Every finding on record at Harbor Hospice of Livingston LP

Observed in Record Review. In 2 of 14 patient records reviewed, it was noted that the organization did not ensure that the plan of care was revised when the patient’s condition changed. For example, during a review of the medical record for RRHV#1, it was noted that the patient experienced a fall with injury during week #4, a fall with injury during week #6, and a fall without injury during week #7, during the 1st benefit period of hospice 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 RRNHV#6, it was noted that during week 10 of the 1st benefit period, the patient experienced a fall with bruising at chin, and bilateral upper/lower extremities. The plan of care was not updated with interventions to maintain patient safety and strategies to prevent injury. This observation was reviewed with the Administrator.

Observed in Competency Session. A review of 2 of 2 Human Resource files for Hospice Aides, revealed that competency assessment was not completed as required before the hospice aides provided patient care. For example, Since the initial competency assessment for Hospice Aide #1, and Hospice Aide #2 were completed using a verbal exam. The requirements for the following tasks to be observed with a patient or a pseudo patient were not implemented: 1) Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other staff; 2) Reading and recording temperature, pulse, and respirations; 3) Appropriate and safe techniques in personal hygiene and grooming that include bed, sponge, tub, or shower bath; sink, tub, or bed shampoo; nail and skin care; oral hygiene; toileting and elimination; 4) Safe transfer techniques and ambulation; 5) and Normal range of motion and positioning. This observation was reviewed with the Administrator.

Observed in Competency Session. A review of 2 of 2 Human Resource files for Hospice Aides, revealed that the organization's policy to perform competency assessments annually was not implemented. For example, a review of the annual competency for Hospice Aide #1, and Hospice Aide #2 revealed that the following tasks were assessed through verbal examination. The requirements for the following tasks to be observed with a patient or a pseudo patient were not implemented: 1) Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other staff; 2) Reading and recording temperature, pulse, and respirations; 3) Appropriate and safe techniques in personal hygiene and grooming that include bed, sponge, tub, or shower bath; sink, tub, or bed shampoo; nail and skin care; oral hygiene; toileting and elimination; 4) Safe transfer techniques and ambulation; 5) and Normal range of motion and positioning. This observation was reviewed with the Administrator.

Observed in Record Review. In 3 of 3 individual tracers, 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#1, and RRHV#2, it was noted that a Hospice Aide supervision visit was not documented by the Registered Nurse every 14 days during the first benefit period. Example #2: During the review of the medical record for RRHV#3, it was noted that a Hospice Aide supervision visit was not documented by the Registered Nurse every 14 days during the 3rd benefit period. This observation was reviewed with the Administrator.

Observed in Tracer Activities. During the Volunteer Program review the organization did not document effective recruitment for volunteers used in direct patient care services. Recruitment efforts resulted in one (1) administrative volunteer for 2024, and one (1) administrative volunteer for 2025. Efforts to recruit volunteers for direct patient care roles was not documented. This observation was reviewed with Volunteer Coordinator, and the Administrator.

Observed in Tracer Activities. During the Volunteer Program review the organization did not document effective efforts to achieve cost savings through the use of Volunteers. For example, volunteers did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff. During the year of 2024, the 1st and 2nd quarters of 2025, the volunteer program achieved less than 3% cost savings through the use of volunteers. This observation was reviewed with the Volunteer Coordinator and the Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed for patients discharged or transferred from the organization, it was noted that the organization did not ensure information was provided to the receiving organization as required. For example, a review of the medical record for RRDC#1, revealed that the receiving organization was not provided with a copy of the hospice discharge summary and requested documents from the medical record. 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 HR File Review. During the Contract review the nurse surveyor noted in the contract for the Medical Director that license expired on 11/30/19 and was not verified until 8/31/22 the day of survey. In addition there was no verification of the DEA license until 8/31/22. This was validated in a discussion with the Alternate Administrator and the Regional Director. Observed in HR File Review. In 1 of 9 files requiring licensure, During the HR record review the nurse surveyor noted in CNA 2, that the license expired on 3/19/20 and was not verified until 3/4/21. This was validated in a discussion with the Alternate Administrator and the Regional Director.

Observed in HR File Review. During the Contract review the nurse surveyor noted in the contract for the Medical Director that a criminal background check had not been done since the contract was signed in 2015. The check was done on the day of survey. This was validated in a discussion with the Alternate Administrator and the Regional Director.