Every finding on record at Traditions Hospice of Conroe, LLC

Observed in Record Review. In 5 of 11 patient records reviewed, the hospice’s interdisciplinary group did not complete the comprehensive assessment no later than five calendar days after the election of hospice care. For example, in the records of HV#2, RR#2, RR#3, RR#4, and RR#6 bereavement assessments were not completed as part of the initial comprehensive assessment. This observation was reviewed with the Branch Director, Regional Administrator and Regional Clinical Specialist.

Observed in Record Review. In 5 of 11 patient records reviewed, the hospice failed to document initial bereavement assessments as part of the comprehensive assessments in the records of HV#2, RR#2, RR#3, RR#4, and RR#6 as required by policy PE.5 entitled Patient Assessment. This was discussed with the organization’s leaders. This observation was reviewed with the Branch Director, Regional Administrator and Regional Clinical Specialist.

Observed in Patient Home. In 1 of 3 home visits conducted, the hospice did not provide the patient with care, treatment, or services according to his or her individualized plan of care. At HV#1 the plan of care was revised the day prior to this visit to include mouth care as the patient had begun the active dying stage. During the visit the RN did not address the patient’s dry and crusted mouth. This observation was discussed with the RN after the visit, and reviewed with the Branch Director, Regional Administrator and Regional Clinical Specialist.

Observed in Patient Home. In 2 of 3 home visits conducted, the hospice did not use standard precautions to reduce the risk of infection. At HV#1 the RN did not perform hand hygiene between doffing and donning gloves. At HV#3 the CHHA did not perform hand hygiene prior to donning gloves before starting a bed bath. These observations were reviewed with the Branch Director, Regional Administrator and Regional Clinical Specialist.

Observed in Patient Home. In 1 of 3 home visits conducted, the hospice failed to treat the patient in a dignified and respectful manner that supports the patient's dignity. For example, during HV#3 the CHHA left the patient uncovered during a bed bath. This observation was reviewed with the Branch Director, Regional Administrator and Regional Clinical Specialist.