Every finding on record at Harbor Hospice of North San Antonio, LP

Observed in Record Review. In 8 of 10 patient records reviewed, the organization failed to complete the comprehensive assessment no later than five calendar days after the election of hospice care. In review of the medical record for RRHV #1 the social worker had not completed the psychosocial assessment until 30 days following the election of the hospice benefit by the patient. For RRHV #2 the psychosocial assessment was completed 7 days following the election of the hospice benefit by the patient and in review of the medical record for RRHV #3 the spiritual assessment was completed 7 days following the election of the hospice benefit. Additionally, this was observed in review of the medical record for RRNHV #1 where the spiritual assessment was conducted 81 days following the election of the hospice benefit, in RRNHV #4 the spiritual assessment was missing, in RRNHV #5 the psychosocial assessment was completed 12 days following the election of the hospice benefit, in RRNHV #6 the psychosocial assessment was missing and in RRNHV #7 both the psychosocial assessment and the spiritual assessment were missing. This was discussed with the Administrator.

Observed in Patient Home. In 1 of 2 home visits conducted, with nursing staff the organization did not assess potential medication-related problems. For RRHV #2 the hospice nurse failed to conduct a medication assessment in accordance with the organization's policy no. 3-002.1 which states; during subsequent hospice visits, the medication profile will be used to evaluate the use of the drugs in the home setting. This was discussed with the Administrator.

Observed in Record Review. In 5 of 12 patient records reviewed, the organization had not provided care, treatment and services according to the hospice plan of care. For RRHV #2 there was no evidence of follow up visits as the social worker had planned in the psychosocial evaluation also, the chaplain who conducted a telephone call with the patient on admission had planned to follow up but there was no evidence of follow up until 2 months later and then again in 3 months. Additionally, for RRNHV #1 there was no evidence that the social worker visited the patient as planned in the months of May, June or October and no evidence of missed visit documentation. For RRNHV #3 there was no evidence that the social worker visited the patient in July as planned and no evidence of missed visit documentation. Finally, in review of BR #1 and BR #1 the bereavement plan of care called for mailings at 3 weeks, 3 months, 9 months and 13 months however there was no evidence in the medical record that the 9 month mailing had been sent to the bereaved as planned. This was discussed with the Administrator.

Observed in HR File Review. In 7 of 9 HR files reviewed, the organization had not assessed compliance with hand hygiene. Although the organization had assessed hand hygiene for the home health aides, there was no evidence that hand hygiene was being assessed for other staff. For example, HR #1 RN, HR #2 RN, HR #3 Social Worker, HR #4 Chaplain, HR #5 Admin/LVN, HR #8 Medical Director and HR #9 Volunteer, there was no evidence that hand hygiene had been assessed. This was discussed with the Administrator.

Observed in Document Review. The hospice had not documented its efforts to recruit and retain volunteers. In review of the Volunteer Program there was no evidence or documentation of recruitment and retention efforts prior to June 2024 when the new Volunteer Coordinator was hired or for 2023. This was discussed with the Administrator.

Observed in Document Review. The organization did not have evidence that volunteers provided at least 5% of the total patient care hours of all paid hospice employees and contract staff prior to June 2024 when the new Volunteer Coordinator was hired or for 2023. This was discussed with the Administrator.

Observed in HR File Review. In 1 of 9 HR files reviewed, the organization failed to assess staff competencies. In review of the personnel file for HR #3 who was a social worker hired 5 months ago there was no evidence that competencies had been assessed prior to providing patient care. This was confirmed by the Administrator.

Observed in Patient Home. In 1 of 2 home visits conducted, with nursing staff the organization did not compare the medication information the patient was currently taking with the medications ordered for the patient in order to identify and resolve discrepancies. For RRHV #1 who resided in a skilled nursing facility (SNF) there were inconsistencies in the medication list for the hospice and the medication list for the SNF. Finasteride 5mg 1 tab daily was on medication list for SNF but not on the medication list for the hospice.. MiraLAX 17grams/dose daily as needed and Simvastatin 40 mg was on the hospice medication list but not on the medication list for the SNF. This was discussed with the Administrator.

Observed in Record Review. In 1 of 10 patient records reviewed, the patient record was not accurately documented. For RRHV #2 the RN completed the home visit without assessing the patients medications in the home however in review of the medical record the RN documented that a review of the medications had been completed. This was discussed with the Administrator.

Observed in Document Review. In 1 of 3 contracts reviewed, the contract did not include a stipulation that the outside agency would complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. In review of the contract the hospice program has for pharmacy services there was no evidence of language regarding criminal background checks. This was validated with the Administrator.

Observed in Record Review. In 3 of 3 patient records reviewed, the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for RR#1, the target dates for goal attainment were all the first day of the recertification benefit period. In addition, goals were not measurable, such as will experience optimal levels of symptom control. This lack of measurability was present in the charts for RR#2 and RR#3 as well, with qualifiers such as within parameters of disease and all SN goals with the same anticipated attainment date, either the date of the next IDT, or the last day of the benefit period, not individualized to the patients unique care. This was discussed with the DON.

Observed in Record Review. In 1 of 3 patient records reviewed, the patient record did not contain the following clinical information: specific notes on care, treatment, or services. In the chart for RR#1, there was no documentation of the communication from the aide to the RN about providing a bed bath rather than the assigned shower during the first aide visit and that the patient's condition had declined. The RN did however, modify the aide care plan after the initial aide visit to a bed bath rather than a shower. Additionally, the chart did not contain any documentation as to why the RN made the prn visit for the patient's death. This information was only contained in the organization's call log, not the patient chart. During SN visits, the SN documented wound measurements, however the notes did not include the dressing change. It was unclear in the documentation how the patient's dressing change needs were met; if the SN performed wound care or if the caregiver provided wound care during or after the SN visits. This was discussed and verified with the QA Nurse.

Observed in Record Review. In 10 of 11 patient records reviewed, the agency failed to document a complete initial comprehensive assessment. In HV#1,HV#2, RR#2, RR#4, RR#5, RR#6, RR#7, and RR#8 the documentation of the MSW assessment did not include the status of funeral arrangements. Additionally in HV#1, HV#3, RR#1, and RR#6 there was no documented bereavement assessment as part of the comprehensive assessment. In HV#3 the initial assessment failed to document a skin assessment or Braden scale, cardiovascular assessment, respiratory assessment, GI, musculoskeletal, or cognitive assessment. This patient's diagnosis list included ASCHD, Parkinsons, and dementia. This was validated with the administrator.

Observed in Record Review. In 8 of 11 patient records reviewed, the plan of care failed to reflect patient and family goals and interventions based on the problems identified in the comprehensive assessment. For example in HV#1 all nursing goals had target dates that coincided with the end of the certification period therefore not providing any prioritization for those goals that should be achieved in the short term to insure patient safety. In HV#2 all nursing goals had target dates 30 days after patient admission including including patient/caregiver will be able to demonstrate safe and effective use of recommended DME and assistive devices. and staff will be compliant with removal of safety hazards from patient's room reducing the risk of falls/injury. In addition MSW goals were not patient centered. MSW goals were documented to be Patient will receive ongoing comfort and support from hospice team. and SW will provide empathetic listening and social support to patient. In all remaining charts except RR#3, RR#5 and RR#7 nursing goals all had the same long term target dates and MSW goals when they were present were not patient centered. This was validated with the administrator.

Observed in Record Review. In 10 of 11 patient records reviewed, the plan of care failed to include all of the drugs and treatments necessary to meet the patient needs. In HV#1 the initial nursing assessment in June indicated that the patient was on oxygen including a complete oxygen safety assessment. However, there were no orders for oxygen to include rate, mode of delivery and frequency documented until December. In HV#3 the patient was assessed to be at high risk for falls but fall prevention was not addressed on the plan of care. In RR#1 the MSW identified that patient wanted nursing home placement and that she would assist to include evaluating Medicaid availability but this was not addressed on the plan of care. The plan of care did not include any MSW problems, interventions or goals. In RR#2 did not address a Foley, an ostomy, pain, fall prevention, a peg tube, and there were no orders for oxygen. All of these were identified in the comprehensive assessment. The assessment also identified multiple wounds but the only orders to address the wounds was wound assessment, there was no wound care ordered on the initial plan of care. The MSW established a frequency but the only intervention documented on the plan of care was Assess family/caregiver's understanding of disease and prognosis and the only goal was Family/Caregiver will verbalize understanding of patient needs. There was no planning for assisting with facility placement or applying for Medicaid as indicated in the social work assessment. In similar fashion the comprehensive assessments in RR#3, RR#4, RR#5, RR#6, RR#7 and RR#8 identified issues that were not addressed in the plan of care. This was validated with the administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, the agency failed to document care in accordance with the plan of care. In HV#1 there was a wound care order as follows: wash unstageable ulcer on left heel with soap and water. Pat dry. Apply Tincture Benzoin 3 times a day and wrap heel with kerlex each application. The wound care documentation on the first visit after receiving orders was: Wound Cleansing/Dressing Change; Cleansed with: Soap and water; Wound Care Frequency BID; Wound Care Performed by: Patient and at the subsequent visit: Wound Cleansing/Dressing Change: Cleansed with: Soap and water; Other: Tincture benzoin; Covered with (dressing type): Kerlex; Wound Care Frequency Daily; Wound Care Performed by: Patient Caregiver; Care Performed: Independently. There was no documentation of wound care on the third nursing visit. The most recent note read (6 months into care): Wound Cleansing/Dressing Change Cleansed with: Wound cleanser; Application/Packing: Gauze; Covered with (dressing type): Non-adherent; Secured with: Tape; Technique Aseptic Wound Care Frequency; Daily prn; Wound Care Performed by: Caregiver; Care Performed: Independently; Patient Tolerated Procedure: Well. There was no documented order for this wound care. In RR#1 wound care was sporadically documented but did not follow orders. At other times the documentation of the wound care was that it was done by the facility with no indication as to whether the facility was providing the ordered wound care. This was validated with the administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, the agency failed to document ongoing sharing of information between all disciplines providing care and services. In RR#4 a patient was discharged due to stabilization of her health status. There was no documentation of interdisciplinary discussion and collaboration to reach this decision. This was validated with the regional director.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: 418.54, 418.56 and 418.100.

Observed in Patient Home. In 1 of 2 home visits conducted, in which medication reconciliation was assessed the agency failed to do an effective medication reconciliation that resulted in an accurate list of medications. IN HV#1 the nurse performed medication reconciliation of all medications stored in a plastic bag but failed to include all of the medications that the patient had on a tray near her bed. Upon the surveyor asking the patient about those medications she stated that she takes them from time to time including Vitamin C, Lactulose, Gas X, a probiotic, Tylenol tablets, Azio, and Tums. None of these medications were on the medication list except for Tylenol. However the Tylenol on the medication list was for a suppository and the patient is taking tablets.

Observed in Patient Home. In 1 of 2 home visits conducted, for patients with oxygen there was no documented oxygen education regarding the storage of oxygen tanks. In HV#3 the surveyor observed one oxygen tank in a stand and two tanks stored leaning up against the wall unsecured. There was no documentation in the record that oxygen education had included the storage of tanks. Additionally the patient and the caregiver stated that they have always been stored that way.

Observed in Patient Home. In 1 of 3 home visits conducted, the agency staff failed to follow current standards of practice for handwashing. The CDC guidelines allow using alcohol to disinfect gloves rather than changing gloves only when the facility can document a shortage of gloves. In HV#3 the RN was observed to use one pair of gloves for the entire visit and used alcohol gel to disinfect gloves when moving from the care of one wound to the next and before entering her nursing bag rather than removing gloves, doing hand hygiene and donning a new pair of gloves.