Every finding on record at Harbor Hospice of Corpus Christi LP

Observed in Record Review. In 1 of 2 patient records reviewed, for discharged patients it was noted that while the organization had a clear revocation process the revocation document could not be found for patient RRDC#1. This was discussed and confirmed with the Administrator/DON.

Observed in Record Review. In 3 of 3 patient records reviewed, that included volunteer services it was noted that the as needed visits did not include the reason(s) for the use of the as needed visits. For example in records RRNHV#1 and #2 the volunteer frequency was for 1 visit a month and 2 as needed visits with no reason for the PRN visits. In RRNHV#7 the volunteer frequency was for 2 visits a month and 3 as needed visits with no reason for the PRN visits. This was confirmed and discussed with the Administrator/DON present.

Observed in Data Session. During the Data session it was noted that the hospice had not identified performance improvement projects or document the reasons for conducting the projects during 2024 and 2023. This was confirmed and discussed with the new Administrator/DON.

Observed in Document Review. It was noted during review of the volunteer program and discussion with the volunteer coordinator that volunteers did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff for 2024. During 2024 the percentage was 2.18%. The new volunteer coordinator reported that for 2025 year to date it had increased to 5.37%. This was discussed and confirmed with the volunteer coordinator and administrator/DON present.

Observed in HR File Review. In 1 of 9 HR files reviewed, it was noted that the staff competency was not assessed as part of orientation. For example the medical directors HR file contained a competency assessment for 2025, but nothing for upon hire/orientation in 2023. This was discuss and confirmed with the Administrator/DON present

Observed in Individual Tracer. In 1 of 13 patient records reviewed, RR12, during review the surveyor noted the organization had not conducted a comprehensive assessment in collaboration with the patient’s attending physician, if any, as frequently as the patient’s condition requires, but no less than every 15 days. For example RR12, the patient's recertification dated 7/7/22, did not have evidence that a comprehensive assessment for recertification was conducted by an RN. RN routine skilled nursing visits were dated 6/15/22 and then 7/13/22. There was no additional comprehensive recertification assessment documented in the record. This was not compliant with the organization's policy and validated by the Administrator/DON and Regional Director of Clinical Operations.

Observed in Individual Tracer. In 3 of 13 patient records reviewed, HV3, RR6, RR7, during the home visit and subsequent record review the surveyor noted the organization had not shown evidence the plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. For example, HV3 the patient with the primary diagnosis of dementia, the Social Worker goals stated patient can describe coping behaviors; patient will feel supported with companionship from social work services with increase in SW fx.; RR 6, skilled nursing goals stated symptoms will be managed throughout the course of care; RR7, the skilled nursing goals stated: maintenance of respiratory baselines as evidenced by breathing at optimal level within disease parameters. These were not measurable and validated by the Administrator/DON and Regional Director of Clinical Operations.

Observed in Data Session. During the data management session with the Regional Director of Clinical Operations, The Regional Director of Nursing Orientation and the Administrator/DON, the surveyor noted the organization had not documented how it used the data collected to monitor the effectiveness and safety of services and the quality of care. For example, while the organization documented data collected and trended over time, there was no documentation of how the data was used to develop or evaluate the effectiveness of action plans implemented. There was no documentation or evidence of action steps taken, analysis of results/response obtained from those action steps, the progress or evaluation of the action steps. This was validated the team.

Observed in Individual Tracer. In 1 of 4 home visits conducted, HV1, the surveyor noted the organization failed to demonstrate it implemented its infection prevention and control activities to minimize, reduce, or eliminate the risk of infection. For example, HV1 the aide failed to change gloves prior to direct contact with patient when providing the bed bath. The aide handled several items including equipment and supplies in preparation for the bath and during the bath, however failed to conduct hand hygiene or change gloves upon direct contact with patient. This was not compliant with the organization's hand hygiene policy and validated by the Administrator/Director of Nursing.

Observed in HR File Review. In 1 of 2 hospice aide personnel files, HR4, during personnel file review, the surveyor noted the organization failed to demonstrate that a registered nurse performed the competency evaluation of the hospice aide. HR4, for example, the initial clinical competency checklist completed upon hire was initialed and signed by the preceptor who was another Hospice Aide and signed by the Supervisor who was an LPN. There were no other signatures noted on the document. This was not compliant with the organization's policy and validated by the Regional Clinical Director and Regional Director of Nursing Orientation.

Observed in HR File Review. In 2 of 11 HR files reviewed, HR 7, HR9, during personnel file review the surveyor noted the organization failed to show evidence the Volunteer Coordinator's or the Medical Director's competence was initially assessed and documented as part of orientation. This was not compliant with the organization policy and validated by the Regional Director of Orientation.

Observed in Individual Tracer. In 1 of 4 home visits conducted, HV2, during the home visit and subsequent record review the surveyor noted the patient record failed to contain an accurate list of medications, including dose, strength, frequency, route, date and time of administration for prescription and nonprescription medications, herbal products, and home remedies that relate to the patient's care, treatment, or services. For example, HV2 the current plan of care/medication list provided to surveyor while the hospice nurse and facility nurse conducted medication reconciliation, did not have an accurate list of medications including: Acetaminophen 650 mg suppository every four hours or Miralax listed; Lactulose gm/15 ml orally three times a day was listed however, the patient had a gastrostomy tube and did not take oral medications; the PRN bowel regimen medications such as Bisacodyl and Docusate Sodium were not listed on the plan of care; Promethazine 25 mg by mouth every 4 hours as needed was listed on the plan of care but not listed in the facility medication list nor was the route of administration accurate. This was not compliant with the organization's medication management policy and validated by the Administrator/DON.

Observed in Individual Tracer. In 4 of 13 patient records reviewed, RR2, RR3, RR9, RR12 during record review the surveyor noted the organization had not demonstrated the patient record was complete, promptly and accurately documented, readily accessible, and systematically organized to facilitate retrieval. For example, RR2, RR3, RR9, RR12 the IDT notes and current Plan of Care were not consistently evident in the electronic record. In the electronic medical record system, the prep note documentation was not consistently uploaded into the IDT notes which subsequently did not generate IDT meeting documentation or a current Plan of Care. In addition, Recertification Reassessments/Comprehensive Assessments were not consistently documented as such, as the nurses appeared to be documenting using routine visit notes. This was not compliant with the organization's policy and validated by the Administrator/DON and Regional Director of Clinical Operations.

Observed in HR File Review. In 1 of 11 HR files reviewed, HR 6, during personnel file review, the surveyor noted the organization failed to show evidence it had verified the credentials of care providers when licensure/certification or registration was not required by law and regulation. For example HR6, the Chaplain/Bereavement Coordinator's copy of an ordination diploma/certificate was not verified by the organization upon hire.