Every finding on record at Harbor Hospice of Southeast Houston, LP

Observed in Record Review. In 3 of 3 patient records with hospice aide services, , it was noted the organization failed to provide written patient care instructions for a hospice aide to follow. For example, in review of records HOSRRHV#3, HOSRRDC#8 and HOSRRDC#9, THE Aide care plan did not include the frequency for each task assigned to the hospice aide. This finding was discussed and validated by the Hospice administrator.

Observed in Record Review. In 2 of 3 active patient record with hospice aide services, it was noted the organization failed to ensure that hospice aide supervision was conducted at the patient's home no less than every 14 days as required. During review of record HOSRRNHV#3, the documentation showed a gap of 15 days between the 3rd week and 5th week of October, and between last week of October and 2nd week of November, no aide supervision had been documented. On record of HOSRRDC#4, there was no evidence documented of hospice aide supervision during the month of June and July. This finding was discussed and validated by the Hospice Administrator.

Observed in Record Review. In 4 of 14 patient records reviewed, it was noted the organization failed to ensure a clinical record containing past and present findings is maintained for each hospice patient. For example in review of record HOSRRDC#10, the skilled nursing visit documentation was not entered in the record 10 days post discharge as opposed to be within 5 days as required by policy. (Policies no 5-006.1 Entries into the Clinical Record paragraph 6nAll documentation will be turned in or completed using the company's contracted EMR provider within 5 days.) Additionally, on records of HOSRRDC#7, HOSRRDC#8, and HOSRRDC#9, it revealed that the following sections, i.e., discharge condition, discharge instruction, care summary and medication profile, of the DC summary was left blank. This finding was discussed and validated by the Hospice Administrator.

Observed in Medication Management Tracer. During the inpatient hospice visit, the clinical nurse described the process for counting controlled substances, which involves both incoming and outgoing staff verifying the count and signing the paper narcotic count documentation log. However, a review of the documentation revealed multiple instances in October and November where clinician signatures missing. There was no documentation provided to explain the absence of these signatures. This was discussed and validated by the Hospice Administrator and 2 (RN) Clinical Managers.

Observed in Document Review. There was no documentation of fire door inspection in 2024. This was verified by the facility manager. Observed in Building Tour. Rusty or dirty sprinkler heads were observed on the loading dock area and in the hot water heater room. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.

Observed in Document Review. During the document review it was observed that the Supervisory Signal Devices were not tested in quarter one and two of 2025. This was verified by the facility manager. Observed in Document Review. It was observed that the NFPA was not referenced on the fire alarm or sprinkler documents date 9/3/2025. This was verified by the facility manager.

Observed in Individual Tracer. In 4 of 12 patient records reviewed, the surveyor observed that the initial bereavement assessment not completed and documented .

Observed in Record Review. In 5 of 12 patient records reviewed, the surveyor observed no evidence that the patient record had documentation of progression toward care plan goals. This was discussed and confirmed with leadership.

Observed in Individual Tracer. In 2 of 3 home visits conducted, the surveyor observed the nurses on both visit 1 and visit 2 had not cleaned equipment that had been used on patient assessment according to organization policy . On visit one the surveyor observed the nurse had assessed patient and simply wrapped dirty equipment in barrier she had laid equipment on and returned to her bag and 2nd home visit the surveyor observed the nurse clean equipment and immediately return to bag without the required wait time. On both visits the nurses also went in and out of nursing bags without cleaning hands. This issue was observed and confirmed with organization leader. Observed in Individual Tracer. The surveyor observed during inpatient tracer that the nurse providing care to a patient with a draining rectal tumor wound that measured extremely large to include parts of patient s back and left upper leg, had not cleaned hands as required by policy and cdc guidelines between ten plus glove changes. The surveyor also observed the CHHA assisting nurse at bedside hold and turn patient had not taken gloves off , before entering patients clean closet area and retrieving supplies for nurse. This issue was discussed and confirmed with the hospice nurse providing wound care , with Hospice house nursing leader in attendance .

Observed in Building Tour. The surveyor observed the large wheeled laundry basket used to carry wet clothes from one location to dryer and onward had been rusted in large amounts in multiple areas on basket area that wet clothes came in contact with. This issue was observed and also discussed with leadership.