Harbor Hospice of Kingsville

Quality assessment & performance improvement (42 CFR 418.58)

“Observed in Data Session. The organization did not ensure that its performance improvement priorities were implemented as required. For example, a review of the QAPI report for 2025 revealed that the following quality indicators did not document annual data collection as outlined in the QAPI plan: Hand Hygiene compliance, Bag Technique. and Total Patient Infections. This observation was reviewed with the Administrator.”

Rule L0559. Condition-level.

EP Training Program (42 CFR 418.113(d)(1)(vi))

“Observed in Individual Tracer. In 4 of 8 HR files reviewed, it was noted that the organization did not ensure that staff participated in ongoing education and training for the emergency program . For example, a review of the HR files for HR#1, HR#4, HR#6, HR#7, revealed that the following required education and training for Emergency Management was not documented for the year 2025. This observation was reviewed with the Administrator.”

Rule E0037. Standard-level.

Program data (42 CFR 418.58(b)(2)(ii))

“Observed in Data Session. The following 2025 quality indicators did not document annual data collection as outlined in the QAPI plan: Hand Hygiene compliance, Bag Technique. and Total Patient Infections. Since the organization did not ensure that its performance improvement priorities were implemented, opportunities and priorities for improvement were not identified. This observation was reviewed with the Administrator.”

Rule L0564. Standard-level.

Control (42 CFR 418.60(b))

“Observed in Data Session. The organization did not ensure its policy for identification of infection prevention and control activities was implemented. For example, a review of the quality indicator labeled Total Patient Infections revealed that the reported patient infection was not identified for the year 2025, and 1st quarter of 2026.. Monthly patient infections were grouped in the section titled other. This did not provide the opportunity to identify the specific patient infection. This observation was reviewed with the Administrator.”

Rule L0580. Standard-level.

Education (42 CFR 418.60(c))

“Observed in Individual Tracer. In 4 of 8 HR files reviewed, it was noted that the organization did not ensure that staff participated in ongoing education and training to maintain competence. For example, a review of the HR files for HR#1, HR#4, HR#6, HR#7, revealed that the following required education and training was not documented for the year 2025: Hand hygiene, Blood Borne Pathogens, OSHA, Bag Techniqueand Infection Control. This observation was reviewed with the Administrator.”

Rule L0582. Standard-level.

In-service training (42 CFR 418.76(d))

“Observed in HR File Review. In 1 of 1 HR files reviewed, for Hospice Aides, the organization did not ensure the hospice aide completed required in-service training. For example, a review of the file for HR#4, revealed that documentation of at least 12 hours of in-service training for the year 2025 was not documented. This observation was reviewed with the Administrator.”

Rule L0620. Standard-level.

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

Rule L0629. Standard-level.

Cost saving (42 CFR 418.78(d))

“Observed in Tracer Activities. During the Volunteer Program review, it was noted that since the organization did not have active volunteers to provide day-to-day administrative and/or direct patient care services, the organization did not document the cost savings achieved through the use of volunteers. This observation was reviewed with the Administrator.”

Rule L0646. Standard-level.

Level of activity (42 CFR 418.78(e))

Rule L0647. Standard-level.

Training (42 CFR 418.100(g)(3))

“Observed in Individual Tracer. In 4 of 8 HR files reviewed, it was noted that the organization did not ensure that staff participated in ongoing education and training to maintain competence. For example, a review of the HR files for HR#1, HR#4, HR#6, HR#7, revealed that the following required education and training was not documented for the year 2025: patient’s rights and responsibilities, and HIPAA. This observation was reviewed with the Administrator.”

Rule L0663. Standard-level.

Discharge or transfer of care (42 CFR 418.104(e)(3)(i))

“Observed in Record Review. In 1 of 2 discharge records reviewed, it was noted that a discharge/transfer summary that included all required information was not completed. For example, a review of the medical records for RRDC#1, revealed no evidence that a discharge summary including the following information was documented: 1) A summary of the patient’s stay, including treatments, symptoms, and pain management, 2) The patient’s current plan of care, and 3) The patient’s latest physician orders. This observation was reviewed with Administrator.”

Rule L0684. Standard-level.