Every finding on record at Harbor Hospice of South Texas LP

Observed in Record Review. In 1 of 2 patient records reviewed, the Surveyor noted the organization failed to assess and reassess its patient's per standards. For example, in RRHV#1, in the month of December, there had been a gap of 17 days between RN comprehensive assessments. This was validated with the Director of Nursing.

Observed in Patient Home. In 1 of 1 home visits conducted, the organization failed to maintain a medical record that reflected the patient's care, treatment, or services. During RRHV#1, the medication profile in the electronic medical record (EMR) had the following discrepancies: medications missing from the EMR list: Phenylephrine nasal spray, Advil PM, Aleve, Promethazine 25 mg tab every 4 hours as needed for nausea, Colace, Vitamin D3, B-12, and Magnesium. Medications that the patient was being administered differently than prescribed (for over a month per the patients wife): Metoprolol 25 mg and Lisinopril 20 mg as needed rather than daily, Janumet 50mg-1000 mg tab, taking 1 tab daily and not 1 tab twice daily, Trazodone 150mg stopped over 1 month ago and Senna 8.6. This was validated with the Director of Nursing present during the visit.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to assess and reassess its patient's. During a home visit for RRHV#3, the Hospice Nurse Surveyor observed a failed medication assessment. The LVN was asked to perform a medication reconciliation based on policy. He began to look at the bottles but had nothing to compare them to. The Surveyor suggested he check the EMR and he was able to pull it up on his phone. He continued by checking names of the medications but did not double check doses and routes. This was discussed and reviewed with the Director of Nursing.

Observed in Record Review. In 4 of 14 patient records reviewed, the organization failed to assess and reassess its patient's. During record review for RRHV#1, RRHV#2, and RRNHV#1, the Hospice Nurse Surveyor observed the assessments not completed as required. For example in RRHV#1, the RN did not complete a comprehensive assessment at least every 15 days. During the month of October there was an 18 day period with no RN assessment. In RRHV#2, the patient had RN comprehensive assessment dates that were 16 days apart. For example in RRNHV#1, the RN did not complete a comprehensive assessment at least every 15 days. During the month of October there was an 16 day period with no RN assessment. This was discussed and reviewed with the Director of Nursing.

Observed in Record Review. In 5 of 14 patient records reviewed, the organization failed to maintain a complete and accurate patient record. During record review for RRHV#1, RRHV#3, RRNHV#1, RRNHV#2 and RRNHV#5, the Hospice Nurse Surveyor observed inaccurate or confusing documentation. For example RRHV#1 had the IDG meeting held on 11/15 and all staff signed off on that date. But the documentation in the IDG showed information of the patient's bowel movements and newly ordered Lorazepam on 11/25. For RRHV#3, the IDG meeting was held on 11/27 and staff signed off on that date. The documentation in the IDG showed information about the patient's bowel movements for 11/30. In RRNHV#1, the IDG meeting was held on 11/15 and staff signed off on that date. The documentation in the IDG showed information about new medication, bowel movement status and PPS for 11/19. In RRNHV#2, the IDG meeting was held 12/30/22 and staff signed off on that date. The documentation in the IDG showed information about PPS and bowel movements through 4/10/23. This occurred on several IDG's for this patient. In RRNHV#5, the patient revoked 13 days prior to IDG. The IDG notes stated discharge but the narrative for IDG supported that the patient was still on service. There was no documentation of the patient revoking for continued treatment. This was discussed and reviewed with the Director of Nursing.

Observed in Record Review. the organization failed to plan the patient's care. During record review for RRHV#3, the Hospice Nurse Surveyor observed the plan of care was not based on the patient's goals, time frames, settings or services required. For example in RRHV#3, the patient had been tested for a UTI 3 weeks prior to survey and goals had been placed on his Plan of Care. The goals were not resolved or removed when the test came back negative and the patient was no longer on an antibiotic. This was discussed and reviewed with the Director of Nursing.

Observed in Record Review. In 4 of 14 patient records reviewed, the organization failed to plan the patients care. During record review for RRHV#1, RRHV#2, RRNHV#1, and RRDC#1,the Hospice Nurse Surveyor observed the plan of care did not contain all needed elements. For example in RRHV#1, the patient was struggling with pain, constipation, anxiety, and two recent falls but these were not addressed on the plan of care. In RRHV#2, the patient had multiple wounds with the only orders stating use Dakins for wound cleanser, let dry and cover with non-adherent dressing. The order did not state which wound this was for. And the nurse was documenting that the caregiver was utilizing betadine and meta-honey for wound care. Also the Plan Of Care did not contain details about the wound care to be provided but the nurse was documenting wound care per plan of care. The SN was also documenting that family was using Zinc-Oxide on redness to the coccyx but there were no orders for this treatment. In RRNHV#1, the SN documented edema on several occasions but it was not addressed on the POC. In RRDC#1, the patient was struggling with restlessness and sleep disturbance but these were not addressed on the POC. This was discussed and reviewed with the Director of Nursing.

Observed in Tracer Activities. The organization failed to document a quality assessment and performance improvement program that demonstrated improvement in the indicators related to improved palliative outcomes and hospice services. There was a corporate wide QAPI plan in place but locally there was no documentation of engagement or implementation of the plan. The hospice surveyor noted the QAPI program did not demonstrate improvement in its palliative outcomes and hospice services as evidenced by the HCO was not able to provide documentation at the time of survey. This was discussed and reviewed with the Director of Nursing.

Observed in Tracer Activities. The organization failed to document that it compiled and analyzed data. During tracer activities for Data Management, the Hospice Nurse Surveyor observed the organization was unable to provide data for 2022 and 2023. And the data collected for the current year was not compiled and compared. This was discussed and reviewed with the Director of Nursing. Observed in Tracer Activities. The organization failed to document that it compiled and analyzed data. During tracer activities for Data Management, the Hospice Nurse Surveyor observed the organization was unable to provide data for 2022 and 2023. And the data collected for the current year was not compiled and compared in order to identify improvement opportunities. This was discussed and reviewed with the Director of Nursing.

Observed in Tracer Activities. The organization failed to document that it collected data to monitor performance. During tracer activities for Data Management, the Hospice Nurse Surveyor observed the organization was unable to provide data for 2022 and 2023. This was discussed and reviewed with the Director of Nursing.

Observed in Tracer Activities. The surveyor noted the number and scope of performance improvement projects were not based on patients’ needs and internal organization needs as evidenced by the organization was unable to provide any documented performance improvement projects. This was discussed and reviewed with the Director of Nursing.

Observed in Tracer Activities. The surveyor noted the organization failed to document what performance improvement projects were being conducted, the reasons for conducting and the measurable progress achieved as evidenced by the HCO was not able to produce this documentation at the time of survey. This was discussed and reviewed with the Director of Nursing.

Observed in Tracer Activities. The organization failed to document an effective and on-going performance improvement program. The surveyor noted the hospice did not evaluate its QAPI program annually as evidenced by the HCO was not able to produce this documentation at the time of survey. This was discussed and reviewed with the Director of Nursing.

Observed in Tracer Activities. The surveyor noted the HCO did not evaluate its improvement actions were effective as evidenced by the HCO was not able to produce this documentation at the time of survey. This was discussed and reviewed with the Director of Nursing. Observed in Tracer Activities. The organization failed to establish priorities for performance improvement. The surveyor noted performance improvement was not organization wide as evidenced by no documentation of improvement opportunities for 2022, 2023 and 2024. This was discussed and reviewed with the Director of Nursing.

Observed in Tracer Activities. The organization failed to document compliance with hand hygiene. During tracer activities for Infection Control, the Hospice Nurse Surveyor observed there was no documentation of data collected for 2022, 2023 or 2024 and therefore there was no evaluation of the compliance with hand hygiene. This was discussed and reviewed with the Director of Nursing.

Observed in Record Review. In 4 of 5 patient records reviewed, with aide services, the organization failed to supervise effectively. During record review for RRHV#1, RRHV#3, RRNHV#1, and RRNHV#7, the Hospice Nurse Surveyor observed supervision did not take place as required. For example in RRHV#1, between the time the patient started aide services and the first supervision was 17 days. The next two supervision visit were completed in 20 day increment not completed every 14 days as required. In RRHV#3, there were two time periods with extended aide supervision beyond 14 days. In RRNHV#1, the patient had 17 days between aide supervision. In RRNHV#7, the patient had home health services 3 times over the course of 21 days and there was no documentation of supervision during that time period. This was discussed and reviewed with the Director of Nursing.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by deficiencies at 418.54, 418.58, 418.104 and 418.100. This was reviewed and discussed with the Director of Nursing.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to maintain a medical record that reflected the patient's care, treatment, or services. During a home visit for RRHV#3, the Hospice Nurse Surveyor observed the LVN do a medication reconciliation. The bottles of medications in the home that the patient was currently taking was not correctly reflected on the medication list in the electronic medical record. The patient was taking Vitamin D3 and B-Complex but these were not on the medical record. The patient had a course of antibiotics the month prior to survey which were completed but it was not removed from the medication list. This was discussed and reviewed with the Director of Nursing.

Observed in Record Review. In 1 of 1 patient records reviewed, patients who transferred, the organization failed to provide the accepting hospice a discharge summary. During record review for RRNHV#2, the organization did not follow the required process for discharge. For example in RRNHV#2, the patient had opted to transfer to another hospice. Per the organizational policy the hospice was to send a transfer summary but there was no documentation that the transfer summary was sent. This was discussed and reviewed with the Director of Nursing.

Observed in Record Review. In 4 of 4 patient records reviewed, patients who revoked or discharged, the organization failed to send the provider a discharge summary. During record review for RRNHV#4, RRNHV#5, RRDC#1, and RRDC#2, the organization did not follow the required process for discharge. In RRNHV#4, the patient was discharged for extended prognosis but there was no documentation that the discharge summary was sent to the provider. The daughter had not decided on which provider at their office to go with but had decided on a certain provider office. There was no collaboration documented. In RRNHV#5, the patient revoked hospice services one day into her certification so she could continue chemotherapy. There was no collaboration or documentation that a discharge summary was provided to the primary care provider, as required by organizational policy. In RRDC#1, the patient revoked hospice services to seek aggressive treatment, revocation was signed but documentation of a discharge summary being sent did not occur. In RRDC#2, the patient revoked hospice services to seek aggressive treatment, revocation was signed but documentation of a discharge summary being sent did not occur. This was discussed and reviewed with the Director of Nursing.

Observed in Individual Tracer. In 2 of 11 patient records reviewed, The hospice nurse surveyor noted (HV#1) that symptoms of anxiety and sleeplessness were identified in the nursing assessments; however there was no evidence that the severity was evaluated. The surveyor also noted that the patient had a diabetic ulcer on her left ankle; however the severity was not assessed and the wound was not measured. Also, on (HV#2) the surveyor noted that the patient assessments indicated that the patient had bilateral surgical hip wounds; however there were no measurements documented. The patient also had a coccyx pressure ulcer; however there was no evidence that the pressure ulcer was assessed. This was confirmed with the administrator.

Observed in Individual Tracer. In 6 of 11 patient records reviewed, The hospice nurse surveyor noted (HV#1) that the patient had a wound on her left ankle and the daughter indicated that she was cleansing it daily with normal saline and applying Betadyne and covering with a DSD. The assessment indicated that it was a diabetic wound; however there were no wound care orders and the plan of care did not include a plan for managing the wound. The surveyor also noted that three visit notes indicated that the patient was having anxiety day and night that was not addressed in the plan of care. Also, on (HV#2), the surveyor noted that the patient had an indwelling Foley catheter and that the patient had bilateral surgical hip wounds and a pressure wound on his coccyx. The comprehensive initial assessment indicated that the patient had a Foley catheter and that the patient had bilateral hip surgical incisions with sutures intact; however there was no plan of care for managing either the catheter or the wounds. In (RR#1), the surveyor noted that the patient assessment indicated that the patient was on oxygen, had a Foley catheter and several wounds. The visit notes indicated that the nurse was performing wound care with Normal Saline and Betadyne; however there were no orders or plan of care for the oxygen, Foley catheter or wound care. In (RR#4), the surveyor noted that the comprehensive assessment indicated that the patient a wound that was treated with Normal Saline and Santyl; however there were no orders or a Plan of care for managing the wound. In (RR#5), the assessment indicated that the patient was on oxygen and had a Foley catheter in place; however there were no orders or plan of care for managing the treatments. In (RR#9), the plan of care or physician orders did not include tracheostomy care orders, suctioning orders. The care plan stated perform tracheostomy care and did not include any specifics such as solutions to use, how often to perform the care, the size of the trach or cuff inflation orders. The nurses notes indicated that the nurse suctioned the trach and performed trach care. Also, there were no orders or plan of care for oxygen via the trach tube. This was confirmed with the administrator.

Observed in Individual Tracer. In 1 of 2 home visits conducted, The hospice nurse surveyor noted (HV#2), that the nurse failed to perform hand hygiene after cleaning equipment and before returning it to the bag, as required by organizational policy 9-014.2 item 6. This was confirmed with the administrator.

Observed in HR File Review. In 2 of 9 HR files reviewed, The hospice nurse surveyor noted that there was no evidence that the competency was completed for the contracted medical director and alternate medical director, when they were hired or since. This was confirmed with the administrator.

Observed in Individual Tracer. In 5 of 11 patient records reviewed, The hospice nurse surveyor noted (HV#2) that the nurse visit notes were not documented according to the time frames described in the organizations policy. The surveyor noted that several November visit notes were not completed until 6-25 days after the care was provided. The organizational policy required that all care be documented the day it is provided. Also, in (RR#1) several November visit notes were not documented in the electronic medical record until over 10 days after the care was provided. The surveyor noted that there were late note entries in RR#2, RR#5 and RR#8 that exceeded 10 days. This was confirmed with the administrator.