Every finding on record at Apex Hospice LLC

Based on record review and interview, the agency failed to maintain a system of communication to ensure that care and services were provided according to the plan of care in 1 (#13) of 4 patient records reviewed with a terminal diagnosis of Chronic Obstructive Pulmonary Disease. The failure resulted in Patient #13 not receiving physical therapy services as ordered in the plan of care. --- Patient #13: Record review of Patient #13's clinical record revealed a Plan of Care dated 1/30/2024 to 3/17/2024. The Plan of Care indicated that Patient #13 started on the agency's services on 1/30/2024. The Plan of Care listed Chronic Obstructive Pulmonary Disease (group of disease that cause airflow blockage and breathing related problems) as the terminal diagnosis. Patient #13's clinical record contained a physician order written by Registered Nurse C which was dated 3/12/2024. The order read; "Patient having difficulty transferring from bed to chair. Physical Therapy 2-3 visits approved. Patient/Caregiver will learn proper techniques for transfers." During record review on 4/5/2024 at 12:30 p.m. with the Administrator, Alternate Administrator, Director of Nursing, the Alternate Supervising Nurse, the Branch Director for Alternate Delivery Site- Allen, Clinical Operations Consultant Team Lead, Operation Consultant, Senior Quality Outcome Specialist, Vice President of Regulatory Affairs, and the Director of Clinical Excellence, the surveyor discussed physical therapy for Patient #13 and whether Patient #13 had received physical therapy. The Director of Nursing stated, "They haven't gone yet. Still working with physical therapy to get out." The surveyor asked what the agencys policy was when orders received for therapy and when physical therapy would start. The Administrator stated, "I will need to look it up." The Administrator was going to get back with the surveyor. A home visit was conducted on 4/5/2024 at 2:50 p.m. to visit Patient #13. Patient #13 was sleeping in a chair. Patient #13's Family Member was present. The surveyor asked Patient #13's Family Member about the physical therapy that had been ordered and had it helped. Patient #13's Family Member responded, "We haven't heard from therapy." Patient #13's Family Member informed the survey that they needed to call the agency. During an interview on 4/8/2024 at 10:25 a.m. with the Director of Nursing, the surveyor was informed that Patient #13's therapy should be started this week. The Director of Nursing was asked who was responsible to ensure therapy had been started. The Director of Nursing informed the surveyor that the Registered Nurse Case Manager should have notified the office Clinical Team Leader that therapy had not started. The Director of Nursing was asked why physical therapy had not been started. The Director of Nursing informed the surveyor that physical therapy hadn't started because they (the contract agency) did not think they had a contract (the agency had a contract with the contract company that had been reviewed by the surveyor). The Director of Nursing was asked how the contract agency was notified of a referral. The Director of Nursing stated, "Through email, I sent the order and the face sheet to the therapy company. They did not get back with me." The Director of Nursing asked if the surveyor had received the policy that the Administrator was going to give to the surveyor, the "S02." The policy that was provided was "Admission Process & Patient Assessment (HH only)" that was labeled S02. During an interview on 4/8/2024 at 4:16 p.m. with Registered Nurse C, the case manager for Patient #13. Registered Nurse C informed the surveyor that Patient #13's Family Member had asked if Patient #13 was eligible for physical therapy. The physician approved 3 sessions during the Interdisciplinary Group meeting and "I wrote the order." Registered Nurse C informed the surveyor that the Director of Nursing, "Reached out to Home Health about therapy." Registered Nurse C informed the surveyor that Patient #13's Family Member had been asked if the therapist had started and was told no one had been out. Registered Nurse C stated, "I notified [the Director of Nursing]." The agency had a policy titled "Admission Process & Patient Assessment (HH only)" that was labeled S02 with a revision date of 10/20/2023. The policy read in part; "Purpose 1.1 Establish criteria for admission of patients into the Agency's homecare program. 1.2 Establish a clear sequence of events in the intake and admission process to confirm appropriate services and timely start of care...3.0 Policy...Agencies that provide hospice services include...Texas...3.2 The agency follows established procedures for...3.2.2 Consulting with the physician and obtaining a verbal or written order for start of care and any services. Verbal orders will be considered updates to the Plan of Care 3.2.3 Coordinating timely services delivery including communication to appropriate staff members...3.4 Evaluations for additional Licensed Professional services will be conducted as ordered and based on patient needs and/or request, or no later than 1 week post referral..."

Based on record review and interview, the agency failed to maintain a system of communication to ensure the ongoing sharing of information between all disciplines providing services directly and under arrangement in 1 (Patient #2) of 4 records reviewed. The failure placed the patient at risk of not receiving services in a timely manner. --- Record review of Client #2s medical record revealed a plan of care with a start of care date of 4/29/2023. The client was on service with a primary diagnosis of lung cancer. Answering service (account 1470) note 5/3/2023 at 6:23 PM stated, ";we [assisted living facility] called earlier regarding [client] having a fall. We have been waiting on the nurse to come. No one has come. She is complaining about a lot of pain in her arm." On call coordination note 5/3/2023 about 6:25 PM Employee #8 stated a ";call was placed earlier regarding the client having a fall and complaining of pain in her arm. A nurse has still not visited." Complaint report dated 5/5/2023 stated ";the patient had not had a visit post fall and was now deceased." Interview 5/12/2023 about 3:13 PM Employee #1 stated, ";the first call came into the office at 1:18 PM regarding a fall. A (agency) nurse visit was scheduled within 30 minutes." In a continued interview 5/12/2023 about 3:13 PM Employee #1 stated, ";the call came in and the volunteer coordinator answered the phone. The volunteer coordinator sent an email to the scheduler and the registered nurse in the building. They scheduled the visit to an agency nurse." It was ";not urgent. A verbal request was that the client fell and her arm hurts. Tramadol (pain medication) was administered can we get a nurse to visit?" Employee #1 stated, ";no other emails or communication was received from the facility, but the facility stated they had called (the agency office) several times. ...Initial call is not documented in the patient record communication notes. The first documentation is the triage call at 6:28 PM and the patient was pronounced at 6:48 PM." In a continued interview 5/12/2023 about 3:13 PM Employee #1 stated, ";scheduler, medical records secretary, volunteer coordinator or anyone else in the office answers the phone. Falls, throwing up, or anything other than supplies goes to the nurse. It should be verbal notification to the nurse." The agency had a policy (S14) titled, ";Clinical Records (HS Only)." The policy read in parts, ";...1.0 Purpose: 1.1 Establish guidelines for maintaining the individual record for every patient in accordance with professional standards; Federal, State and local laws. 1.2 Confirm that every clinical record contains appropriate physician orders and other documentation. 1.3 Promote documentation that is a true and accurate account of the patients status and the care provided. ...3. Documentation of interdisciplinary, physician, patient or caregiver communication, education and/ or supervision in the clinical or visit notes, additional clinical notes, or minutes of IDG (interdisciplinary group) meetings..." The agency had a policy (S05) titled, ";Coordination of Services." The policy read in parts, ";...1.0 Purpose 1.1 Establish guidelines for communication and liaison between care providers that 1.1.1 Confirm continuity, consistency, efficacy, and appropriateness of service delivery. ...1.2 Confirm that documentation in the clinical record shows coordination of services. ...3.0 Policy ...3.3.2 Staff document actions which reflect coordination according to established procedures..."

Based on record reviews and interviews, the agency failed to provide nursing services on a 24-hour basis 7 days a week for 1 (Patient #3) of 4 patients receiving hospice services. The failure placed the patient at risk of not having their needs met or possible unnecessary harm to the patient. --- Record review of Patient #3s clinical record revealed a plan of care with a start of care date of 3/6/2023. The plan of care revealed the primary diagnosis of Alzheimers Disease (forgetfulness)with secondary conditions of Hypertensive Chronic Kidney Disease (high blood pressure causing kidney disease) and Cerebral Infarction (stroke). The clinical record showed the patient was receiving Hydralazine and Lisinopril for high blood pressure. A nurse visit note dated 3/14/2023 revealed a blood pressure of 162/79. A nurse visit note dated 3/21/2023 revealed a blood pressure of 161/79. The answering service report (Account 8245) reveals a call from the patients spouse regarding elevated blood pressure and mottled skin was received 3/25/2023 at 1:44 PM. The on-call coordination note dated 3/25/2023 revealed that the triage nurse (Employee #5) followed up and deemed a nurse visit necessary. Employee #5 wrote a physician order 3/25/2023 at 2:07 PM to add a nursing visit for elevated blood pressure and mottled skin. Employee #6 wrote a coordination note dated 3/27/2023 and stated, ";allowed her [spouse] to call 911 but to call back once patient is transported to the ER (emergency room). 2 hours later spouse called and said that 911 (emergency ambulance personnel) came by and checked the patient but the blood pressure was WNL (within normal limits). ...Theres no need to send him to the ER (emergency room). Patients spouse BP (blood pressure) machine is not working she needs to buy a new one with accurate digitals." Employee #6 also wrote a coordination note 3/27/2023 for a missed visit notification on 3/25/2023. Complaint report on 3/27/2023 stated the patient spouse and child requested a nurse to come assess the patient over the weekend for high blood pressure but were told to call 911. The nurse would be there for a visit the next day but did not call or show up." Per interview on 5/10/2023 about 1:50 PM with Employee #1, Employee #2, and Employee #3; Employee #2 stated, ";the call comes into the answering service who then calls the triage nurse. The triage nurse then returns the call to the patient or caregiver to obtain additional information and determine if a nurse needs to make a visit or if the issue can be addressed by the triage nurse." When asked where the information is documented Employee #2 stated, ";it should always go into a coordination/ communication note." In a continued interview 5/10/2023 about 1:50 PM with Employee #1, Employee #2, and Employee #3; when asked where the answering service communication is documented Employee #1 stated, ";the calls for the Fort Worth office from 3/1/2023 to today are in this binder." Per interview on 5/12/2023 about 1:59 PM Employee #3 stated, ";per my understanding the triage nurse takes the call and determines if a nurse visit is needed and assigns the nurse and a coordination note is done. The on-call nurse then does the follow up visit and documentation." When asked regarding the triage report and if it contained all calls received Employee #3 stated, ";from my understanding the report includes all calls received during that day." Per interview with Employee #1 and Employee #3 regarding the on-call procedure on 5/12/2023 about 3:50 PM, Employee #3 stated, ";once the triage nurse determines the need for a nurse visit a visit is expected to be made." Per interview with Employee #1 and Employee #3 regarding the complaint report 5/12/2023 about 3:50 PM Employee #3 stated, ";no nurse visits are located [3/25/23 and 3/26/23]" in the electronic medical record. The agency had a policy (S01) titled, ";Scope of Services." The policy read in parts, ";...F1.0 Purpose ...F1.0 ...1.3. Describe the responsibilities of the services. ...3.0 Policy ...3.3 The agency provides ...3.3.1.1 Nursing Services and physician services, are made routinely available on 24-hour basis 7 days a week..." The agency had a policy (5.30) titled, ";Branch Procedures." The policy read in parts, ";...5.32 On-call procedure ...Purpose: To ensure a consistent process for managing patient and employee needs after hours. ...Routine on-call ...Purpose and Process ...Purpose for on-call staffing. The purpose of the on-call nursing and therapy staffing is to manage unplanned patient needs during office closures ...HCHB (homecare home base electronic medical record) on-call coordination notes. The on-call nurse and therapist must keep accurate records of all incoming calls using the on-call coordination note including: reason for call, action taken, follow-up needed during next business day... ...Triage Communications: ...Hospice: Post visit-Branch on-call staff is asked to send a post visit report via text, call, or email. Triage staff is required to note the visit report in their coordination note that generated the visit and added to the Triage Report sent to the branches by opening of business the next day..."