Every finding on record at Harbor Hospice of Portland, LP

Observed in Individual Tracer. The surveyor observed in 1/6 in room tracers that the SN had not followed the organization hand hygiene policy. The surveyor observed during wound care dressing change that the SN providing wound care for patient cleaned dirty diaper, then did wound care to coccyx decubitus ulcer, changing gloves multiple times and not cleaning hands between any glove change. The organization policy followed CDC guidelines and required hand hygiene between glove changes. This issue was discussed with nurse providing care, administrator and confirmed .

Observed in Tracer Activities. The surveyor observed during the volunteer system session that the organization had not achieved the minimum of 5 percent of total patient care hours of all paid hospice employees and contract staff had been provided by volunteers. The surveyor observed 2% in 2024 and 0% in 2025 of volunteer hours. The issue was discussed and confirmed with volunteer coordinator and organization administrator.

Observed in Document Review. It was observed that there was no annual inspection of the rated door assemblies. The observation was confirmed by the Facilities Manager. Observed in Building Tour. In 1 of 2 fire-rated walls inspected, it was observed that there was an unsealed penetration above the corridor ceiling above patient room 122. The observation was confirmed by the Facilities Manager. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy:

Observed in HR File Review. In 2 of 2 medical staff/credentialing files reviewed, During the file review, the surveyor noted that in both MD files there was no documentation of a current DEA license. This was validated in a discussion with and observation by the Regional Director of Clinical Operations and Office Manager.