Every finding on record at Traditions Health Care of Chickasha, LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 01/05/22 to 01/06/22.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 01/05/22 to 01/06/22.An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered.Staff B and C were identified as the contact persons for administrative and clinical issues.Findings were discussed during an informal exit conference with Staff B and C.A deficiency was cited as a result of the re-certification survey.

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 development of an individualized plan of care for one (Patient #3) of seven patients. Patient #3 A review of the plan of care dated 10/05/21 to 12/03/21 showed a primary diagnosis of hypertensive heart with heart failure and documented a skilled nurse frequency of one visit per week for nine weeks. The plan of care documented no interventions to monitor patient's weight in relation to the primary disease process. A review of the electronic medical record showed the following: A skilled nurse assessment dated 10/08/21 documented no patient weight. A skilled nurse assessment dated 10/15/21 documented no patient weight. A skilled nurse assessment dated 10/22/21 documented no patient weight. A skilled nurse assessment dated 10/28/21 documented no patient weight. A skilled nurse assessment dated 11/19/21 documented no patient weight. A skilled nurse assessment dated 12/01/21 documented no patient weight. On 01/06/22 at 10:30 am., Staff B and C stated the plan of care for Patient #3 should have documented interventions to monitor the patient's weight in relation to the primary disease process.