Every finding on record at Harbor Hospice of Dallas, L.P.

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 reviewed and revised every 15 days. For example, 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 a 28-day timeframe during benefit period #2. Example #2: 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 a 28-day timeframe during benefit period #3. Example #3: During a review of the medical record for RRNHV#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 56-day timeframe during benefit period #1. This observation was reviewed with the Administrator.

Observed in Tracer Activities. During the Volunteer Program review, it was revealed that the organization did not have any active volunteers to provide day-to-day administrative and/or direct patient care services during the year 2025. In addition, as of the survey date the organization remained with no active volunteers. This observation was reviewed with the Administrator.

Observed in Tracer Activities. During the Volunteer Program review, it was noted that the organization did not document effective recruitment for volunteers used in day-to-day administrative and/or direct patient care services. Recruitment efforts resulted in zero (0) administrative volunteers for 2025. Recruitment efforts resulted in zero (0) direct patient care services volunteers for 2025, This observation was reviewed with the Administrator.

Observed in Tracer Activities. During the Volunteer Program review, it was noted that since the organization did not have active volunteers to provide day-to-day administrative and/or direct patient care services; the organization did not document the cost savings achieved through the use of volunteers. This observation was reviewed with the Administrator.

Observed in Tracer Activities. During the Volunteer Program review, it was noted that since the organization did not have active volunteers to provide day-to-day administrative and/or direct patient care services, the organization did not document the type of activity provided by volunteers and the work time spent providing volunteer services. Since volunteer work activity was not documented, the organization did not demonstrate that volunteer staff provided services in an amount that at a minimum equals 5% of the total patient care hours of all paid hospice employees and contract staff. This observation was reviewed with the Administrator.

Observed in Record Review. In 1 of 7 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#1, it was noted that hospice aide services were ordered three (3) visits per week. The medical record did not include hospice aide visit notes describing the care, treatment, and services provided during the visit. This observation was reviewed with the Administrator.

Observed in Record Review. In 1 of 4 patient records reviewed, During RR# 3's patient record review it as noted the organization had not ensured the hospice interdisciplinary group completed the comprehensive assessment within five calendar days after the election of hospice care. For example: review of RR# 3's patient record revealed that the Spiritual Care Coordinator had completed the initial comprehensive assessment 21 days after the election of hospice care and there was no documentation the Social Worker had completed their initial comprehensive as of the day the surveyor reviewed the record, or 30 days after the election of hospice care. 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 initial bereavement assessment had been completed. For example: review of RR# 3 and RR# 4's patient records revealed no documentation of an initial bereavement assessment. This was reviewed, discussed, and validated with the Administrator

Observed in Record Review. In 3 of 5 inactive patients' records reviewed, the patients' right to elect and revoke hospice care were not honored in accordance with Medicare hospice regulations and the organizational Policy No. 2-068.1-Revocation of Hospice Benefit Election. For example, in the review of RR#6, it was documented that the patient was Discharged for Cause (Patient/Staff Safety). In further review of the Discharge Summary, it was documented that the patient was hospitalized for a heart attack. There was no provision of the Notice of Medicare Non-Coverage (NOMNC) or Revocation paperwork signed. In RR#7, it was documented that the patient Revoked the hospice benefit, due to being unhappy with services. There was no signed revocation form in the patient record. In RR#8 it was documented that the patient Revoked the hospice benefit, and according to the Discharge Summary, the patient was hospitalized for encephalopathy. The Revocation form was not signed until 16 days after the documented Discharge Date. This was reviewed and validated with the Administrator.

Observed in Record Review. In 1 of 6 active patients' records reviewed, the hospice interdisciplinary group did not complete the comprehensive assessment within five calendar days after the election of hospice care. For example in the review of RR#3, it was identified that the Spiritual Care Coordinator and the Social Worker completed their initial comprehensive assessments on day seven (7) after the election of hospice care. This was reviewed and validate with the Administrator.

Observed in Patient Home. In 2 of 2 home visit observations conducted where a Registered Nurse (RN) Case Manager performed an Ongoing Comprehensive Assessment, the RN did not compete the assessment in its entirety per organizational Policy No. 2-031.1: 1) During each home visit, the Case Manager . . . will evaluate the patient according to the problems identified during the initial assessment, and thereafter the comprehensive assessment; and, 2-G) The nurse will assess the patient on each visit, for: G. Skin integrity. Observed in both HV#1 and HV#2, the RN did not assess either of the chairbound patients' posterior skin integrity. Additionally, in HV#2, the RN removed the patients socks to the mid arch of the bilateral feet to assess pedal pulses but did not remove the socks completely to assess the patient's toes. Reviewed in the records for HV#1 and HV#2, Skin Integrity was identified as a potential problem in the individual plans of care. This was reviewed and validated with the Administrator and Regional director.

Observed in Record Review. In 3 of 6 active patient records reviewed, the initial bereavement assessments were not completed. In the review of the patient records for HV#1, HV#2, and RR#2 there were no initial Bereavement Risk Assessments completed. This was reviewed and validated with the Administrator and the Regional Director.

Observed in Record Review. In 1 of 5 inactive records reviewed, the patient's record contained inaccurate and/or conflicting documentation. For example, in the review of RR#6, it was documented that the patient was Discharged for Cause (Patient/Staff Safety). In further review of the Discharge Summary, it was documented that the patient was hospitalized for a heart attack. This was reviewed and validated with the Administrator.

Observed in Record Review. Reviewed in 5 of 6 active patient records, the frequency of visits for Hospice Interdisciplinary Group included PRN (as needed) visits without indication for what circumstances constitute the need for PRN visits or the timeframe for the visits. For example, in the record for HV#1, the frequency for Skilled Nurse was 1 visit per week, and 25 PRN; and the frequency for Social Worker was 1 visit monthly and 3 PRN. In the record for HV#2, the frequency for Skilled Nurse was 1 visit weekly, and 3 PRN; and the frequency for Spiritual Care was 1 visit monthly, and 3 PRN. In the record for RR#1, the Skilled Nurse frequency was 1 per week, and 5 PRN; and the frequency for Spiritual Care was 3 PRN. In the record for RR#2, the frequency for Social Worker was 1 weekly for 4 weeks, and 3 PRN; and the frequency for Spiritual Care was 3 PRN. In the record for RR#3, the Skilled Nurse frequency was 1 weekly and 3 PRN; Spiritual Care 2 monthly and 3 PRN; and Social Worker 2 monthly, 4 PRN.

Observed in Tracer Activities. Identified during the review of the organization's Quality Assessment and Performance Improvement Program (QAPI) there was no evidence of any Performance Improvement Projects (PIPs) in 2021, 2022, or 2023 thus far. This was reviewed with the Administrator and Regional Director.

Observed in Tracer Activities. Identified during the review of the organization's Quality Assessment and Performance Improvement Program (QAPI), there was no evidence of Performance Improvement Projects (PIPs)in 2021, 2022, or 2023 thus far: therefore, there was no documentation recorded. This was reviewed with the Administrator and Regional Director.

Observed in Patient Home. In 1 of 2 home visit observations conducted with a Skilled Nurse, the clinician did not implement infection prevention and control activities when cleaning and disinfecting reusable medical equipment and supplies per organizational Policy No. 9-014-2 -Bag Technique: 5) When the visit is completed, reusable equipment will be cleaned using antibacterial wipes . . ., and equipment and supplies will be returned to the bag Observed in HV#1, the Registered Nurse, placed the hand sanitizer on furniture in the patient's home while completing the patient assessment. Upon completion of cleaning and returning the reusable medical equipment into the clean side of the nursing bag, she returned the bottle of hand sanitizer into the clean side of the bag without disinfecting the bottle. Observed in Patient Home. In 1 of 1 home visit observations conducted where the patient received a complete bed bath, the clinician did not practice standard precautions to reduce the risk of infection per organizational Policy No. 9-009.1 - 3) Hand decontamination using an alcohol-based hand rub should be performed: E. When moving from a contaminated body site to a clean body site during patient care; and, G. After removing gloves. Observed in HV#1, the Hospice Aide did not change gloves or perform hand hygiene while providing a bed bath during which she performed peri-care both on the front side and posterior side of the patient. This was reviewed and validated with the Administrator and the Regional Director.

Observed in Tracer Activities. Identified during the review of the Volunteer Program, there was no documentation of recruitment or retention activities during 2021 or 2022. This was reviewed and validated with the Administrator and the Regional Director.

Observed in Tracer Activities. Identified during the review of the Volunteer Program, there was no cost savings achieved through the use of volunteers over the past approximate 22 months. This was reviewed and validated with the Administrator and Regional Director.

Observed in Tracer Activities. Identified during the review of the Volunteer Program, there was no volunteer hours achieved over the past approximate 22 months, thus the 5% of the total patient care hours requirement was not achieved. This was reviewed and validated with the Administrator and Regional Director.

Observed in Tracer Activities. The Surveyor identified that there was no evidence that the governing body and leadership had established processes to support patient care treatment and services through sustained compliance as evidenced by not implementing corrective measures to ensure compliance in meeting the requirements of the Volunteer Program (§418.78) and Bereavement Program (§418.54) following the previous survey from February 2021.