Every finding on record at Apex Hospice, LLC

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan. A revised plan of care includes information from the patient’s updated comprehensive assessment. This standard was not met as evidenced by a review of clinical records and interview. 1 of 5 (20%) clinical records reviewed a plan of care was not revised following a patient's updated comprehensive assessment. Clinical Record #3: The patient elected the hospice benefit on 5/12/2022 with a primary diagnosis of unspecified dementia with behavioral disturbance. The updated comprehensive assessment documented by the RN on 7/18/2022 states the patient had a new abrasion. The RN received an order on 7/18/2022 written as "abrasion to back of the head, keep clean and dry, and monitor for signs and symptoms of infection." There was no evidence in the plans of care dated 7/19/2022 and 8/2/2022 that included an intervention for the wound identified during the comprehensive assessment on 7/18/2022. The Administrator stated in an interview during a joint review of the clinical records on 8/3/2022 that the plan of care was not updated. This standard was not meet as evidenced by review of clinical records and interview. 1 of 5 (20%) records reviewed did not contain evidence of a revised plan of care as a result of an updated comprehensive assessment. Clinical Record #3; Patient elected the hospice benefit on 5/12/2022 with a primary diagnosis of unspecified dementia with behavioral disturbance. The updated comprehensive documented by the RN on 7/18/2022 states the patient had a new abrasion. The RN received an order on 7/18/2022 written as "abrasion to back of head, keep clean and dry, and monitor for signs and symptoms of infection." There was no evidence in the plans of care dated 7/19/2022 and 8/2/2022 as identified in the comprehensive assessment and order related to the wound. The administrator stated in an interview during a joint review of the clinical records on 8/3/2022 that the plan of care was not updated.