Every finding on record at Harbor Hospice Medical Center - Houston LP

Observed in Record Review. In 3 of 12 patient records reviewed, it was noted that the organization did not ensure the plan of care was individualized to the patient’s needs and condition. For example, during a review of the medical record for RRHV#3, a clinician documented that the patient experienced a fall with injury during week 7, of the 2nd benefit period. The plan of care did not include a goal statement to evaluate care, treatment, and services related to fall prevention interventions. In addition, during week 8 of the 2nd benefit period, a clinician documented that the patient’s oxygen saturation was 76% and the patient was placed on oxygen at 6 liters per nasal cannula. The plan of care did not include a goal statement to evaluate care, treatment, and services related to oxygen therapy interventions. Example #2: During a review of the medical record for RRNHV#1, and RRNHV#4, it was noted that the patient's terminal illness diagnosis was Senile degeneration of brain, not elsewhere classified. The plan of care did not include a goal statement to evaluate care, treatment and services related to Senile degeneration of brain, not elsewhere classified. This observation was reviewed with the Administrator.

Observed in Record Review. In 3 of 12 patient records reviewed, it was noted that the organization did not ensure the plan of care was revised when the patient’s condition changed. For example, during a review of the medical record for RRHV#3, it was noted that during week 7 of the 2nd benefit period, the patient experienced a fall with injury. The plan of care was not updated with interventions to maintain patient safety, and strategies to prevent injury. In addition, during week 8 of the 2nd benefit period, a clinician documented that the patient’s oxygen saturation was 76% and the patient was placed on oxygen at 6 liters per nasal cannula. The plan of care did not include an order for oxygen therapy. The plan of care did not include oxygen therapy interventions. Example #2: During a review of the medical record for RRNHV#1, and RRNHV#4, it was noted that the patient's terminal illness diagnosis was Senile degeneration of brain, not elsewhere classified. The plan of care did not include interventions to address the care, treatment, and services related to Senile degeneration of brain, not elsewhere classified. This observation was reviewed with the Administrator.

Observed in Record Review. In 5 of 12 patient records reviewed, it was noted that the organization did not ensure the plan of care was reviewed and revised every 15 days. For example, during a review of the medical record for RRHV#2, there was no documented evidence that the interdisciplinary group, in collaboration with the patient’s attending physician reviewed and revised the plan of care for a 54-day timeframe during benefit period #1. The plan of care was not reviewed and revised for an 89-day timeframe for benefit period #2. The plan of care was not reviewed and revised for a 49-day timeframe during benefit period #3. Example #2: During a review of the medical record for RRHV#3, there was no documented evidence that the interdisciplinary group, in collaboration with the patient’s attending physician reviewed and revised the plan of care for an 89-day timeframe for benefit period #1. The plan of care was not reviewed and revised for a 67-day timeframe during benefit period #2. Example #3: During a review of the medical record for RRNHV#1, there was no documented evidence that the interdisciplinary group, in collaboration with the patient’s attending physician reviewed and revised the plan of care for an 89-day timeframe for benefit period #1. The plan of care was not reviewed and revised for a 55-day timeframe for benefit period #2. Example #4: During a review of the medical record for RRNHV#4, there was no documented evidence that the interdisciplinary group, in collaboration with the patient’s attending physician reviewed and revised the plan of care for an 25-day timeframe for benefit period #1. Example #5: During a review of the medical record for RRNHV#5, there was no documented evidence that the interdisciplinary group, in collaboration with the patient’s attending physician reviewed and revised the plan of care for an 67-day timeframe for benefit period #1. The plan of care was not reviewed and revised for a 60-day timeframe for benefit period #2. This observation was reviewed with the Administrator.

Observed in Record Review. In 3 of 6 patient records reviewed, for patient's receiving hospice aide services, it was noted that the organization did not ensure all requirements for planning the care of patient's were implemented. For example, a review of the medical record for RRHV#3, RRNHV#1, and RRNHV#2, revealed that the Plan of Care did not include written patient care instructions for the hospice aide prepared by the registered nurse member of the interdisciplinary group. This observation was reviewed with the Administrator.

Observed in Record Review. In 1 of 6 patient records reviewed, for patients receiving Hospice Aide services, it was noted that the organization did not ensure Hospice Aide supervision was effective. For example, during the review of the medical record for RRNHV#1, it was noted that a Hospice Aide supervision visit was not documented by the Registered Nurse every 14 days. A Hospice Aide supervision visit was not documented during the 90-day timeframe for benefit period #1. A Hospice Aide supervision visit was not documented during a 55-day timeframe for benefit period #2. This observation was reviewed with the Administrator.

Observed in HR File Review. In 1 of 9 Human Resource files reviewed, it was noted that the organization did not complete competence assessment when required. For example, during a review of the Human Resource file for the Social Worker, it was noted that competence was not initially assessed and documented as a part of orientation. This observation was reviewed with the Administrator.

Observed in Record Review. In 3 of 6 medical records reviewed, for patient's receiving hospice aide services, it was noted that the organization did not ensure medical record entries were complete, promptly, and accurately documented. For example, during a review of the medical record for RRHV#3, it was noted that hospice aide services were ordered two (2) visits per week. The hospice aide visit notes for a 4 week period did not include documentation of the care, treatment, and services provided during the visit. Example #2: During a review of the medical record for RRNHV#1, it was noted that hospice aide services were ordered three (3) visits per week. The hospice aide visit notes for a 13 week period did not include documentation of the care treatment, and services provided during the visit for benefit period #1. The hospice aide visit notes for an 8 week period did not include documentation of the care, treatment, and services provided during the visit for benefit period #2.Example #3: During a review of the medical record for RRNHV#2, it was noted that hospice aide services were ordered three (3) visits per week. The hospice aide visit notes for a 2 week period did not include documentation of the care treatment, and services provided during the visit. This observation was reviewed with the Administrator.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to ensure the hospice IDG complete the comprehensive assessment no later than 5 calendar days after the election of hospice care. For example: In HV#2 there was no documentation of a initial comprehensive assessment for MSW noted on the record. Survey was later presented with a hand written Social Work Assessment by the document lacked a date or time in/ time out. In RR#9 there was no documentation a comprehensive assessment being completed by the MSW. This observation was reviewed with the Director of Nursing and Clinical Manager.

Observed in Record Review. In 2 of 11 patient records reviewed, the hospice failed to conduct and document patient-specific comprehensive assessment and reassessment that identified the patient's need for hospice care and services. For example: In RR#5 the patient had wounds and there was no assessment or treatment of the wound noted in week 2. In review of RR#6 the patient was diabetic and medication profile noted patient was on insulin and an oral hypoglycemic, however there was no assessment in the initial comprehensive assessment or follow up documented beyond endocrine system WNL. These observations were reviewed with the Director of Nursing and the Clinical Manager.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to ensure that the comprehensive assessment was conducted as frequently as the condition of the patient required, but no less frequently that every 15 days. In review of RR#10 the initial comprehensive assessment was completed on admission and there was no further documentation of an RN comprehensive assessment throughout the patient's care. The patient was discharged in week 5. This observation was reviewed with the Director of Nursing and Clinical Manager.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to ensure that the patient and primary caregiver receive education and training by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care. For example: on review of RR#6 the patient was diabetic and on insulin and an oral hypoglycemic, yet there was no documentation noted in the record of education provided concerning diabetes management as the patient declines, nor education on insulin administration to include proficiency in administering subcutaneous injections. This observation was reviewed with the Director of Nursing and Clinical Manager.

Observed in Record Review. In 3 of 11 patient records reviewed, the organization failed to ensure that the written plan of care was based on the patient's goals that were specific, measurable, achievable, realistic and time bound. For example: in review of HV#2 the were goals established that were not specific and measurable but read more like interventions than goals, such as apply skin moisture barrier cream to affected skin area daily and PRN, and Oxygen 2 lts via NC PRN for SOB. RR#6 there were also goals that were not measurable and specific such as Patient will achieve optimum nutritional status for his stage of disease progression x 14 days, and patient symptoms will be consistent with stage of disease process and problems managed as well as disease process will allow. In RR#7 there was also goals that read like interventions such as Patient/caregiver will administer O2 to alleviate respiratory distress, dyspnea, Caregiver will post signs in the home, store O2 tanks properly, and have signs posted stating O2 usage in home. These observations were reviewed with the Director of Nursing, and Clinical Manager.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to ensure that the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: upon review of RR#9 there were no orders for medications included on the patient's plan of care. Upon discussion with the Clinical Manager she noted that the medication orders were in the BetterRX system but were not transferred over to the plan of care. The patient was on service for 2 months yet the medications were never included on the plan of care.

Observed in Record Review. In 4 of 11 patient records reviewed, the organization failed to ensure that plan of care was revised based on information from updates to the patient's comprehensive assessment and address the patient's progress toward goals and outcomes. In review of HV#1, HV#2, RR#6 and RR#7 the plan of care goals and interventions remained unchanged IDG to IDG. There were many goals that were short term such as pt/cg will verbalize..... and Pt/Cg will demonstrated... however there was no documentation of the patient's progress toward the goals and outcomes. This observation was reviewed with the Director of Nursing and Clinical Manager.

Observed in Record Review. In 4 of 11 patient records reviewed, The organization failed to ensure that care and services are provided in accordance with the plan of care. For example: in review of HV#1 the chaplain was ordered 1 time a month but no visit was documented for September or November. The MSW was 1 time a month and no visit was documented for January or September. In HV#2 there was no documentation of a MSW visit in December and in RR#6 there was no January visit for the MSW. All were ordered 1 time a month. In review of RR#7 the patient was ordered dressing changes for wound care, however there was no documentation that wound care was performed 5/19/22, 5/20/22 or 5/27/22. These observations were reviewed with the Director of Nursing and Clinical Manager.

Observed in Leadership Session. It was noted throughout the survey process and record reviews that the organization was utilizing contracted staff to provide core nursing services. There were two staffing contracts presented, one was AccuCare Nurse Staffing that began March 14, 2022, and the agreement noted initial term of 1 year with automatic renewal. There were 3 RN's and their credentials presented for the AccuCare contract. Another contract presented was with St. Bernard Medical and Staffing: Independent Contractor Agreement commenced on May 30th 2022 and was noted to continue unless terminated. Staff noted that the organization utilized contract nursing from approximately March to September 2022. Upon discussion with the Administrator the organization did not apply for a waiver for core staff.

Observed in Record Review. In 4 of 11 patient records reviewed, the organization failed to ensure that the registered nurse provide written patient care instruction for the hospice aide. For example: on review of HV#2, RR#4, RR#9, and RR#10 the hospice aide plan of care noted the assignment for hygiene noted: Bath: Complete but it fails to specify the type of bath the aide is to give. This observation was reviewed with the Director of Nursing, and Clinical Manager.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to ensure that the hospice aide was supervised to assess the quality of care and services provided and to ensure that services ordered by the hospice IDG meet the patient's needs. For example: on review of RR#6 there were greater than 14 day gaps in aide supervision noted throughout the 4th benefit period. These observations were reviewed with the Director of Nursing and the Clinical Manager

Observed in Tracer Activities. Upon review of the tracer activities, it was noted that there was a pattern of failing to follow established organization policy and procedure for assessment and governing body/leadership did not ensure that the COP's for 418.100, 418.54, 418.56, 418.104, and 418.64 were met as determined through observation, documentation, and staff interviews.

Observed in HR File Review. In 1 of 8 HR files reviewed, the organization failed to assess the skills and competence of individuals furnishing care. For example: on review of the personnel file for HR#6 for the chaplain there was no initial competency documented as part of orientation. This observation was reviewed with the HR manager.

Observed in Record Review. In 4 of 11 patient records reviewed, the organization failed to maintain a clinical record that was complete, promptly and accurately documented, readily accessible, and systematically organized to facilitate retrieval. For example throughout the survey process after record review the organization brought documentation that was hand written and not originally a part of the clinical record presented. In RR#6 there were 2 RN visits that were noted to come from another office. In HV#2 a paper Hospice Social Worker Assessment was presented that lacked a date and time in and time out. In HV#1 there were 2 hand written non-visit reports presented, and in RR#10 there was a non-visit report and a Notice of Discharge/Transfer that was not originally noted on the Electronic record or the paper chart. These observations were reviewed with the Director of Nursing and Clinical Manager.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to ensure the clinical record contain all information to reflect the patient's care, treatment, and services. For example: upon review of RR#10 the documentation noted that the patient was discharged for cause, however there is no documentation in the record to detail the circumstances surrounding the patient discharge, or any steps taken to prevent discharge. This observation was reviewed with the Clinical Manager. Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to ensure the patient record contain information that reflect the patient's care, treatment, and services provided. For example: when observing the medication reconciliation for HV#1 there were multiple discrepancies between the ALF medication profile to the hospice medication profile. The hospice profile had gabapentin that was ordered in October 2022 yet the facility noted that the medication had never been a part of their medication profile. The hospice had promethazine that was not noted on the facility profile. Further, the facility had PRN medications of tramadol, stomach relief, simethicone, ondansetron, ipratropium/albuterol, oxygen, Tylenol, and throat lozenges that were not included on the hospice medication profile. Also, the facility record noted allergy to morphine, and hydromorphone that were not listed as allergies on the hospice record. These observations were reviewed with the Director of Nursing.

Observed in Record Review. In 1 of 2 patient records reviewed, where the patient was discharged live, the organization failed to ensure that the discharge summary include all of the required elements. For example: upon review of the discharge summary for RR#10 the summary lacked the reason for patient discharge, a summary of the care, treatment, or services provided, and progress to goals. This observation was reviewed with the Director of Nursing, and Clinical Manager.