Traditions Health Care of Norman LLC

The agency failed to ensure an Emergency Preparedness Communication Plan for the agency (call tree) included staff contact information for all patients and staff.

The agency failed to ensure the emergency preparedness testing and training program was implemented and reviewed/updated for all patients and staff.

The agency failed to ensure emergency preparedness disaster declarations, table-top exercises, drills, community drills or plan activation events were conducted for calendar year 2022 for all patients and staff.

The agency failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement in calendar year 2022 for all patients and staff.

The agency failed to ensure the initiation and review of a PIP through their QAPI Program for calendar year 2022 for all patients and staff.

The agency failed to ensure its infection control program surveillance monitoring and reporting was included in QAPI program activities for all patients and staff.

The agency failed to ensure advance beneficiary notice was provided to one (Patient #1) of eight patients.

The agency failed to ensure individualized patient POC included finger stick blood sugar intervention for physician reporting parameters for one (Patient #1) of eight patients.

The agency failed to ensure: 1. SN conducted assessment of patient’s weight and blood sugar every visit and report to the physician weight gain for one (Patient #1) of eight patients; 2. CHHA visits were conducted for one (Patient #1) of eight patients and; 3. PT visits were conducted for three…

The agency failed to ensure a completed discharge summary was provided for two (Patients #2 and 3) of eight patients.

The agency failed to ensure compliance with infection control surveillance activities for three (Pt's #5, 6 and #11) of 11. Findings: Patient #5 A review of the clinical documents dated 11/19/20 showed the patient reported being exposed to a person with an active COVID-19 infection.

The agency failed to ensure medication profiles were reviewed and updated with ordered medication changes for two (Pt's #9 and #10) of 11 patients.

The agency failed to ensure: 1) physical therapy evaluation was completed as orderd for one (Pt #1) of 11; and 2) skilled nurse visit was completed to perform wound care for one (Pt #8) of 11. Findings: Patient #1 A review of a POC dated 09/02/20 - 10/31/20 showed orders for a PT evaluation the…