Every finding on record at American Prime Healthcare, Inc.

Observed in HR File Review. In 3 out of 9 personnel records reviewed, the organization failed to ensure that emergency management education had been provided to their staff. For example, in review of HR#1, the medical director had no evidence of emergency management training upon hire in 2024 or annual training in 2025. In review of HR#7, the Director of Patient Care Services (DPCS) did not have annual training for 2025. In review of HR#9, the alternate medical director did not have annual training for 2023, 2024, and 2025. This was reviewed, discussed, and validated with the administrator.

Observed in Patient Home. In 1 out of 1 home visits conducted, the organization failed to respect, protect, and promote the patient's right to and need for effective communication. For example, during the home visit for RRHV#1, the patient and family were primarily Spanish-speaking and verbally requested Spanish-speaking staff during the course of the visit. However, the staff provided did not speak the patient's preferred language and had limited ability to translate through the use of the patient's granddaughter. This was reviewed, discussed, and validated with the administrator.

Observed in Record Review. In 1 out 14 records reviewed, the organization failed to respect the patient's right to revoke hospice care. For example, in the record review for RRNHV#2, the patient revoked hospice services to seek aggressive treatment at an inpatient facility, however, there was no evidence that the organization had received a signed revocation form from the patient or their representative. This was reviewed, discussed, and validated with the administrator.

Observed in Patient Home. In 1 of 1 home visits conducted, it was noted the organization did not maintain confidential patient records in accordance with privacy and security standards of the Health Insurance Portability and Accountability Act (HIPAA). For example: during RRHV# 1's home observation RRNHV# 9's medical record binder with RRNHV# 9's name on the outside of the medical record binder and hospital admission records located in the binder was found on the coffee table in the living room of RRHV# 1's home. The Administrator shared he brought RRNHV# 9's medical record binder to RRHV# 1's home approximately one hour prior to the surveyors home observation and thought it was the patient folder for RRHV# 1.

Observed in Record Review. In 3 out of 14 records reviewed, the organization failed to ensure that the patient was provided with information about the services covered under the hospice benefit. For example, during the record review for RRNHV#3, RRDC#2, and RRBR#1, there was no evidence that the organization had obtained signed consent forms or hospice election forms from the patient or their representative. This was reviewed, discussed, and validated with the administrator.

Observed in Record Review. In 2 out of 14 records reviewed, the organization failed to ensure that it assessed the patient and patient's condition according to defined time frames. For example, in record review for RRNHV#4, the psychosocial assessment was completed seven (7) days after the election of hospice care. In the record review of RRDC#2, the psychosocial assessment was completed 12 days after the election of hospice care. This was reviewed, discussed, and validated with the administrator.

Observed in Record Review. In 3 out of 14 records reviewed, the organization failed to assess its patients. For example, in record review of RRNHV#2, RRNHV#3, and RRBR#1, there was no evidence that the organization had completed a psychosocial assessment. This was reviewed, discussed, and validated with the administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, During RRNH# 8's patient record review it was noted the organization did not ensure the RN updated the comprehensive assessment no less than every 15 days. For example: review of RRNHV# 8's patient record revealed an LVN conducted all the assessment for RRNHV# 8 after the start of care or for approximately 28 days. This was reviewed, discussed, and validated with the Administrator.

Observed in Record Review. In 14 out of 14 records reviewed, the organization failed to maintain complete and accurate patient records. For example, in all records reviewed, an oxygen safety assessment had completed, however, none of the patients had orders for oxygen and no documentation that indicated oxygen was in use. Upon further review, all assessments included detailed education that was provided to the patients regarding the specific equipment in their home setting such as, Instructed patient to keep their oxygen tanks away from gas stoves, Provided demonstration on safe oxygen storage in an upright position, Patient performed correct return demonstration of oxygen use, and Patient/representative verbalized correct procedure for utilizing emergency oxygen tank. This was reviewed, discussed, and validated with the administrator.

Observed in Record Review. In 2 of 14 patient records reviewed, During RRNHV# 8 and RRNHV# 6's patient record review it was noted the organization did not ensure the plan of care included interventions to manage pain and symptoms. For example: review of RRNHV# 8's RN comprehensive assessment revealed RRNHV# 8 had difficulty swallowing and was on a mechanical soft diet. However, review of RRNHV# 8's plan of care and updates to the plan of care revealed no intervention for mechanical soft diet. Review of RRNHV# 6's RN comprehensive assessment revealed RRNHV# 6 had difficulty swallowing and was on a puree diet and thickened liquids. However, review of RRNHV# 6's plan of care and updated plan of care revealed no interventions for a puree diet or thickened liquids. Further review of RRNHV# 6's patient record revealed RRNHV# 6 had a pressure ulcer to the coccyx and it was being cleaned with normal saline and a duoderm was being applied by the nurse during visits and by the family daily. However, review of RRNHV# 6's plan of care revealed no interventions for wound care. This was reviewed, discussed, and validated with the Administrator.

Observed in Record Review. In 1 out of 14 records reviewed, the organization failed to provide for its planned scope and level of care, treatment, or services. For example, in the record review for RRNHV#1, the Medical Social Worker (MSW) noted in their initial psychosocial assessment that the patient reported 10/10 pain during the visit. Upon further review, the MSW noted that they would report the change in condition to the hospice, however, there was no evidence that the hospice IDG or physician was notified. There were no documented communication notes indicating that the MSW reported the change in condition, and the next visit from a hospice team member occurred three days later by a skilled nurse. This was discussed, reviewed, and validated by the administrator.

Observed in Leadership Session. During the leadership and data system tracer, the organization failed to use data to monitor the effectiveness and safety of services and the quality of care. For example, the organization was unable to provide evidence that they used their collected data to monitor the effectiveness and safety of services and the quality of care for 2025. This was reviewed, discussed, and validated with the administrator.

Observed in Leadership Session. During the leadership and data system tracer, the organization failed to act when it did not achieve or sustain planned improvements. Because the organization did not have evidence of any performance improvement activities for 2025, there was no evidence that it acted when planned improvements were not achieved or sustained. This was reviewed, discussed, and validated with the administrator. Observed in Leadership Session. During the leadership and data system tracer, the organization failed to act on improvement priorities. For example, the organization did not identify any improvement priorities for 2025. Because they did not identify any improvement priorities, they could not act on them. This was reviewed, discussed, and validated with the administrator. Observed in Leadership Session. During the leadership and data system tracer, the organization failed to evaluate actions to confirm that they resulted in improvements. For example, the organization had no evidence that they completed any performance improvement activities for 2025, and could not demonstrate any evaluation of their actions to confirm they resulted in improvement. This was reviewed, discussed, and validated with the administrator.

Observed in Leadership Session. During the leadership and data system tracer, the organization failed to improve performance. For example, the organization had no evidence that it determined the number and scope of annual improvement projects based on patients' needs and organizational needs for 2025. This was reviewed, discussed, and validated with the administrator.

Observed in Leadership Session. During the leadership and data system tracer, the organization failed to improve performance. For example, the organization had no documented performance improvement projects for the year 2025. This was reviewed, discussed, and validated with the administrator.

Observed in HR File Review. In 3 out of 9 personnel records reviewed, the organization failed to ensure that bloodborne pathogen education had been provided to their staff. For example, in review of HR#1, the medical director had no evidence of bloodborne pathogen training upon hire in 2024 or annual training in 2025. In review of HR#7, the Director of Patient Care Services (DPCS) did not have annual training for 2025. In review of HR#9, the alternate medical director did not have annual training for 2023, 2024, and 2025. This was reviewed, discussed, and validated with the administrator.

Observed in Tracer Activities. During review of the organization's contracted services, the organization failed to provide for its planned scope and level of care, treatment, or services. For example, during the contract review, it was noted that the organization did not have a contract or arrangement for physical therapy (PT), occupational therapy (OT), and speech language pathology (SLP) services. Upon further review, there was no evidence of direct employees that the organization maintained to provide PT, OT, and SLP services. Furthermore, the administrator shared that these services were not provided or applicable to the patients served by the organization. This was reviewed, discussed, and validated with the administrator.

Observed in HR File Review. In 2 of 9 HR files reviewed, During HR# 9 and HR# 8's HR file review it was noted the organization did not ensure competence was evaluated per organization policy Competence Assessment No. 1-008.1 that included competence evaluation annually. For example: review of HR# 9/Alternate Medical Director's HR file revealed unsigned annual competence evaluation for 2024 and 2025. Review of HR# 8/MSW's HR file revealed an unsigned competence evaluation for 2024. This was reviewed, discussed, and validated with the HR Administrative Assistant and the Administrator.

Observed in Tracer Activities. During the volunteer system tracer, the organization failed to provide services that meet patient needs. For example, the organization had no evidence of volunteer recruitment and retention efforts for the year 2025. This was reviewed, discussed, and validated with the administrator.

Observed in Tracer Activities. During the volunteer system tracer, the organization failed to provide services that meet patient needs. For example, the organization had no evidence of the cost savings achieved through the use of volunteers for the year 2025. This was reviewed, discussed, and validated with the administrator.

Observed in Tracer Activities. During the volunteer system tracer, the organization failed to provide services that meet patient needs. For example, the organization had no evidence to demonstrate that volunteer staff provide day-to-day administrative or direct patient care in an amount that equals 5% of the total patient care hours of all paid hospice employees and contracted staff for 2025. This was reviewed, discussed, and validated with the administrator.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had consistently implemented policies and procedures to support the patient care, treatment, and services as evidenced by condition level deficiencies at §418.54, §418.102, §418.116, §418.72, §418.104, §418.100, §418.58, §418.78, and §418.52. This was reviewed, discussed, and validated with the administrator. Observed in Leadership Session. During Leadership session it was noted the Governing Body had not ensured an Administrator was appointed for the day-to-day operations of the hospice. For example: review of the only Governing Body minutes from 2023 and the prior owners revealed an Administrator that was no longer with the organization. The new owner/Administrator was unable to provide documentation the current Governing Body had appointed an Administrator. This was reviewed, discussed, and validated with the Administrator/owner. Observed in Leadership Session. During Leadership it was noted the organization's new owners did not have an annual operating budget for the past year nor did they have a governing body to oversee and approve a budget. This was discussed, reviewed, and validated with the Administrator.

Observed in HR File Review. In 1 of 9 HR files reviewed, During HR# 8's HR file review it was noted the organization did not ensured competence was assessed as part of the orientation. For example: review of HR#8/MSW's HR file revealed no evidence of an initial competence evaluation. This was reviewed, discussed, and validated with the HR Administrative Assistant and Administrator. Observed in HR File Review. In 1 out of 9 personnel records reviewed, the organization failed to ensure that staff competence is initially assessed. For example, in the review of HR#2, there was no evidence that the organization completed initial competencies for the Licensed Vocational Nurse (LVN). The LVN had been employed for approximately one month, however, no competencies had been performed. Furthermore, the LVN was observed during RRHV#1 working independently without supervision. This was reviewed, discussed, and validated with the administrator.

Observed in Record Review. In 1 of 15 patient records reviewed, During RRNHV# 8's patient record review it was noted the organization did not ensure the initial Certification of Terminal Illness (CTI) included medical management of the patient's conditions unrelated to the terminal condition. For example: review of the initial revealed a copy and pasted LCD Guideline from the start of care RN comprehensive assessment that included possible signs and symptoms the patient was not experiencing such as a. Aspiration pneumonia in the past 12 months?, d. Decubitis ulcer stage 3 or 4 in the past 12 months?, and f. Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin less than (<) 2.5 gm/dl?. This was reviewed, discussed, and validated with the Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed, with recertification of terminal illness. During RRNHV# 7's patient record review it was noted the organization did not ensure the Medical Director reviewed the clinical information and signed the certification of terminal illness (CTI) prior to the recertification. For example: review of RRNHV# 7's patient record revealed four recertification CTI. Review of the recertification CTIs revealed 3 out of 4 recertifications were signed after the recertification date. This was reviewed, discussed, and validated with the Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, During RRNHV# 8's patient record review it was noted the organization did not ensure staff followed the organization policy Entries into the Clinical Record No.5-006.2, that included hospice personnel providing direct patient care and supervisory functions have authority to make entries into the clinical record. For example: review of RRNHV# 8's patient record revealed a discharge summary signed by HR# 5/Community Liason with no direct patient care responsibilities. This was reviewed, discussed, and validated with the Administrator. Observed in Record Review. In 2 of 14 patient records reviewed, During RRNHV# 9 and RRNHV# 6's patient records review it was noted the organization had not maintained complete patient records. For example: during RRNHV# 9's patient record review it was noted the Election of Benefit (EOB) and Patient Consent forms were not present in the electronic medical record (EMR) or the paper medical record. The Administrator shared the documents had been scanned from home and not upload with the original documents at home and not in the RRNHV# 9's medical records at the time of the surveyor review of the record. Review of RRNHV# 6's EMR revealed no documentation of an EOB or Patient Consent form. The Administrator stated the original documents were on a different computer at home. This was reviewed, discussed, and validated with the Administrator. Observed in Record Review. In 1 of 14 patient records reviewed, During RRNHV# 9's patient record review it was noted the organization had not ensured it maintained complete and accurate patient records. For example: review of RRNHV# 9's start of care RN comprehensive assessment revealed documentation that an additional assessment was completed two days in the future of the RN signature date. Further review of RRNHV# 9's patient record revealed a SN visit note dated two days after the start of care with documentation that the SN visit note was signed by the DPCS for the clinician that completed the assessment. Audit trails was requested and not provided. This was reviewed, discussed, and validated with the Administrator.

Observed in Patient Home. In 1 out of 1 home visits conducted, the organization failed to ensure that the patient record contains information that reflects the patient's care, treatment, or services. For example, during the home visit conducted for RRHV#1, the nurse was observed performing a medication reconciliation. During the reconciliation, the following medications were included on the medication profile, but not present in the home; Timolol Malate 0.5% ophthalmic solution. Upon further discussion, the daughter shared that those medications were discontinued three months prior to the patient's admission to hospice. Furthermore, during the reconciliation, the following medications were present in the home, but not included on the medication profile; Refresh Eye Drops, Vicks Nasal Saline Spray, and Omeprazole 40 mg DR capsules. This was reviewed, discussed, and validated with the administrator.

Observed in Record Review. In 2 out of 14 records reviewed, the organization failed to ensure that entries in the patient record are authenticated. For example, in the record review for RRNHV#5, the consent forms and hospice election date were left blank. Upon further review of the documents, the patient, representative, and organization's witness had left no identifying date of when the document was signed and when the hospice election was to take effect. In the record review for RRNHV#2, the signed hospice election form had an election date that was dated two (2) days after the RN comprehensive assessment and start of care date had been completed. This was reviewed, discussed, and validated with the administrator.

Observed in Record Review. In 4 out of 14 records reviewed, the organization failed to ensure that the patient's attending physician received a copy of the hospice discharge summary. For example, in record review of RRNHV#2, the patient was hospitalized and there was no evidence that the receiving facility had received a copy of the discharge summary. In record review of RRDC#1 and RRNHV#4, the patients had transferred to another hospice, however, there was no evidence that the discharge summary was sent to the receiving provider. In record review of RRDC#2, the patient refused further services, however, there was no evidence that the discharge summary had been sent to the patient's attending physician. This was reviewed, discussed, and validated with the administrator.

Observed in HR File Review. In 2 of 9 HR files reviewed, During HR# 2 and HR# 8's HR file review it was noted the organization did not obtain a criminal background check. For example: review of HR# 2/LVN's and HR# 8/MSW's HR files revealed no evidence a criminal background check had been completed. This was reviewed, discussed, and validated with the HR and Administrator.

Observed in Regulatory Review. Review of the organization's State Health Department License revealed that the license had expired 37 days prior to the surveyor arrival to the organization. The organization provided a Cashier's Check to the state for licensure issued three days after the licensed had expired and provided a Federal Express receipt that was dated four days after the license had expired with no other documents to verify the State Health Department had renewed the organization's license. This was reviewed, discussed, and validated with the Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed, the Surveyor noted an RN did not visit the hospice patient every 15 days to conduct an assessment. in RRNHV #1, the patient went 24 days without an RN comprehensive assessment. All patient visits had been conducted by an LVN. This was validated with the DPCS and the Administrator.

Observed in Record Review. In 2 of 2 patient records reviewed, The Surveyor noted the goals in patient records were not measurable and time specific. On review of RRNHV #1 and RRNHV #2, the patient goals on the plan of care were - 'for constipation: Facilitate bowel elimination and comfort. [END OF CERT] ; for Altered Sleep Pattern: Pcg will verbalize understanding of medication orders and side effects. [END OF CERT]; Neuro: will be able to anticipate his needs - Will be able to provide adequate care as the need arises [END OF CERT] anxiety Patient will have decreased episodes of anxiety during the next 1 week. This finding was reviewed with the Administrator and DPCS.

Observed in Record Review. In 1 of 2 patient records reviewed, In 1 out of 1 patient records reviewed, the medication orders were not clear and accurate for duplicative therapy. The surveyor noted in RRHV #2 the patient had 3 medications ordered for pain that the physician's orders in the plan of care documented Norco 5mg-325mg Tablet take one pill by mouth 3x day as needed for pain, Morphine Sulfate Concentrated 20mg/mL Solution Note: Give 0.25mL for mild pain/SOB; give 0.5mL for moderate pain/SOB; give 1mL for severe pain/SOB every 2hr as needed Moderate to severe pain or shortness of breath, and Acetaminophen 325mg Tablet 2 Tabs mild pain every 6 hours as needed with no direction on which order to give duplicate therapies. The organization's policy Medication Profile 3.002.1 states that a review for duplicate therapy will be done on mediation review. This finding was reviewed with the agency administrator and the DPCS.

Observed in Record Review. In 5 of 5 patient records reviewed, The organization did not ensure patient care plan goals were individualized, measurable and realistic. Examples include the following: “Pt's genito-urinary and gastro-intestinal status improved with medication treatment by the end of the 3rd week as evidenced by no constipation and daily bowel moment”, for a care plan problem listed as alteration in bowel and bladder elimination r/t occasional incontinence. There are no incontinence medications listed on the patient’s medication profile., “By the end of 4th week, cardiovascular status stabilized with current tx as evidenced by no c/o syncope, shortness of breath, headaches and blood pressure w/in normal range of 90/60-150/90 mm Hg and resolved edema.”, This goal is listed for a patient with a diagnosis of Kidney Disease., “Patient and family will have normal grieving as related to terminal disease by verbalizing grief by next IDG.”, For a care plan problem of knowledge deficit r/t medication: “Pcg/family will verbalize understanding on medications as evidenced by compliance and verbalizing it's uses/indication, dosage and frequency by the end of 2nd week.”, “Alteration in Nutrition r/t loss of appetite, Patient will maintain good nutrition and weight with not weight loss of more than 1-2 lbs in a week.” And, “Pt skin turgor maintained normal as evidenced by no evidence of saggy, normal skin color.” These stated goals do not contain information, including realistic time frames, that can be accurately measured to assist staff in determining whether the patient is progressing towards achieving their goals. These findings were reviewed, discussed, and validated with the Administrator/DPCS designee.

Observed in Patient Home. The staff failed to perform hand hygiene at times required by the organization's policies. For example, on HV #1/RR #1, the surveyor observed the LVN donning gloves, obtaining the patient’s vital signs one at a time, individually cleaning each piece of medical equipment, documenting the value and then returning to patient contact each time, without completing hand hygiene. The organization’s policies require standard precautions to be used, including hand hygiene after handling medical equipment, to prevent and control infection when conducting direct patient care. These findings were reviewed, discussed, and confirmed with the Administrator/DPCS designee.