Every finding on record at Harbor Hospice of Harlingen LP

Observed in Individual Tracer. In 4 of 8 HR files reviewed, it was noted that the organization did not ensure that staff participated in ongoing education and training for the emergency program . For example, a review of the HR files for HR#1, HR#4, HR#6, HR#7, revealed that the following required education and training for Emergency Management was not documented for the year 2025. This observation was reviewed with the Administrator.

Observed in Data Session. The organization did not ensure that its performance improvement priorities were implemented as required. For example, a review of the QAPI report for 2025 revealed that the following quality indicators did not document annual data collection as outlined in the QAPI plan: Hand Hygiene compliance, Bag Technique. and Total Patient Infections. This observation was reviewed with the Administrator.

Observed in Data Session. The following 2025 quality indicators did not document annual data collection as outlined in the QAPI plan: Hand Hygiene compliance, Bag Technique. and Total Patient Infections. Since the organization did not ensure that its performance improvement priorities were implemented, opportunities and priorities for improvement were not identified. This observation was reviewed with the Administrator.

Observed in Data Session. The organization did not ensure its policy for identification of infection prevention and control activities was implemented. For example, a review of the quality indicator labeled Total Patient Infections revealed that the reported patient infection was not identified for the year 2025, and 1st quarter of 2026.. Monthly patient infections were grouped in the section titled other. This did not provide the opportunity to identify the specific patient infection. This observation was reviewed with the Administrator.

Observed in Individual Tracer. In 4 of 8 HR files reviewed, it was noted that the organization did not ensure that staff participated in ongoing education and training to maintain competence. For example, a review of the HR files for HR#1, HR#4, HR#6, HR#7, revealed that the following required education and training was not documented for the year 2025: Hand hygiene, Blood Borne Pathogens, OSHA, Bag Techniqueand Infection Control. This observation was reviewed with the Administrator.

Observed in HR File Review. In 1 of 1 HR files reviewed, for Hospice Aides, the organization did not ensure the hospice aide completed required in-service training. For example, a review of the file for HR#4, revealed that documentation of at least 12 hours of in-service training for the year 2025 was not documented. This observation was reviewed with the Administrator.

Observed in Record Review. In 1 of 5 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 a Hospice Aide supervision visit was not documented by the Registered Nurse every 14 days. A Hospice Aide supervision visit was documented during week 7 of the 16th benefit period. The next Hospice Aide supervision visit was documented 20 days later. 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 Individual Tracer. In 4 of 8 HR files reviewed, it was noted that the organization did not ensure that staff participated in ongoing education and training to maintain competence. For example, a review of the HR files for HR#1, HR#4, HR#6, HR#7, revealed that the following required education and training was not documented for the year 2025: patient’s rights and responsibilities, and HIPAA. This observation was reviewed with the Administrator.

Observed in Record Review. In 1 of 2 discharge records reviewed, it was noted that a discharge/transfer summary that included all required information was not completed. For example, a review of the medical records for RRDC#1, revealed no evidence that a discharge summary including the following information was documented: 1) A summary of the patient’s stay, including treatments, symptoms, and pain management, 2) The patient’s current plan of care, and 3) The patient’s latest physician orders. This observation was reviewed with Administrator.

Observed in Record Review. In 8 of 8 patient records reviewed, the organization did not assess the need for volunteer services to offer support or respite to the patient, family, or other caregivers. This was confirmed by the Administrator/Director of Nursing.

Observed in Record Review. In 1 of 11 patient records reviewed, the initial comprehensive assessment by the Hospice Spiritual Counselor and Medical Social Worker had not been completed within five calendar days of the patient electing the hospice benefit. In RR#10, there had been no visit made by the Spiritual Counselor and Medical Social Worker during the first month of service. This was confirmed by the Administrator/Director of Nursing.

Observed in Record Review. In 1 of 8 patient records reviewed, the organization did not plan the patient's care. In RR#5, the patient had a Stage III and Stage IV wound and the aide care plan did not provide any instructions to notify nurse if dressing becomes soiled or dislodged. This was confirmed by the Administrator/Director of Nursing.

Observed in Record Review. In 1 of 8 patient records reviewed, the organization did not plan patient's care. In RR#4, patient went from routine level of care to general inpatient care in January 2023 and again in the beginning of March 2023. No level of care order found in the patient's record. This was confirmed by the Administrator/Director of Nursing. Observed in Record Review. In 11 of 11 patient records reviewed, the organization did not develop plans of care with measurable goals. During review of patient records the surveyor noted that most goals were not measurable. For example, patient will be pain free or verbalize an acceptable pain level with current pain management regimen and patient's nutritional needs will be met as patient's condition /comfort allows. This was confirmed by the Administrator/Director of Nursing.

Observed in Patient Home. In 1 of 3 home visits conducted, staff failed to perform hand hygiene at times required by the organization's Hand Hygiene Policy No. 9-009.1 as evidenced by: During HV#1, aide failed to perform hand decontamination using an alcohol-based hand rub after removing gloves multiple times while providing care. This was confirmed by the Administrator/Director of Nursing.

Observed in Record Review. In 1 of 8 patient records reviewed, the organization did not plan patient's care. In RR#4, patient was on continuous oxygen and the aide care plan did not address whether the oxygen could be removed for the bath. This was confirmed by the Administrator/Director of Nursing.

Observed in Tracer Activities. The organization did not document recruitment efforts. They have no Volunteer Coordinator since December 2022 and have had no active volunteers. This was confirmed by the Administrator/Director of Nursing.

Observed in Record Review. In 8 of 11 patient records reviewed, the patient record contains information that reflects the patient's care, treatment, or services. Surveyor noted that the organization was not capturing the IDG meeting notes in one centralized form in the patient's record. Due to recent staffing changes, the leadership team had not been aware that the IDG meeting note was not being generated. The organization was able to show the surveyor past IDG agendas, sign-in sheets, and individual notes entered by each discipline. This was confirmed by the Administrator/Director of Nursing.

Observed in Record Review. In 3 of 8 patient records reviewed, the patient record did not contain accurate information regarding the aide services received. In HV#1, HV#3, RR#5, the surveyor noted that the last entry made by the CNA was 4 weeks ago, even though there was no stop in service. According to the organization's Management of Information Policy No. 5-006.2, Entries into the clinical record will be made on the day care is provided to the patient. This was confirmed by the Administrator/Director of Nursing.

Observed in Patient Home. In 2 of 3 home visits conducted, no documentation that instructions on use and disposal of controlled substances was given. In HV#1 and HV#2, the information was not found in admission packet, patient handbook or documents provided to patient and family. This was confirmed by the Administrator/Director of Nursing.

Observed in Tracer Activities. In 2 of 4 contracts reviewed, the therapy and pharmacy contracts failed to stipulate that the contractor would obtain a criminal background check on all employees who have direct patient contact or access to patient records. This was confirmed by the Administrator/Director of Nursing.