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

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 11/01/21 to 11/02/21. 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 11/01/21 through 11/02/21. 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 issues and for clinical issues. Findings were discussed during an informal exit conference with Staff B and C. Deficiencies were cited as a result of the re-certification survey. GLOSSARY: PIP Performance Improvement Project PIPs Performance Improvement Projects QAPI Quality Assessment and Performance Improvement

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 two (Patients #2 and 5) of seventeen patients. Findings: Patient #2 A review of the plan of care dated 08/29/21 to 10/27/21 showed a primary diagnosis of hypertensive heart and chronic kidney disease with heart failure with no patient specific weight gain or weight loss parameters to notify the physician. Patient #5 A review of the plan of care dated 08/12/21 to 10/10/21 showed a primary diagnosis of hypertensive heart disease with heart failure with no patient specific weight gain or weight loss parameters to notify the physician. On 11/02/21 at 10:58 am., Staff B stated the plans of care for Patients #2 and 5 failed to document weight parameters for physician notification.

Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a patient centered QAPI Program which measured and tracked agency performance strategies to ensure improvements was sustained for all 298 patients and employees. A review of administrative records showed no ongoing QAPI program activities which measured and tracked agency performance strategies to ensure improvements were sustained to improve the care, services, and operations of the agency from January 20, 2020 to November 02, 2021. On 11/02/21 at 12:15 p.m., Staff B stated they had no QAPI documentation which measured or tracked performance strategies from January 20, 2020 to November 02, 2021.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the review and status of PIPs through their QAPI Program for 298 patients and all employees. A review of QAPI records showed no review, data analysis, or status of PIPs from January 20, 2020 to November 02, 2021.