Every finding on record at Traditions Health Care of SE Oklahoma, LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the hospice on 01/08/24 to 01/10/24. No deficiencies were cited as a result of the Medicare Emergency Preparedness Program survey.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 01/08/24 to 01/10/24. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff B was identified as the contact person for administrative and Staff A was identified as the contact person for clinical issues. Findings were discussed during an informal exit conference with Staff A and B. Deficiencies were cited as a result of the Medicare re-certification survey.

Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to document resolutions for five (Complaint #1, 2, 3, 4 and 5) of eight agency complaints which had the potential to affect all agency patients in receipt of services. A review of agency records showed the following: Complaint #1 A complaint dated 07/14/23 which documented no resolution. Complaint #2 A complaint dated 07/19/23 which documented no resolution. Complaint #3 A complaint dated 08/16/23 which documented no resolution. Complaint #4 A complaint dated 09/14/23 which documented no resolution. Complaint #5 A complaint dated 11/01/23 which documented no resolution. On 01/09/24 at 3:45 pm, Staff B stated Complaints #1, 2, 3, 4 and 5 documented no resolutions.

Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This ELEMENT is not met as evidenced by: Based upon record review and interview, the agency failed to demonstrate adequate discharge for cause for one (Patient #10) of three patients. Patient #10 A review of the plan of care dated 05/22/23 to 07/10/23 showed a skilled nurse frequency of two visits per week for one week and one visit per week for eight weeks. A skilled nurse note dated 05/22/23 documented the presence of "vicious dogs" with no other issues noted. A skilled nurse note dated 06/02/23 documented "vicious dogs" and the patient meeting the nurse outside. A complaint form dated 06/07/23 (four days after the last skilled nurse visit) documented that upon the skilled nurse visit performed on 06/02/23 the patient informed the nurse of the "viciousness of the dogs" and how the dogs would "kill" her if the patient instructed them to and the patient had met the nurse outside of his fence due to the nature of the dogs. The complaint form also noted the skilled nurse was subject to racial slurs concerning the admitting nurse. Neither skilled nurse visit reflected any of these issues at the time of documentation. Patient #10 was discharged "for cause" due to the complaint allegations. On 01/09/24 at 3:25 pm, Staff B stated the complaint was not reflective of the narrative statements on the skilled nurse assessments for Patient #10 and did not document adequate cause for discharge for cause.

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 hospice failed to ensure the plan of care was fully developed to include individualized interventions in relation to the primary diagnosis for seven (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) of 13 patients reviewed. Patient #1 A review of the plan of care dated 09/12/23 to 11/10/23 showed a primary diagnosis of basal cell carcinoma of skin of nose and showed no patient specific interventions for the management of the primary diagnosis. Patient #2 A review of the plan of care dated 10/31/23 to 12/29/24 showed a primary diagnosis of other specified chronic obstructive pulmonary disease and showed no patient specific interventions for the management of the primary diagnosis. Patient #3 A review of the plan of care dated 09/20/23 to 11/18/24 showed a primary diagnosis of aftercare following joint replacement surgery and showed no patient specific interventions for the management of the primary diagnosis. Patient #4 A review of the plan of care dated 11/10/23 to 01/08/24 showed a primary diagnosis of hypertensive chronic kidney disease and showed no patient specific interventions for the management of the primary diagnosis. Patient #5 A review of the plan of care dated 10/10/23 to 12/08/23 showed a primary diagnosis of unspecified atrial fibrillation and showed no patient specific interventions for the management of the primary diagnosis. Patient #6 A review of the plan of care dated 10/17/23 to 12/15/23 showed a primary diagnosis of unspecified open wound, left lower leg and showed no patient specific interventions for the management of the primary diagnosis. Patient #7 A review of the plan of care dated 11/22/23 to 01/20/24 showed a primary diagnosis of pressure ulcer of sacral region, stage II and showed no patient specific interventions for the management of the primary diagnosis. Patient #8 A review of the plan of care dated 11/15/23 to 01/13/24 showed a primary diagnosis of other intervertebral disc degeneration, lumbar region and showed no patient specific interventions for the management of the primary diagnosis. Patient #9 A review of the plan of care dated 09/05/23 to 11/03/23 showed a primary diagnosis of hypertensive heart disease with heart failure and showed no patient specific interventions for the management of the primary diagnosis. Patient #10 A review of the plan of care dated 05/22/23 to 07/20/24 showed a primary diagnosis of hypertensive heart disease with heart failure and showed no patient specific interventions for the management of the primary diagnosis. On 01/10/23 at 1:50 pm, Staff A stated there were no patient specific interventions for the primary diagnosis for Patients #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.

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 the physician was notified of fasting blood sugars outside of parameters for one (Patient #3) of 13 patients. Patient #3 A review of the plan of care dated 09/20/23 to 11/18/23 showed a skilled nurse frequency of one visit per week for nine weeks and documented orders to notify the physician of fasting blood sugar greater than 150 and to notify the physician of a pattern (three or more) of blood glucose levels greater than 150. A review of the clinical record showed the following: A skilled nurse assessment dated 10/23/23, for the week of 10/22/23 to 10/28/23, showed a fasting blood sugar of 154 and documented the physician was not notified and a fax was sent with no documented follow up. A skilled nurse assessment dated 10/30/23, for the week of 10/29/23 to 11/04/23, showed a fasting blood sugar of 202 and documented the physician was not notified and a fax was sent with no documented follow up. A skilled nurse assessment dated 11/09/23, for the week of 11/05/23 to 11/11/23, showed a fasting blood sugar of 1161 and documented the physician was not notified and a fax was sent with no documented follow up. Documentation showed no physician notification of three consecutive blood sugar readings above 150. A skilled nurse assessment dated 11/15/23, for the week of 11/12/23 to 11/18/23, showed a fasting blood sugar of 170 and documented the physician was not notified and a fax was sent with no documented follow up. Documentation showed no physician notification of three consecutive blood sugar readings above 150. On 01/10/24 at 1:25 pm, Staff A stated the skilled nurse assessments documented the physician was not notified of the fasting blood sugars exceeding 150 and the blood sugars exceeding 150 three and more consecutive times. Staff A stated there was no documentation of any follow up regarding the physician faxes.

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 measure, analyze, track quality indicators and assess processes of care, HHA services, and operations potentially affecting all patients and staff. A review of administrative records showed no documentation to measure, analyze, track quality indicators and assess processes of care, HHA services, and operations for 2022 and 2023. On 01/10/23 at 1:45 pm, Staff B stated there was no documentation of the QAPI to measure, analyze, track quality indicators and assess processes of care, HHA services, and operations for 2022 and 2023.

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 quality indicator data to improve program effectiveness, quality of patient care and overall program improvement for all agency patients and staff. A review of administrative records showed no data collection of quality indicators were utilized in the agency's QAPI Program for calendar years of 2022 and 2023. On 01/10/24 at 1:45 pm, Staff A stated they had no collection or analysis of quality indicators available that showed improved quality of patient care and program improvement for 2022 and 2023.

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 documentation of governing body oversight of the agency for 2022 and 2023. A review of governing body minutes for 2022 and 2023 provided showed oversite to many agencies including hospice with no specific documentation for the surveyed agency. On 01/10/24 at 1:50 pm, Staff B stated there were no Governing body minutes to show oversight directly related to the surveyed agency for 2022 and 2023.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the hospice on 02/12/21. No deficiencies were cited as a result of the Medicare Emergency Preparedness Program survey.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 02/12/21. 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 by telephone with Staff B. A standard level deficiency was cited as a result of the Medicare re-certification survey. GLOSSARY: POC Plan of Care

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure medication embedded wound care supplies were included in the review of medications for potential/adverse effects, drug reactions, side effects, interactions and duplicate drug therapy for three (Patients #1, 3 and 4) of seven patients. Findings: Patient #1 A review of the plan of care dated 12/02/20 to 01/30/12 documented a principal diagnosis of non pressure chronic ulcer to right foot. A physician order dated 01/20/21 ordered nursing to perform wound site care using prisma to wound bed and then to apply calcium alginate three times weekly. A review of the clinical record showed the prisma and calcium alginate were not added to the medication profile. Patient #3 A review of the plan of care dated 12/04/20 to 02/01/21 documented a principal diagnosis of stage II pressure ulcer of sacral region. The documentation showed orders for skilled nursing to perform wound site care using calmoseptine ointment to wound bed. A physician order dated 12/28/20 ordered nursing to apply alginate dressing and cover with sacral dressing. A review of the clinical record showed the calmoseptine and calcium alginate were not added to the medication profile. Patient #4 A review of the plan of care dated 11/03/20 to 01/01/21 showed a principal diagnosis of cellulitis of left upper limb. The POC showed orders for the skilled nurse to perform wound site cleansing with iodine, apply aquacel (a medication embedded wound care supply material). A review of the clinical record showed the iodine and aquacel were not added to the medication profile. On 02/12/21 at 12:18 pm, Staff A stated: 1) all wound care supplies should be added to the medication profile and the wound care supplies ordered for wound care on Patients #1, 3 and 4 were not on the medication profiles and 2) the agency did not review the medication embedded wound care supply materials for patient interactions, effects, or allergies for Patients #1, 3 and 4.