Every finding on record at Harbor Hospice of El Paso, LP

Observed in Record Review. In 1 of 6 patient records reviewed, it was noted in record review #1, there was a period of 18 days following SOC with no IDG documented. Review of agency policy indicated that the initial IDG is to take place within 5 days of admission. This observation was reviewed with the administrator.

Observed in Record Review. In 6 of 10 patient records reviewed, it was noted that the organization did not ensure that the comprehensive assessment was updated at least every 15 days. For example, during a review of the medical record for RRHV#1, it was noted that 33 days had elapsed since the last update to the comprehensive assessment was documented during benefit period #7. In addition, during benefit period #8, 23 days had elapsed since the start of care date, and an update to the comprehensive assessment had not been documented.Example #2: During a review of the medical record for RRHV#2, 57 days had elapsed since the start of the 2nd benefit period, and an update to the comprehensive assessment had not been documented, in addition, it was noted that a Registered Nurse comprehensive assessment for the interdisciplinary team was completed during week 2 of services. The subsequent Registered Nurse comprehensive assessment was completed 17 days later. Example #3: During a review of the medical record for RRHV#3, 29 days had elapsed since the start of the first benefit period, and an update to the comprehensive assessment had not been documented. Example #4: During a review of the medical record for RRNHV#2 and RRNHV#4, 56 days had elapsed since the last update to the comprehensive assessment was documented during benefit period #2.Example #5: During a review of the medical record for RRNHV#3, 28 had elapsed since the last update to the comprehensive assessment was documented during benefit period #4. In addition, 28 days had elapsed since the start of the 5th benefit period, and an update to the comprehensive assessment had not been documented. This observation was reviewed with the leadership team.

Observed in Record Review. In 1 of 10 patient records reviewed, it was noted that the organization did not ensure the plan of care goals included outcome measures for specific care activities. For example, a review of the medical record for RRHV#3, revealed that the patient’s terminal illness diagnosis was Atherosclerotic Heart Disease. The plan of care did not include a goal statement to evaluate the response to the delivery of care, treatment, and services related to the terminal illness diagnosis of Atherosclerotic Heart Disease. This observation was reviewed with the leadership team.

Observed in Record Review. In 2 of 10 patient's records, it was noted that the plan of care did not include interventions based on the problems identified in the comprehensive assessment. For example, the plan of care for RRHV#2, identified potential for fall as a problem. The plan of care included the following interventions for this problem: Assess for history of falls and/or injury. The plan of care did not include interventions to maintain patient safety, and strategies to prevent injury. In addition, the patient experienced a fall without injury during week 7, and week 8 of services. The plan of care was not updated with interventions to maintain patient safety, and strategies to prevent injury. Example #2: During a review of the medical record for RRHV#3, it was noted that the patient’s terminal illness diagnosis was Atherosclerotic Heart Disease. The plan of care did not include interventions to address the delivery of care, treatment, and services related to the terminal illness diagnosis of Atherosclerotic Heart Disease. In addition, the plan of care identified potential for fall as a problem. The plan of care included the following interventions for this problem: Assess cognitive status for sensory limitation, impairments. The plan of care did not include interventions to maintain patient safety, and strategies to prevent injury. This observation was reviewed with the leadership team.

Observed in Tracer Activities. In 3 of 3 individual tracers, the organization did not ensure that nursing services were routinely provided directly by hospice employees. For example, during interviews with the patient's and/or the patient's caregiver for RRHV#1, RRHV#2, and RRHV#3, it was noted that the patient and/or the patient's caregiver was not aware of the Registered Nurse visit schedule. The patient's caregiver for RRHV#2 stated, the Registered Nurse is always changing, and I am not sure when the Registered Nurse will visit. During interviews with the RN/Administrator and the Regional Director it was noted that nursing services were routinely provided by contract nurses for the last 6 months. The contract nurses are not directly employed by the hospice organization. This observation was reviewed with the leadership team.

Observed in Competency Session. In 1 of 1 Human Resource files reviewed for Hospice Aides, it was noted that the organization did not ensure ongoing education and training was provided as required. For example, a review of the Human Resource file for a Hospice Aide, revealed no documented evidence that at least 12 hours of in-service training was provided during the most recent 12 month period. This observation was reviewed with the agency leadership team.

Observed in Record Review. In 2 of 2 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 RRHV#2, it was noted that Hospice Aide services started during week 2. A Hospice Aide supervision visit was documented by the Registered Nurse 24 days after Hospice Aide services started. Example #2: During a review of the medical record for RRNHV#3, it was noted that Hospice Aide services started during week 6 of the 4th benefit period. A Hospice Aide supervision visit was documented by the Registered Nurse 21 days after Hospice Aide services started. This observation was reviewed with the leadership team.

Observed in Competency Session. In 1 of 1 Human Resource files for Hospice Aides, it was noted that an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she was performing care was last documented August of 2024. There was no documented evidence that an annual on-site visit was completed during the last 12-month period. This observation was reviewed with the agency leadership team.

Observed in Record Review. In 2 of 10 patient records reviewed, the organization did not ensure its policy titled Certification of Terminal Illness was implemented. For example, a review of the Certification of Terminal Illness statement(s) for benefit period #8, and benefit period #6 for RRHV#1, revealed that the Certifying Physician Summary documenting clinical information to support the medical prognosis and support for recertification of hospice services was not present in the medical record. Example #2: A review of the Certification of Terminal Illness statement for benefit period #1, for RRHV#3, revealed that the Certifying Physician Summary documenting clinical information to support the medical prognosis and support for certification of hospice services was not present in the medical record. This observation was reviewed with the organization leadership team.

Observed in Record Review. In 2 of 13 patient records reviewed, the organization failed to assess and reassess its patient. During record review for BR#1, the hospice nurse surveyor observed the patient had SOC on 2/6 and the IDG did not meet until 2/21. During record review for BR#2, the hospice nurse surveyor observed the patient had SOC on 10/2 and the IDG did not meet until 10/19. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 13 of 13 patient records reviewed, the organization interdisciplinary group failed to document its review and revisions of the patient's plan of care. During record review for all records, the hospice nurse surveyor observed the IDG notes only contained prep notes from some clinicians , not all. And the IDG notes did not have documentation of the discussion that occurred during IDG. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 13 of 13 patient records reviewed, the organization failed to provide interdisciplinary, collaborative care, treatment, or services. During record review for all records the hospice nurse surveyor observed no documentation from the medical director attending IDG. After discussion with the Hospice Leadership Team, it was noted the physician signs in to IDG on a log but does not document collaboration in the medical record. Also in RR#1, RR#4, and RR#5 there was no documentation from the SW or SC for IDG. In RR#7 there was no documentation from the SC for IDG. Also during record review for RR#3, the hospice nurse surveyor observed documentation from a 3/17 nursing note that the patient slid to the floor and needed EMS to pick him up. This fall was not reported to the Medical Director. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to implement the infection prevention and control activities it had planned. During HV#1, the hospice nurse surveyor observed the nurse disinfect her equipment with sani- wipes and did not allot for the 2 minute wet time per manufacturer guidelines. This was discussed and reviewed with the Hospice Leadership Team. Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to implement the infection prevention and control activities it had planned. During HV#1, the hospice nurse surveyor observed the nurse fail to perform hand hygiene consistent with the organization policy. She entered her nursing bag several times without performing hand hygiene in between. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Patient Home. In 3 of 13 patient records reviewed, the organization failed maintain a complete and accurate patient record. During HV#1 , the hospice nurse surveyor observed the nurse ask what the patient was taking for her headaches and the patient responded with Tylenol. Tylenol was not on the patient record and the nurse did not stop to write it on the record in the home. During record review for RR#7, the hospice nurse surveyor observed notes on 11/19 stating the nurse told the patient you may take ibuprofen PRN for pain but Ibuprofen was not on the patient record. During record review for RR#9, the hospice nurse surveyor observed notes on 9/30 that patient's son giving Tylenol but Tylenol was not on the patient record. This was discussed and reviewed with the Hospice Leadership Team.