Every finding on record at Harbor Hospice of Fort Worth, LP

Observed in Record Review. In 1 of 2 discharged records reviewed, it was noted that the patient's right to revoke hospice services was not fully implemented. For example, a review of the medical record for RRDC#2, revealed that the discharge summary indicated the patient chose to revoke hospice services. The medical record did not include a written revocation statement signed by the patient. This observation was reviewed with the Administrator.

Observed in Record Review. In 2 of 12 patient records reviewed, it was noted that the organization did not ensure that the plan of care goals included outcome measures for specific care activities. For example, during a review of the medical record for RRHV#1, the following goal statement was noted, “Patient will maintain optimum level of functioning appropriate for stage of disease process”. This goal statement was written to address the care needs related to the patient’s terminal illness diagnosis of Senile degeneration of brain, not elsewhere classified. The goal statement did not include a method to measure the effectiveness of problem interventions. The patient’s initial assessment identified care needs related to the patient’s risk for fall and bowel/bladder incontinence. The plan of care did not include goal statements to evaluate the response to care, treatment, and services related to fall prevention and bowel/bladder incontinence interventions. Example #2: A review of the medical record for RRNHV#3, revealed that the patient’s terminal illness diagnosis was Alzheimer’s disease. The plan of care did not include a goal statement to evaluate the response to care, treatment, and services related to Alzheimer’s disease interventions. This observation was reviewed with the Administrator.

Observed in Record Review. In 2 of 12 patient's records reviewed, 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#1, identified the following problems: Cognitive decline related to the terminal illness diagnosis of Senile Degeneration of brain, not elsewhere classified; Risk of fall; and Bowel/Bladder incontinence. The plan of care did not include interventions to address the delivery of care, treatment, and services for identified care concerns. Example #2: A review of the medical record for RRNHV#3, revealed that the patient’s terminal illness diagnosis was Alzheimer’s disease. The plan of care did not include interventions related to Alzheimer’s disease. This observation was reviewed with the Administrator.

Observed in Record Review. In 1 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 RRNHV#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 during week 3 of services. This observation was reviewed with the Administrator.

Observed in Record Review. In 1 of 6 patient records reviewed, for patient's receiving hospice aide services, it was noted that the organization did not ensure all requirements for planning the care of patient's were implemented. For example, a review of the medical record for RRHV#1, revealed that the Plan of Care did not include written patient care instructions for the hospice aide prepared by the registered nurse member of the interdisciplinary group. This observation was reviewed with the Administrator.

Observed in Data Session. During the Volunteer Program review it was noted that the organization did not provide volunteer activity that equals 5% of the total patient care hours of all paid hospice employees and contract staff for the year 2025. This observation was reviewed with the Administrator.

Observed in Record Review. In 1 of 12 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 #10, for RRNHV#3, revealed that the Certifying Physician Summary did not document clinical information to support the medical prognosis and support for recertification of hospice services. This area of the document was left blank. This observation was reviewed with the Administrator.

Observed in Record Review. In 1 of 6 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 two (2) visits per week. The hospice aide visit notes for a 10 week period did not include documentation of the care, treatment, and services provided during the visit(s). This observation was reviewed with the Administrator.

Observed in Record Review. In 4 of 6 patient records reviewed, the Hospice Surveyor noted Nursing narrative notes that had been duplicates of each other and had not reflected the current comprehensive visit. For example: in RR #1, the narrative notes had been the same and not edited for the current visit. In the note, the RN had indicated the patient last bowel movement specific date, and then had not edited it over the month. The duplication of narrative notes had also been observed in RR #2, RR #3, and RR #5. This was validated with the Administrator.

Observed in Record Review. In 4 of 6 patient records reviewed, the Hospice Surveyor noted the agency had not ensured visits were being made according to the POC as documentation had been on multiple patient care visits. For example: in RR #1, the patient record had been missing documentation on 1 RN visit and 3 HA visits. There was no way to validate the visits had occurred or been missed. RR #2, the patient record had been missing 1 RN visit and 4 HA visits, again with no method of validating whether the visits occurred. RR #3, the HA was to see the patient 5 times per week; however, there had no documented visits for a 10 day period. RR #4 had the HA frequency at 3 times per week, but there had been 9 visits without documentation. This was validated with the Administrator.

Observed in Record Review. In 4 of 11 patient records reviewed, the organization failed to ensure the IDG in consultation with the attending physician (if any), complete the comprehensive assessment no later than 5 calendar days after the election of hospice care. For example: upon review of HV#1 the initial comprehensive for the MSW was made 30 days after admission, and there was no documentation of an initial comprehensive assessment for the Chaplain. In HV#2 there was no documentation of an initial comprehensive assessment for MSW until 3 months after admission. In RR#6 the Chaplain was accepted on admission yet there is no initial assessment to date. There was a note to reschedule documented on day 7. On RR#10 the MSW was order to assess on admission yet no documentation of a visit was noted on the record. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 6 of 11 patient records reviewed, the organization failed to ensure that an initial and/or a post death bereavement risk assessment was conducted. For example: upon review of Bereavement Record #2 there was no documentation of a post death bereavement risk assessment. Upon review of HV#3, RR#4, RR#5, RR#6, an RR#8 there was no documentation of an initial bereavement risk assessment. This observation was reviewed with the Administrator/DPCS.

Observed in Record Review. In 6 of 11 patient records reviewed, the organization failed to ensure the update of the comprehensive assessment is accomplished by the hospice interdisciplinary group, considering any changes that have taken place since the initial assessment. For example: In review of RR#5 the RN failed to conduct a comprehensive assessment every 15 days as there was a 20 day gap noted from December 2022 to January 2023. In review of RR#6 there was no documentation of a IDG visit conducted on 1/5/23, leaving a 4 week gap. In RR#7 there was no documentation of an IDG review of the comprehensive assessment on 11/10/22. In RR#9 and RR#10 there was no documentation of an IDG review after the patient's death. In RR#11 there was a documented IDG meeting after patient discharge however there was no documentation that the patient had been discharged and it appeared the patient was still on service. These observations were reviewed with the Administrator/DPCS and the Regional Director.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to maintain complete and accurate records. For example: upon review of RR#4 the documentation noted in the record was conflicting regarding the patients primary terminal diagnosis. The diagnosis noted in the EMR and on referral noted COPD. The nurses initial assessment and care plan noted dementia, and the physician's narrative on the CTI noted the primary diagnosis of Parkinson's. This observation was reviewed with the Administrator/DPCS.

Observed in Tracer Activities. upon discussion with the Administrator/DPCS and office staff it was noted that the organization was without an MSW and Spiritual Counselor for an extended period of time (up to six months) during 2022. During this period of time there was no MSW of Spiritual Counselor in attendance at the IDG meeting to review the comprehensive assessment. The organization now has on staff a MSW in December and Spiritual Counselor late November of 2022.

Observed in Record Review. In 3 of 8 resident records reviewed, with active records, the organization failed to ensure that each patient and the primary caregiver receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified. For example: In review of RR#6 the patient was documented to have antibiotics ordered for signs and symptoms of UTI, yet there was no documentation that the patient/caregiver was educated on the disease process, medication ordered and how to safely administer, nor was there any follow up noted in the record. In RR#7 the patient also was treated for signs and symptoms of a UTI yet no education and training was noted in the record to address their role in treating and monitoring the suspected infection. Further, the patient was diabetic and documentation noted the patient/family was monitoring blood glucose yet there was no documentation of education and proficiency assessed for blood glucose monitoring. RR#8 was also noted to be diabetic with blood glucose monitoring by the family yet there was no documentation of education provided on blood glucose monitoring and proficiency in performing the task. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization failed to ensure the written individualized plan reflect patient and family goals and interventions based of the problems identified in the comprehensive assessments and that goals established are specific, measurable, realistic, attainable, and time bound. For example: upon review of HV#1 the patient was documented to be a high fall risk, and have a poor appetite with decreasing MAC yet these issues were not reflected in the care plans. In HV#2 the SN on the home observation discussed the patient's issues with neck pain yet there were no goals and interventions to address pain. Goal that were established were not specific and measurable, such as: anxiety/agitation controlled through course of care and family/caregiver can identify safety concerns. The intervention to achieve those goals was Teach regarding dementia disease process, including prognosis, symptoms, treatment, and complications. There was a disconnect between the intervention to achieving the established goals. Similar observations of lack of goals and interventions to address issues in the comprehensive assessment can be seen throughout all clinical records reviewed. Further, RR#9 had no documentation any goals and interventions, and RR#6, and RR#10 had a psychosocial or spiritual care plan, but no clinical goals and interventions to address issues noted in the comprehensive assessment. These observations were reviewed with the Administrator/DPCS and Regional Director.

Observed in Record Review. In 5 of 11 patient records reviewed, the organization failed to ensure that the plan of care include all services needed for the palliation and management of the terminal illness. For example: upon review of HV#1 the patient was receiving visits from the volunteer 1 time a week however there were no current orders for volunteer services as the previous order expired last month. In HV#2 the MSW had an established plan of care and documented visits yet there was no ordered MSW frequency. In HV#3 and RR#5 there were no orders for MSW as there was no MSW when the patient was admitted. In RR#9 there were no medication orders noted on the record although the nursing assessment noted that the patient was on O2 and pain medication. These observations were reviewed with the Administrator/DPCS and the Volunteer Coordinator.

Observed in Record Review. In 10 of 11 patient records reviewed, the organization failed to ensure the plan of care was revised based on information from updates to the patient's comprehensive assessment and address the patient's progress toward goals and outcomes. Throughout all clinical records reviewed there was a noted lack of documentation of progress toward goals. After goals and interventions were established there was little to no changes made to the care plans as most remained unchanged from IDG meeting to IDG meeting. This observation was reviewed with the Administrator/DPCS.

Observed in Record Review. In 8 of 11 patient records reviewed, the organization failed to ensure that services were provided in accordance with the established plan of care. For example: on review of HV#1 the MSW was ordered 1x month yet there were no visits documented for July through November of 2022. In HV#2 the Chaplain was ordered 2 times a month yet there had been no documentation of a Spiritual Care visit since October of 2022. In HV#3 the chaplain was 1 x month but no visits were documented since initial assessment, further the SN did not meet the established frequency on the week of Christmas. In RR#4 the aide was ordered at admission but visits did not begin until a month later. In RR#5 the SN documented that she was going on vacation the week of Christmas and would not see the patient until she returned, and the chaplain was ordered but no visits documented. In RR#6 the aide was ordered 5x week but had not met the frequency. In RR#7 the aide was ordered 5x week but was seeing the patient 3x week for an extended period of time and the SN had a missed visit in week 7 of benefit period 1. In RR#8 the MSW was scheduled 1xmonth but there were no visits documented after the initial in June and not again until December 2022. These observations were reviewed with the Administrator/DPCS.

Observed in Tracer Activities. upon review of the records and discussion with the Administrator/DPCS, and office staff it was noted the organization was without a MSW and Spiritual Counselor for quite some time (up to six months) in 2022. Both positions have now been filled with the MSW starting in December and spiritual counselor in late November of 2022. The record reviews reveal multiple gaps in services provided for both MSW and Spiritual and a time where it was unclear if these services were offered on admission.

Observed in Record Review. In 1 of 2 patient records reviewed, the organization failed to ensure that a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery was established. For example: on review of Bereavement record #2 there was no documentation of a bereavement plan of care that included the services to be offered and the frequency of service delivered. This observation was reviewed with the Bereavement Coordinator and Administrator/DPCS.

Observed in HR File Review. upon review of the HR file for the hospice aide, the organization failed to ensure that the aide competency was evaluated by observing the aide's performance of the tasks with a patient or a pseudo-patient. For example: In the aide's initial competency all tasks on the aide competency sheet were evaluated verbally and not with direct observation. On the aide's annual competency, all tasks were marked as observed, however the documentation failed to confirm the competencies were completed with a patient or a pseudo-patient. Further, on the annual competency it noted that all tasks were observed on the same day to include cooking, laundry, and errand running. These observations were reviewed with the Regional Clinical Services Director.

Observed in Record Review. In 2 of 8 patient records reviewed, for active patient's receiving hospice aide services, the organization failed to ensure that a RN provide the aide with written patient care instructions. For example: in review of RR#4 the aide assignment lacked any tasks to perform beyond noting full code, record BM, report pain, and standard precautions. In RR#6 there was no aide plan of care established although the aide had made multiple patient visits. These observations were reviewed with the Administrator/DPCS and Regional Director.

Observed in Record Review. In 5 of 8 patient records reviewed, the organization failed to ensure that the registered nurse supervise the hospice aide during an on-site visit to the patient's home to ensure that services ordered meet the patient's needs, no less frequently that every 14 days. For example: in review of HV#3 there was a 15 day gap in aide supervisory visits when the SN was off during Christmas. In RR#5 there was a 20 day gap in aide supervisory visits in the final weeks of 2022. In RR#6 there was one supervisory visit documented on 12/21/22 and no further supervisory visits since that date. Further, the one supervisory visit failed to note that there was no plan of care assigned for the aide. In RR#7 there was a greater than 50 day gap in supervisory visits noted from week 3 to week 11 of benefit 1. RR#10 also revealed a greater than 14 day gap in aide supervision. These observations were reviewed with the Administrator/DPCS and the Regional Director.

Observed in Tracer Activities. Upon review of all tracer activities, it was noted that there was a pattern of staff failing to follow established organization policy and the governing body/leadership did not ensure that the Conditions of Participation for 418.100, 418.116, 418.56, and 418.54 were met per policy as determined through observations, documentation, and staff interviews.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to ensure that the medical director provide written certification that the patient’s life expectancy is six months or less if the illness runs its normal course to include all of the required elements. For example: upon review of HV#1 the CTI for the current benefit period, the CTI was incomplete with no physician narrative or physician signature. This observation was reviewed with the Administrator/DPCS.

Observed in Record Review. In 3 of 11 patient records reviewed, the organization failed to ensure that the clinical record contain all information that reflects the patient's care, treatment, and services. For example: in review of RR#7 the patient chose an attending physician on admission that was not the hospice medical director, however this information was noted on the patient record or the CTI. In review of RR#6 the Administrator relayed that a hospice aide visit was conducted on 12/20/22 yet there was no documentation of the visit on the record. In RR#9 there is no documentation of a visit to attend the patient's death. These observations were reviewed with the Administrator/DPCS and the Regional Director.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization failed to ensure that entries in the medical record were appropriately authenticated and dated in accordance with hospice policy and currently accepted standards of practice. For example: upon review of HV#1 and HV#2 is was noted that multiple CTI's were completed yet lacked a physician signature and date. The lack of physician signatures on CTI's was noted throughout all clinical records reviewed. Upon discussion with the Administrator this issue was noted on record review prior to survey by leadership, and a PIP was put in place. There was a noted glitch in the EMR causing the CTI to be returned with an indication that the document had been signed but when reviewing the document it remained unsigned.

Observed in Record Review. In 7 of 11 patient records reviewed, the leadership failed to ensure that the hospice and its staff operate and furnish services in compliance with all applicable Federal, State, and local laws and regulations related to health and safety of patients. For example: upon review of the record for RR#11, who was discharged for extended prognosis, the patient was not presented with the Medicare Notice of Non-Coverage (ABN). Discussion with Regional Leadership revealed that Harbor Hospice has a process for presenting the form at least 2 days prior to discharge, however this process was not in place in this office. Example 2: upon review of RR#10 the patient revoked hospice services, however there was no revocation form in the record. Example 3: Upon review of the informed consent and legal paperwork throughout the records, it was noted that when the Medicare Notification of Non-Covered items was presented to patients on admission the form was left incomplete.