Every finding on record at Traditions Hospice of Tomball, LLC

Observed in Record Review. In 13 of 13 patient records reviewed, the surveyor observed that the hospice team had not developed an individualized plan of care that included measurable goals with time frames that reflected family goals. The goals had been vague statements and had not been measurable. The issue was discussed reviewed with organization as chart review completed with organization assistance. The organization confirmed this as an issue and stated that they were working on issue.

Observed in Tracer Visit. In 2 of 3 home visits conducted, the surveyor observed staff not following organizational policy or cdc guidelines for hand hygiene . In visit one the surveyor observed the nurse providing care using hand gel, drying hands by swinging them in air and further stating, as she was donning gloves, its hard to put gloves on when my hands are damp. The second visit with home health aide the surveyor observed the home health aide don gloves and clean all areas of the patients body with same gloves. The surveyor observed further that the aide went on to clean feet with wounds after cleaning the perineal area and return to finish hair washing without ever changing gloves or cleaning hands. This issue was discussed with organization.

Observed in Record Review. In 5 of 13 patient records reviewed, the surveyor observed that the patients on continuous oxygen, with home health aide services, did not have oxygen address on the home health aide care plan. The surveyor observed that the home health aide care plan had not addressed if the oxygen should be removed or left in place for the bath. The issue was discussed and confirmed with organization leaders.

Observed in Record Review. The surveyor observed that the hospice patient in nursing home had not been receiving a medication (metformin) that was on the Hospice medication profile, but had not been on the nursing facility MAR. This issue was because the nursing facility MAR was not revised and this was not identified by the initial nursing assessment. The surveyor found that the patient had been getting 2 eye drops that was on the nursing facility MAR, but had not been on the hospice medication profile. The surveyor identified the issue along with hospice leadership, who reviewed both profiles with surveyor.

Observed in Record Review. In 3 of 3 patient records reviewed, that had been transferred or discharged , the surveyor observed no evidence that the organization had sent a copy of the discharge summary forward . This issue was discussed and confirmed with hospice leadership.

Observed in Record Review. In 3 of 3 patient records reviewed, of discharged patients ,the surveyor observed that a summary of care had not included a summary of the treatments, symptoms and pain management. The surveyor found no evidence of a discharge summary that had been sent forward.

Observed in Tracer Visit. In 2 of 3 home visits conducted, the surveyor observed no evidence of written policies and procedures for the management and disposal of controlled drugs in the patient's home. This issue was discussed and confirmed with organization leaders.

Observed in Tracer Visit. In 2 of 3 home visits conducted, the surveyor observed that no education on patient-specific written emergency management plan had been left in the patient's home. This issue was discussed with the 2 hospice nurses on visit with surveyor and organization leaders. The nurse on visit #1 did find a emergency form, but it had not been completed. The issue was discussed with organization leadership and confirmed. Observed in Individual Tracer. The surveyor observed in home visit #3 that the patient complained of no education had been given on the wheelchair provided by hospice through DME. The surveyor, along with organization leaders reviewed record and found no evidence of wheelchair education. The nurse on visit with surveyor did not provide education or assess patient knowledge during visit with surveyor.