Harbour Hospice

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed revealed that the agency did not ensure that the initial comprehensive assessment, including the psychosocial, spiritual, and bereavement assessments, was completed no later than five calendar days after the election of hospice care. CLINICAL RECORD 7: The patient’s date of the election was 12/20/2024. The initial spiritual and bereavement assessments occurred on 12/27/2024 (2 days late). CLINICAL RECORD 9: The patient’s date of the election was 08/23/2024. The initial psychosocial, spiritual, and bereavement assessments occurred on 08/29/2024 (1 day late). CLINICAL RECORD 12: The patient’s date of the election was 04/08/2025. The initial spiritual and bereavement assessments occurred on 04/14/2025 (1 day late). During a joint clinical record review and interview on 07/24/2025, the Administrator/Licensed Vocational Nurse confirmed that the records lacked evidence that the initial comprehensive assessment, including the psychosocial, spiritual, and bereavement assessments, was completed no later than five days after the election of hospice care. During a joint clinical record review and interview on 07/24/2025, the Executive Director/Registered Nurse confirmed that the records lacked evidence that the initial comprehensive assessment, including the psychosocial, spiritual, and bereavement assessments, was completed no later than five days after the election of hospice care.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following, the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed revealed the agency did not ensure that the comprehensive assessment identified medications or treatments that the patient was currently taking, and that any potential adverse effects and drug reactions were identified. HOME VISIT 3: The patient’s date of election was 06/20/2025. During the Home Visit on 07/23/2025 with the home health aide (Personnel Record 8), the medication profile that was printed on 07/22/2025 was compared with the medications at the nursing facility, which revealed Acidophilus oral tablet, one tablet by mouth twice daily started on 09/06/2024; Cetirizine HCl 10 mg tablet, one tablet by mouth daily started on 07/06/2023; Colace 100 mg capsule, one capsule by mouth twice daily started 12/22/2023; Estradiol 1 mg tablet, one tablet by mouth daily started on 12/07/2023; and Multivitamins with minerals tablet, one tablet by mouth daily started on 07/05/2023. These medications were not listed on the agency’s medication profile. There was no documented evidence that a medication reconciliation was completed. HOME VISIT 4: The patient’s date of election was 11/07/2023. The medication profile was printed on 07/22/2025 revealed Acetaminophen-Codeine 300-30 mg tablet, one tablet by mouth three times a day; Aspirin 81 mg enteric coated tablet, one tablet by mouth daily; Carvedilol 3.125 mg tablet, one tablet by mouth daily; Colace 100 mg capsule, one capsule by mouth daily; Duloxetine HCl 20 mg capsule, one capsule by mouth twice daily; DuoNeb (Ipratropium Bromide-Albuterol Sulfate) 0.5/3 mg/3 ml solution, one solution respiratory (inhalation) every four hours for shortness of breath; Ferrous Sulfate 325 (65 Fe) mg tablet, one tablet by mouth daily; Hydrochlorothiazide 12.5 mg tablet, one tablet by mouth daily; Memantine 10 mg tablet, one tablet by mouth twice daily; Mucinex DM maximum strength (60-1200 mg) tablet ER [extended release] 12 HR [hour], one tablet twice daily; Potassium Chloride 10 mEq tablet, one tablet by mouth daily; and Tylenol 325 mg tablet; two tablets by mouth every six hours as needed for pain/fever. During the Home Visit on 07/23/2025 with the chaplain (Personnel Record 7), the medications at the nursing facility revealed Acetaminophen-Codeine 300-30 mg tablet, one tablet by mouth twice daily started 02/05/2024; DuoNeb (Ipratropium Bromide-Albuterol Sulfate) 0.5/3 mg/3 ml solution, one solution respiratory (inhalation) every eight hours for shortness of breath started 02/13/2025; and Memantine 10 mg tablet, one tablet by mouth daily started 11/28/2023; Acetaminophen 650 mg suppository, one suppository rectally every four hours as needed for fever/pain started 02/05/2024; Artificial Tears ophthalmic solution 0.2-0.2-1%, one drop to both eyes every four hours as needed for dry eyes started 02/17/2024; Multivitamins with minerals tablet, one tablet by mouth daily started on 03/27/2024; and Vitamin C 500 mg tablet, one tablet by mouth twice daily started 06/19/2024. The facility’s assistant director of nursing confirmed that the following medications were discontinued: Aspirin on 04/01/2025, Carvedilol on 08/15/2023, Duloxetine HCl on 11/08/2023, Ferrous Sulfate on 08/15/2023, Hydrochlorothiazide on 11/22/2023, Mucinex DM on 01/14/2025, and Potassium Chloride on 10/27/2023. The agency’s medication profile did not list Acetaminophen suppository, Artificial Tears, Multivitamin with minerals, and Vitamin C. There was no documented evidence that a medication reconciliation was completed. During a joint record review and interview on 07/24/2025 with the Executive Director/Registered Nurse and the Administrator/Licensed Vocational Nurse, they confirmed that there was no documented evidence that the medications had been reconciled and the medication profiles updated.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview and observation. In 2 of 4 (50%) home visit observations revealed the agency did not ensure the staff followed the hand hygiene policy. Agency Policy: Hand Hygiene IC.15 dated 09/01/2024, stated in part, “Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Staff may use an alcohol-based hand rub for routinely decontaminating hands in the clinical situations described below: 2. Immediately before touching a patient... 5. Before moving from a contaminated body site to a clean body site during patient care. 6. After touching a patient or the patient’s immediate environment.” HOME VISIT 3: During the Home Visit (Clinical Record 4) on 07/23/2025 with the hospice aide (Personnel Record 8), the aide was observed washing the hands and donning gloves. The hospice aide removed a brief and placed it on the wheelchair. The brief fell on the floor. The hospice aide picked up the brief and put it back on the wheelchair. The hospice aide placed the soap on the over-the-bed table next to the water basins. The bottle of soap fell on the floor. The hospice aide picked up the bottle and placed it back on the table. After providing patient care, the hospice aide placed the linens in a bag and then adjusted the hospice aide glasses with gloved hands. The hospice aide completed dressing the patient, putting the remaining linens on the bed, emptied the water basins, and emptied the bag of trash from the bathroom. The hospice aide opened the curtains, finished bagging the linens, and took the trash and bagged dirty linens to the dirty utility room. The hospice aide then removed the pair of gloves and washed the hands. The hospice aide did not change the gloves or disinfect the hands after picking up items that fell on the floor, before adjusting glasses, before moving from a contaminated body part to a clean body part, and after handling dirty linen and trash. HOME VISIT 4: During the Home Visit (Clinical Record 11) on 07/23/2025 with the Chaplain (Personnel Record 7), the Chaplain was observed not using hand hygiene immediately before touching the patient. During an interview on 07/24/2025, the Executive Director/Registered Nurse and the Administrator/Licensed Vocational Nurse confirmed that the staff did not follow the hand hygiene policy.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 4 of 15 (27%) clinical record review with hospice aide services revealed that the agency did not ensure that the registered nurse prepared the written patient care instructions for a hospice aide. CLINICAL RECORD 9: The patient’s date of election was 08/23/2024. The primary hospice diagnosis was Alzheimer’s disease, unspecified. The hospice aide plans of care dated 06/05/2025, 06/13/2025, 06/21/2025, and 06/27/2025 assigned the hospice aide tasks of “Companionship and supply delivery, declines care at this time; high fall risk - do not leave patient alone while bathing or showering; COVID prescreening completed patient denies having been in contact with anyone suspected of having COVID-19 or traveling in the past month. Patient does not have fever, cough, shortness of breath, sore throat; ambulatory with assistance - walker and wheelchair; durable medical equipment present - equipment declined.” There is no evidence of direct patient care provided in the care plan. DOCUMENT 1: The 26 Texas Administrative Code § 558.842(c) stated in part, “The duties of a hospice aide include: providing hands-on personal care; performing simple procedures as an extension of therapy or nursing services; assisting with ambulation or exercises; assisting with self-administered medication; reporting changes in a client’s medical, nursing, rehabilitative, and social needs to an RN as the changes relate to the client’s plan of care and the hospice’s quality assessment and improvement activities; and completing client record documentation in compliance with the hospice’s policies and procedures.” CLINICAL RECORD 11: The patient’s date of election was 11/07/2023. The primary hospice diagnosis was heart failure, unspecified, with a comorbidity of dementia. The hospice aide plans of care dated 11/08/2023, 11/13/2023, 11/27/2023, 11/29/2023, 12/27/2023, 08/22/2024, 03/20/2025, 04/08/2025, 06/13/2025, and 06/21/2025 assigned the hospice aide tasks of “Complete Bed Bath.” The hospice aide plan of care dated 06/26/2025 assigned the hospice aide tasks of “Caregiver is cognitively and functionally able to make a choice in care” but does not include a type of bath. The care plan did not provide clear instructions to the hospice aide regarding the type of bath. CLINICAL RECORD 12: The patient’s date of election was 04/08/2025. The primary hospice diagnosis was hypertensive chronic kidney disease. The hospice aide care plan dated 04/09/2025 assigned the hospice aide the tasks of “Bed bath when needed and Shower.” The care plan did not provide clear instructions to the hospice aide regarding the type of bath. CLINICAL RECORD 19: The patient’s date of election was 12/11/2024. The primary hospice diagnosis was senile degeneration of the brain. The hospice aide care plan dated 12/12/2024 assigned the hospice aide the tasks of “Bed bath and Shower.” The care plan did not provide clear instructions to the hospice aide regarding the type of bath. During a joint record review and interview on 07/24/2025, the Administrator/Licensed Vocational Nurse confirmed that the records lacked evidence that the registered nurse prepared the written patient care instructions for a hospice aide. The Administrator/Licensed Vocational Nurse stated that it was recommended to use the phrase, “Caregiver is cognitively and functionally able to make a choice in care,” when there is a caregiver who can make the decision. The Administrator/Licensed Vocational Nurse confirmed that the caregiver for CRR #11 was no longer able to make decisions on behalf of the patient. During a joint record review and interview on 07/24/2025, the Executive Director/Registered Nurse confirmed that the records lacked evidence that the registered nurse prepared the written patient care instructions for a hospice aide.”

“It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 15 (20%) clinical records reviewed of patients receiving hospice aide services revealed the agency did not ensure that the hospice aide provided services included in the plan of care. CLINICAL RECORD 1: The hospice aide visit documentation for 06/27/2025 did not include documentation for COVID prescreening completed patient denies having been in contact with anyone suspected of having COVID-19 or traveling in the past month. Patient does not have fever, cough, shortness of breath, sore throat; cover any wounds or open areas with plastic wrap while bathing; report to RN identified safety issues; report to RN if no BM in 3 days. The hospice aide visit documentation for 07/02/2025 and 07/07/2025 did not include documentation for COVID prescreening completed patient denies having been in contact with anyone suspected of having COVID-19 or traveling in the past month. Patient does not have fever, cough, shortness of breath, sore throat; cover any wounds or open areas with plastic wrap while bathing; report to RN identified safety issues; report to RN if no BM in 3 days; and report to RN pain. CLINICAL RECORD 12: The hospice aide visit documentation for 07/10/2025 did not include documentation for high risk - do not leave patient alone while bathing or showering; fall precautions; range of motion; ambulatory with assistance - walker; bed bound with scheduled repositioning when in bed; chair as tolerated; durable medical equipment (DME) present - declined; COVID prescreening completed patient denies having been in contact with anyone suspected of having COVID-19 or traveling in the past month. Patient does not have fever, cough, shortness of breath, sore throat; change linens; cover any wounds or open areas with plastic wrap while bathing; O2 may be removed during care; report to RN identified safety issues; report to RN if no BM in 3 days; report to RN pain; report to RN red or broken skin bruising, lumps, bumps anything unusual looking; safety check/universal precautions; barrier products in use - large pullups, pink pads, wipes; bathroom assistance - independent; document last BM; draw sheet; incontinence pads - bed pads; incontinent - bladder; clothing assist - assist patient with dressing after every shower; complete bed bath when needed; denture care at every visit if needed; foot care - with every visit; nail care with every visit; oral care with every visit; perineal care - wash peri area with every shower; shampoo hair with every shower; shower; and skin care - assist patient with wash, dry, and apply lotion after every shower. CLINICAL RECORD 19: The hospice aide visit documentation for 12/13/2024 did not include documentation for fall precautions; range of motion; ambulatory with assistance - wheelchair; chair as tolerated; durable medical equipment (DME) present - wheelchair; COVID prescreening completed patient denies having been in contact with anyone suspected of having COVID-19 or traveling in the past month. Patient does not have fever, cough, shortness of breath, sore throat; cover any wounds or open areas with plastic wrap while bathing; empty trash in patient room and bedroom; report to RN identified safety issues; report to RN if no BM in 3 days; report to RN pain; report to RN red or broken skin bruising, lumps, bumps anything unusual looking; safety check/universal precautions; bathroom assistance - total assist for safety; draw sheet; and incontinent - bowel and bladder. The hospice aide visit documentation for 12/16/2024 did not include documentation for fall precautions; range of motion; bed bound with scheduled repositioning when patients is in bed; chair as tolerated; durable medical equipment (DME) present - wheelchair; COVID prescreening completed patient denies having been in contact with anyone suspected of having COVID-19 or traveling in the past month. Patient does not have fever, cough, shortness of breath, sore throat; cover any wounds or open areas with plastic wrap while bathing; report to RN identified safety issues; report to RN if no BM in 3 days; report to RN pain; report to RN red or broken skin bruising, lumps, bumps anything unusual looking; safety check/universal precautions; bathroom assistance - total assist for safety; and incontinent - bowel and bladder. The hospice aide visit documentation for 12/28/2025 did not include documentation for fall precautions; range of motion; ambulatory with assistance - wheelchair; chair as tolerated; durable medical equipment (DME) present - wheelchair; COVID prescreening completed patient denies having been in contact with anyone suspected of having COVID-19 or traveling in the past month. Patient does not have fever, cough, shortness of breath, sore throat; cover any wounds or open areas with plastic wrap while bathing; report to RN identified safety issues; report to RN if no BM in 3 days; report to RN pain; report to RN red or broken skin bruising, lumps, bumps anything unusual looking; safety check/universal precautions; barrier products in use - barrier cream and briefs; bathroom assistance - total assist for safety; incontinent - bowel and bladder; and shampoo hair with every bed bath. During a joint review of the record and an interview on 07/24/2025 with the Executive Director/Registered Nurse and the Administrator/Licensed Vocational Nurse confirmed that the hospice aide did not provide services included in the plan of care.”