Every finding on record at Traditions Health Care of Ponca City, LLC

The Oklahoma State Department of Health conducted an unannounced Emergency Preparedness Program Survey at the agency on 1/10/23 to 1/11/23. 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 1/10/23 to 1/11/23. An entrance conference was conducted with Admin1 and VPO. The survey process was explained. Questions were answered. Admin1 was identified as the contact person for clinical issues and VPO was identified as the contact person for administrative issues. Findings were discussed during an informal exit conference with Admin1, VPO and RDO. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: Admin Administrator VPO Vice President of Operations RDO Regional Director of Operations RN Registered Nurse SN Skilled Nurse PT Physical Therapist POC Plan of Care SOC Start of Care

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on record review and interviews, the Physical Therapist (PT) failed to conduct an initial assessment and evaluation within 5 days of the Start of Care (SOC) for one (#5) of six (#1, #5, #6, #8, #9 and #10) records reviewed with orders for Physical Therapy services. Patient #5 A record review for Patient #5 certification period 12/17/22 to 02/14/23 revealed a primary diagnosis of Fracture Left Femur and orders for a PT Evaluation at SOC on 12/17/22. PT documentation indicated the initial contact to schedule the PT evaluation was attempted on 12/27/22 (10 days later) with a comment that PT was unable to contact patient. Further review revealed no PT evaluation was documented as of the time of this survey on 01/11/23 (25 days later) and no documentation as to the reason the PT evaluation was not initially conducted as required. During an interview on 01/11/23 at 2:30 PM, VPO stated the PT failed to conduct an evaluation within 5 days of the SOC as required for Patient #5.

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 interviews, SN staff failed to provide an individualized POC to include patient-specific interventions for two (#2 and #7) of ten (#1 - #10) records reviewed. Patient #2 A record review for Patient #2 certification period 12/29/22 - 02/26/23 revealed a primary diagnosis of Acute Pyelonephritis and secondary diagnosis Type II Diabetes Mellitus. The POC did not contain patient-specific blood sugar parameters, orders or interventions for diabetes management. During an interview on 01/11/23 at 10:00 AM, Patient #2 stated she randomly checks her blood sugar and she does not take any diabetes medications. Further review of SN Visit Notes revealed the SN obtained a random blood sugar on 01/04/23 of "207" and on 01/05/23 of "186" with no orders to perform random blood sugar checks and no patient-specific parameters for reference. Patient #7 A record review for Patient #7 certification period 12/16/22 - 02/13/23 revealed a primary diagnosis of Hypertensive Heart Disease with Heart Failure. The POC contained an order for, "SN to perform/teach wound care to remove Unna Boots, apply Unna Boots, apply rolled gauze and secure with Coban". The order did not contain a frequency for the application of Unna Boots. When asked to clarify if the Patient was taught and performing the Unna Boot application, Admin 1 stated the SN staff are providing Unna Boot care for lymphedema and that Patient #7 is not performing the application and removal of the Unna Boots. The POC contained an order for, "SN to obtain weights q day and notify RN/MD of weight gain or loss of 2-3 lbs within 1 day". When asked to clarify if the SN staff were obtaining weights each day, Admin 1 stated the order should be for Patient #7 to weigh each day and notify RN/MD of weight gain. During an interview on 01/11/23 at 2:30 PM, VPO stated the SN staff failed to provide patient-specific orders for Patient #2 and Patient #7.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, SN performed random blood sugar checks without orders for one (#2) of ten (#1 - #10) records reviewed. Patient #2 A record review for Patient #2 certification period 12/29/22 - 02/26/23 revealed a primary diagnosis of Acute Pyelonephritis and secondary diagnosis Type II Diabetes Mellitus. The POC did not contain patient-specific blood sugar parameters, orders or interventions for Diabetes management. Further review of SN Visit Notes revealed the SN obtained a random blood sugar on 01/04/23 of "207" and on 01/05/23 of "186". There was no order for SN to conduct random blood sugar checks or patient-specific parameters for reference and no documentation the SN notified the Physican of the blood sugar results. During an interview on 01/11/23 at 2:30 PM, VPO stated the SN staff had no orders for diabetes interventions and failed to notify the Physician of the blood sugar results for Patient #2.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on record review and interview, SN staff failed to provide wound care assessments according to current clinical practice for one (#4) of two (#4 and #5) records reviewed with orders for wound care. Patient #4 A record review for Patient #4 certification period 12/05/22 - 02/02/23 revealed a primary diagnosis of Chronic Osteomyelitis and Quadriplegia. The POC contained wound care orders for a Stage 4 left ischial pressure ulcer and a Stage 2 left heel pressure ulcer. Review of SN documentation in the Wound Record Report indicated wound measurements were not obtained for either pressure ulcer during the SN visits conducted weeks #2 and #5 of the certification period. Further review of the agency policy titled "Wound Assessment" indicated the procedure for measurements as "Wounds shall be measured at least weekly upon assessment". During an interview on 01/11/23 at 2:30 PM, VPO stated the SN staff failed to obtain weekly wound measurements as required for Patient #4.