Every finding on record at Apex Hospice Care, Inc.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (50%) home visits, it was revealed that the agency did not ensure the drug profile contained the patient's current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. Home Visit 1: The patient elected the hospice benefit on 05/23/2025 for a diagnosis of Parkinson's disease. The patient resided in a skilled nursing facility (SNF). During Home Visit 1 with Personnel Record 7 (Hospice Aide) on 10/30/2025, the hospice medication profile (printed on 10/29/2025) was compared to the SNF medication profile (printed on 10/30/2025). The following medications were listed on the hospice profile and were not listed on the SNF profile: Bisacodyl 10 mg suppository, 1 every 3 days if needed (ordered 05/22/2025). The following medications were listed on the SNF medication profile and were not listed on the hospice medication profile: Cholecalciferol 1000 unit tablet, daily (ordered 05/13/2025); Atorvastatin 40 mg tablet, nightly (ordered 05/13/2025). The last comprehensive visit nursing visit was dated 10/29/2025. Home Visit 2: The patient elected the hospice benefit on 04/23/2025 for a diagnosis of chronic obstructive pulmonary disease. The patient resided in a board and care (BC). During Home Visit 2 with Personnel Record 5 (Social Worker) on 10/30/2025, the hospice medication profile (printed on 10/29/2025) was compared to the BC medication profile (printed on 10/30/2025). The following medications were listed on the hospice profile and were not listed on the BC profile: Imodium 2 mg caplet, 1-2 after first loose stool as needed (ordered 05/24/2025). The following medications were listed on the BC medication profile and not on the hospice profile: Atropine 1%, every 2 hours as needed (unknown order date); Lorazepam 2mg/ml, 0.25 ml -2 ml every 2 hours as needed (unknown order date); Morphine 100 mg/5ml, every hour as needed (unknown order date). The following discrepancy was noted: Hospice had Zofran 4 mg and BC had Zofran 8 mg every 8 hours (ordered 04/22/2025). The last comprehensive nursing visit was dated 10/27/2025. A joint clinical record review and interview was conducted with the clinical manager on 10/31/2025 in which she confirmed the medication discrepancies and advised the "nurses should be reconciling the medications with each visit."

It is required that written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the registered nurse provided specific written instructions for the hospice aide. CLINICAL RECORD 3: The hospice aide care plan dated 06/17/2025 included the following relevant tasks: "non-ambulatory-bed-bound, bed rails up x 2, objects within reach, bed in low position, turn and reposition; toileting-adult diapers; urinary-incontinent, incontinent care; bowel-incontinent; transfer-fall precautions; dressing-pajamas/gown; feeding-diet as tolerated; bath-bed bath; shave-safety razor; hair-comb, shampoo; mouth-brush teeth; skin-nails, clean, file, visualize condition of skin and report to RN (registered nurse), peri care; patient status-alert, fall risk; housekeeping-change patient linens, tidy patient's room, empty trash, light housekeeping; if the patient is experiencing pain and or change of condition report to RN." All tasks were to be completed every visit. The aide visit frequency was twice weekly. A physician's order dated 06/17/2025 noted the following: "right sided facial cancerous lesion, cover with xerofoam, calcium alginate, and dry sterile dressing, three times a week." A physician's order dated 07/04/2025 noted the following: "left lower leg open lesion. Cleanse with normal saline, pat dry, apply a non-stick dressing." A physician's order dated 07/31/2025 noted the following: "apply heel protectors to offset pressure." The hospice aide care plan did not notify the aide of the wounds, nor provide specific instructions to notify the nurse if the wound dressing became soiled, dislodged, or wet. The hospice aide care plan did not notify the aide of the heel protectors nor provide specific instructions for care of the heel protectors during tasks. A joint clinical record review and interview was conducted with the clinical manager and quality manager on 10/30/2025 in which it was stated there "had been communication about the wounds but it had not been placed in the aide care plan."

It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review, interview and observation. In 2 of 19 (11%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure hospice aide provided services included in the plan of care. Home Visit 1: The hospice aide care plan dated 08/08/2025 included the following relevant tasks: "non-ambulatory-bed-bound, objects within reach, bed in low position, turn and reposition; toileting-adult diapers; urinary-incontinent, incontinent care; bowel-incontinent; record bowel movements; transfer-fall precautions; dressing; feeding-diet as tolerated, aspiration precautions, feeding assistance; bath-bed bath; shave-safety razor; hair-comb, shampoo; mouth-brush teeth; skin-nails, clean, file, visualize condition of skin and report to RN (registered nurse), peri care; patient status-alert, confused, fall risk; if the patient is experiencing pain and or change of condition report to RN." All tasks were to be completed every visit. The aide visit frequency was twice weekly. Home Visit 1/Clinical Record 1 was conducted with the Hospice Aide (Personnel Record 7) on 10/30/2025. The aide was observed to complete all assigned tasks on the care plan except filing the nails as the patient had severely contracted hands. The aide did state he would notify the charge nurse at the facility and the hospice nurse of this. The aide was observed to change the linens which was not included on the aide care plan. Clinical Record 17: The hospice aide care plan dated 12/15/2024 included the following relevant tasks: "ambulatory-ad lib, walker; toileting-bathroom, urinal, briefs; urinary-continent, incontinent care; bowel-continent; transfer-fall precautions; dressing-street clothes; feeding-diet as tolerated; bath-shower chair; hair-brush, shampoo; skin-nails, clean, apply lotion, visualize condition of skin and report to RN (registered nurse), peri care; patient status-alert, HOH (hard of hearing), fall risk; oxygen-2-4 liters per minute; housekeeping-change patient linens, tidy patient's room, empty trash, light housekeeping; if the patient is experiencing pain and or change of condition report to RN. All tasks were to be completed every visit. The aide visit frequency was twice weekly. The hospice aide visit dated 12/19/2024 noted the following: "Sponge bath provided." The hospice aide visit dated 12/24/2024 noted the following: "Bed bath provided." The clinical manager was present during Home Visit 1 on 10/30/2025 and observed the aide performed tasks that were not on the aide care plan. When interviewed on 10/30/2025 regarding Clinical Record 17, it was agreed the aide documented "performed baths that were not included on the care plan."

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A review of the volunteer program was conducted with the Volunteer Coordinator and Administrator on 10/29/2025, during which time the volunteer percentage for the last twelve (12) months (October 2024 to September 2025) averaged to 1.08%. The Volunteer Coordinator advised she was recently hired (November 2024) and has been actively recruiting and onboarding volunteers since being hired. A review of the volunteer program was conducted with the Volunteer Coordinator and Administrator on 10/29/2025, during which time the volunteer percentage for the last twelve (12) months (October 2024 to September 2025) averaged to 1.08%. The Volunteer Coordinator advised she was recently hired (November 2024) and has been actively recruiting and onboarding volunteers since being hired.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, interview and personnel record review. In 1 of 9 (11%) personnel records reviewed revealed the agency did not ensure the skills and competencies of all individuals providing care, including volunteers were assessed.   Document 2: Agency policy titled "Competency Based Orientation Policy 6-004.1 Revised Oct 2012" stated in relevant part: "Policy. Hospice ensures that the competency is assessed of all personnel prior to providing care to patients." Personnel Record 9: A personnel record review was conducted on 10/30/2025, which revealed that the volunteer, hired on 08/11/2025 did not have a competency included in their file. Per the volunteer coordinator, interviewed on 10/30/2025, the volunteer "had already been given patients and completed assignments." A joint personnel record review and interview was conducted with the administrator and volunteer coordinator on 10/29/2025, during which time it was confirmed that the personnel file did not contain a competency checklist for the volunteer.

It is required that the hospice must obtain the patient's or representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 13 (8%) records reviewed revealed that the agency did not ensure to obtain the patient's or representative's signature confirming that he or she had received a copy of the notice of rights and responsibilities. Clinical Record 9: The patient elected hospice care on 8/30/22. The representative initialed each page at the bottom of the page. There was no signature or date under the acknowledgment and agreement. The boxes were not checked confirming they received the information and agreed to the terms described. The Administrator stated in an interview on 12/6/22 that there were no signatures on the hospice benefit election. All findings were reviewed and confirmed with the Administrator, Clinical Manager, and the agency consultant during the final exit on 12/7/22.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum: signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by a review of clinical records, document review, and interviews. 1 of 13 (8%) records reviewed revealed that the agency did not ensure the clinical record contained signed copies of the notice of patient rights and the hospice election statement. The agency's policy # H:2-024.5, stated in part "patient or his/her representative will sign the required forms indicating the election of hospice care and receipt of patient rights and privacy information." The agency's policy #H:2-026.1 "Hospice Election Statement Procedure" , stated in part, "The patient and family or legal representative will be asked to sign the hospice election form". Clinical Record 9: The patient elected hospice care on 8/30/2022. The agency form "Hospice Benefit Election" page 7 "Request for confidential communications regarding medical information" was not signed and dated by the patient, or a legal representative. During an interview on 12/6/22, the findings were reviewed and confirmed with the Administrator and Clinical Manager during the daily wrap-up. All findings were reviewed and confirmed with the Administrator, Clinical Manager, and the agency consultant during the final exit on 12/7/22.