Trinity River Valley Home Health

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on clinical record review and staff interview, it was determined the agency failed to ensure the assessment for the Physician ordered weight goal was completed as ordered in 1 (#2) of 14 (#1-#14) clinical records reviewed. This failed practice had the potential to affect all patients on census that have Congestive Heart Failure in that a patients weight changes and fluctuations over the course of a few days to a week can profoundly impact early care interventions and the ability to manage the condition in the patients home instead of readmission to hospital for treatment or complications. Findings: Review of a document titled “Home Health Certification And Plan of Care” with certification dates from 10/16/2024 through 12/14/2024 showed a diagnosis of Heart Failure. On the same document, an order to report to physician for “weight gain of three pounds in 24 hours or five pounds in a week.” and a SN (Skilled Nurse) Goal of “Patient weight will be maintained between 232 pounds and 237 pounds during episode” Further review of Skilled Nurse Visit Note revealed the following weight entries10/16/2024-no weight entry, 10/17/2024-no weight entry, 10/18/2024-no weight entry, 10/21/2024- no weight entry, 10/22/2024- no weight entry, 10/23/2024- no weight entry, 10/24/2024- 232 pounds, 10/25/2025-232 pounds, 10/28/2024-no weight entry, 10/29/2024-no weight entry but SN (Skilled Nurse) documented “edema BLE” (swelling to both lower extremities),11/01/2024-no weight entry, 11/04/2024-no weight entry, 11/06/2024-no weight entry, 11/08/2024-no weight entry, 11/12/2024- no weight entry, 11/15/2024-221 pounds, 11/18/2024-no weight entry, 11/20/2024-no weight entry, 11/25/2024-no weight entry, 11/27/2024-no weight entry, 11/29/2024- no weight entry. Agency Representatives were given an opportunity to provide additional information. None was provided.”

“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 Clinical Record review and patient interview, it was determined the Agency failed to assure all medications were included in a comprehensive medication review 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 in one (#1) of 14 (#1-#14) records reviewed. Findings: Review of Record #1 revealed a diagnosis of Malignant Neoplasm of stomach (growing cancer of stomach).During a home visit on 12/11/2025 at 10:10 AM, surveyor asked patient if they were under care of an oncologist (A doctor specializing in the treatment of cancer). Patient #1 replied, “Yes. I go for chemo (chemotherapy infusions) every two weeks right now.” A review of a document titled “Patient Medication Record” showed no evidence of the chemotherapy medications listed. Agency Representatives were given an opportunity to provide additional information. Agency Representative #1 stated, “We will contact the oncologist and get them (the chemotherapy medications added to medication record).””