Every finding on record at Ssm Health Businesses

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 06/15/21 - 06/17/21. No deficiencies were cited as a result of the Emergency Preparedness Program survey.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 06/15/21 - 06/17/21. An entrance conference was conducted with Staff A and B. The survey process was explained. Questions were answered. Staff A was identified as the contact person for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A and B and by telephone with Staff C, D and E. Standard level deficiencies were sited as a result of the survey. Glossary: POC Plan of Care Pt Patient Pts Patients SN Skilled Nurse

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure POC orders included 1) oxygen use for one (Pt #8) of seventeen patients; and 2) Pain parameters for two (Pt #10 and 15) of seventeen patients. Findings: Pt #8 A review of the POC dated 05/29/21 to 07/27/21 showed no orders for oxygen. The POC contained instructions for SN to teach home oxygen therapy safety precautions under safety measures and had orders for oxygen as ordered under interventions. A review of physician orders and the medication profile showed no orders for the use of oxygen. Pt #10 A review of the POC dated 04/22/21 to 06/20/21 showed no pain parameters. POC documentation showed a diagnosis of encounter for other orthopedic aftercare. Nurses notes dated 06/02/21, 06/08/21 and 06/14/21 showed pain level of eight on a one to ten scale. No physician notification of pain was documented. Pt #15 A review of the POC dated 05/04/21 to 07/02/21 showed no pain parameters. POC documentation showed a diagnosis of infection following a procedure, superficial incisional surgical site. Nurses notes dated 05/04/21 and 05/13/21 showed pain levels at a nine and ten, respectively, on a one to ten scale. No physician notification of pain was documented. On 06/17/21 at 12:26 pm, Staff A stated: 1. the POC should include orders for oxygen for Pt #8; 2. the POC should include pain parameters for Pts #10 and 15 and 3. the documentation did not show physician notification of elevated pain levels for Pts #10 and 15.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure SN frequencies were followed as ordered on the POC for two (Pt #1 and 3) of 17 patients. Findings: Pt #1 A review of a POC dated 04/21/21 - 06/19/21 showed orders for a SN frequency of once a week for four weeks. An order dated 05/31/21 showed additional SN visits ordered for once a week for three weeks effective 05/31/21. A review of nurses notes showed no SN visit the weeks of 05/30/21 - 06/05/21 and 06/06/21 - 06/12/21 (two visits missing). Documentation showed no orders for SN frequency changes, no patient/caregiver refusal of visits and no missed visit notes. Pt #3 A review of a POC dated 03/31/21 - 05/29/21 showed orders for a SN frequency of once a week for five weeks. A review of nurses notes showed no SN visit the weeks of 04/18/21 - 04/24/21 (one visits missing). Documentation showed no orders for SN frequency changes, no patient/caregiver refusal of visits and no missed visit notes. On 05/12/21 at 11:13 am, Staff A stated the ordered SN frequency was not followed for Pts #1 and 3.