Harbor Hospice Medical Center - Houston LP

“Observed in Record Review. In 3 of 12 patient records reviewed, it was noted that the organization did not ensure the plan of care was individualized to the patient’s needs and condition. For example, during a review of the medical record for RRHV#3, a clinician documented that the patient experienced a fall with injury during week 7, of the 2nd benefit period. The plan of care did not include a goal statement to evaluate care, treatment, and services related to fall prevention interventions. In addition, during week 8 of the 2nd benefit period, a clinician documented that the patient’s oxygen saturation was 76% and the patient was placed on oxygen at 6 liters per nasal cannula. The plan of care did not include a goal statement to evaluate care, treatment, and services related to oxygen therapy interventions. Example #2: During a review of the medical record for RRNHV#1, and RRNHV#4, it was noted that the patient’s terminal illness diagnosis was Senile degeneration of brain, not elsewhere classified. The plan of care did not include a goal statement to evaluate care, treatment and services related to Senile degeneration of brain, not elsewhere classified. This observation was reviewed with the Administrator.”

“Observed in Record Review. In 3 of 12 patient records reviewed, it was noted that the organization did not ensure the plan of care was revised when the patient’s condition changed. For example, during a review of the medical record for RRHV#3, it was noted that during week 7 of the 2nd benefit period, the patient experienced a fall with injury. The plan of care was not updated with interventions to maintain patient safety, and strategies to prevent injury. In addition, during week 8 of the 2nd benefit period, a clinician documented that the patient’s oxygen saturation was 76% and the patient was placed on oxygen at 6 liters per nasal cannula. The plan of care did not include an order for oxygen therapy. The plan of care did not include oxygen therapy interventions. Example #2: During a review of the medical record for RRNHV#1, and RRNHV#4, it was noted that the patient’s terminal illness diagnosis was Senile degeneration of brain, not elsewhere classified. The plan of care did not include interventions to address the care, treatment, and services related to Senile degeneration of brain, not elsewhere classified. This observation was reviewed with the Administrator.”

“Observed in Record Review. In 5 of 12 patient records reviewed, it was noted that the organization did not ensure the plan of care was reviewed and revised every 15 days. For example, during a review of the medical record for RRHV#2, there was no documented evidence that the interdisciplinary group, in collaboration with the patient’s attending physician reviewed and revised the plan of care for a 54-day timeframe during benefit period #1. The plan of care was not reviewed and revised for an 89-day timeframe for benefit period #2. The plan of care was not reviewed and revised for a 49-day timeframe during benefit period #3. Example #2: During a review of the medical record for RRHV#3, there was no documented evidence that the interdisciplinary group, in collaboration with the patient’s attending physician reviewed and revised the plan of care for an 89-day timeframe for benefit period #1. The plan of care was not reviewed and revised for a 67-day timeframe during benefit period #2. Example #3: During a review of the medical record for RRNHV#1, there was no documented evidence that the interdisciplinary group, in collaboration with the patient’s attending physician reviewed and revised the plan of care for an 89-day timeframe for benefit period #1. The plan of care was not reviewed and revised for a 55-day timeframe for benefit period #2. Example #4: During a review of the medical record for RRNHV#4, there was no documented evidence that the interdisciplinary group, in collaboration with the patient’s attending physician reviewed and revised the plan of care for an 25-day timeframe for benefit period #1. Example #5: During a review of the medical record for RRNHV#5, there was no documented evidence that the interdisciplinary group, in collaboration with the patient’s attending physician reviewed and revised the plan of care for an 67-day timeframe for benefit period #1. The plan of care was not reviewed and revised for a 60-day timeframe for benefit period #2. This observation was reviewed with the Administrator.”

“Observed in Record Review. In 1 of 6 patient records reviewed, for patients receiving Hospice Aide services, it was noted that the organization did not ensure Hospice Aide supervision was effective. For example, during the review of the medical record for RRNHV#1, it was noted that a Hospice Aide supervision visit was not documented by the Registered Nurse every 14 days. A Hospice Aide supervision visit was not documented during the 90-day timeframe for benefit period #1. A Hospice Aide supervision visit was not documented during a 55-day timeframe for benefit period #2. This observation was reviewed with the Administrator.”

“Observed in Record Review. In 3 of 6 medical records reviewed, for patient’s receiving hospice aide services, it was noted that the organization did not ensure medical record entries were complete, promptly, and accurately documented. For example, during a review of the medical record for RRHV#3, it was noted that hospice aide services were ordered two (2) visits per week. The hospice aide visit notes for a 4 week period did not include documentation of the care, treatment, and services provided during the visit. Example #2: During a review of the medical record for RRNHV#1, it was noted that hospice aide services were ordered three (3) visits per week. The hospice aide visit notes for a 13 week period did not include documentation of the care treatment, and services provided during the visit for benefit period #1. The hospice aide visit notes for an 8 week period did not include documentation of the care, treatment, and services provided during the visit for benefit period #2.Example #3: During a review of the medical record for RRNHV#2, it was noted that hospice aide services were ordered three (3) visits per week. The hospice aide visit notes for a 2 week period did not include documentation of the care treatment, and services provided during the visit. This observation was reviewed with the Administrator.”