Every finding on record at Harbor Hospice of East Texas LP

Observed in Record Review. In 4 of 14 patient records reviewed, it was noted that the hospice did not complete the initial assessment within the 48 hour time frame. For example in record RRHV#2 and RRHV#3 the initial assessment was completed on day 5 and RRHV#4 on day 13. In record RRNHV#2 the initial assessment was completed on day 9. There was no documentation in the records related to the delay in the initial assessment. This was discussed with and confirmed by the Administrator.

Observed in Individual Tracer. In 1 of 1 tracers conducted, with the inpatient hospice unit nurse dispensing medication that required splitting a pill, it was noted that the equipment had not been maintained. For example during medication dispensing for patient IPU#1, the nurse needed to split a pill in half. She retrieved a pill splitter from the top drawer of the medication cabinet that was visibly dirty with a white powder like substance. The nurse did not clean the device and returned it to the drawer. This was discussed and confirmed with the DON and Administrator present.

Observed in Building Tour. A fire barrier penetration was filled with spray foam in the ceiling space by central supply. Observed by the Facility Manager. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy:

Observed in Document Review. Medical gas outlet inspection(s) were not completed in the 12 months prior to survey. The hospice did not have a prescriptive policy for testing frequency. Observed by the Facility Manager. Observed in Document Review. Code reference and edition(s) were not included on annual fire alarm testing documents. Observed by the Facility Manager. Observed in Building Tour. The source valve was not labeled / identified at the O2 tank farm. Observed by the Facility Manager.

Observed in Building Tour. The organization did not ensure that its policy related to the control and accountability of all medications was implemented. For example, a review of the policy titled: Medication Control and Accountability revealed the following information: (9) At shift change the in-coming RN charge nurse unlocks the narcotic drawer/refrigerator and counts the narcotics present with the out-going RN charge nurse. Both will verify accuracy and reconciliation and co-sign, date, and time the narcotic count sheet. A review of the narcotic count verification/reconciliation form revealed that a second nurse signature was not present on the following date(s): July 9 Day Shift, July 13 Day Shift, Aug 5 Night Shift, Aug 7 Night shift, Aug 11 Night Shift, Aug 16 Night Shift, August 19 Day Shift, Aug 20 Night shift, and Aug 22 Night Shift. This observation was reviewed with the Administrator and Director of Nursing.

Observed in Building Tour. The surveyor observed that the piping for approved automatic sprinkler systems was supporting other items. For example, there were red cords resting on the sprinkler pipe. This observation was reviewed with the Maintenance Director, Administrator, and Director of Nursing. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.