Every finding on record at Harbor Hospice of Houston LP

Observed in Record Review. In 3 of 18 patient records reviewed, it was noted that the comprehensive assessment was not completed no later than 5 calendar days after the election of hospice care. For example, in the record RRNHV#8 the social worker failed to complete their initial assessment within five days after the election of hospice, it was documented on day 9. In record RRNHV#9 the social worker completed the initial assessment day 15. In record RRNHV#11 the social worker completed the initial assessment day 7. This was confirmed and discussed with the Administrator present.

Observed in Record Review. In 2 of 18 patient records reviewed, it was noted that the hospice had not conducted a comprehensive assessment. For example, in records RRNHV#1 and RRNHV#4 the initial psychosocial assessment was not completed or documented. This was confirmed with the Administrator present.

Observed in Record Review. In 16 of 18 patient records reviewed, it was noted that the written plan of care was not individualized for each patient. For example, in record RRHV#1 8 of 9 goal's time frames were in the past and had not been updated. Also, the wound care intervention had not been updated when the order was changed 3 months ago from unna boot dressing to wound cream #4 dressing. For example, in record RRHV#2 the aide's POC target dates for all goals were 3 months in the past and not updated. Also, in RRHV#2 and RRHV#6 the MSW goals were Resolved with no current goals or interventions although the patient's record included visit orders and visit notes from the MSW. For example in record RRHV#3 the MSW goals, in record RRHV#5 the Spiritual Counselor goals and in record RRNHV#1 the aide goals time frames were dated in the past. For example in record RRHV#5 the goals were not individualized; Judith will feel the sense that God is with her in her situation in spite of and Judith achieves feeling of spiritual comfort. In records RRNHV#1, #4, #5, #6, #7, #8, #9, #10 and #11 the goals time frames were dated in the past. In record RRNHV#2 the aide POC goal stated care to be provided 3 times a week had not been changed when the order and care changed to 5 times a week. In record RRNHV#2 there was an order for volunteer visits and volunteer visits were documented however there were no goals or interventions in the POC for the volunteer care to be provided. Also the goals were not individualized, for example; Jackie/family will demonstrate a good level of understanding regarding Advanced Directives and will be open to education/assistance offered by sw Patient will maintain a pain score of ___ (left blank)or less, per patient/family preference, on a scale of 0-10 Caregiver will consult with staff as needed for support Peripheral edema will be reduced within limitations of disease process This was discussed with the DPCS and Administrator present.

Observed in Record Review. In 1 of 2 patient records reviewed, that included volunteer services it was noted that care was not provided according to hospice plan of care. For example in record RRNHV#12 the plan of care required the volunteer provide weekly visits, howver during January only 2 visits were documented and during November only 3 visits were documented with no missed visit documentation. This was confirmed with the Administrator and Regional Quality Director present.

Observed in Data Session. During document review, the administrator confirmed that the organization's QAPI did not meet the following criteria:- Reflects the complexity of the organization and its services- Involves all services provided by the organization, including those provided under contract or arrangementAs evidenced by the lack of contract evaluation detail in the QAPI meeting minutes that are reported to the governing board.

Observed in Record Review. In 3 of 3 home visits conducted, when equipment was utilized during a visit, it was noted that staff did not implement activities for prevention and control of infections, such as using standard precautions. For example, during visits RRHV#3, RRHV#4, and RRHV#6 the nurses used purple top sani wipes to clean equipment after use and the 2 minute contact time, as directed in the IFU and on the packaging, was not observed. For example, during visit RRHV#4 the nurse was observed to use bare hands to remove the used dressing from around the PEG tube, then without performing hand hygiene she reached into the nursing bag, removed gloves and put them on. This was confirmed and discussed with the Administrator present.

Observed in Record Review. In 3 of 3 patient records reviewed, for bereavement care it was noted that the bereavement plan of care did not specify the type of bereavement services to be offered. For example, in record RRBR#2 the bereavement assessment indicated that the bereaved was at a level 2 or medium level of risk, but the POC that was documented was for a level 1 or low level of risk. Also, all level 1 risk POCs were identical and all level 2 POCs were identical. There were no level 3 risks identified. This was discussed and confirmed with the Bereavement Coordinator and Administrator present.

Observed in Record Review. In 1 of 18 patient records reviewed, it was noted that a registered nurse had not written the patient care instructions for the hospice aide. For example; in record RRHV#1 the aide POC did not address the wound dressings on the patient's lower legs bilaterally, such as what the aide was to do if there was a problem such as bleeding through dressing or the dressings falling off. This was discussed with the Administrator present.

Observed in Tracer Activities. During discussion with the Volunteer Coordinator, Regional Director of Quality and the Administrator it was noted that there was no documentation of volunteer retention activities. There was documentation of recruitment activities, but the Volunteer Coordinator indicated that she had not been aware of the need for retention.

Observed in Tracer Activities. During discussion with the Volunteer Coordinator, Regional Director of Quality and Administrator it was noted that volunteers did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff. For example during 2024 volunteers provided 2.84% of the total patient care hours.

Observed in Patient Home. In 1 of 3 home visits conducted, that included oxygen therapy it was noted that multiple oxygen tanks were standing upright unsecured and education had not been provided during visit to reinforce the safety of securing the tanks. For example during visit RRHV#6 there was 1 E tank free standing in the middle of a bedroom and 2 small tanks free standing on the kitchen table. The nurse did not provide education to the patient or her son about properly securing the tanks. This was discussed with the Administrator present.

Observed in Individual Tracer. In 2 of 11 patient records reviewed, the hospice did not advise the patient verbally and in writing of his/her rights. RR#2 had several medications not covered by hospice upon admission. A non coverage form was not completed because per the compliance director, the patient signed a consent form that indicated he did not want to receive the non coverage form. There was a consent form signed with a box checked to not receive information on non covered items for this patient. However, there was no written notification that was signed by the patient which acknowledged receipt of information related to non covered items such as medications and or diagnosis. Additionally, this election of benefit /consent form, with check box indicating that the patient does not want receive the non coverage form, was also observed in RR#11 and RR#10. Based on discussions with the compliance director, this was part of the hospice's routine process to address noncovered items with patients. Patients can opt out of receiving information regarding noncovered items and or diagnosis(s) by checking the box on the election of benefit forms.

Observed in Individual Tracer. In 1 of 13 patient records reviewed, the hospice care plan or updates to the care plan did not reflect the medications that the patient was taking. Per the manager of the ALF, the patient was not given at least four medications listed on the comprehensive care plan and medication list of RR#2. These medications included a statin and allergy medication. This observation was discussed with the director.

Observed in Individual Tracer. In 1 of 13 patient records reviewed, the hospice did not ensure that medical supplies and appliances necessary to meet the patient's needs is reflected on the care plan. RR#12 had a Foley that was being managed by the hospice nurse. The most recent recertification did not include the Foley size, frequency of change, or balloon size. This observation was discussed with the compliance director.

Observed in Individual Tracer. In 1 of 13 patient records reviewed, the hospice did not ensure that services were provided based on assessed needs. The IDT and assessment prior to the most recent recertification of RR#3 reflected that the patient required social work and chaplain visits. These services did not appear on the most recent recertification nor were there any visits made by the social worker. The wife confirmed that she has been visited by the chaplain but not the social worker. This observation was discussed with the compliance director.

Observed in Patient Home. In 1 of 3 home visits conducted, the hospice did not follow their policy and or process related to hand hygiene. the LPN RR#1 was observed cleaning a wound with NS than applied a new treatment and new dressing. The LPN did not change gloves or disinfect hands prior to moving from dirty to clean areas of the wound. The RN in RR#2 was also observed not cleaning her hands and or changing her gloves after cleaning the patient's wound and prior to packing this wound. Additionally, the RN in RR#2 was observed removing the old dressing on a second wound lower on the thigh with the same gloves she utilized to perform the first wound care. This observation was discussed with the director and was not consistent with the policy #9-007.1.

Observed in Individual Tracer. In 2 of 3 patient records reviewed, the hospice did not follow family and or other individuals for a 12 month period for bereavement counseling. Both bereavement record #1 and Bereavement record #2 did not have follow up for bereavement services after the 7th month which was not consistent with the bereavement care plan of these patients. Additionally, there was no follow up documentation detailing that the services were refused after the 7th month. These observations were discussed with the bereavement coordinator.

Observed in Individual Tracer. In 3 of 3 patient records reviewed, the hospice aide care plan did not reflect all of the services required based on the assessed needs of the patient. RR#1 had a thigh wound which required care. The home health aide care plan did not reflect wound precautions. RR#2 required aspiration precautions per the nursing assessment and the home health aide care plan did not include this precautions. Additionally, for RR#2 the aide care plan only indicated to give a bath without further qualifications. It also indicated directions for the aide to give a soap suds enema as directed by the nurse. Based on discussions with the director, the aide did not give the patient this enema. RR#4 had seizures and required aspiration precautions. The aide care plan of RR#4 did not reflect seizures or aspiration precautions. This observation was discussed with the director.

Observed in Record Review. In 2 of 13 patient records reviewed, the hospice record did not contain accurate documentation. RR#1's assessment reflected that the patient had a wound vac. This patient did not have a wound vac. A visit note for RR#13 reflected that a Foley catheter was inserted. The orders for the Foley was dated one week after the Foley was inserted. Based on discussions with the compliance director, this was probably an issue of inaccurate documentation.

Observed in Individual Tracer. In 3 of 3 patient records reviewed, the hospice did not provide a copy of the discharge/transfer summary to the next Medicare provider. RR#9, RR#10, and RR#11 were transferred to another hospice. There was no documentation in the record and or elsewhere that reflected that the summaries were sent to the next provider. These observations were discussed with the compliance director.

Observed in Individual Tracer. In 1 of 5 patient records reviewed, the hospice comprehensive care plan did not detail who would provide services. RR#4 resided in a nursing home and based on a review of the record required daily wound care. The RN was visiting weekly and the review of the comprehensive care plan did not specify who would be providing the daily wound care. This observation was discussed with compliance.