Harbor Hospice of East Dallas - Fort Worth, LP

Governing body and administrator (42 CFR 418.100(b))

“Observed in Tracer Activities. : There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by a condition level finding at 418.78 volunteer services.”

Rule L0651. Condition-level.

Plan Based on All Hazards Risk Assessment (42 CFR 418.113(a)(1))

“Observed in Emergency Management Session. During the Emergency Management session it was noted that the organization did not conduct a hazard vulnerability analysis for the current location. For example the HVA included in the plan was for the previous location in Dallas, not the current location in Corsicana many miles away from Dallas. This was confirmed and discussed with the DPCS present.”

Rule E0006. Standard-level.

Patient outcome measures (42 CFR 418.54(e)(2))

Rule L0535. Standard-level.

Content of plan of care (42 CFR 418.56(c))

Rule L0545. Standard-level.

Content of plan of care (42 CFR 418.56(c)(2))

“Observed in Record Review. In 4 of 14 patient records reviewed, it was noted that there was no a statement of the scope and frequency of services necessary to meet the patient and family needs. For example, Record RRNHV#2 the second IDG documentation was incomplete with no frequencies. Record RRNHV#4 there was no SN frequency order. Record RRNHV#6 IDG #1 and RRNHV#7 IDG#2 there were no frequencies. . This was confirmed and discussed with the DPCS present.”

Rule L0547. Standard-level.

Review of the plan of care (42 CFR 418.56(d ))

“Observed in Record Review. In 3 of 14 patient records reviewed, it was noted that the IDG had not reviewed and revised the POC. Record RRNHV#2 the second IDG documentation was incomplete with no goals and interventions it stated No current plan of care. Record RRNHV#6 IDG #1 and RRNHV#7 IDG#2 there were no goals and interventions they stated No goals. and No interventions. This was confirmed and discussed with the DPCS present.”

Rule L0552. Standard-level.

Supervision of hospice aides (42 CFR 418.76(h)(1)(i))

“Observed in Record Review. In 2 of 6 patient records reviewed, it was noted that the hospice aide supervision not completed every 14 days. For example in record RRHV#3 there was 21 days from the start of aide services to the first documentation of supervision of aide services. Record RRNHV#3 there was 20 days between documentation of supervisory visits. This was confirmed and discussed with the Administrator/DPCS present.”

Rule L0629. Standard-level.

Recruiting and retaining (42 CFR 418.78(c))

“Observed in Tracer Activities. During review of the volunteer program and discussion with the Volunteer Coordinator and DPCS it was noted that the hospice was not able to demonstrate viable and ongoing efforts to recruit and retain volunteers. For example, the organization documented that there were no volunteers the year 2025 and January to current 2026. The Volunteer Coordinator stated that she was new to the organization February 2026 and discussed plans for recruitment, but was unable to demonstrate that recruitment had taken place.”

Rule L0645. Standard-level.

Cost saving (42 CFR 418.78(d))

“Observed in Tracer Activities. During review of the Volunteer Program and discussion with the Volunteer Coordinator and DPCS it was noted that there was no cost savings documented. During discussion there have been no volunteers for the year 2025 and January to current 2026, so unable to document cost savings. This was confirmed and discussed with Volunteer Coordinator and DPCS.”

Rule L0646. Standard-level.

Level of activity (42 CFR 418.78(e))

“Observed in Tracer Activities. During the Volunteer Program review and the Data session it was noted that volunteers did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff. For example the year 2025 and January to April 2026 volunteers provided 0% of the total patient care hours. This was confirmed and discussed with the DPCS present.”

Rule L0647. Standard-level.

Clinical records (42 CFR 418.104)

“Observed in Record Review. In 1 of 2 patient records reviewed, for live discharge patients it was noted that the record was inaccurate or contains errors. For example in record RRDC#1 the discharge summary stated the patient had revoked services, there was no revocation document in the record. The last IDG documented stated the patient had transferred to another hospice, there was no transfer document and no transfer order. This was confirmed and discussed with the DPCS present.”

Rule L0670. Standard-level.

Use and mintenance of equipment and supplies (42 CFR 418.106(f)(2))

“Observed in Patient Home. In 1 of 1 home visits conducted, that included oxygen therapy it was noted that staff did not provide education on the safe storage of oxygen cylinders in the home. For example during visit RRHV#3 there were 3 oxygen tanks free standing in the living room and 1 additional that was on a cart. The visit was attended by both the aide and the RN and neither of these staff members educated on proper storage of oxygen tanks. This was discussed with the DPCS.”

Rule L0702. Standard-level.