Every finding on record at Harbor Hospice of Texas LP

Observed in Individual Tracer. An unused and unopened vial of oral liquid medication of Morphine was found in the home, the expiration date was listed as 3/23. The medication was reordered during the survey.

Observed in Record Review. It was noted in one out of ten records reviewed that the care plan did not reflect the patient's priority needs. The patient had a PEG tube but there was no mention of the PEG, the PEG care, education or monitoring of this PEG. This was confirmed by the DON and Corporate Quality Representative.

Observed in Record Review. In 2 of 19 patient records reviewed, HCO did not inform patient of their rights both orally and in writing. In RRNHV#4, the surveyor noted that patient requested to be informed of covered and non-covered items. The section on the consent form confirming that information was provided was left blank. In RRNHV#8, the surveyor noted that the financial section on the consent form was left blank. This was confirmed by the Director of Nursing.

Observed in Record Review. HCO did not respect the patient's right to elect when to start hospice care. In RRDC#1, RRDC#2, RRBR#1, RRNHV#1, and RRNHV#6, the surveyor noted that the the EOB date was left blank. This was confirmed by the Director of Nursing.

Observed in Patient Home. In 1 of 4 home visits conducted, expired medications found in the home. In RRHV#4, the nurse almost left the home without completing a medication reconciliation. Nurse began to review the medication profile with the caregiver. Surveyor asked caregiver to bring out medications to compare medication orders with pharmacy labels. Caregiver stated that she was pleased that nurse was reviewing the medications because it can be overwhelming. Upon review, surveyor noted that the patient's Nitroglycerin had expired in 2022. Expired medication was part of the medication review process and had not been found on previous medication reviews. This was confirmed by the Director of Nursing.

Observed in Record Review. In 2 of 19 patient records reviewed, HCO did not document a patient-specific comprehensive assessment that identified the patient’s needs. In RRHV#1 and RRNHV#9, the surveyor noted that the bereavement risk assessment was not completed as part of the comprehensive assessment. This was confirmed by the Director of Nursing.

Observed in Record Review. In RRNHV#1, the surveyor observed that the nurse had not evaluated progress toward goals. For example, the target date for the goals listed for Impaired Skin Integrity was 7/31/2023; however, there was no documentation found to show progress toward goals or whether goal was met. The target date had passed at the time of survey. This was confirmed by the Director of Nursing. Observed in Record Review. In 1 of 19 patient records reviewed, HCO did not document a patient-specific comprehensive assessment that identified the patient’s needs. In RRNHV#1, the surveyor noted that the RN Comprehensive Assessment was not completed. Upon review of the record, the surveyor found an administrative note on the date the RN Comprehensive Assessment was done; however, the actual visit note was not found in the EMR, nor the paper chart. As a result, subsequent visit notes could not consider the changes that had taken place since the initial assessment to be review by the Interdisciplinary Team. This was confirmed by the Director of Nursing. Observed in Record Review. In 2 of 19 patient records reviewed, In RRHV#4, the surveyor observed that the nurse had not evaluated progress toward goals. For example, the target date for the goals listed under Impaired Respiratory Status was 7/26/2023; however, there was no documentation found to show progress toward goals or whether goal was met. The target date had passed at the time of survey. In RRNHV#1, the surveyor observed that the nurse had not evaluated progress toward goals. For example, the target date for the goals listed under Impaired Skin Integrity was 7/31/2023; however, there was no documentation found to show progress toward goals or whether goal was met. The target date had passed at the time of survey. This was confirmed by the Director of Nursing.

Observed in Record Review. In 1 of 19 patient records reviewed, no physician orders were obtained. In RRDC#2, the surveyor noted that patient was transferred to another hospice. No discharge orders found in the record. This was confirmed by the Director of Nursing.

Observed in Record Review. In RRNHV#3, the registered nurse documented multiple wounds and indwelling catheter as current issues in the RN Comprehensive Assessment, but did not address those needs in the plan of care. This was confirmed by the Director of Nursing. Observed in Record Review. In 2 of 19 patient records reviewed, Staff did not create an individualized plan of care based on assessed needs. In RRHV#2, the registered nurse identified pain and skin integrity as current issues on the RN Comprehensive Assessment, but did not address those needs in the plan of care. Patient reported a pain level of 6 during the visit and has an ileostomy and nephrostomy. This was confirmed by the Director of Nursing.

Observed in Record Review. In 2 of 19 patient records reviewed, there were multiple visit notes missing from the record. In RRHV#1, the surveyor noted missing RN visit notes for the first 4 weeks after patient was admitted even though the visit frequency was 1 x week. In RRHV#3, the surveyor noted missing RN visit notes for Week 2 and 3 after admission even though the visit frequency was for 1 x week. The organization's Entries Into The Clinical Record Policy No. 5-006.1, states, entries into the clinical record will be made on the day care is provided to the patient. This was confirmed by the Director of Nursing.

Observed in Record Review. In 4 of 19 patient records reviewed, the CTI did not consider all of the required elements. In RRHV#4, current subjective and objective medical findings not included, other than PPS 50%. Current medication and treatment orders and information about the medical management of the patient's conditions unrelated to the terminal condition were also not considered upon review of the Initial CTI. This was confirmed by the Director of Nursing. Observed in Record Review. In RRNHV#2, current subjective and objective medical findings not included, other than PPS 50%. Current medication and treatment orders and information about the medical management of the patient's conditions unrelated to the terminal condition were also not considered upon the review of the CTI. This was confirmed by the Director of Nursing.

Observed in Record Review. In 6 of 19 patient records reviewed, HCO did not maintain complete and accurate patient records. In RRHV#1, the surveyor noted that the Interdisciplinary Team meeting notes did not capture what was discussed in the meeting. There was no current or past findings and no discussion of plan of care issues needing to be updated or revised. According to the organization's Interdisciplinary Group Meeting Policy No. 2-050.1, meeting Interdisciplinary group meeting plan of care will note changes, responses to treatment and progress toward outcomes, which may include pharmacotherapy effectiveness of symptom management outcomes, an increase or decrease in symptoms or acuity, increase or decrease in frequency of visits by team members and reason for the change, changes in the location of care, psychosocial and other consultations/conferences with patient and family/caregiver, changes that may contribute to risk for pathological grief, ongoing spiritual support, and plan for changes in treatment or procedures. Observed in Record Review. In RRNHV#5, the surveyor noted that the Interdisciplinary Team meeting notes did not capture what was discussed in the meeting. There were no clinical notes reflecting current or past findings and no discussion of plan of care issues needing to be updated or revised. This was confirmed by the Director of Nursing. Observed in Record Review. In RRHV#1, the surveyor noted that the Interdisciplinary Team meeting notes did not capture what was discussed in the meeting. In 3 out of 10 Interdisciplinary Team meeting motes reviewed there was no current or past findings and no discussion of plan of care issues needing to be updated or revised.

Observed in Record Review. In 1 of 19 patient records reviewed, Upon review of medication profile for RRHV#4, t the surveyor noted that patient had Furosemide 20 mg tablet listed, even though caregiver stated that patient hasn't had a refill in months. In addition, patient did not have Bisacodyl 10 mg rectal suppository and Acetaminophen 650 mg rectal suppository in the home. Nurse informed caregiver that she would place an order. The caregiver stated that he was never provided a medication list. This was confirmed by the Director of Nursing.

Observed in Record Review. In RRDC#1, the surveyor noted that the Interdisciplinary Team meeting notes were not in the record. According to the Director of Nursing, someone has to close out the meeting and generate a meeting note in order for note to appear in patient's record. Due to staffing issues, this task was not being completed timely. This was confirmed the Director of Nursing. Observed in Record Review. In RRHV#4, the surveyor noted that the Interdisciplinary Team meeting notes were not in the record. Director of Nursing had to close out the last meeting note in order to view. This was confirmed by the Director of Nursing. Observed in Record Review. In RRHV#2, the surveyor noted that the Interdisciplinary Team meeting notes were not in the record. Director of Nursing had to close out the last 2 meeting notes in order to view. This was confirmed by the Director of Nursing. Observed in Record Review. HCO did not maintain completed and accurate patient records. In RRNHV#4, the surveyor noted did not find the RN Comprehensive Assessment on file. DON contacted RN to submit missing documentation. At the time of survey, documentation was still not entered in the EMR. According to the organization's Entries Into The Policy No. 5-006.1 entries into the clinical record will be made on the day care is provided to the patient. This was confirmed by the Director of Nursing. Observed in Record Review. In RRBR#1, the surveyor noted that the Interdisciplinary Team meeting notes were not in the record. Director of Nursing had to close out the meeting note which took place a year ago in order to view. Upon review, the surveyor noted that the IDG Meeting Notes did not capture what was discussed in the meeting. Patient was admitted and expired, yet there was no current or past findings and no discussion from the IDG team. In addition, bereavement mailings and/or a communication note showing when mailings were sent out was not found in the EMR. DON provided a log that contained dates of the first few mailings. Report still had to be requested from Corporate Office to confirm mailing dates for the rest of the year. This was confirmed by the Director of Nursing.

Observed in Record Review. In 1 of 4 patient records reviewed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions. In the chart for RR#3, the initial POC did not include an order for MSW evaluation. This was confirmed with the Quality Manager.

Observed in Record Review. In 2 of 4 patient records reviewed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions. In the chart for RR#3, the POC did not include any interventions/goals related to the patient's risk for pressure ulcer development, assessed at the time of the initial comprehensive assessment. In the chart for RR#4, the patient's Braden score was 9 at admission, yet the POC did not include any interventions to educate the caregiver about pressure risk reduction techniques, only assessment by the nurse for PU development . This was confirmed with the Quality Manager.

Observed in Record Review. In 2 of 4 patient records reviewed, the patient record was not complete, promptly and accurately documented, readily accessible, and systematically organized to facilitate retrieval. In the chart for RR#1, the Braden score was 7 upon admission yet there were no interventions on the POC related to pressure ulcer risk reduction. Per discussion with the QA Manager who had personal knowledge of the patient, this was inaccurate documentation of the Braden risk. In the chart for RR#2, there was no POC in the chart. The patient had been admitted ten days prior to the date of this survey and deceased within 48 hours. Per the QA Manager, organizational policy requires the POC to be documented within 5 days of the admission.

Observed in Record Review. the hospice had not provided the receiving facility with a copy of the hospice discharge summary. In the chart for RR#1, the discharge summary was provided to the patient's physician, not the receiving facility per discussion with the QA Manager.