Every finding on record at Silverado Hospice of Houston, Inc

Observed in Individual Tracer. In 2 of 2 patient records reviewed, During review of Hospice patient records and confirmed by the primary care nurse. The initial assessment had not been completed the start of care within 48 hours and the physician had not been notified of the delay. Example: During review of HOS #1 and confirmed by Patient Care Nurse. The patient admission had been greater than 48 hours by 9 days from referral date without documentation to the physician reflecting the reason for the delay. During review of HOS #2 the SOC had been greater than 48 hours by 3 days from the refferral . there had not been documentation to support the delay, nor had the physician been notified of the delay.

Observed in Record Review. In 1 of 2 Hospice records reviewed and confirmed by the Patient Care Nurse. the hospice interdisciplinary group had not completed the comprehensive assessment no later than five days from the election of hospice care. Example: During review of HOS #1 and confirmed by Patient Care Nurse. The Chaplain had not evaluated the patient within 5 days after the start of care. Documentation had not reflected the reason for the delay. The patient had been brought on service at the beginning of the month, however the Chaplain completed the assessment until the end of the month.

Observed in Record Review. In 1 of 2 patient records reviewed and confirmed by the Patient Care Nurse. The organization had not informed the Physician when there had been a change in the care plan. Example: During review of HOS#2 the patient had refused care as documented in the plan of care for the HHA visits, but the physician had not been notified.

Observed in Tracer Activities. Leadership failed to provide sufficient staffing, as evidenced by an increased number of missed visits which generated patient complaints; late starts of care; and increased workload for home health agency staff as evidenced by a home health aide reporting providing up to 16 visits per day due to lack of staffing.

Observed in Tracer Activities. In 1 of 1 volunteer staff' HR Files reviewed there was no evidence of Emergency Management training. The Surveyor identified during the Competency Session and validated with the Regional Volunteer Manager, that the organization does not train volunteer staff for their assigned emergency response roles. This was reviewed and validated with the Director of Patient Care Services and the Senior Leadership Team.

Observed in Tracer Activities. The organization did not evaluate the effectiveness of its Emergency Operations Plan (EOP). It was identified that approximately two months prior to the survey date, the organization activated the EOP in response to a winter weather event. There was no evaluation of the emergency response. This was reviewed and validated with Director of Patient Care Services and the Senior Leadership Team. Observed in Tracer Activities. The organization did not evaluate the effectiveness of its Emergency Operations Plan (EOP) following a winter weather event approximately two months prior to the survey date in which the EOP was activated, therefore there were no deficiencies and/or opportunities for improvement identified. This was reviewed and validated with Director of Patient Care Services and the Senior Leadership Team.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization did not use standard precautions to protect against possible exposure to infectious agents. For example, observed in HV#1, the Registered Nurse failed to perform hand hygiene following documenting on the tablet and prior to donning gloves. Observed in HV#2, the Registered Nurse, tore one of the sterile gloves while donning but continued to wear the torn glove while completing a sterile dressing change. This was observed with the Director of Patient Care Services (DPCS) present, and reviewed and validated with the DPCS and the Patient Care Manager.

Observed in Tracer Activities. It was identified during the review of the Volunteer Program that Volunteer Staff did not provide administrative or direct patient care in an amount that equals 5% of the total patient care hours. The Surveyor identified that the organization had not met the 5% requirement since the prior survey date of February 2, 2021 in which this was also a Requirement for Improvement, and the subject of a Performance Improvement Project. This was reviewed with the Regional Volunteer Coordinator and the Senior Leadership Team.

Observed in Patient Home. The patient record did not contain information that reflected the patients treatment. In 2 of 2 home visits conducted where the skilled nurse completed a medication reconciliation, it was identified that the medication profiles were inaccurate. For example, in HV#1, the patient was taking Trazodone 100mg tablet at bedtime, but the Trazodone was documented on the medication profile as discontinued approximately 10 weeks prior to the survey date. In HV#2, the medication profile listed Allopurinol 100mg tablet, 1 tablet every other day, but the patient stated he had stopped taking the medication weeks ago. This was observed with the Director of Patient Care Services (DPCS) present, and reviewed and validated with the DPCS and the Patient Care Manager.