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

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 03/14/22 to 03/16/22. 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 03/14/22 to 03/16/22. An entrance conference was conducted with Staff C. The survey process was explained. Questions were answered. Staff A was identified as the contact person for administrative issues and Staff B was identified as the contact persons for clinical issues. Findings were discussed during an informal exit conference with Staff A, B, and D. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: HHA Home Health Aide OT Occupational Therapy POC Plan of Care SN Skilled Nurse SNF Skilled Nurse Facility

Patient/payer will no longer pay for services CFR(s): 484.50(d)(2) The patient or payer will no longer pay for the services provided by the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure an advance beneficiary notice or notice of non-medicare coverage was provided to one (Patient #17) of 17 patients prior to discharge from the agency. Patient #17 A review of the clinical record showed no advance beneficiary notice or notice of non-medicare coverage prior to discharge from the agency on 03/10/22. On 03/15/22 at 3:15 p.m., Staff B stated there was no advance beneficiary notice or notice of non-medicare coverage for Patient #7 prior to being discharged from the agency on 03/10/22 and should have been.

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 seven (Patients #7, 9, 10, 12, 13, 16 and #17) of 17 patients. An agency policy titled physician notification stated physician notification of a missed visit will occur within 24 hours of the missed visit date. Patient #7 A review of a plan of care dated 01/25/22 to 03/25/22 documented a primary diagnosis of Diabetes Mellitus Type II. The POC showed an occupational therapy visit frequency of one time a week for one week then two times a week for eight weeks. A review of the documentation showed a missed OT visit on 02/08/22 with no physician notification, no change in orders and no patient or caregiver refusal of the missed visit. Patient #9 A review of a plan of care dated 01/27/22 to 03/27/22 documented a primary diagnosis of fracture of the sacrum. The POC showed a skilled nurse visit frequency of one time a week for nine weeks. A review of the documentation showed no SN visit during the week of 01/30/22 through 02/05/22 (one missed SN visit) with no physician notification, no change in orders and no patient or caregiver refusal of the missed visit. Patient #10 A review of a plan of care dated 12/31/22 to 02/28/22 documented a primary diagnosis of chronic obstructive pulmonary disease with respiratory infection. The POC showed a skilled nurse visit frequency of three times a week for eight weeks then one time a week for one week and a home health aide visit frequency of two times a week for eight weeks then one time a week for one week. A review of the documentation showed missed SN visits on 02/04/22 with notification to the physician of the missed visit on 03/02/22 (26 days after the missed visit date) and 02/23/22 with notification to the physician of the missed visit on 03/02/22 (7 days after the missed visit date) and; HHA missed visit on 02/04/22 with notification to the physician of the missed visit on 03/02/22 (26 days after the missed visit date) and 02/25/22 with notification to the physician of the missed visit on 03/02/22 (5 days after the missed visit date). Documentation showed no change in orders and no patient or caregiver refusal of the missed visits. Patient #12 A review of a plan of care dated 01/20/22 to 03/20/22 documented a primary diagnosis of non-pressure chronic ulcer to right lower leg. The POC showed a skilled nurse visit frequency of one time a week for one week then three times a week for eight weeks. A review of the documentation showed missed SN visits on 02/04/22 with notification to the physician of the missed visits on 02/21/22 (17 days after the missed visit date), 02/07/22 with notification to the physician of the missed visits on 02/21/22 (14 days after the missed visit date), and on 02/14/22 with notification to the physician of the missed visits on 02/21/22 (7 days after the missed visit date). Additional review of the documentation showed during the week of 02/20/22 through 02/26/22 no SN visits were made (3 SN visits ordered, 3 SN visits missed, and 1 SN missed visit documented). The documentation showed during the week of 02/20/22 through 02/26/22 a missed visit on 02/26/22 (one of three ordered visits in that week) with no physician notification, changes in orders or patient and caregiver refusal of the missed visits (3 SN visits ordered, 3 SN visits missed); and during the week of 03/06/22 through 03/12/22 a missed visit on 03/07/22 with no physician notification, changes in orders or patient and caregiver refusal of the missed visit. Patient #13 A review of a plan of care dated 01/27/22 to 03/27/22 documented a primary diagnosis of Diabetes Mellitus Type II with foot ulcer. The POC showed a skilled nurse visit frequency of one time a week for one week then three times a week for eight weeks. A review of the documentation showed during the week of 02/27/22 through 03/05/22 a SN visit was missed on 03/03/22 with no physician notification, no change in orders and no patient or caregiver refusal of the missed visit. Patient #16 A review of a plan of care dated 02/15/22 to 04/15/22 documented a primary diagnosis of squamous cell carcinoma. The POC showed a skilled nurse visit frequency of one time a week nine weeks. A review of the documentation showed during the week of 02/20/22 through 02/26/22 a SN visit was missed on 02/23/22 with no physician notification, no change in orders and no patient or caregiver refusal of the missed visit. Patient #17 A review of a plan of care dated 02/20/22 to 04/20/22 documented a primary diagnosis of chronic kidney disease. The POC showed a skilled nurse visit frequency of one time a week nine weeks. A review of the documentation showed during the week of 02/20/22 through 02/26/22 a SN visit was missed on 02/22/22 with notification to the physician of the missed visit on 03/07/22 (13 days after the missed visit date) and during the week of 02/27/22 through 03/05/22 no SN visit was made (1 SN visit ordered, 1 SN visit missed) with no physician notification, no change in orders and no patient or caregiver refusal of the missed visit. On 03/15/22 at 2:50 p.m., Staff B stated the physician should have been notified within 24 hours of missed SN and HHA visits for Patient’s #7, 9, 10, 12, 13, 16 and #17.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure improvement activities were included as a part of a comprehensive patient centered QAPI Program for 835 patients and all employees. A review of administrative records showed no documentation quality improvement activities were a part of an ongoing QAPI program to improve the care, services, and operations of the agency for calendar years 2020 and 2021. On 03/15/22 at 2:00 p.m., Staff A and B stated the agency did not document ongoing quality improvement activities as a part of the comprehensive patient centered QAPI Program for calendar years 2020 and 2021.

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 835 patients and all employees. A review of administrative records showed no data collection activities utilized in an agency QAPI Program for calendar year's 2020 and 2021. On 03/15/22 at 2:00 p.m., Staff A and B stated they had no analysis of the data collected for calendar year's 2020 and 2021 available that showed improved quality of patient care.

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 reviews and interview, the agency failed to ensure SN staff performed weekly wound care measurements for one (Patient #10) of 17 patients. An agency policy titled wound care standard stated wound care measurements will be conducted weekly during a wound care visit. Patient #10 A review of the POC dated 12/31/22 to 02/28/22 showed a SN frequency of three times a week for eight weeks then one time a week for one week for SN to perform wound care to the right tibia each SN visit. Clinical documentation showed no wound care measurement were conducted during the SN visits to perform wound care from 01/03/22 through 01/26/22 and 01/31/22 through 02/09/22. Documentation showed skilled nurse visits were conducted on 01/03/22, 01/05/22, 01/07/22, 01/10/22, 01/12/22, 01/14/22, 01/17/22, 01/19/22, 01/21/22, 01/25/22, 01/27/22, 01/28/22, 01/31/22, 02/02/22, 02/07/22 and on 02/09/22 to perform wound care but documented no wound care measurements. Documentation showed no physician notification of change in wound status, no change in orders, and no patient or caregiver refusal of the wound care measurements. On 03/15/22 at 2:45 p.m., Staff B stated wound care measurements for the right tibia site should have been conducted by the SN weekly for Patient #10.

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 an operating budget, allocation of resources and a capital expenditure plan for the agency in calendar years 2020 and 2021 for 435 patients and all staff members. A review of administrative records showed no governing body oversite of an operating budget, allocation of resources and capital expenditure plan activities for calendar years 2020 and 2021 for all agency staff and patients. On 03/15/22 at 1:00 p.m., Staff A stated the agency had no governing body meeting minutes which showed governing body oversite activities related to an operating budget, allocation of resources and capital expenditure plan activities for calendar years 2020 and 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 discharge summary was provided to the receiving service providers for four (Patients #1, 2, 3 and #4) of 17 patients. Patient #1 A review of the clinical record showed the patient was discharged from the agency on 10/29/21 to in-patient hospital care services. Documentation showed no discharge summary was provided to the hospital service provider. Patient #2 A review of the clinical record showed the patient was discharged from the agency on 01/07/22 to in-patient hospital care services. Documentation showed no discharge summary was provided to the hospital service provider. Patient #3 A review of the clinical record showed the patient was discharged from the agency on 09/27/21 to in-patient SNF care services. Documentation showed no discharge summary was provided to the SNF service provider. Patient #4 A review of the clinical record showed the patient was discharged from the agency on 03/02/22 to hospice care services. Documentation showed no discharge summary was provided to the hospice service provider. On 03/15/22 at2:30 p.m., Staff B stated no discharge summary was sent to: the receiving hospital service providers for Patient #1 and #2; the receiving SNF service provider for Patient #3 and;the receiving hospice service provider for Patient #4.