Every finding on record at Traditions Hospice of Tyler, LLC

Observed in Record Review. In 13 of 13 patient records reviewed, The surveyor observed no evidence that the organization had not documented evidence of progress toward goals . The surveyor discused issue with organization leaders who confirmed the issue of lack of documentation related to progress toward goals.had been documented

Observed in Record Review. In 6 of 6 patient records reviewed, with oxygen in home the surveyor observed that all of the plans of care had documented oxygen to be delivered at 2-5 liters except one that was documented as 2-10 liters. In discussion with organization leaders it was verbalized that at this time all oxygen on plan of care was documented to be delivered at 2-5 or 2-10 liters. Further the surveyor observed on 11/13 records that multiple goals that were short term had remained on plan of care over months some up to 11 months later without being updated or documented as met. This was discussed and confirmed with hospice leadership. Observed in Document Review. In 8 of 13 resident records reviewed, the surveyor observed that the plan of care had not included goals for falls when the falls assessment identified patient as high risk for falls and in addition the surveyor also observed that the plans of care had not in 2/13 records not identified goals, nor interventions for falls.

Observed in Individual Tracer. The surveyor observed during home visit 3 that the aide was not wearing the appropriate PPE for respiratory according to organization policy that required mask for all home visits. The surveyor observed that the aide provided care without mask for entire visit .  This was observed and confirmed with hospice leadership.

Observed in Tracer Activities. In 3 of 3 bereavement files reviewed, the surveyor observed that the bereavement care plans had not include specific, individualized interventions, and the timing and frequency . This issue was discussed with bereavement coordinator and hospice leadership and confirmed.