Every finding on record at Vistacare USA, LLC

Upon patient record review, 1 of 5 (Patient #5) 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 #5: There is no evidence of weekly wound measurements from 6/26/25 -7/7/25, as required by agency policy.

Upon patient record review 4 of 19 (Patients #1,#5,#6,#10) 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: The medical record contained an initial spiritual assessment 2/18/25 with start of care 2/12/25. Patient 5: The medical record contained an initial spiritual assessment 4/22/25 with start of care 4/16/25. Patient 6: The medical record contained an initial spiritual assessment 4/25/25 with start of care 4/17/25. Patient 10: The medical record contained an initial spiritual assessment 4/10/25 with start of care 4/2/25.

Upon patient record review, 7 of 19 (Patients #1,#2,#5,#6,#7,#9,#12) 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 1: The medication profile contained a lidocaine topical patch with no area defined for administration. Corrected on site. Patient 2: During home visit medication reconciliation, the facility and hospice profiles did not match. The facility did not have lorazepam listed. Corrected on site. Patient 5: The medication profile contained an asperflex topical patch with no area defined for administration. Corrected on site. Patient 6: The medication profile contained Clearlax oral powder with no instructions for a diluent, and nystatin and triamcinolone topical creams with no area defined for administration. Corrected on site. Patient 7: The medication profile contained duplicative metoprolol doses with no instructions to take together. Corrected on site. Patient 9: During home visit medication reconciliation, the facility and hospice profiles did not match. The facility had acetaminophen PRN every 4 hours, midodrine as a PRN, and clonidine PRN. Hospice had acetaminophen PRN every 8 hours, midodrine scheduled, and clonidine not listed. The medication profile also contained Biofreeze topical gel with no area defined for administration, immodium with no instructions for frequency, miralax oral powder with no instructions for a diluent, and synthroid as a PRN instead of scheduled. Corrected on site. Patient 12: The medication profile contained polyethylene glycol oral powder with no instructions for a diluent. Corrected on site.

Upon patient record review, 4 of 19 (Patients #1,#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 1: The medical record contained an initial bereavement assessment 2/18/25 with start of care 2/12/25. Patient 6: The medical record contained an initial bereavement assessment 4/24/25 with start of care 4/17/25. Patient 10: The medical record contained an initial bereavement assessment 4/8/25 with start of care 4/2/25. Patient 13: The medical record contained an initial bereavement assessment 12/5/24 with start of care 11/29/24.

Condition of participation: Interdisciplinary group, care planning, and coordination of services The hospice must designate an interdisciplinary group or groups as specified in paragraph (a) of this section which, in consultation with the patient's attending physician, must prepare a written plan of care for each patient. The plan of care must specify the hospice care and services necessary to meet the patient and familyspecific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions.

Upon patient record review, 1 of 19 (Patient #3) 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 3: There was no evidence of weekly wound measurements since 4/16/25, and no weekly assessments from 4/16/25-5/15/25, as required per agency policy.

Upon patient record review, 4 of 19 (Patients #2,#3,#7,#12) 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 contained nursing documentation since admission identifying patient is a high risk for skin impairment. There was no evidence of problems, goals, and interventions related to skin included in the plan of care. Patient 3: The medical record contained nursing documentation since admission identifying patient is a high risk for falls. There was no evidence of problems, goals, and interventions related to fall safety included in the plan of care. Patient 7: The medical record contained nursing documentation since admission identifying patient is a high risk for skin impairment and falls. There was no evidence of problems, goals, and interventions related to skin and fall safety included in the plan of care. Skin corrected on site. Patient 12: The medical record contained nursing documentation since admission identifying patient is a high risk for falls and issues with nausea. There was no evidence of problems, goals, and interventions related to fall safety and nausea included in the plan of care. Corrected on site.

Upon patient record review, 7 of 19 (Patients #1,#2,#5,#6,#7,#9,#12) 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 medical record contained an order for a lidocaine topical patch with no area defined for administration. Corrected on site. Patient 2: During home visit medication reconciliation, the facility did not have current orders for lorazepam. Hospice did not have orders indicating a discontinuation of the medication. Corrected on site. Patient 5: The medical record contained an order for an asperflex topical patch with no area defined for administration. Corrected on site. Patient 6: The medical record contained an order 4/18/25 for a trilogy ventilator. There was no evidence of an order for setting parameters. The record also contained orders for Clearlax oral powder with no instructions for a diluent, nystatin and triamcinolone topical creams with no area defined for administration. Corrected on site. Patient 7: The medical record contained two metoprolol orders with no instructions to take together. Corrected on site. Patient 9: During home visit medication reconciliation, the facility and hospice medication orders did not match. The facility had acetaminophen PRN every 4 hours, midodrine as a PRN, and clonidine PRN. Hospice had acetaminophen PRN every 8 hours, midodrine scheduled, and no order for clonidine. The medical record also contained orders for Biofreeze topical gel with no area defined for administration, immodium with no instructions for frequency, miralax oral powder with no instructions for a diluent, and synthroid as a PRN instead of scheduled. Corrected on site. Patient 12: The medical record contained an order for polyethylene glycol oral powder with no instructions for a diluent. Corrected on site.

Upon patient record review, 8 of 19 (Patients #1,#2,#3,#6,#7,#8,#9,#14) 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 medical record contained nursing documentation identifying patient use of a wheelchair since admission and a low air loss mattress since recertification 4/22/25. There was no evidence of an order for the DME included in the plan of care. Corrected on site. Patient 2: The medical record contained nursing documentation identifying patient use of a low air loss mattress since admission. There was no evidence of an order for the DME included in the plan of care. Corrected on site. Patient 3: The medical record contained nursing documentation identifying patient use of a low air loss mattress and bedrails since admission. There was no evidence of an order for the DME included in the plan of care. Patient 6: The medical record contained nursing documentation identifying patient use of a nebulizer and walker since admission. There was no evidence of an order for the DME included in the plan of care. Corrected on site. Patient 7: The medical record contained nursing documentation identifying patient use of a low air loss mattress since admission. There was no evidence of an order for the DME included in the plan of care. Corrected on site. Patient 8: The medical record contained nursing documentation identifying patient use of a walker since admission. There was no evidence of an order for the DME included in the plan of care. Corrected on site. Patient 9: The medical record contained nursing documentation identifying patient use of floor fall mats since admission. There was no evidence of an order for the DME included in the plan of care. Corrected on site. Patient 14: The medical record contained nursing documentation 5/7/25 identifying patient use of a hospital bed. There was no evidence of an order for the DME included in the plan of care. Corrected on site.

Upon patient record review, 3 of 19 (Patients #8,#12,#14) 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 8: The medical record contained orders discontinuing spiritual care and social work 4/17/25. The plan of care was not updated to remove problems, goals, and interventions provided by spiritual care and social work. Corrected on site. Patient 12: The medical record contained nursing documentation 3/26/25 identifying patient is a high risk for skin impairment. There was no evidence the plan of care was updated to add problems, goals, and interventions related to skin. Corrected on site. Patient 14: The medical record contained orders discontinuing spiritual care 6/28/24 and social work 7/31/24. The plan of care was not updated to remove problems, goals, and interventions provided by spiritual care and social work. Corrected on site.

Upon patient record review, 1 of 19 (Patient #7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 7: The medical record contained an ordered nursing visit frequency of twice weekly. There was no evidence of a second visit completed the week of 4/27/25.

Upon patient record review, 3 of 19 (Patients #1,#12,#13) did not have evidence in the patient record that hospice aide assignments and duties are specific to patient needs. Patient 1: The medical record contained nursing documentation identifying patient required transfers with a lift since admission. The aide care plan did not contain instructions to transfer the patient with a sit to stand lift. Corrected on site. Patient 12: The most recent CTI identified the patient is a max assist for transfers. The aide care plan did not contain instructions for safe transfer of the patient. Corrected on site. Patient 13: The medical record contained nursing documentation identifying patient is a max assist for transfers since admission. The aide care plan did not contain instructions for safe transfer of the patient. Corrected on site.

Upon patient record review 3 of 19 (Patients #7,#9,#14) 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 7: The medical record contained an order for aide visit frequency of twice weekly. There was one missed visit and no completed visits the week of 5/11/25. Patient 9: The medical record contained an order for aide visit frequency of twice weekly. There was no evidence of a second visit completed the week of 5/4/25. Corrected on site with late data entry for reason of missed visit. Patient 14: The medical record contained an order for aide visit frequency of three times weekly. There was no evidence of a third visit completed the week of 5/4/25. Corrected on site with late data entry for reason of missed visit.

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. Agency volunteer utilization was 1.63% for 2024.

Upon patient record review, 1 of 19 (Patient #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 7: The medical record contained missed visit coordination notes 5/9/25, 5/12/25, and 5/19/25 with wrong dates entered for the scheduled visits. Each note stated the missed visit was one month prior, which was an error in documentation. Corrected on site.

Upon inpatient contract review, 1 of 6 (Johnson Memorial contract) did not have evidence that the inpatient provider has established patient care policies consistent with those of the hospice and agrees to abide by the palliative care protocols and plan of care established by the hospice for its patients.

Upon inpatient contract review, 2 of 6 (Johnson Memorial and SouthPoint contracts) did not have evidence that the hospice retains responsibility for ensuring that the training of personnel who will be providing the patient's care in the inpatient facility has been provided and that a description of the training and the names of those giving the training are documented.

Upon SNF/NF contract review, 1 of 6 (SouthPoint contract) did not have a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation.

Upon SNF/NF contract review, 1 of 6 (SouthPoint contract) did not have a delineation of the responsibilities of the hospice and the SNF/NF to provide bereavement services to SNF/NF personnel.

Upon patient record review, 1 of 19 (Patient #3) 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 3: The medical record contained an order for hospice to complete wound care once weekly. There was no evidence of wound care completed by hospice from 4/16/25-5/15/25.

Upon patient record review, 2 of 19 (Patients #2,#5) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Physician certification and recertification of the terminal illness specific to each patient Patient 2: During the home visit, the facility did not have the certifications of terminal illness. Corrected on site. Patient 5: During the home visit, the facility did not have the certification of terminal illness and a recent updated plan of care. Corrected on site.

Based on record review and interview, the agency failed to ensure the hospice staff reported misappropriation of a patients property when reported by the patient (L508). Failure of the RN reporting the missing cell phone to the Administrator resulted in the Administrators inability to investigate the possible theft (L509). Failure of the RN reporting the missing cell phone to the Administrator resulted in the Administrators inability to report the possible violation to State and local authorities (L511). This deficiency has a potential cumulative effect on all 69 patients. The cumulative effect of this systemic problem resulted in the hospice agencys inability to ensure the protection and promotion of their patients exercising their rights for the Condition of Participation at 418.52 Patient Rights. --- *

Based on record review and interview, the hospice agency failed to ensure the hospice staff reported misappropriation of a patients property when reported by the patient in 1 of 2 inactive records reviewed. (Patient: #1) Findings Include: --- 1. Review of a Gentiva-Hospice Division policy, revised 04-13-2022, titled ";Complaint/Grievance Process," indicated but was not limited to, "; ... The Administrator and/or Executive Director will be informed of grievances ... 1. The hospice staff member who has a complaint themselves or has received a complaint ... will discuss, verbally and in writing with a supervisor ... a. A record of complaints received will be kept with documentation to include: the name of the complainant, the relationship to the patient, the nature of the complaint, and the action taken to resolve the complaint ... " 2. Review of Patient #1's clinical record election date 05-28-2024 with a diagnosis of Malignant Neoplasm of unspecified Ovary (cancer cells multiplying quickly, destroying the healthy tissue), indicated Patient #1 lived at Entity 6, a long-term care facility until the date of death 07-13-2024. Patient #1's record contained agency documents titled " Client Coordination Note Report." The coordination notes dated 05-28-2024 to 07-13-2024 evidenced the following: On 06-29-2024, the Triage Nurse received a call from Patient #1's sister, Person 10, regarding Patient #1 being upset about her phone being missing. The Triage Nurse reported the incident to RN 1. On 07-02-2024, Former Employee 12 documented they visited Patient #1, and Patient #1 was unable to locate their phone. 3. Review of agency documents titled ";Complaint Tracking Log" dated January 2024 through October 2024 evidenced 3 complaints regarding on-call untimely visits, untimely durable medical equipment, and staff approach. The complaints log failed to evidence Patient #1s complaint of their missing phone. During an interview on 10-17-2024 at 2:44 PM, Patient #1s caregiver, Person 10, confirmed Patient #1 had lost their phone, and they had not received any calls from Gentiva regarding their complaint. 4. A review of an agency document titled "Nursing Facility Hospice Services Agreement" dated 05-24-2024 between Entity 6, the long-term care facility, and Gentiva indicated the agreement of services provided collectively for Patient #1. The agreement indicated but was not limited to, "; ... 2.12 The Hospice shall report alleged violations involving ... and misappropriation of patient property ... " During an interview on 10-18-2024 at 10:32 AM, RN 1, confirmed they were aware of Patient #1s phone missing and did not report the complaint to the Administrator. During an interview on 10-18-2024 at 11:23 AM, the Administrator confirmed they had not received a complaint regarding Patient #1s phone being missing. The Administrator further confirmed the complaint process: whenever the staff receives a complaint, they are to report it to the Administrator or the Designee in their absence.

Upon patient record review 1 of 13 records (Patient #7) did not have evidence in the patient record that the comprehensive assessment identifies the spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #7: There was not evidence of a spiritual comprehensive assessment identified spiritual needs for patient as this was not completed. [corrected on site]

Upon patient record review, 1 of 13 records (Patient #7) 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 #7: There was not evidence that a bereavement assessment was completed.

Upon patient record review, 4 of 13 records (Patient #2, 3, 8 and 11) 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: On 05/25/2022, communication note from social worker revealed visit was made with daughter and patient to discuss potential long term placement in facility however, there was no evidence of problems/interventions/goals for possible placement and social work involvement. Patient on Cipro and Macrobid for UTI in May, and Bactrim DS for bladder infection in June. No evidence of an update to problems/goals. [corrected on site] Patient #3: The patient's terminal prognosis was malignant neoplasm of lung however, there was no evidence of any problems/interventions/goals on plan of care related to this diagnosis. [corrected on site] Patient #8: There was no evidence plan of care was updated to reflect problems/goals for new orders for nystatin on 05/02/2022 or Torsemide 20mg daily for edema. [corrected on site] Patient #11: There was no evidence the plan of care was updated to reflect problems/goals for new order on 12/02/2021 for cephalexin for 7 days for UTI.

Upon client record review, 3 of 13 records (Patient #1, #2, #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The volunteer visit frequency order date 05/01/2022 reflected 4 times/month, however evidence could only be found for visits performed on 05/01/2022 and 05/08/2022. [corrected on site] Patient #2: There was no evidence of visit frequency orders for social worker, however, evidence was found that visit was performed by social worker on 05/25/2022. [corrected on site] Patient #4: The volunteer visit frequency order date 05/17/2022 reflected 4 times/month, however evidence could not be found for any visits after 05/17-05/31/2022.

Upon patient record review 2 of 10 applicable records (Patient #3, #5) 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 Patient #3: The aide plan of care dated 04/20/2022 included shampoo and nail care weekly however, on the following dates were performed twice in one week (04/25 and 04/27, 05/02 and 05/05, 05/09 and 05/13 -both shampoo and nail care). Patient #5: The aide plan of care dated 04/20/2022 included shampoo and nail care weekly however, on the following dates were one or both were performed twice in one week (04/20 and 04/22-nail care, 05/18 and 05/20 -both shampoo and nail care).

Upon patient record review, 1 of 13 records (Patient #4) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #4: The hospice physician CTI stated patient terminal prognosis was CHF however, evidence on plan of care and patient record stated Alzheimer's.

Upon patient client record review, 1 of 13 records (Patient #13) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #13: Patient requested addendum again on 03/26/2022 however, the addendum was not signed until 03/30/2022.