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

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 06/20/22 to 06/21/22. 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 06/20/22 to 06/21/22. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A and Staff B were identified as the contact persons for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A and B. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: FSBS Finger Stick Blood Sugar QAPI Quality Assessment Performance Improvement SN Skilled Nurse

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure care was coordinated between the agency and physician for one (Patient #7) of seven patients. Findings: Patient #7 A review of a plan of care dated 04/28/22 to 06/26/22 documented a primary diagnosis of hypertensive chronic kidney disease and a secondary diagnosis of Diabetes Mellitus Tye II and a SN frequency of once a week for nine weeks. Documentation showed orders for SN to assess and instruct on blood sugar testing. SN visit notes dated 04/28/22, 05/04/22, 05/11/22, 05/18/22, 05/27/22, 05/31/22, 06/01/22, 06/03/22, 06/08/22, 06/10/22, 06/15/22 and on 06/17/22 showed the patient refused to do FSBS testing. Documentation showed no physician notification of patient’s refusal to perform FSBS’s to monitor blood sugar levels and no changes in orders. On 06/21/22 at 10:15 a.m., Staff A stated SN staff should have notified the physician of the patient’s refusal to perform FSBS’s to monitor blood sugar levels but did not.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for 51 patients and all employees. Findings: A review of administrative records showed no data collection activities utilized in the agency's QAPI Program for calendar years 2020, 2021 and 01/01/22 through 06/20/22. On 06/21/22 at 11:00 a.m., Staff A stated the agency had no documentation which showed analysis of data collected and improved quality of patient care for calendar years 2020, 2021 and 01/01/22 through 06/20/22.

Program activities CFR(s): 484.65(c) Standard: Program activities. The HHA's performance improvement activities must-- This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure conduction of patient centered QAPI Program activities for 51 patients and all employees. Findings: A review of administrative records showed no ongoing QAPI program activities to improve the care, services, and operations of the agency for 2nd and 3rd quarters calendar year 2020; 1st and 2nd quarters calendar year 2021; and 1st quarter of calendar year 2022. On 06/21/22 at 11:00 a.m., Staff A stated they had no documentation which showed QAPI program activities for 2nd and 3rd quarters calendar year 2020; 1st and 2nd quarters calendar year 2021; and 1st quarter of calendar year 2022.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Infection Control Program was included in QAPI activities for 51 patients and all staff. Findings: A review of QAPI administrative records showed infection control surveillance data for calendar year's 2020, 2021 and 01/01/22 to 06/21/22. On 06/21/22 at 11:00 a.m., Staff A stated infection surveillance activities were not reported through the agency's QAPI program.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure services were provided as ordered for SN visit frequency for one (Patient #7) of seven patients Findings: Patient #7 A review of the POC dated 04/28/22 to 06/26/22 showed an updated order (dated 05/26/22) for a SN visit frequency of three times a week for SN to perform wound care. Skilled nurse visits for the week of 06/12/22 to 06/17/22 SN showed visits conducted on 06/15/22 and on 06/17/22 (one missing SN visit). Documentation showed no patient refusal of visit, physician notification of the missed visit and no change in orders. On 06/21/22 at 10:30 a.m., Staff A stated: The SN should have conducted a third SN visit during the week of 06/12/22 to 06/17/22 but did not.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversite of: 1. A patient centered QAPI Program and; 2. An operating budget and capital expenditure plan for fiscal year 2020 -2021. Findings: A review of administrative records showed no governing body oversite of an ongoing patient centered QAPI program for 2nd and 3rd quarters calendar year 2020; 1st and 2nd quarters calendar year 2021; or operating budget and capital expenditure plan for fiscal year 2020 -2021. On 06/21/22 at 11:00 a.m., Staff A stated there was no documentation which showed governing body oversight for the agency for: an ongoing patient centered QAPI program for 2nd and 3rd quarters calendar year 2020; 1st and 2nd quarters calendar year 2021 and nooperating budget and capital expenditure plan for fiscal year 2020 -2021.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure a completed transfer/discharge summary was provided to receiving service providers for three (Patients #2, 4 and #7) of seven patients. Findings: Patient #2 A review of the clinical record documented discharge from the agency on 06/15/22 to hospice provider services. Documentation showed no discharge summary was provided to the hospice service provider. Patient #4 A review of the clinical record documented transfer from the agency on 05/09/22 to in-patient hospital provider services. Documentation showed no transfer summary was provided to the in-patient hospital service provider. Patient #7 A review of the clinical record documented transfer from the agency on 05/18/22 to in-patient hospital provider services. Documentation showed no transfer summary was provided to the in-patient hospital service provider. On 06/21/22 at 11:00 a.m., Staff A stated: No discharge summary was sent to the hospice service providers for Patient #2 and;No transfer summaries were provided to in-patient hospital service providers for Patients #4 and #7.