DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
671774 A. BUILDING __________
B. WING ______________ 		01/02/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
HARBOR HOSPICE OF SOUTHEAST HOUSTON LP 11990 KIRBY DRIVE, HOUSTON, TX, 77045
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0554      
34887 Based on record review and interview, the hospice agency failed to enforce its written policy to ensure that the interdisciplinary team maintains responsibility for coordinating and supervising the care and services for 1 of 1 Patient (#1) who had a Port-a-Cath, in that: The interdisciplinary team failed to coordinate Patient #1's care regarding Port-a-Cath dressing changes and Port changes requirement with all staff providing care. This failure could result in Patients not receiving adequate care or interventions and potentially affect the ability of the hospice agency to properly meet the Patients' needs. Findings include: Record review of the agency's policy manual included an agency policy titled "INTERDISCIPLINARY GROUP COORDINATION OF CARE" policy No. GIP:1-022.1. The purpose of the policy stated in part: "To ensure the coordination of services for each client. The hospice interdisciplinary group will retain professional management responsibilities for the provision of services, including inpatient care, and will insure that services are furnished in a safe and effective manner. 4. ... Hospice personnel will communicate changes in a timely manner via telephone, one-to-one meetings and interdisciplinary group meetings. Documentation of all communications will be included in the clinical record on a communication note, interdisciplinary group meeting form, and/or clinical note. Documentation will include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication." Patient #1 Record review of Patient #1's CR revealed a Hospice General inpatient admission date of 12/03/2019. Diagnosis included malignant neoplasm of colon, unspecified. Review of the inpatient admission orders dated 12/03/2019 revealed selected order to "flush central line, PICC or PAC with NS Q 7 days and after each use,...,...wound care: Skin tears: Cleanse with NS, apply TAO, cover with Tegaderm every 3 days and PRN soilage ..." Record review of Patient #1's Hospice Clinical note dated 12/04/2019 revealed that Port-a-Cath was accessed on 12/04/2019. Record review of the daily Hospice Nursing clinical notes dated 12/05/2019, 12/06/2019, 12/09/2019, 12/10/2019, 12/12/2019, 12/13/2019, 12/14/2019, 12/15/2019, 12/16/2019, 12/0/2019, 12/18/2019, 12/19/2019, 12/20/2019, 12/20/2019, 12/21/2019, 12/22/2019, 12/23/2019, 12/24/2019, 12/25/2019, 12/26/2019, 12/27/2019, 12/28/201912/30/2019, 12/31/2019, and 01/01/2020 failed to include that the Port-a-cath dressing was done every 3 days or that the Port-a-Cath was changed every 6 days when the port was accessed. Record review of Patient #1's CR form titled "Services rendered - GIP" failed to address that new skills regarding Port-a-Cath care were taught and discussed with the family. Observation and interview on 01/02/2020 at approximately 3:15 p.m. during an onsite visit, at the inpatient hospice facility, Patient #1's Family Member (Identifier A) showed the surveyors the Port-a-Cath site located on the far-left upper chest wall of the Patient #1. Surveyor observed the dressing date noted as 12/03/2019 (see Appendix A). Identifier A stated she was not informed about the Port-a-Cath care otherwise she would have asked the nurse to change it. She indicated she just googled the information about Port-a-Cath and realized the dressing was supposed to be changed every three or seven days. At approximately 3:30 p.m. surveyor observed Registered Nurse (RN) (#58) in the process of changing the Port-a-Cath dressing and Port. Surveyor asked the RN #58 in charge the reason the Port-a-Cath dressing was not changed since 12/03/2019, RN #58 stated she does not know. Interview with the administrator/ADON (#50) on 01/02/2020 at approximately 4:00 p.m. surveyor asked for the policy regarding Port-a-Cath dressing change when the port is accessed. Administrator/ADON #50 provided the policy titled "WOUND CARE STANDING ORDERS" and informed the surveyors that the procedure regarding "skin tears" is applicable to Port-a-Cath and dressing changes which required dressing change every three (3) days and PRN and Port change every 6 days. Surveyor asked Administrator/ADON #50 where documentation of catheter dressing and Port change would be documented. Administrator/ADON #50 stated it will be in the nursing notes and not in the narratives. Administrator/ADON #50 reviewed the skilled nursing notes and admitted that there was no documentation regarding catheter dressing and Port change and that the port was accessed on 12/04/2019. Surveyor asked for the reason the dressing and Port change and has not occurred since 12/03/2019 and 12/04/2019 respectively and asked for the designated staff to change the dressing/Port. Administrator/ADON #50 stated the nurses on duty are responsible for the dressing change and don't know the reason it was missed. Surveyor asked for the reason the Interdisciplinary Team (IDT) failed to be addressed the Port-a-Cath care in the Plan of care. Administrator/ADON #50 stated the facility/IDT dropped the ball on that one.
L0732      
34887 Based on record review and interview the hospice failed to have hot water supply at a general Inpatient Hospice facility from 12/20/2019 through 01/01/2020. This failure had the potential in not meeting Patient's needs and providing adequate care that potentially affected the agency's ability to repair all equipment timely. The agency had 13 inpatient residents during the survey that was potentially affected by this failure Findings include: Record review revealed that the hospice inpatient unit had a census of 13 Patients at the time of the equipment failure. Record review of Intake #173970 revealed the incident reported that "the facility has not had any hot water for about a month. The washer and dryer have not been working for longer than a month. The staff are having to bathe the Patients with cold water. Staff are afraid that the elderly Patients will get sick or have a heart attack because of how cold the water is." Interview with the Administrator/ADON #50 on 01/02/2020 at approximately 12:40 PM, informed the surveyors that the inpatient facility did not have hot water starting on 12/20/2019. Administrator/ADON #50 indicated that the facility maintenance staff ordered the part for a replacement but there was a back order for the part and delay in fixing the problems. The hot water issue and the washer was fixed on 01/02/2020 prior to the surveyors' arrival to the facility.