Trinity Health of New England at Home

“Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures. This Standard is not met as evidenced by: Based on clinical record reviews, review of agency documentation and staff interviews, for one of five patients reviewed (Patient #11), the agency failed to ensure weekly wound measurements were conducted in accordance with the agency policy. The findings include: Patient #11 had a start of care date of 3/01/26 and diagnoses that included cerebrovascular accident with right hemiplegia, peripheral vascular disease, non-pressure chronic ulcer of the right foot and chronic kidney disease. The physician orders dated 3/01/26 included nursing services two times a week for four weeks and once a week for five weeks for assessments, wound care to the right lateral foot three times a week and teaching the caregiver to perform wound care using teach back technique. Additionally, home health aide services, physical therapy and occupational therapy services were provided. Review of the clinical record from 3/01/26 to 3/29/26 identified the presence of a right lateral foot wound measuring 0.6 centimeters/cm x 1.0 cm x 0.2 cm but failed to identify weekly wound measurements for the weeks of 3/15/26 to 3/21/26 and 4/05/26 to 4/11/26. Interview and review of the clinical record with the Administrator on 5/06/26 at 11 AM failed to identify weekly wound measurements were completed in accordance with agency policies. Review of the agency policy for Wound Management Program directed wound measurements should be done weekly to document wound progress. Patient #19 elected hospice benefits on 04/05/2025 with diagnoses including senile dementia of the brain, hypertensive heart failure and a fall resulting in a left fibula fracture. Physician orders for the certification period of 04/10/2026 through 06/08/2026 included weekly nursing visits for assessment and management of end-of-life symptoms. In addition, the Patient received home health aide visits twice (2) weekly for personal care, social work visits as needed, and chaplain visits twice (2) monthly. The Patient resided in a skilled nursing facility, was non-ambulatory, and required use of a mechanical lift (Hoyer lift) for transfers. Review of Patient #19’s plan of care summary note for the recertification period of 04/10/2026 through 06/08/2026, identified the Patient sustained a left distal fibula fracture of an unknown origin on 01/12/2026. Skilled nursing facility wrapped the Patient’s leg in an ACE bandage and applied an immobilizer. The plan of care identified the Patient as being at risk for skin breakdown; however, it did not include an intervention to remove the immobilizer and assess the underlying skin for signs of breakdown. During a joint home visit conducted on 05/06/2026 at 10:00 AM, the surveyor observed Patient #19 with an immobilizer applied to the left leg that was not properly secured or positioned to ensure appropriate fit and function. In addition, hospice RN #1 failed to remove the immobilizer during the visit to assess the Patient’s skin for signs of breakdown. Interview with hospice RN #1 on 05/06/2026 at 10:40 AM confirmed the nurse should have assessed the Patient’s immobilizer for proper application and patient comfort and should have assessed the skin underneath the immobilizer for signs of breakdown. Interview with the hospice Supervisor of Clinical Services (SCS) on 05/06/2026 at 1:30 PM confirmed the nurse should have ensured Patient #19’s immobilizer was properly positioned and should have assessed the skin beneath the immobilizer. Following surveyor inquiry, an intervention was added to the patient’s plan of care directing staff to remove the immobilizer for skin assessment.”

“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 a review of clinical records, review of agency documentation and staff interviews for one of twenty-three patients reviewed (Patient #14), the agency failed to ensure the rescheduling of five (5) missed weekly nursing visits by licensed personnel, and failed to follow the physician’s-certified plan of care. The findings include: Patient #14 had a start of care date of 2/21/26 and diagnoses that included urinary tract infection, chronic obstructive pulmonary disease, chronic respiratory failure and prostate cancer. The physician’s orders dated 2/21/26 included nursing services twice a week for one week and once a week for seven weeks for medication teaching and assessments, physical therapy, occupational therapy and medical social worker evaluations. Review of the clinical record from 3/01/26 to 3/07/26 identified documentation of a missed visit on 3/04/26 due to nurse unavailability and on 3/06/26 due to inability to locate the patient. Review of the clinical record for the week of 3/15/26 to 3/21/26 identified documentation of a missed visit on 3/18/26 due to nurse unavailability. Interview and review of the clinical record with the Administrator on 5/06/26 at 12:55 PM indicated that the physician was notified of the missed visits but failed to identify attempts to visit the patient on 3/05/26, 3/07/26, 3/19/26, 3/20/26 and 3/21/26 (within the same Medicare week) in order to meet the nursing frequency of once weekly. Patient #19 elected hospice benefits on 04/05/2025 with diagnoses including senile dementia of the brain, hypertensive heart failure and a fall resulting in a left fibula fracture. Physician orders for the certification period of 04/10/2026 through 06/08/2026 included weekly nursing visits for assessment and management of end-of-life symptoms. In addition, the Patient received home health aide visits twice (2) weekly for personal care, social work visits as needed, and chaplain visits twice (2) monthly. The Patient resided in a skilled nursing facility, was non-ambulatory, and required use of a mechanical lift (Hoyer lift) for transfers. Review of Patient #19’s plan of care summary note for the recertification period of 04/10/2026 through 06/08/2026, identified the Patient sustained a left distal fibula fracture of an unknown origin on 01/12/2026. Skilled nursing facility wrapped the Patient’s leg in an ACE bandage and applied an immobilizer. The plan of care identified the Patient as being at risk for skin breakdown; however, it did not include an intervention to remove the immobilizer and assess the underlying skin for signs of breakdown. During a joint home visit conducted on 05/06/2026 at 10:00 AM, the surveyor observed Patient #19 with an immobilizer applied to the left leg that was not properly secured or positioned to ensure appropriate fit and function. In addition, hospice RN #1 failed to remove the immobilizer during the visit to assess the Patient’s skin for signs of breakdown. Interview with hospice RN #1 on 05/06/2026 at 10:40 AM confirmed the nurse should have assessed the Patient’s immobilizer for proper application and patient comfort and should have assessed the skin underneath the immobilizer for signs of breakdown. Interview with the hospice Supervisor of Clinical Services (SCS) on 05/06/2026 at 1:30 PM confirmed the nurse should have ensured Patient #19’s immobilizer was properly positioned and should have assessed the skin beneath the immobilizer. Following surveyor inquiry, an intervention was added to the patient’s plan of care directing staff to remove the immobilizer for skin assessment. Review of the agency’s Care Planning Process policy identified the plan of care would be assessed and discussed the active problems of the individual patients including physical, psychosocial and spiritual needs. Reassess and revise the plan of care as indicated by patient/family response to care, changes in patient’s condition or diagnoses Patient #14 had a start of care date of 2/21/26 and diagnoses that included urinary tract infection, chronic obstructive pulmonary disease, chronic respiratory failure and prostate cancer. The physician’s orders dated 2/21/26 included nursing services twice a week for one week and once a week for seven weeks for medication teaching and assessments, physical therapy, occupational therapy and medical social worker evaluations. Review of the clinical record from 3/01/26 to 3/07/26 identified agency documentation of missed visits on 3/04/26 due to nurse unavailability and on 3/06/26 due to inability to locate the patient, and for the week of 3/15/26 to 3/21/26 identified documentation of a missed visit on 3/18/26 due to nurse unavailability. Interview and review of the clinical record with the Administrator on 5/06/26 at 12:55 PM indicated that the physician was notified of the missed visits, but could not provide documentation of the attempts for the rescheduling of the weekly nursing visits by agency staff to visit the patient on alternate days for week one, 3/05/26 or 3/07/26, and the week of 3/19/26, 3/20/26 and 3/21/26 (within the same Medicare week) in order to meet the nursing frequency of once weekly within the plan of care.”

“Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures. This Standard is not met as evidenced by: Based on clinical record reviews, review of agency documentation and interviews with agency personnel for six (Patients # 22 through 27) of twenty-seven patients, the home health care agency failed to ensure licensed personnel completed assigned nursing visits per the plan of care. The findings include. Patient #22 had a start of care date of 08/30/2025 with diagnoses including mild cognitive impairment, type II diabetes, chronic kidney disease and cardiovascular disease. Physician orders for the certification period 08/30/2025 through 10/28/2025 included skilled nursing visits once weekly for nursing assessment. Patient #23 had a start of care date of 08/25/2025 with diagnoses including subdural hemorrhage and chronic kidney disease. Physician orders for the certification period of 08/26/2025 through 10/24/2025 included skilled nursing visits twice weekly for assessment, physical and occupational therapy services. Patient #24 had a start of care date 08/28/2025 with diagnoses including cardiovascular disease and an aortocoronary bypass graft. Physician orders for the certification period of 08/28/2025 through 10/26/2025 included skilled nursing visits once weekly for assessment and physical therapy services. Patient #25 had a start of care date of 08/06/2025 with diagnoses including cardiovascular disease and an aortocoronary bypass graft. Physician orders for the certification period of 08/06/2025 through 10/04/2025 included skilled nursing visits once weekly for assessment, physical and occupational therapy services. Patient #26 had a start of care date of 08/01/2025 with diagnoses including chronic atrial fibrillation, heart failure and chronic kidney disease. Physician orders for the certification period of 08/01/2025 to 09/29/2025 included skilled nursing visits once weekly for assessment and physical therapy services. Patient #27 had a start of care date of 09/13/2025 with diagnoses including cognitive deficits, type II diabetes and cerebral infarction. The physician orders for the certification period of 09/13/2025 through 11/11/2025 included skilled nursing visits twice weekly for assessment and physical therapy services. Review of the home health agency’s investigation dated 09/18/2025, identified that on 09/16/2025 the responsible caregiver for Patient #22 contacted the agency to report that the Patient did not receive a scheduled skilled nursing visit from Registered Nurse (RN) #1 on 09/16/2025. Agency review of the clinical records for the patients assigned to RN #1, Patients #22 through #27, identified documentation by RN #1 indicating visits were completed on 08/23/2025, 09/02/2025, 09/15/2025 and 09/16/2025; however agency interviews with Patient #22 through #27 confirmed on the 4 identified visits dates, RN #1 did not complete the assigned visits. In addition, there were no GPS (Global Positioning Systems) coordinates to determine RN #1’s location for those identified dates, and the required patient signatures with the patients clinical records to verify the visits were completed. Interview and review of the agency’s investigation with the Administrator on 05/07/2026 at 12:30 PM, confirmed that RN #1 documented completion of home visits for Patient #22 through #27 on 08/23/2025, 09/02/2025, 09/15/2025 and 09/16/2025. The agency indicated, based on patient/caregiver interviews, clinical record audits, review the agency GPS location verification system, and absence of patient signatures for service provision, the agency determined RN #1 engaged in fraudulent documentation practices, and failed to follow the agency’s employee standard of conduct and failed to provide the necessary nursing assessments as directed in the plan of care.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on clinical record reviews, review of agency documentation and interviews with agency personnel for six of twenty-seven patients (Patients # 22 through 27), the home health care agency failed to ensure the accuracy and authenticity of patient documentation by a licensed professional. The findings included: Patient #22 had a start of care date of 08/30/2025 with diagnoses including mild cognitive impairment, type II diabetes, chronic kidney disease and cardiovascular disease. Physician orders for the certification period 08/30/2025 through 10/28/2025 included skilled nursing visits once weekly for nursing assessment. Patient #23 had a start of care date of 08/25/2025 with diagnoses including subdural hemorrhage and chronic kidney disease. Physician orders for the certification period of 08/26/2025 through 10/24/2025 included skilled nursing visits twice weekly for assessment, physical and occupational therapy services. Patient #24 had a start of care date 08/28/2025 with diagnoses including cardiovascular disease and an aortocoronary bypass graft. Physician orders for the certification period of 08/28/2025 through 10/26/2025 included skilled nursing visits once weekly for assessment and physical therapy services. Patient #25 had a start of care date of 08/06/2025 with diagnoses including cardiovascular disease and an aortocoronary bypass graft. Physician orders for the certification period of 08/06/2025 through 10/04/2025 included skilled nursing visits once weekly for assessment, physical and occupational therapy services. Patient #26 had a start of care date of 08/01/2025 with diagnoses including chronic atrial fibrillation, heart failure and chronic kidney disease. Physician orders for the certification period of 08/01/2025 to 09/29/2025 included skilled nursing visits once weekly for assessment and physical therapy services. Patient #27 had a start of care date of 09/13/2025 with diagnoses including cognitive deficits, type II diabetes and cerebral infarction. The physician orders for the certification period of 09/13/2025 through 11/11/2025 included skilled nursing visits twice weekly for assessment and physical therapy services. Review of the home health agency’s investigation 09/18/2025, identified that the responsible caregiver for Patient #22 contacted the agency on 09/16/2025 to report that the Patient did not receive a scheduled skilled nursing visit from Registered Nurse (RN) #1 on 09/16/2025. Further review of the clinical records for Patient #22 through #27 identified documentation by RN #1 indicating visits were completed on 08/23/2025, 09/02/2025, 09/15/2025 and 09/16/2025; however, Patient #22 through #27 confirmed the visits did not occur. In addition, there were no GPS (Global Positioning Systems) coordinates to determine RN #1’s location or the agency required patient signatures within the clinical record to verify the visits were completed. Interview and review of the agency’s investigation and agency documentation with the Administrator on 05/07/2026 at 12:30 PM, confirmed that RN #1 documented home visits for Patient #22 through #27, on 08/23/2025, 09/02/2025, 09/15/2025 and 09/16/2025, but were not performed. Based on the agency’s patient/caregiver interviews, clinical record audits, lack of GPS verification, and absence of patient signatures, the agency determined RN #1 engaged in fraudulent documentation practices by failing to provide timely, accurate and authentic clinical documentation. As a result of the agency’s investigation, RN #1 was terminated on 09/18/2025 and the visits for Patients #22 through #27 were designated as non-billable.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on a review of agency documentation and staff interviews, for one of three patients (Patient #1) reviewed for wound care, the agency failed to ensure wound care was administered in accordance with physician’s orders. The findings include: Patient #1 had a start of care date of 11/05/25 and diagnoses that included chronic obstructive pulmonary disease, acute respiratory failure and osteoporosis. The physician orders dated 11/05/25 included nursing services weekly for assessments. On 12/07/25 at 3:25 PM, a prn/as needed visit was conducted by Registered Nurse/RN #2 after the next of kin notified the agency that the patient sustained a traumatic left tibial wound measuring 3 centimeters/cm x 2.5 cm x 0.2 cm after walking into a wheelchair. Wound care orders included cleansing with normal saline, applying Adaptic (a non-adhering dressing) to the wound bed followed by non-adhering gauze and Kerlix wrap. Interview with RN #1 on 1/15/26 at 11:50 AM indicated that wound care treatment included applying Neosporin (an antibiotic ointment) per the next of kin request, although she indicated that she hadn’t communicated this to the physician, nor did she obtain and order for the application of Neosporin to the wound bed. Review of RN #1’s nursing note dated 1/02/26 indicated that the patient requested discharge, the left shin was progressing towards healing, the wound bed was red and measured 2.5 cm x 1.8 cm x 0.1 cm. Interview and review of the clinical record with the Administrator on 1/15/26 at 1 PM indicated that the nurse should have contacted the physician for the addition of Neosporin to the left shin and failed to ensure wound care was administered in accordance with physician’s orders.”