Every finding on record at Traditions Hospice of Elk City, LLC

Based on record review and interview, the agency failed to ensure that the plan for Emergency Preparedness was updated for all current patients and staff. --- Findings:A review of the Emergency Preparedness document "Continuity of Operations Business Plan" was not updated after the appointment of a new administrator, and Healthcare Coalitions Readiness and Response Coordinator for Region 1 did not list the current person holding that position.04/22/26 at 4:22 p.m., Staff B stated the "Continuity of Operations Business Plan" needed to be updated.

Based on record review and interview, the hospice failed to ensure the initial social work assessment was completed within five days for one (Pt #5) of fourteen patients. --- Findings:Pt #5A review of the initial nursing start of care assessment was dated 02/02/26 with a POC dated 02/02/26 - 05/02/26.  The initial psycho-social assessment was completed by the social worker on 02/10/26.  The clinical record showed no patient refusal or physician's order to extend the date of the assessment.On 04/22/26 at 3:50 p.m., Staff A stated the initial social work assessment was not completed until the ninth day after admission.

Based on record review and interview, the agency failed to ensure a home health aide supervisory visit was completed every 14 days for one (Patient #5) of fourteen patients. --- Findings:Patient #5A plan of care dated 04/21/26 to 04/22/26 showed orders for aide visits once a week for one week beginning 02/08/26 for twelve weeks.  A review of the clinical record showed during the weeks of:02/08/26 - 02/14/26 home health aide visit was 02/11/26.02/15/26 - 02/21/26 home health aide visit was 02/17/26.02/22/26 - 02/28/26 home health aide visit was 02/24/26. 03/01/26 – 03/07/26 home health aide visit was 03/04/26. 03/08/26 – 03/14/26 home health aide visit was 03/11/26.  03/15/26 – 03/21/26 home health aide visit was 03/19/26.  03/22/26 – 03/28/26 home health aide visit was 03/26/26.  03/29/26 – 04/04/26 home health aide visit was 04/02/26.   04/05/26 - 04/11/26 home health aide visit was 04/09/26.   04/12/26 - 04/18/26 home health aide visit was 04/19/26.   The clinical record showed supervisory visits on 03/04/26 and 03/27/26 (23 days between supervisory visits).On 04/22/26 at 3:50 p.m., Staff A stated the supervisory visit was not completed by 03/18/26.

Based on record review and interview, the hospice failed to ensure volunteer services met hospice program requirements in calendar years 2024, 2025, and January 2026 for all patients, caregivers, and staff. --- Findings:A review of volunteer records showed the hospice program had the following utilization of volunteer personnel:January 2024 - 1.28%February 2024 - .94%March 2024 - 1.36%April 2024 - 1.70%May 2024 - 1.94%June 2024 - 2.36%July 2024 - 1.76%August 2024 - 1.26%September 2024 - .31%October 2024 - .42%November 2024 - 1.44%December 2024 - 1.77%Yearly total of 1.35%January 2025 - 1.51%February 2025 - 1.60%March 2025 - 1.24%April 2025 - 1.57%May 2025 - 1.28%June 2025 - 2.28%July 2025 - 1.66%August 2025 - 3.37%September 2025 - 2.12%October 2025 - 1.15%November 2025 - 1.92%December 2025 - 2.07%Yearly total of 1.77%January 2026 - 2.54%On 04/22/26 at 1:50 p.m., Staff A stated they did not meet volunteer hour requirements.

Based on record review and interview, the hospice failed to ensure a professional's license was available for review for one (Staff D) of one physician. --- Findings:Staff D A review of the personnel record showed no current professional license.On 04/22/26 at 1:50 pm, Staff A stated the hospice did not have a complete personnel record for Staff D.

Based on record review and interview, the hospice failed to ensure OKSCREEN background checks were completed for one (Staff D) of five employees reviewed.Findings:A review of the "Long Term Care Act" documented requirements for hospices to acquire and maintain an OKSCREEN background check on all employees with access to patients and patient records and whose employment began after 06/01/14.Staff DA review of the personnel record showed no documentation of a background check through OKSCREEN.On 04/22/26 at 1:50 pm, Staff A stated the hospice did not have an OKSCREEN for Staff D.

Observed in Record Review. In 7 of 10 patient records reviewed, the surveyor found no evidence of documented progress toward goals. The issue was noted with goals for all disciplines. This surveyor , together with hospice leadership looked for documented progress toward goals and found inconsistent documentation of progress toward goals as evidenced by 7/10 charts no evidence of documented progress toward goals. The issue was discussed and confirmed with hospice leadership that stated it was an issue they had also noted and had begun some education to staff on.

Observed in Record Review. In 7 of 10 patient records reviewed, the surveyor observed that the POC goals did not have time frames for achieving goals. Goals for example: Pain managed at a level acceptable to patient no pain number given., Patient exhibits reduction of cardiopulmonary symptoms, Patients stress/anxiety reduced to a level of comfort, Patient/caregiver exhibit improved coping skills, Appropriate referrals made to deal with mental illness The issue was discussed and confirmed with hospice leadership, who stated it was an issue they also identified.

Observed in Patient Home. In 2 of 3 home visits conducted, The surveyor observed that the nurse providing care had not completed hand hygiene after each glove change. During visit #1 the surveyor observed on 2 occasions the nurse removed gloves after completing patient care tasks and had not completed hand hygiene as required by organization policy and cdc guidelines. On visit #2 on one occasion the nurse removed gloves and had not completed hand hygiene as required by CDC guidelines and organization policy. The issue was discussed and confirmed with hospice leadership.

Observed in Infection Control System Tracer. the surveyor observed that the organization had not included hand hygiene goals in their Infection control plan. The issue was discussed and confirmed with hospice leadership.

Based on record review and interview, the hospice failed to ensure effective pain management was provided for one (Patient #10) of 14 patients. --- Patient #10 A review of the plan of care dated 01/04/23 to 04/03/23 with plan of care updates dated 01/06/23, 01/20/23, 02/03/23, 02/17/23 and 03/03/23 showed a primary diagnosis of cancer of the lung and documented a skilled nurse frequency of two visits per week for one week and one visit per week. A review of the medical record showed the following: A skilled nurse assessment dated 01/04/23 documented the patient pain as 7 out of 10 on the classic 1-10 pain scale. The plan of care did not include an acceptable pain rating for the patient. Documentation showed no interventions provided directly by the nurse, no direct physician notification of the elevated pain level and no documented follow up related to the pain level. A skilled nurse assessment dated 01/05/23 documented the patient pain as 9 out of 10 on the classic 1-10 pain scale. The plan of care did not include an acceptable pain rating for the patient. Documentation showed no interventions provided directly by the nurse, no direct physician notification of the elevated pain level and no documented follow up related to the pain level. A skilled nurse assessment dated 01/11/23 documented the patient pain as 7 out of 10 on the classic 1-10 pain scale. The plan of care did not include an acceptable pain rating for the patient. Documentation showed no interventions provided directly by the nurse and no documented follow up related to the pain level. A skilled nurse assessment dated 01/18/23 documented the patient pain as 4 out of 10 on the classic 1-10 pain scale. The plan of care did not include an acceptable pain rating for the patient. Documentation showed no interventions provided directly by the nurse, no direct physician notification of the current pain level and no documented follow up related to the pain level. A skilled nurse assessment dated 01/25/23 documented the patient pain as 4 out of 10 on the classic 1-10 pain scale. The plan of care did not include an acceptable pain rating for the patient. Documentation showed no interventions provided directly by the nurse, no direct physician notification of the current pain level and no documented follow up related to the pain level. A skilled nurse assessment dated 01/30/23 documented the patient pain as 6 out of 10 on the classic 1-10 pain scale. The plan of care did not include an acceptable pain rating for the patient. Documentation showed no interventions provided directly by the nurse and no documented follow up related to the pain level. A skilled nurse assessment dated 02/08/23 documented the patient pain as 6 out of 10 on the classic 1-10 pain scale. The plan of care did not include an acceptable pain rating for the patient. Documentation showed no interventions provided directly by the nurse, no direct physician notification of the elevated pain level and no documented follow up related to the pain level. A skilled nurse assessment dated 02/13/23 documented the patient pain as 7 out of 10 on the classic 1-10 pain scale. The plan of care did not include an acceptable pain rating for the patient. Documentation showed no interventions provided directly by the nurse, no direct physician notification of the elevated pain level and no documented follow up related to the pain level. A skilled nurse assessment dated 02/16/23 documented the patient pain as 7 out of 10 on the classic 1-10 pain scale. The plan of care did not include an acceptable pain rating for the patient. Documentation showed no interventions provided directly by the nurse, no direct physician notification of the elevated pain level and no documented follow up related to the pain level. A skilled nurse assessment dated 02/24/23 documented the patient pain as 6 out of 10 on the classic 1-10 pain scale. The plan of care did not include an acceptable pain rating for the patient. Documentation showed no interventions provided directly by the nurse, no direct physician notification of the elevated pain level and no documented follow up related to the pain level. On 04/27/23 at 2:25 pm, Staff B stated the pain for Patient #10 was not properly managed.

Based on record review and interview, the hospice failed to ensure the patient was included in the development of effective pain management for one (Patient #10) of 14 patients. --- Patient #10 A review of the plan of care dated 01/04/23 to 04/03/23 with plan of care updates dated 01/06/23, 01/20/23, 02/03/23, 02/17/23 and 03/03/23 showed a primary diagnosis of cancer of the lung and documented a skilled nurse frequency of two visits per week for one week and one visit per week. The plan of care documented no tolerable or acceptable pain level identified by the patient for the measurement of effective pain management. A review of the medical record showed the following: A skilled nurse assessment dated 01/04/23 documented the patient pain as 7 out of 10 on the classic 1-10 pain scale. A skilled nurse assessment dated 01/05/23 documented the patient pain as 9 out of 10 on the classic 1-10 pain scale. A skilled nurse assessment dated 01/11/23 documented the patient pain as 7 out of 10 on the classic 1-10 pain scale. A skilled nurse assessment dated 01/18/23 documented the patient pain as 4 out of 10 on the classic 1-10 pain scale. A skilled nurse assessment dated 01/25/23 documented the patient pain as 4 out of 10 on the classic 1-10 pain scale. A skilled nurse assessment dated 01/30/23 documented the patient pain as 6 out of 10 on the classic 1-10 pain scale. A skilled nurse assessment dated 02/08/23 documented the patient pain as 6 out of 10 on the classic 1-10 pain scale. A skilled nurse assessment dated 02/13/23 documented the patient pain as 7 out of 10 on the classic 1-10 pain scale. A skilled nurse assessment dated 02/16/23 documented the patient pain as 7 out of 10 on the classic 1-10 pain scale. A skilled nurse assessment dated 02/24/23 documented the patient pain as 6 out of 10 on the classic 1-10 pain scale. On 04/27/23 at 2:25 pm, Staff B stated the plan of care for Patient #10 did not include an acceptable or tolerable pain level.

Based on record review and interview, the hospice failed to ensure the plan of care was fully developed to include all services necessary for the palliation and management of the terminal illness for thirteen (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) of 14 patients reviewed. --- Patient #1 A review of the plan of care dated 02/15/23 to 04/15/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #2 A review of the plan of care dated 01/01/23 to 03/31/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #3 A review of the plan of care dated 03/13/23 to 06/10/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #4 A review of the plan of care dated 02/21/23 to 04/21/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #5 A review of the plan of care dated 01/01/23 to 03/31/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #6 A review of the plan of care dated 02/11/23 to 04/11/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #7 A review of the plan of care dated 01/31/23 to 03/31/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #8 A review of the plan of care dated 01/12/23 to 04/11/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #9 A review of the plan of care dated 01/20/23 to 03/20/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #10 A review of the plan of care dated 01/04/23 to 04/03/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. On 04/27/23 at 1:55 pm, Staff B stated the plans of care for Patients #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 failed to include services necessary for the palliation and management of the terminal illness.

Based on record review and interview, the hospice failed to ensure the plan of care was revised to reflect: 1. the use of a foley catheter for one (Patient #7) of 14 patients and; 2. the presence of pressure ulcers for one (Patient #9) of 14 patients. --- Patient #7 A review of the plan of care dated 01/31/23 to 03/31/23 with plan of care updates dated 02/02/23, 02/17/23, 03/03/23, 03/17/23 and 03/31/23 documented a primary diagnosis of Ataxia and showed a skilled nurse frequency of three visits per week. A skilled nurse assessment dated 03/03/23 documented the insertion of a 16 French catheter. The plan of care was not updated to reflect the presence, care or management of the foley catheter. Patient #9 A review of the plan of care dated 01/20/23 to 03/20/23 with plan of care updates dated 01/20/23, 02/03/23, 02/17/23, 03/03/23 and 03/17/23 documented a primary diagnosis of severe protein calorie malnutrition and showed a skilled nurse frequency of two visits per week. A skilled nurse assessment dated 02/08/23 documented the presence of a Stage II pressure ulcer to the lower right buttock. The plan of care was not updated to reflect the compromised skin integrity or the treatment and management of the pressure ulcer. A skilled nurse assessment dated 02/13/23 documented the presence of a Stage II pressure ulcer to the lower right buttock. The plan of care was not updated to reflect the compromised skin integrity or the treatment and management of the pressure ulcer. A skilled nurse assessment dated 02/17/23 documented the presence of a Stage II pressure ulcer to the lower right buttock. The plan of care was not updated to reflect the compromised skin integrity or the treatment and management of the pressure ulcer. A skilled nurse assessment dated 02/20/23 documented the presence of a Stage II pressure ulcer to the lower right buttock. The plan of care was not updated to reflect the compromised skin integrity or the treatment and management of the pressure ulcer. A skilled nurse assessment dated 02/23/23 documented the presence of a Stage II pressure ulcer to the lower right buttock. The plan of care was not updated to reflect the compromised skin integrity or the treatment and management of the pressure ulcer. A skilled nurse assessment dated 02/27/23 documented the presence of a Stage II pressure ulcer to the lower right buttock. The plan of care was not updated to reflect the compromised skin integrity or the treatment and management of the pressure ulcer. A skilled nurse assessment dated 02/28/23 documented the presence of a Stage II pressure ulcer to the lower right buttock. The plan of care was not updated to reflect the compromised skin integrity or the treatment and management of the pressure ulcer. A skilled nurse assessment dated 03/03/23 documented the presence of a Stage II pressure ulcer to the lower right buttock. The plan of care was not updated to reflect the compromised skin integrity or the treatment and management of the pressure ulcer. A skilled nurse assessment dated 03/06/23 documented the presence of a Stage II pressure ulcer to the lower right buttock. The plan of care was not updated to reflect the compromised skin integrity or the treatment and management of the pressure ulcer. A skilled nurse assessment dated 03/08/23 documented the presence of a Stage II pressure ulcer to the lower right buttock. The plan of care was not updated to reflect the compromised skin integrity or the treatment and management of the pressure ulcer. On 04/27/23 at 2:35 pm, Staff B stated: 1. the plan of care for Patient #7 should have been updated to reflect the presence and services provided for the management of a foley catheter and; 2. the plan of care for Patient #9 should have been updated to reflect the presence and services provided for the treatment of a Stage II pressure ulcer to the lower right buttock.

Based on record review and interview, the agency failed to ensure a coordinated plan of care was developed with long term care facilities for three (Patients #1, 2 and 3) of 14 patients. --- Patient #1 A review of the clinical record and review of long-term care records showed no coordinated plan of care between the agency and the long-term care facility for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #2 A review of the clinical record and review of long-term care records showed no coordinated plan of care between the agency and the long-term care facility for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #3 A review of the clinical record and review of long-term care records showed no coordinated plan of care between the agency and the long-term care facility for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. On 04/27/23 at 1:15 pm, Staff B stated there was no coordinated plan of care with long term care facilities for Patients #1, 2 and 3.