record review, 3 of 19 (Patient #8,9,13) 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: Patient current takes Phenobarbital and Dilantin for seizures. Seizures listed as related diagnosis. There was no evidence of problems, goals, and interventions related to seizures included in the plan of care. Corrected on site. Patient 9: Patient has type 2 diabetes listed as a related diagnosis. There was no evidence of problems, goals, and interventions related to diabetes included in the plan of care. Corrected on site. Patient 13: Plavix 75mg as a blood thinner and has a history of GI hemorrhage. There was no evidence of problems, goals, and interventions related to safety for risk for bleeding included in the plan of care. Corrected on site.

Upon patient record review, 2 of 19 (Patient #1,13) 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 1: The record indicates that patient had a wound at the time of admit that was deactivated in the wound chapter on 10/28/2024. No evidence that an order was received to take the wound care supplies off the current POC supply list. Corrected on site. Patient 13: Wound supplies were listed on the patient active plan of care supply list. No evidence that the patient had a wound at the time of admit or at any time during the current benefit period. Corrected on site.

Upon patient record review 4 of 19 (Patient #1,4,6,13) 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 record indicated that the aide plan of care has orders for the aide to provide nail care and shampoo weekly with the visit frequency of 3 visits a week. Aide documentation showed that those task were performed at multiple visits for the following weeks: Twice for the weeks of 12/15/24 (12/16 and 12/18), 12/22/2024 (12/23 and 12/26), and 01/13/2024 (01/13 and 01/15). Three times for the week of 01/05/2024 (01/06, 01/08, and 01/10). Also for this patient the record indicated that the aide plan of care has visit frequency ordered 3 times a week. No evidence that 3 visits occurred for the week of 12/23/24. Documentation shows visits were completed on 12/23 and 12/26. No missed visit noted or an order to decrease the visits for that week. Patient 4: Aide plan of care has visit frequency ordered as 3 times a week. No evidence that 3 visits occurred for the week of 12/2/24. Documentation shows visits were completed on 12/5 and 12/6. No evidence that the missed visit was at the request of the patient/caregiver or physician order entered to decrease visits for that week. Patient 6: Aide plan of care has visit frequency ordered as 3 times a week. No evidence that 3 visits occurred for the week of 11/10/24. No documentation to support that any aide visits were provided for that week. No evidence that 3 visits occurred for the week of 11/17/24. Documentation shows visits were completed on 11/21 and 11/22. No evidence that the missed visit was at the request of the patient/caregiver or physician orders entered to decrease visits for those weeks. Patient 13: The record indicated that the aide plan of care has orders for the aide to provide nail care and shampoo weekly with the visit frequency of 3 visits a week. Aide documentation showed that those task were performed at multiple visits for the following weeks: Twice for the weeks of 11/04/24 (11/5 and 11/8), 11/11/24 (11/11 and 11/15), 11/18/24 (11/25 and 11/27), 12/01/24 (12/02 and 12/06), 12/08/24 (12/09 and 12/13), 12/15/24 (12/16 and 12/20), 01/05/25 (01/06 and 01/10) and 01/12/25 (01/13 and 01/17).

Upon patient record review 1 of 19 (Patient #3) 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 3: The record indicated that patient has been receiving aide services since the time of admission. No evidence that a registered nurse made supervised visits every 14 days between 10/13/2024 and 11/02/2024 - 20 days between supervised visits.

Upon patient record review, 1 of 19 (Patient #2) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #2: Family elected to receive the notice of Hospice Non-Covered Items at the time of admission 06/13/2024. No evidence that the responsible party had received a copy of the non-covered items at the time of survey.

Upon patient record review, 1 of 19 (Patient #4) 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: The record indicated that the aide entered a missed visit note on 10/16/2024 that was not completed, had no evidence of which physician/RN was notified that the visit was missed. The record indicated that the SC entered a missed visit note on 08/20/2024 that was not completed, did not include a reason why the visit was missed in the note.

Upon patient record review, 1 of 16 (Patient #16) did not have evidence that the discharge summary includes all required information. Patient 16: No evidence that a discharge summary was completed at the time of discharge.

Upon patient record review, 1 of 19 (Patient #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. Patient 2: Plan of care has chaplain frequency as once a month. No evidence that the patient received a visit for the month of August, September, and October 2024. No evidence that the missed visits were at the request of the patient/caregiver or physician orders entered to skip visits for those month.

Based on record review, staff interviews, and review of policy titled ";ASSESSMENT OF POSSIBLE ABUSE/NEGLECT No. 2-035, it was determined that the agency failed to ensure that the violation of sexual harassment against P#1 was reported to the Department of Community Health (DCH) and investigated by the agency for resolution within twenty-four hours or next business day. --- Findings include: Cross Reference to L0508, L0509, and L0511 for findings related to this citation.

Based on record review, staff interviews, and review of policy titled ";ASSESSMENT OF POSSIBLE ABUSE/NEGLECT No. 2-035, it was determined that the agency failed to ensure that the violation of sexual harassment against P#1 was reported to the Department of Community Health (DCH) and investigated by the agency for resolution within twenty-four hours or next business day for one patient (P) (P#1) of three sampled patients. --- The findings include: Review of the policy titled ASSESSMENT OF POSSIBLE ABUSE/NEGLECT Policy No. 2-035, (3, 4, 5) revised 8.2023, revealed the following: PURPOSE To provide guidelines for identification of suspected abuse victims for care and referral to community resources. POLICY Gentiva – Hospice Division (the hospice) will report all suspected cases of abuse, neglect, or exploitation in compliance with appropriate state statutes to appropriate protection organizations. 3. Upon receiving a report of a potential patient violation, the hospice must: a. Begin an immediate Investigation to verify allegation. b. Ensure patient is protected from further potential violations during the investigational period. c. Report any verified violations to State/Local or Accreditation bodies within 5 working days of violation verification (specific to most stringent criteria) d. The suspected abuse/neglect investigation report with specific information relating to the occurrence is forwarded to the Clinical Supervisor, who will: i. Notify the physician and referral source (as appropriate) or direct the clinician to do so. ii. Review the documentation for completeness and objectivity. iii. Forward the information to the Administrator and/or Executive Director e. The Administrator and/or Executive Director will: i. Review all reports (incident report and follow-up investigation) ii. Conduct any further review if necessary. iii. Document additional information iv. Submit reports to the proper authorities. v. Reports, reviews, and investigations of suspected abuse/neglect will be held in strictest confidence. 4. The hospice will maintain evidence that all allegations of abuse, neglect, and/or mistreatment have been thoroughly investigated and that further potential abuse has been prevented while the investigation is in progress. 5. The hospice will maintain a list of private and public community agencies that provide or arrange for assessment of suspected or alleged abuse/neglect victims. Review of the complaint log dated 7/26/2023 and 7/27/2023 revealed that the family of patient (P) (P#1) submitted a web review that revealed P#1 was touched and kissed against his will. During an interview on 8/16/2023 at 2:59 p.m., with P#1s family member revealed that family member stated Registered Nurse (RN) AA came out to the patients home on 7/8/2023 around 4:30 p.m., to complete the admission. The family member stated RN AA was unprofessional when she touched and kissed her son against his will." P#1s family member stated on the day of admission RN AA started caressing and messaging P#1s shoulders and rubbing his back; kissed P#1 on the side of the head and forehead without his consent; sat on the bed and sat crossed legged in the patients bed without his consent. Family member stated, ";the whole process made my (patient) very uncomfortable. He told me when she walked out of the room, he did not want to be left alone with her (RN AA) because she makes him very uncomfortable. During an interview with Registered Nurse (RN) AA on 8/16/2023, at 12:06 p.m., RN AA stated that she touched, and air kissed into patients ear without patients approval. RNAA also stated that she hugged the patients mother without approval. During a second phone interview with RN AA on 8/17/2023 at 12:50 pm, RN AA stated she did position herself in the patients bed, sitting crossed legged, without P#1s permission to obtain signatures for legal documents. When surveyor questioned RN AA if this was normal procedure for staff to sit on patients bed while doing an admission RN AA stated, ";no it is not normal or professional and I know I made a bad decision when I sat on his bed". During an interview with the Executive Director (ED)/Administrator on 8/16/2023 at 1:30 p.m., she reported she was aware of the familys allegation of sexual harassment. The ED revealed she was aware of the web review submitted by the family on 7/26/2023 and 7/27/2023 stating P#1 was touched and kissed against his will. The ED/Administrator additionally revealed, ";I really did not take it seriously, I talked to the nurse about the review, but the higher ups told me I could not do anything about it. To my knowledge it was not reported or investigated by the company". During an interview with the Area Vice President (AVP) on 8/17/2023 at 12:30 p.m., she reported she was aware of the familys allegation of sexual harassment. The AVP stated she was aware of the google review submitted by the family on 7/26/2023 and 7/27/2203, stating (P#1) was touched and kissed against his will; that she spoke with RN AA about the allegation of sexual harassment but did not document; and that she was not aware that the State agency has to be notified of such allegations of sexual harassment. AVP stated that hospice agency legal department did not notify the AVP that the State agency has to be notified of the alleged sexual harassment and that she has read the agency policy titled ASSESSMENT OF POSSIBLE ABUSE/NEGLECT Policy No. 2-035 and ";COMPLAINT/GRIEVANCE PROCESS Policy No. 2-006", several times but never realized that the policy states to notify the STATE of such allegations. The AVP verbalized understanding that the agency failed to report the allegation to the State agency as required by the agency policy and as per the State and CMS guidelines. AVP acknowledged that the agency did not notify the patients family nor the patient of the allegations.

Based on staff and family interviews it was determined the agency failed to investigate all alleged violations involving anyone furnishing services on behalf of the agency. The agency failed to take immediate action to prevent further potential violations while the alleged violation was being verified for one patient (P) (P#1) of three sampled patients. --- During an interview with Executive Director (ED)/ Administrator on 8/16/2023 at 1:30 p.m., she reported she was aware of the familys allegation of sexual harassment. The ED revealed she was aware of the google review submitted by the family on 7/26/2023 and 7/27/2023 stating the patient (P#1) was touched and kissed against his will. The ED/Administrator stated. ";I really did not take it seriously, I talked to the nurse about the review, but the higher ups told me I could not do anything about it. To my knowledge it was not reported or investigated by the company". During an interview with Registered Nurse (RN) AA on 8/16/2023, at 12:06 p.m., RN AA stated that she touched, and air kissed into patients ear without patients approval. RN AA also stated that she hugged the patients mother without approval. During a second phone interview with RN AA on 8/17/2023 at 12:50 pm, RN AA stated she did position herself in the patients bed, sitting crossed legged, without P#1s permission to obtain signatures for legal documents. When surveyor questioned RN AA if this was normal procedure for staff to sit on patients bed while doing an admission RN AA stated, ";no it is not normal or professional and I know I made a bad decision when I sat on his bed". During an interview with the Area Vice President (AVP) on 8/17/2023 at 12:30 p.m., she reported she was aware of the familys allegation of sexual harassment. The AVP stated she was aware of the google review submitted by the family on 7/26/2023 and 7/27/2203, stating (P#1) was touched and kissed against his will; that she spoke with RN AA about the allegation of sexual harassment but did not document; and that she was not aware that the STATE has to be notified of such allegations of sexual harassment. AVP stated that Gentiva legal department did not notify the AVP that the STATE has to be notified of the alleged sexual harassment and that she has read the agency policy titled ASSESSMENT OF POSSIBLE ABUSE/NEGLECT Policy No. 2-035 and ";COMPLAINT/GRIEVANCE PROCESS Policy No. 2-006", several times but never realized that the policy states to notify the STATE of such allegations. The AVP verbalized understanding that the agency failed to report the allegation to the DCH as required by the agency policy and as per the State and CMS guidelines. AVP acknowledged that the agency did not notify the patients family nor the patient of the allegations. During an interview on 8/16/2023 at 4:04p.m., with family member #3 of P#1 confirmed he witnessed RN AA voice to P#1 that when the IV drip runs out, are you ready to go see Jesus. Family member (#3) stated RN AA was abrupt and not appropriate for a patient who knew he was sent home to die. During an interview on 8/16/2023, at 4:12 p.m., with family member #2 of P#1 revealed P#1 told her not leave him alone with RN AA, because she made him feel ";uncomfortable." Family member (#2) of P#1 confirmed RN AA sat in the middle of the bed with P#1 with inappropriate touching. She stated, ";nurse was handsy." Family member #2 confirmed she witnessed RN AA voice when this bag of IV fluids runs out, you will go to Heaven. During an interview on 8/16/2023 at 4:24 p.m., with family member #4 of P#1 revealed he witnessed RN AA kiss P#1 near his forehead and touched P#1 back and shoulders inappropriately. He stated, RN AA was ";caressing" P#1. He confirmed he heard RN AA say to P#1 that he would see Jesus after the bag of fluids was empty.

Based on staff and family interviews, complaint log review, and review of the agency's policies titled, ";ASSESSMENT OF POSSIBLE ABUSE/NEGLECT Policy No. 2-035" and ";COMPLAINT/GRIEVANCE PROCESS Policy No. 2-006", it was determined that the agency failed to report in writing the alleged sexual abuse/harassment to the State Department of Community Health within 24 hours or the next business day for one patient (P#1) (P#1) of three sampled patients. --- Findings include: Review of the policy titled ASSESSMENT OF POSSIBLE ABUSE/NEGLECT Policy No. 2-035, (3, 4, 5) revised 8.2023, revealed the following: PURPOSE To provide guidelines for identification of suspected abuse victims for care and referral to community resources. POLICY Gentiva – Hospice Division (the hospice) will report all suspected cases of abuse, neglect, or exploitation in compliance with appropriate state statutes to appropriate protection organizations. 3. Upon receiving a report of a potential patient violation, the hospice must: a. Begin an immediate Investigation to verify allegation. b. Ensure patient is protected from further potential violations during the investigational period. c. Report any verified violations to State/Local or Accreditation bodies within 5 working days of violation verification (specific to most stringent criteria) d. The suspected abuse/neglect investigation report with specific information relating to the occurrence is forwarded to the Clinical Supervisor, who will: i. Notify the physician and referral source (as appropriate) or direct the clinician to do so. ii. Review the documentation for completeness and objectivity. iii. Forward the information to the Administrator and/or Executive Director e. The Administrator and/or Executive Director will: i. Review all reports (incident report and follow-up investigation) ii. Conduct any further review if necessary. iii. Document additional information iv. Submit reports to the proper authorities. v. Reports, reviews, and investigations of suspected abuse/neglect will be held in strictest confidence. 4. The hospice will maintain evidence that all allegations of abuse, neglect, and/or mistreatment have been thoroughly investigated and that further potential abuse has been prevented while the investigation is in progress. 5. The hospice will maintain a list of private and public community agencies that provide or arrange for assessment of suspected or alleged abuse/neglect victims. Review of the agency policy titled ";COMPLAINT/GRIEVANCE PROCESS Policy No. 2-006", revised 04.13.2022, (1.,12.) revealed the following: ";COMPLAINT/GRIEVANCE PROCESS Policy No. 2-006" Policy: Any difference of opinion, dispute, or controversy between a patient or family/caregiver or patient representative and Gentiva – Hospice Division (the hospice) or contracted vendor concerning any aspect of services, or the application of policies or procedures will be considered a grievance. The Administrator and/or Executive Director will be informed of grievances and will address all grievances in order to maintain patient relations and resolve issues, if possible. The hospice will provide the patient with written information concerning how to contact the hospice, appropriate state agencies, and applicable accreditation organization(s) concerning grievances/complaints at time of admission. PROCEDURE 1. The hospice staff member who has a complaint themselves or has received a complaint related to patient care will discuss, verbally and in writing, the grievance with a supervisor within five (5) days of the alleged grievance unless otherwise stipulated by a specific State Regulation. The supervisor will investigate the grievance within five (5) days after receipt of such grievance and will make every effort to resolve the grievance to the patient's satisfaction. Response to the patient regarding the complaint will occur within ten (10) days of receipt. Complaints will be handled specific to State requirements where more stringent. 12. Complaints will be reported to the state, as required by the specific state regulations. Review of the complaint log dated 7/26/2023 and 7/27/2023 revealed that a family member of patient (P) (P#1) wrote a web review of the agency stating that P#1 was touched and kissed against his will by a Registered Nurse (RN). Complaint log lacked documentation of the Executive Director (ED) and Area Vice President (AVP) addressing the specific allegations of sexual harassment with RN AA and lacked evidence that the allegation was reported to appropriate State agency. During an interview with Registered Nurse (RN) AA on 8/16/2023, at 12:06 p.m., RN AA stated that she touched, and air kissed into patients ear without patients approval. RN AA also stated that she hugged the patients mother without approval. During a second phone interview with RN AA on 8/17/2023 at 12:50 pm, RN AA stated she did position herself in the patients bed, sitting crossed legged, without P#1s permission to obtain signatures for legal documents. When surveyor questioned RN AA if this was normal procedure for staff to sit on patients bed while doing an admission RN AA stated, ";no it is not normal or professional and I know I made a bad decision when I sat on his bed". During an interview with Executive Director on 8/16/2023 at 1:30 p.m., revealed she reported she was aware of the familys allegation of sexual harassment. The ED stated she was aware of the review submitted by the family on 7/26/2023 and 7/27/2023, stating P#1 was touched and kissed against his will. The ED stated ";I really did not take it seriously, I talked to the nurse about the review, but the higher ups told me I could not do anything about it. To my knowledge it was not reported or investigated by the company". The hospice agency failed to monitor and address the violation of patients rights and failed to notify appropriate State agency of the alleged allegation of sexual harassment in the time specified. During an interview with the Area Vice President (AVP) on 8/17/2023 at 12:30 p.m., revealed she was aware of the familys allegation of sexual harassment. The AVP stated she was aware of the review submitted by the family on 7/26/2023 and 7/27/2023, stating P#1 was touched and kissed against his will. The AVP stated that she spoke with RN AA about the allegation of sexual harassment but did not document; that she did not think it was an abuse case mainly because the agencys lawyers did not relay to her that they thought the allegations were abuse; that she was not aware that the State agency has to be notified of such allegations of sexual harassment; that the hospice agency legal department did not notify the AVP that the State agency has to be notified of the alleged sexual harassment. AVP further revealed that she has read the agency policy titled ASSESSMENT OF POSSIBLE ABUSE/NEGLECT Policy No. 2-035 and ";COMPLAINT/GRIEVANCE PROCESS Policy No. 2-006" several times but never realized that the policy states to notify the State agency of such allegations. The AVP verbalized understanding that the agency failed to report the allegation to the State agency as required by the agency policy and as per the State agency guidelines. During an interview on 8/16/2023 at 4:04p.m., with family member #3 of P#1 confirmed he witnessed RN AA voice to P#1 that when the IV drip runs out, are you ready to go see Jesus. Family member (#3) stated RN AA was abrupt and not appropriate for a patient who knew he was sent home to die. During an interview on 8/16/2023, at 4:12 p.m., with family member #2 of P#1 revealed P#1 told her not leave him alone with RN AA, because she made him feel ";uncomfortable." Family member (#2) of P#1 confirmed RN AA sat in the middle of the bed with P#1 with inappropriate touching. She stated, ";nurse was handsy." Family member #2 confirmed she witnessed RN AA voice when this bag of IV fluids runs out, you will go to Heaven. During an interview on 8/16/2023 at 4:24 p.m., with family member #4 of P#1 revealed he witnessed RN AA kiss P#1 near his forehead and touched P#1 back and shoulders inappropriately. He stated, RN AA was ";caressing" P#1. He confirmed he heard RN AA say to P#1 that he would see Jesus after the bag of fluids was empty.

Based on staff interviews, record review, and review of the agency's policies titled, ";ASSESSMENT OF POSSIBLE ABUSE/NEGLECT Policy No. 2-035", revised 8.2023, and ";COMPLAINT/GRIEVANCE PROCESS Policy No. 2-006", revised 04.13.2022, it was determined that the agency failed to report in writing the alleged sexual abuse/harassment to the State Department of Community Health within 24 hours or the next business day, for one patient (P) (P#1) of three sampled patients. --- Findings include: Cross Reference to L0651 for findings related to this citation.

Based on staff interviews, record review, and review of the agency's policies titled, ";ASSESSMENT OF POSSIBLE ABUSE/NEGLECT Policy No. 2-035", revised 8.2023, and ";COMPLAINT/GRIEVANCE PROCESS Policy No. 2-006", revised 04.13.2022, it was determined that the agency failed to report in writing the alleged sexual abuse/harassment to the State Department of Community Health within 24 hours or the next business day, for one patient (P) (P#1) of three sampled patients. --- Findings include: Review of the policy titled ASSESSMENT OF POSSIBLE ABUSE/NEGLECT Policy No. 2-035, (3, 4, 5) revised 8.2023, revealed the following: PURPOSE To provide guidelines for identification of suspected abuse victims for care and referral to community resources. POLICY Gentiva – Hospice Division (the hospice) will report all suspected cases of abuse, neglect, or exploitation in compliance with appropriate state statutes to appropriate protection organizations. 3. Upon receiving a report of a potential patient violation, the hospice must: a. Begin an immediate Investigation to verify allegation. b. Ensure patient is protected from further potential violations during the investigational period. c. Report any verified violations to State/Local or Accreditation bodies within 5 working days of violation verification (specific to most stringent criteria) d. The suspected abuse/neglect investigation report with specific information relating to the occurrence is forwarded to the Clinical Supervisor, who will: i. Notify the physician and referral source (as appropriate) or direct the clinician to do so. ii. Review the documentation for completeness and objectivity. iii. Forward the information to the Administrator and/or Executive Director e. The Administrator and/or Executive Director will: i. Review all reports (incident report and follow-up investigation) ii. Conduct any further review if necessary. iii. Document additional information iv. Submit reports to the proper authorities. v. Reports, reviews, and investigations of suspected abuse/neglect will be held in strictest confidence. 4. The hospice will maintain evidence that all allegations of abuse, neglect, and/or mistreatment have been thoroughly investigated and that further potential abuse has been prevented while the investigation is in progress. 5. The hospice will maintain a list of private and public community agencies that provide or arrange for assessment of suspected or alleged abuse/neglect victims. Review of the agency policy titled ";COMPLAINT/GRIEVANCE PROCESS Policy No. 2-006", revised 04.13.2022, (1.,12.) revealed the following: ";COMPLAINT/GRIEVANCE PROCESS Policy No. 2-006" Policy: Any difference of opinion, dispute, or controversy between a patient or family/caregiver or patient representative and Gentiva – Hospice Division (the hospice) or contracted vendor concerning any aspect of services, or the application of policies or procedures will be considered a grievance. The Administrator and/or Executive Director will be informed of grievances and will address all grievances in order to maintain patient relations and resolve issues, if possible. The hospice will provide the patient with written information concerning how to contact the hospice, appropriate state agencies, and applicable accreditation organization(s) concerning grievances/complaints at time of admission. PROCEDURE 1. The hospice staff member who has a complaint themselves or has received a complaint related to patient care will discuss, verbally and in writing, the grievance with a supervisor within five (5) days of the alleged grievance unless otherwise stipulated by a specific State Regulation. The supervisor will investigate the grievance within five (5) days after receipt of such grievance and will make every effort to resolve the grievance to the patient's satisfaction. Response to the patient regarding the complaint will occur within ten (10) days of receipt. Complaints will be handled specific to State requirements where more stringent. 12. Complaints will be reported to the state, as required by the specific state regulations. Review of the complaint log dated 7/26/2023 and 7/27/2023 revealed that a family member of patient (P) (P#1) wrote a web review of the agency stating that P#1 was touched and kissed against his will by a Registered Nurse (RN). Complaint log lacked documentation of the Executive Director (ED) and Area Vice President (AVP) addressing the specific allegations of sexual harassment with RN AA and lacked evidence that the allegation was reported to appropriate State agency. During an interview with Registered Nurse (RN) AA on 8/16/2023, at 12:06 p.m., RN AA stated that she touched, and air kissed into patients ear without patients approval. RN AA also stated that she hugged the patients mother without approval. During a second phone interview with RN AA on 8/17/2023 at 12:50 pm, RN AA stated she did position herself in the patients bed, sitting crossed legged, without P#1s permission to obtain signatures for legal documents. When surveyor questioned RN AA if this was normal procedure for staff to sit on patients bed while doing an admission RN AA stated, ";no it is not normal or professional and I know I made a bad decision when I sat on his bed". During an interview with Executive Director on 8/16/2023 at 1:30 p.m., revealed she reported she was aware of the familys allegation of sexual harassment. The ED stated she was aware of the review submitted by the family on 7/26/2023 and 7/27/2023, stating P#1 was touched and kissed against his will. The ED stated ";I really did not take it seriously, I talked to the nurse about the review, but the higher ups told me I could not do anything about it. To my knowledge it was not reported or investigated by the company". The hospice agency failed to monitor and address the violation of patients rights and failed to notify appropriate State agency of the alleged allegation of sexual harassment in the time specified. During an interview with the Area Vice President (AVP) on 8/17/2023 at 12:30 p.m., revealed she was aware of the familys allegation of sexual harassment. The AVP stated she was aware of the review submitted by the family on 7/26/2023 and 7/27/2023, stating P#1 was touched and kissed against his will. The AVP stated that she spoke with RN AA about the allegation of sexual harassment but did not document; that she did not think it was an abuse case mainly because the agencys lawyers did not relay to her that they thought the allegations were abuse; that she was not aware that the State agency has to be notified of such allegations of sexual harassment; that the hospice agency legal department did not notify the AVP that the State agency has to be notified of the alleged sexual harassment. AVP further revealed that she has read the agency policy titled ASSESSMENT OF POSSIBLE ABUSE/NEGLECT Policy No. 2-035 and ";COMPLAINT/GRIEVANCE PROCESS Policy No. 2-006" several times but never realized that the policy states to notify the State agency of such allegations. The AVP verbalized understanding that the agency failed to report the allegation to the State agency as required by the agency policy and as per the State agency guidelines.

Upon patient record review, 2 of 13 records (Patient #2,#10) 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. Patient #2: The order on admission was for oxygen 4L/min continuously. The nurse documentation from 12/21/21-1/5/22 indicated that oxygen was on the patient at 3.5L/min. From 1/5/22 to current, the nurse documentation, including the narrative section in the IDG dated 1/20/22 indicated that oxygen was on the patient at 4L/min. There was not evidence that this was changed on the medication profile. In addition, Atorvastatin 20 mg at bedtime was on the medication profile as a duplicate med. Also, there was a listing for Acetaminophen 325mg q6h by mouth for fever greater than 100.1 and/or pain, and a listing for Acetaminophen 325mg q8h by mouth for fever greater than 100.1 and/or pain. All corrected on site. Patient #10: The record indicated oxygen via nasal cannula at 2L/min prn. The nurse documentation dated 12/31/21 and 1/20/21 indicated that oxygen was being used at 4L/min and the nurse documentation dated 1/1/22 and 1/3/22 indicated that oxygen was being used at 5L/min. There was not evidence of a revision on the medication profile. In addition, the medication profile contained Azithromycin dated 12/3/21 2 by mouth on day 1 and then 1 the next 4 days. This medication was still listed on the medication profile. Both corrected on site.

Upon patient record review, 1 of 13 records (Patient #13) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient which reflects patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. Patient #13: The record indicated that the spiritual care counselor was involved with the care of the patient. There was not evidence that the plan of care reflected goals and interventions related to the spiritual well being of the patient and family. In addition, the patient was admitted with a primary hospice diagnosis of Arteriosclerotic Heart Disease. There was not evidence of care plan problems that reflect patient/family goals and interventions related to the patient's cardiac status.

Upon patient record review, 4 of 13 records (Patient #2,#6,#10,#13) did not have evidence the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2: The order on admission for oxygen was 4L/min continuously. The nurse documentation from 12/21/21-1/5/22 indicated that oxygen was on the patient at 3.5L/min. From 1/5/22 to current, the nurse documentation, including the narrative section in the IDG dated 1/20/22 indicated that oxygen was on the patient at 4L/min. There was not evidence of an order indicating a change in the liter flow. Corrected on site Patient #6: Wound care orders written on 12/14/21 and 1/6/22 indicated Cleanse wound with soap and water. Pat dry. Place optifoam dressing on wound. Change every other day and as needed. There was not evidence of a location. Corrected on site. Patient #10: The record indicated an order for oxygen via nasal cannula at 2L/min prn. The nurse documentation dated 12/31/21 and 1/20/21 indicated that oxygen was being used at 4L/min and the nurse documentation dated 1/1/22 and 1/3/22 indicated that oxygen was being used at 5L/min. There was not evidence of an order to change the liter flow. Corrected on site. Patient #13: The record indicated an order for wound care dated 9/21/21 to Clean, pat dry, apply moderate amount of skin barrier cream to Stage II coccyx and upper buttock area. Apply clean gel foam dressing bandage. There was not evidence of a frequency for the wound care.

Upon patient record review, 1 of 13 records (Patient #10) did not have evidence the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #10: The nurse documentation included that the patient was on oxygen, he had a gait balance disturbance that required assistive devices, he was on nebulized treatments and would 'roll' himself down the hall to go and smoke. The plan of care did not contain evidence of any DME or supplies. Corrected on site.

Upon client record review, 2 of 10 applicable records (Patient #8,#11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #8: The visit frequency for the social worker was for an evaluation then 1 every 2m2, 1m2 and 3 prn. The record indicated that the evaluation was performed on 11/5/21 and subsequent visits were conducted on 12/20/21 and 1/21/22. Patient #11: The visit frequency for the social worker was for an evaluation then 1 every 2m2, 1m2 and 2 prn. An evaluation was conducted on 10/18/21 and routine visits were conducted on 11/3/21 and 12/6/21.

Upon patient record review 3 of 11 applicable records (Patient #1,#7,#12) did not have evidence of documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #1: The aide plan of care dated 12/10/21 indicated to provide a shower with each visit. The aide documentation dated 1/20/22 indicated that the aide provided a bed bath. There was not evidence that the nurse revised the care plan or was notified and approved the bed bath. Patient #7: The aide visit frequency dated 11/7/21 was 2x/week. For the week of 1/2/22-1/8/22, the record indicated only 1 visit. Corrected on site. Patient #12: The aide plan of care indicated to provide a shower every visit. For the dates of 9/24/21, 9/27/21, 9/28/21, and 9/29/21 the aide documented 'per caregiver request, patient refused, patient had a bed bath. There was not evidence that the nurse revised the care plan or was notified and approved the bed bath.

Upon patient client record review, 1 of 13 records (Patient #3) did not have evidence that each patient record contains a signed election statement in accordance with 418.24. Patient #3: The benefit election statement signed by the caregiver indicated that the Notification of Non-covered items was requested. There was not evidence that this was provided to the responsible party.

Upon client record review, 1 of 3 applicable records (Patient #10) did not have evidence that services were provided in accordance with the plan of care for a patient in a SNF/NF. Patient #10: The visit frequency for the social worker was for an evaluation then 1 every 2m2, 1m1 and 1 prn. An evaluation was conducted on 11/16/21 and routine visits were conducted on 12/2/21 and 1/5/22. Corrected on site.

Upon patient record review, 1 of 1 applicable record (Patient #3) did not have evidence that the hospice provided the following information: • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice's 24-hour on-call system Corrected on site.

Based on clinical record review and staff interview, it was determined the hospice failed to develop and maintain a system of communication and integration that ensured the interdisciplinary group maintained responsibility for directing, timely coordination, and supervising the care and services provided for 1 of 11 active sampled patients (P#3). The finding include: Review of the clinical record for P#3 revealed the patient was admitted to hospice services on 10/14/21, with a diagnosis of pure hypercholesterolemia. The hospice aide services were ordered three times a week starting 10/16/21. The patient was admitted to services on 10/14/21, with a plan of care that required the hospice aide to provide shower baths to the patient three times a week for twelve weeks. On 10/28/21, the hospice aide reported to supervisor that the patient was not safe with one person transfer to the shower as the patient was combative and reluctant to get in shower. On 10/29/21, the caregiver met with the interdisciplinary team to discuss the patient's safety during the shower bath and to consider bed baths as an option for bathing. The complainant was not in agreement with a bed bath being given and was insistent on a shower bath being given. During the meeting, the Administrator agreed to perform a home visit to observe the shower activity with the aide and patient on 11/2/21. The clinical record did not show evidence that the Administrator performed the home visit on 11/2/21, as stated. On 11/4/21, a physician's order was written for aide services to be placed on hold for 2 weeks until safety issue could be resolved. On 11/11/21, a physician's order was written to obtain a safety risk assessment however, the order was not followed up until 12/7/21, (26 days later). During this time, the patient was not receiving hospice aide services. On 11/23/21, the order was extended to hold aide services for an additional two weeks until a physical therapy (PT) evaluation was completed. An order for a physical therapy evaluation was written 12/7/21, to obtain a safety risk assessment and sent to Kindred Home Health via email and fax. The PT evaluation was completed on 12/14/21, with safety recommendations. A physician's order dated 12/14/21, resumed hospice aide services to visit the patient three times a week. On 12/15/21, the agency was able to notify the complainant that the decision was made to place two aides in the home to provide the shower bath. The complainant was in agreement for the dual aides to start on 12/17/21. During an interview with the Administrator on 1/12/22, at approximately 11:00 a.m., the Administrator acknowledged that the clinical record lacked documentation of timely care coordination efforts with the team to ensure that the safety risk assessment was completed timely to ensure the patient was receiving the care and services needed to meet the needs of the patient.