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

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 02/09/22. 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 02/09/22.An entrance conference was conducted with Staff A. 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.Deficiencies were 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 develop the plan of care of physician notification of proper weight parameters for one (Patient #1) of seven patients. Patient #1 A plan of care dated11/11/21 to 01/09/22 showed a skilled nurse frequency of one visit per week for one week and on visit every two weeks for six weeks and documented the physician was to be notified of weight greater than 165 kilograms. A review of the electronic medical record showed skilled nurse assessments dated 11/23/21, 12/09/21, 12/21/21, 12/28/21 and 01/06/21 all of which documented the patient's weight in pounds (not kilograms). On 02/09/22 at 2:52 pm, Staff A stated the plan of care should have documented the physician was to be notified of a weight greater than 165 pounds and not kilograms for Patient #1.

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 included interventions to reduce future infections and promote learning and preventative measures throughout the agency for all 18 patients and staff. A review of administrative records showed no ongoing infection control program to reduce future infections and provide preventative measures throughout the agency for calendar year's 2020 and 2021. On 02/09/22 at 2:40 pm, Staff A stated the agency had no comprehensive infection program in place to reduce future infections and provide preventative measures for 2020 and 2021.