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

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 12/08/21 to 12/09/21. 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 12/08/21 to 12/09/21. 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 and B. Deficiencies were cited as a result of the re-certification survey. Glossary: QAPI Quality Assessment and Performance Improvement

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: 2. weights were obtained as ordered for two (Patient #4 and 5) of 17 patients and 3. the physician was notified of systolic blood pressure outside of ordered parameters for one (Patient #6) of 17 patients. 1. Patient #4 A review of the plan of care dated 09/06/21 to 11/04/21 showed orders for the skilled nurse to obtain weight every visit and documented a skilled nurse frequency of one visit per week for nine weeks. A review of the electronic medical record showed the following: A skilled nurse assessment dated 09/20/21 showed no documented weight. A skilled nurse assessment dated 09/23/21 showed no documented weight. Patient #5 A review of the plan of care dated 08/19/21 to 10/17/21 showed orders for the skilled nurse to obtain weight every visit and documented a skilled nurse frequency of two visits per week for one week and one visit per week for eight weeks. A review of the electronic medical record showed the following: A skilled nurse assessment dated 08/20/21 showed no documented weight. A skilled nurse assessment dated 08/25/21 showed no documented weight. A skilled nurse assessment dated 09/02/21 showed no documented weight. A skilled nurse assessment dated 09/22/21 showed no documented weight. 2. Patient #6 A review of the plan of care dated 10/21/21 to 12/19/21 showed orders for the physician to be notified of systolic blood pressure greater than 150 pounds. A skilled nurse assessment dated 10/28/21 documented a systolic blood pressure of 178 with no physician notification at the time of the assessment. On 12/09/21 at 2:00 pm, Staff A stated: 1) weights should have been obtained as ordered for Patients #4 and 5, and 3) the physician should have been notified of the systolic blood pressure outside of the ordered parameters for Patient #6 the day of the assessment.

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: 1) The Infection Control Program included comprehensive infection control surveillance activities and interventions to reduce future infection throughout the agency and; 2) The Infection Control Program was included in QAPI activities. A review of administrative records showed no ongoing infection control program for the agency or infection control surveillance data for calendar year's 2019, 2020 and 01/01/21 to 12/09/21. Additional infection control surveillance documentation was requested and yielded no further reports. On 12/09/21 at 2:00 p.m., Staff A stated: 1. the agency had no comprehensive infection surveillance program in place and 2. no infection surveillance activities were reported through the agency's QAPI program.