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 ______________ 		07/03/2020
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)
L0555      
34887 Based on record review and interview, the agency failed to enforce its written policy to ensure the effective exchange of information and coordination of services among all agency personnel providing care and services for 1 of 1 Patient (#1) with wound care and whose record was reviewed. The agency failed to coordinate Patient #1's wound care and updated IDG care plan with the clinical staff This failure could place the agency's active patients at risk of inaccurate care and services and could result in negative health outcomes. The agency has 24 inpatient Hospice Patient that could be affected by this failure The findings included: Policy: Review of an agency policy titled "Interdisciplinary Group Coordination of Care" numbered GIP: 1: 022.1 revealed in part: " ...will utilize a registered nurse or ADON to guide an interdisciplinary group to provide comprehensive, coordinated healthcare to patients and families/caregivers serviced by the hospice. The registered nurse or ADON will be responsible for coordination of services with the interdisciplinary group from referral to discharge." Observation: Observation on 07/02/2020 at 11:30 AM noted that Patient #1 was verbally incoherent and grunting during perineal care and brief change performed by staff #54. Surveyor observed > A 4 x 4 gauze secured at the sacral area. > The gauze was minimally saturated with serosanguinous drainage of the gauze, > The dressing was not dated as to when it was changed and there was no initial of the clinical staff that completed the wound care. Record Review: Review of Patient #1's record revealed inpatient hospice admission on 05/15/2020. The "Inpatient admission orders / GIP admission orders" revealed documentation that Patient #1 had "no open wound" and "skin intact." There was an initial check for "wound care: Assess skin and follow inpatient wound care orders per stage." Review of Patient #1's record revealed a "hospice nursing clinical note" dated 05/27/2020 with documentation of "Stage 2 (wound) on sacrum." Skilled intervention revealed that "wound care done by LVN. Dressing clean, dry and intact." There was no documentation about the wound on the hospice nursing clinical notes dated 05/28/2020 and 05/29/2020. Review of the Clinical note dated 5/30/2020 revealed the following wound documentation: "Stage 3 sacrum" with intervention related to the Patient exhibiting pain during repositioning and wound care, as well as a plan for LVN to "premedicate for wound care......." There was no documentation of wound size, color, or drainage. There was no documentation that a physician was notified of the change in status prior to IDG meeting on 06/03/2020. Review of the IDG Care Plan Update for 06/03/2020 revealed documentation of "unstageable sacral decubitus" with interventions to "assess skin integrity; turning & repositioning, daily wound care ..." Review of the Clinical Nursing Note dated 06/03/20 "Stage 3 to sacrum" was documented as well as "wound care performed by LVN." Review of the clinical note of 06/07/2020 failed to indicate if wound care was done or the status of the wound. Review of clinical note dated 06/06/2020 revealed a documentation that wound care "done in early a.m. by nightshift." Review of Clinical note dated 06/09/2020 indicated that sacral area "wound care" done, there was no documentation of the wound description on type of wound care provided. Review of Clinical note dated 06/10/2020 failed to acknowledge sacral wound or daily wound care. There was no skin sheet attached. Review of IDG Care Plan Update dated 06/10/2020 revealed documentation of "sacral DTI" with interventions to "reposition as needed." Review of Clinical note dated 6/12/20 documented "Stage 3 to sacrum" and "wound care done by LVN." There was no description of the wound or wound status. Review of the Clinical note dated 06/14/2020 indicated a "Stage 2 to sacrum" and "wound care done by LVN." There was no skin sheet attached. Review of the IDG Care Plan Update dated 06/24/2020 revealed documentation of "Stage II pressure ulcer decubitus" with the interventions to "assess wound; prepare wound care as indicated daily and PRN for soilage; keep skin clean & dry' turn and reposition q 2 hrs." Review of the Clinical note dated 06/25/2020 indicated wound care performed, with the skin sheet indicating that stage III wound measurement in centimeters was "6 x 7 x 0.1" Review of the clinical note dated 06/30/2020 revealed wound measurement of "7 x 8 x 0.1" indicating progression in the sacral pressure ulcer. Interviews Interview with the administrator on 07/02/2020 at 12:55PM the surveyor was informed that Patient #1's daughter performs wound care daily. Surveyor requested for the agency documentation and wound care order by the hospice physician. Administrator looked through the clinical records and could not find any On 07/03/2020 at 1:15 PM Administrator presented surveyor with an agency policy titled "Wound Care Standing Orders." The Administrator also stated that the IDG documentation of wound care were the orders staff followed during wound care. When the administrator was asked which of the orders were followed when clinical staff interchangeably documented stage II and stage III pressure ulcer when the standing wound care order has two different wound care guidelines for stage II and stage III. The Administrator stated she did not know. Interview with the administrator on 07/03/2020 at 3:20 PM surveyor asked if the agency had a designated registered nurse or ADON that coordinated IDG care plans with the clinical staff for Patient #1's wound care. The Administrator stated that the it's the responsibility of the charge nurse on duty to coordinate IDG care plans and update with the clinical staff. The Administrator added she did not know the reason the charge nurse did not inform the nurses of the treatment plan after each Care Plan Update.
L0556      
34887 Based on clinical record review and interview, the agency failed to enforce its written policy to make sure client care was coordinated for 1 of 1 clients (Client #2), with contact with a staff that exhibited signs and symptoms of COVID-19 infection, in that; - The agency failed to coordinate with and notify Patient#2 and /or family member of Patient #2's potential exposure to COVID-19 on night of admission date: 06/24/2020. This failure could place the agency's clients at risk of inaccurate care and services and could result in negative client's health outcomes. The agency has 24 inpatient Hospice client that could be affected by this failure Findings: Review of an agency policy titled "Interdisciplinary Group Coordination of Care" numbered GIP: 1: 022.1 revealed in part: 3. "It will be the responsibility of the nursing staff to facilitate communication about changes in the patient's status between interdisciplinary group members and the patient's attending physician. 4. ...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." Client #2 Review of Client #2's clinical records revealed that client #2 is a 25-year-old female admitted with hospice diagnosis of nasopharyngeal cancer. Review of the admission record revealed that the client was brought to the inpatient facility by ambulance with family present on admission. Review of the agency form titled "GIP change in status report" dated 06/24/2020 revealed that client #2 was admitted the night of 06/24/2020 by Staff #53, a Registered Nurse. Review of the agency documentation revealed a form titled "Proactive health check survey" with three health screening questions which was completed by nurse Staff #53 on 06/24/2020. The completed form revealed a self-check with positive responses from nurse Staff #53 of "yes" to having had fever greater that 100 degrees and flu like symptoms (N/V, shortness of breath, coughing, sneezing, or sniffles) in the last 72 hours. Review of the agency incident (Exception Report) documentation presented by the administrator on 07/02/2020 revealed that on June 27, 2020, agency received information that staff #53 was positive for COVID-19. There was no documentation that the facility informed the client's family of the possibility of client #2 and the family member present during admission was exposed to COVID-19 infection and to conduct self-monitoring for themselves and possible self-isolation. There was no evidence that the agency put a surveillance protocol in place to track, and screen patient #2, specific to COVID-19 signs and symptoms such as fever or signs or symptoms of a respiratory infection, such as cough, shortness of breath, or sore throat. Interview on 07/02/2020 at 2:15 PM with staff #56, staff #56 informed the surveyor that on the night of 06/24/2020, every night staff on duty was present when staff #53 walked in with the cough. Staff #56 stated that staff #53 was observed to be "coughing, sneezing and verbalizing that she had elevated temperature." Staff #56 stated staff #53 had on a surgical mask which she thinks was doubled, but it was not an N95 mask. Interview on 07/02/2020 at 2:26 PM with staff #57 revealed that she had worked the night shift with staff #53 on 06/24/2020. Staff #57 stated she could hear staff #53 "coughing, a really bad cough, she just had a hard time like a having a cough attack." Staff #57 indicated she observed staff #53 putting on a surgical mask during the shift. During an interview with the administrator on 07/03/2020 at approximately 3:35 PM when asked if the agency notified client #2's family member about having contact with a staff that tested positive to COVID-19 on 06/24/2020 when client #2 was admitted to the agency, the administrator stated, "No.., we did not tell the client or family."
L0581      
34887 Based on record review and interview, the hospice failed to implement its written policies for the prevention and control of infectious and communicable diseases that included a plan for taking appropriate actions expected to result in improvement and disease prevention for 1 of 1 patient (Client #2), in that: The agency failed to notify Patient #2 and family of their direct contact with a staff member, during admission, who tested positive for COVID 19, so they could take appropriate actions. This failure placed the clinical staff, family members, and all 24 current patients at an increased risk of exposure to / acquiring infections from facility staff and not being aware. Findings: Review of an agency policy titled "Infection Control Plan" numbered GIP: 9:001.1 revealed in part: "Purpose: 4. "provide for surveillance systems to track the occurrence and transmission of infections. 6. Comply with all applicable state and federal regulations, including, but not limited to: B. CDC recommendations and guidelines .... Policy: ...recognized prevention and control mechanisms will be implemented for planning, surveillance, identification, prevention/control, and reporting procedure ..." Review of the CDC guidelines for contact tracing exposure notification read in part: " ....A successful notification of exposure allows for an exchange of information with the person (contact) exposed to COVID-19 and offers an opportunity to answer questions and provide referrals for testing, medical evaluation and other necessary support services. The goals of this interaction are to inform the person that they may have been exposed to COVID-19, assess their medical condition and other risk factors,. ... ...." Client #2 Review of Client #2's clinical records revealed that the client was a 25-year-old female admitted with hospice diagnosis of Nasopharyngeal Cancer. Review of the admission record revealed that the client was brought to the inpatient facility by ambulance with family present on admission. Review of the agency form titled "GIP change in status report" dated 06/24/2020 revealed that client #2 was admitted the night of 06/24/2020 by Staff #53, a Registered Nurse. Review of agency documentation (relating to Infection Control) revealed a form titled "Proactive health check survey" with three health screening questions which was completed by nurse Staff #53 on 06/24/2020. The completed form revealed a self-check with positive responses from nurse Staff #53 of "yes" to having had fever greater that 100 degrees and flu like symptoms (N/V, shortness of breath, coughing, sneezing, or sniffles) in the last 72 hours. Review of the agency incident (Exception Report) documentation presented by the administrator on 07/02/2020 revealed that on June 27, 2020, agency received information that staff #53 was positive for COVID-19. There was no documentation that the facility informed the client's family of the possibility of client #2 and the family member present during admission was exposed to COVID-19 infection and to conduct self-monitoring for themselves and possible self-isolation. There was no evidence that the agency put any surveillance protocol in place to track, and screen patient #2 specific to COVID-19 signs and symptoms such as fever or signs or symptoms of a respiratory infection, such as cough, shortness of breath, or sore throat. Interview on 07/02/2020 at 2:15PM with staff #56, staff #56 informed the surveyor that on the night of 06/24/2020, every night staff on duty was present when staff #53 walked in with the cough. Staff #56 stated that staff #53 was observed to be "coughing, sneezing and verbalizing that she had elevated temperature." Staff #56 stated that staff #53 had on a surgical mask which she thinks was doubled, but it was not an N95 mask. Interview on 07/02/2020 at 2:26PM with staff #57 revealed that she had worked the night shift with staff #53 on 06/24/2020. Staff #57 stated she could hear staff #53 "coughing, a really bad cough, she just had a hard time like a having a cough attack." Staff #57 indicated she observed staff #53 putting on a surgical mask during the shift. During an interview with the administrator on 07/03/2020 at approximately 3:35PM when asked if the agency notified client #2's family member about having contact with a staff that tested positive to COVID-19 on 06/24/2020 when client #2 was admitted to the agency? The Administrator stated, "No, I did not inform the family, but all residents are normally having their vital signs checked daily. We monitor fever, or spike of fever. No, we did not tell the client or family."