Every finding on record at Harbor Hospice of Central Houston LP

Observed in Record Review. In 2 of 3 patient records reviewed with a wound, During RR# 3 and RR# 4's patient records review it was noted the organization had not ensured staff followed the organization's policy Wound Care Practice that included if a wound was identified during skin assessment, it would be measured with each assessment. For example RR# 3's RN initial comprehensive assessment revealed RR# 3 had wound on the coccyx with wound measurements. However, further review of RR# 3's patient record revealed no documentation of wound measurements for the subsequent three SN visit notes. Review of RR# 4's RN initial comprehensive assessment revealed RR# 4 had a wound on the coccyx. However, review of the three subsequent SN visit notes revealed no wound measurements of the coccyx. This was reviewed, discussed, and validated with the Administrator.

Observed in Record Review. During RR# 3's patient record review it was noted the organization not and ensured the comprehensive assessment was updated no less than every 15 days per regulations. For example: review of RR# 3's patient record revealed there were 16 days between RN visits/assessments. This was reviewed, discussed, and validated with the Administrator.

Observed in Record Review. In 2 of 4 patient records reviewed, During RR# 3 and RR# 4's patient record review it was noted the organization had not ensured the Interdisciplinary group prepared a written plan of care for each patient. For example: review of RR# 3's patient record revealed an election of benefit dated approximately 29 days prior to the surveyor review of the record with no documentation of a written plan of care. Review of RR# 4's patient record revealed an election of benefit dated approximately 22 days prior to the surveyor review of the record with no documentation of a written plan of care. This was reviewed, discussed, and validated with the Adminstratr.

Observed in Record Review. In 3 of 4 patient records reviewed, During RR# 2, RR# 3, and RR# 4's patient record review it was noted the organization had not ensured the Interdisciplinary Group (IDG) reviewed and revised the plan of care as frequently as the patient's condition requires, but no less frequently than every 15 days For example: Review of RR# 2's patient record revealed an IDG/care plan update approximately 19 days prior to the surveyor review of the record. Review of the IDG sign-in sheet and agenda revealed RR# 2 listed to be reviewed, however review of RR# 2's patient record revealed no documentation of any additional IDG/care plan updates. Review of RR# 3's patient record revealed the last documented IDG/care plan update approximately 20 days prior to the surveyor review of the record. Review of the IDG sign-in sheet and agenda revealed RR# 3 listed to be reviewed, however review of RR# 3's patient record revealed no documentation of any additional IDG/care plan update or a plan of care. Review of RR# 4's patient record revealed RR# 4's election of benefit was approximately 22 days prior to the surveyor review of the record. Further review of RR# 4's patient record revealed no documentation of a plan of care or an IDG/care plan update. This was reviewed, discussed, and validated with the Administrator.

Observed in Record Review. In 3 of 4 patient records reviewed, During RR# 2, RR# 3, and RR# 4's patient record review it was noted the organization had not ensured the RN supervised the hospice aide during an on -site visit to the patient's home no less frequently than every 14 days. For example: review of RR# 2's patient record revealed the RN had not documented an on-site hospice aide supervisory visit since the hospice aide services were initiated or approximately 28 days. Review of RR# 3's patient record revealed the RN had not documented an on-site hospice aide supervisory visit since the hospice aide services were initiated or approximately 22 days. Review of RR# 4's patient record revealed the RN had not documented an on-site hospice aide supervisory visit since the hospice aide services were initiated or approximately 22 days. This was reviewed, discussed, and validated with the Administrator.

Observed in Record Review. In 2 of 4 patient records reviewed, There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by the following Conditions of Participation deficiencies CoP 418.56 and 418.110. This was reviewed, discussed, and validated with the Administrator.

Observed in Record Review. In 1 of 4 patient records reviewed, During RR# 3's patient record it was noted the organization had not ensured staff followed the organization policy Entries into the clinical record that included all documentation be completed and in the EMR [electronic medical record] within five day. Review of RR# 3's patient record revealed no Interdisciplinary Group/care plan update. The Administrator shared it was completed on paper and would need to retrieve it from the patient's paper record. On further review of RR# 4's patient record an IDG/care plan update dated 20 days prior to the surveyor review of the record was uploaded to the EMR. this was reviewed, discussed, and validated with the Administrator.

Observed in Emergency Management Session. During a review of three emergency plan activation events, the quality assurance manager confirmed that the organization had not utilized After-Action reports and HOTWASHs from the two events reviewed in 2023 to address identified concerns or make improvement in the Emergency Plan.

Observed in Individual Tracer. In HOSHV#4, 2 Wounds were not measured weekly as required by HCO Ongoing Comprehensive Assessment policy. Examples included the following: The record for HOSHV#4, indicated a Bilateral Medial Dorsal Inner Buttocks Coccyx/Decubitus. During the 2nd and 3rd week of the first certification, there were no measurements completed. During the home visit, the RN did not assess the wound. The RN had documented on their first visit in the 3rd week of the certification that the wound bed was clean. However, no measurements were obtained. During HOSHV#4, the RN removed a dressing from and assessed a right lower leg wound that was not noted on the plan of care. During the visit with the surveyor, the RN stated the leg wound was noted to be a closed blister at the first visit of the week. The family requested additional supplies for the leg wound during the visit with the surveyor present. No orders found in the chart for the right lower leg wound. Nurse Administrator present during the visit and confirmed.

Observed in Record Review. In record HOSNV#8, the comprehensive assessment was not completed within the 5-day window. Example includes the following: SW spoke with patient’s daughter who expressed that her mother is Spanish speaking only and that she is unable to translate. SW documented a plan to follow up with the daughter the next day. However, the assessment of needs by the SW occurred 20 days after the Hospice SOC. Nursing Administrator made aware and confirmed.

Observed in Individual Tracer. the surveyor observed in HOSHV1 record review that the patients wound had not been measured per policy. The organization policy required weekly measures of wounds and surveyor found no evidence of weekly wound measures . The surveyor observed that the wound had been identified, measured and documented on date RN observed for first time, however the following four weeks there was no evidence of wound measures. The issue was discussed and confirmed with organization leadership.

Observed in Individual Tracer. In 2 out of 2 home visits (HOSHV#3 AND HOSHV#4), the hospice RN did not complete the reassessment of patient medications as required by agency policy. This was confirmed by the Nurse Administrator. Observed in Individual Tracer. In 2 of 2 home visits conducted, the surveyor observed on HOSHV#1 and HOSHV#2 that the hospice nurse had not completed the reassessment of patients medications as required by organization policy. The issue was observed by hospice administer on visit with surveyor and confirmed.

Observed in Record Review. During HOSHV#3, the RN did not visit the Hospice patient every 15 days to conduct an assessment. Example #1: RN Revisit made 2 days late . Example #2: RN Revisit made 1 day late. Nursing Administrator confirmed. Observed in Record Review. In HOSNV#8 record review, surveyor noted the RN did not visit the Hospice patient every 15 days. One example included RN Revisit made 2 days late. This was confirmed by the Nurse Administrator. Observed in Record Review. associated with HOSHV1 and HOSHV2 the surveyor observed that the RN had not visited the hospice patient every 15 days to conduct an assessment. The surveyor observed HOSHV1 that RN visited early in the month of December and then exceeded the required 15 day reassessment by 4 days. HOSHV2 the RN made visit in Late December and the following RN assessment was greater than 15 days which exceed regulation and organization policy of RN visit every 15 days. Further in HOSNV1 the surveyor observed that between RN visit completed at the beginning of one month and no other RN visit for 28 days. Organization policy and regulation state RN visits not to exceed 15 days. This issue was discussed and confirmed with organization staff.

Observed in Record Review. In HOSNV#9, care was not provided according to hospice plan of care. Example includes the following: Hospice Aide services were ordered with a frequency of 3w14. Surveyor did not note any Aide visits being made within the record. No Communication notes related to the missed visits found. Finding confirmed with the Nursing Administrator.

Observed in Data Session. During document review, the regional quality assurance manager confirmed that the organization's QAPI had not been meeting the following criteria:- Reflects the complexity of the organization and its services- Involves all services provided by the organization, including those provided under contract or arrangementAs evidenced by the lack of contract evaluation detail in the QAPI meeting minutes that are reported to the governing board.

Observed in Individual Tracer. the surveyor observed on HOSHV2 that the RN had assessed quadriplegic patient without following organization policy as evidenced by assessing the patients tracheostomy, g-tube, and foley catheter without changing gloves or cleaning hands. The surveyor and organization administer observed that the RN assessed patient from one site to the next without changing gloves or cleaning hands. Further the surveyor observed that the RN had not cleaned equipment according to organization policy, the RN placed dirty used equipment in plastic bag and stated he cleaned equipment at car after visit. The issue was discussed and confirmed with organization administrator .

Observed in Data Session. During a review of the QAPI data spreadsheet from 2024, the quality assurance manager confirmed that hand hygiene compliance surveillance data had not been collected in the last two quarters of 2024.

Observed in HR File Review. In 1 of 1 nursing aide HR records reviewed, the organization did not have documentation of initial hospice aide training requirements. This observation was confirmed with the Quality Assurance manager.

Observed in HR File Review. In a review of the aide's employee record, the organization could not demonstrate that initial competency was done by an RN, as evidenced by the skills checkoff completed by the lead aide. This observation was confirmed with the HR specialist.

Observed in HR File Review. In a review of the aide's employee record, the organization could not demonstrate compliance with the required 12 hours of in-service annually, as evidenced by only 4 hours of inservice education completed in the last 6 months out of the 6 hours of in-service assigned.

Observed in Record Review. In 3 of 7 patient records reviewed, The surveyor found that the hospice aide supervision not been done every 14 days as required by policy and regulation. The surveyor observed on 3 records of patients with CHHA services that the RN had not made at least every 15 day visit, and therefore had also not completed CHHA supervisory visit every 14 days. The RN CHHA supervision had been on the 3 records had been from 2 to 6 days late. This was discussed and confirmed with hospice administrator. Observed in Record Review. During HOSHV#3, Hospice aide supervision not done every 14 days. Example includes the following: RN did not visit the Hospice patient every 15 days to conduct an assessment and therefore failed to complete the Aide Supervisory Visits during these timeframes. The missed Aide Supervisory visits would therefore had been in excess of 14 days. This was confirmed with the Nursing Administrator.

Observed in Document Review. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by multiple identified records that RN exceeded the 15 day required reassessment by regulation and organization policy. The issue was discussed and confirmed with organization leadership.

Observed in HR File Review. In 4 of the 10 employee and physician records reviewed, the organization could not demonstrate job specific orientation (2 RN case managers, 1 aide and the back-up medical director) at the time of survey. This observation was confirmed with the Quality Assurance manager.

Observed in HR File Review. In 3 of 10 employee and physician records reviewed, the administrator confirmed that the initial competency could not be located at the time of survey (1 nurse aide, 1 RN case manager and 1 physician).

Observed in Record Review. In HOSHV#4, the medication profile in the clinical record was inaccurate. The example includes the following: The Medication Profile in the clinical record for HOSHV#4 was noted to have two active Seroquel orders. 1 was for Seroquel 25 mg every night and a second one was for Seroquel 50 mg every night. RN's last clinical note indicated the receipt of an MD order for Seroquel 25 mg every morning and to continue the 50 mg dose every night, which was being followed in the home by the caregiver. This was confirmed by the Nursing Administrator.

Observed in Individual Tracer. In 2 of 2 home visits conducted, of patients receiving oxygen therapy the surveyor observed during home visit 1 that the hospice RN had not taken any action or provided education to patient family when 3 unsecured standing upright oxygen tanks in an extremely cluttered closet was found. Further during second home visit of oxygen patient the family stored the portable tank with multilevels of clothes and other items on top of oxygen tank and again no action had been taken by RN. The issue was discussed and observed by organization administrator.

Observed in Individual Tracer. In 1 of 13 home visits conducted, The organization had not assessed potential medication-related problems. For example, during HV1 the nurse was requested to perform a medication reconciliation during the visit. The nurse did not do a medication to medication list comparison but did comment that the patient was taking a blood thinner. There was no evidence of an order or documentation on the medication list of the medication discussed. However, the medication was in the home and the Nurse did not believe this medication had been recently added. This was confirmed by the Regional Director of Quality.

Observed in Individual Tracer. In 1 of 13 patient records reviewed, The organization had not ensured the patient was assessed and reassessed. For example, in the review of record for HV1 the surveyor noted the care plans were past projected goal dates and the record did not indicate progression toward the patient's goals. This was confirmed by the Director of Nursing.

Observed in Record Review. In 3 of 13 patient records reviewed, The organization had not written plans of care that were adequately specific to the patient. For example, during the review of record of HV1 the surveyor noted interventions and goals that were vague. In one example an intervention was check perfusion in one goal, and another goal of will have spiritual needs met. This was confirmed by the Director of Nursing. The second example, during RR2 it was identified that the SN documented the progression of goal achievement as goals partially achieved-continues to make progress according to the plan of care. This was confirmed by the Regional Director of QA. The third example was noted in RR1 wherein the social worker goals had passed the targeted date for six months. This was confirmed by the Regional Director of quality.

Observed in Record Review. In 3 of 13 patient records reviewed, The organization had not ensured the medical record included all of medications and treatment necessary to meet the patient’s needs. For example one, during HV1 the RN indicated the patient was taking a blood thinner. The patient was noted to have several bruises. A thorough review of the record including orders and the medication list did not indicate the patient should be on a blood thinner. The RN on a second occasion (during Interdisciplinary Team Meeting) indicated that the patient was taking the blood thinner. Following the meeting the RN indicated the medication was not new. It should also be noted that there were no safety measures identified in the medical record, i.e. bleeding precautions noted for this high risk medication. This was confirmed by the Director of Nursing. The second example identified , during review of record RR3 that the patient was referred with a diagnosis of seizure disorder however there was no evidence of a plan in the event of a seizure, no medications identified to intervene in the event of a seizure and no prompts to monitor for the event of a seizure i.e. seizure precautions. This was confirmed by the Regional director of Quality. The Third example related to RR4 wherein thee patient was taking a antiplatelet-anticoagulant and did not have Bleeding precautions indicated. This was confirmed by the Regional Director of Quality.

Observed in Individual Tracer. In 1 of 13 home visits conducted, The organization had not ensured the maintenance of universal precautions to reduce the risk of infection. For example, during HV1 the Surveyor noted the Nurse washed her hands and then dried them with a paper towel but then she proceeded to shut off the water but then returned to drying her hands with the same paper towel. This was brought to the attention of the Director of Nursing.

Observed in Record Review. In 1 of 13 patient records reviewed, The organization had not ensured that the patient record was complete and accurate. For example, during the review of record that accompanied HV1 the surveyor noted the consents for start of care had multiple dates missing as indicated in the CMS COP # 418.104(b). This was confirmed by the Regional Quality Manager.

Observed in Individual Tracer. In 1 of 3 home visits conducted, The organization had not implemented infection prevention and control activities. For example during HV1 the nurse did not follow the organizations bag policy policy which indicates a separate clean and dirty area in the bag to ensure cleanliness of supplies and monitoring devices. This was brought to the attention of the Director of Nursing and the nurse at the close of the visit.