Trinity Home Health

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on Centers for Medicare & Medicaid Services (CMS) Home Health Agency (HHA) Error Summary by agency report, staff interview, and policy titled “Oasis Data Capture, Transmission, Verification, Display and Reports,” it was determined that the agency failed to electronically transmit monthly Outcome and Assessment Information Set (OASIS) data collected to the CMS system every 30. Failure to submit OASIS within 30 days has the potential to cause delay in care and affect quality of care for all patients with late OASIS submission. The Findings include: Review of the policy titled “OASIS Data Capture, Transmission, Verification, Display and Reports,” last revised 03/01/2021, revealed the following: 1e. “Once an OASIS data set passes the OASIS edit check program, the OASIS data set will be reserved to prevent subsequent editing. The reserving mechanism ensures the stability of the patient assessment data at the time point of the assessment. The reserving mechanism prevents the override of current assessment information with future or past information without specific documentation as to why the assessment is being opened. All assessments will be reserved and transmitted within 30 days of the M0090 date”. Review of CMS HHA Error Summary by agency report ran on 02/11/2025 for period 01/01/2024 to 12/31/2024 revealed the agency failed to transmit OASIS data to the CMS system within 30 days. On 2/24/2025 at 3:56 p.m., an interview was conducted with the Administrator who stated that the agency was bought by a new company and during the transition the OASIS was transmitted late. The Administrator confirmed awareness of the 30-day OASIS submission time limit requirements not met during the time frame of 01/01/2024 to 12/31/2024.”

“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 reviews, and staff interviews, and agency policy “Plan of Care (POC),” it was determined the agency failed to include goals, and interventions with a diagnosis of end stage renal disease (a medical condition in which a person’s kidneys are no longer able to function adequately on their own and requires dialysis or kidney transplant to maintain life) for one patient (P) (P#16) of 17 sampled patients. The Findings include: Review of the policy titled “Plan of Care (POC) (Policy Number: 2.1.007),” revised 009/01/24, reveals the following: Policy: “Each patient has an individualized Plan of Care (POC) developed in consultation with the patient, physician or authorized practitioner, and staff that integrates comprehensive assessment findings to address patient’s problems, needs, and goals, as well as to address specific services being provided”. PROCEDURE: 2. The POC includes: h. Pertinent diagnosis (es). i. Patient specific interventions and education; measurable outcomes and goals identified by the agency and patient. Review of the plan of care (POC) for P#16 (certification period (start of care) of 2/8/2024 to 4/7/2024) revealed P#16 was admitted to the Home Health agency on 2/28/2024, with a diagnosis of end stage renal disease. The agency failed to address goals, and interventions, on the POC to assess and monitor the fistula (connection that a surgeon makes between an artery and a vein to make it possible for you to receive hemodialysis) on left upper arm site for dialysis for bleeding and signs of infection. During an interview on phone with Registered Nurse (RN) DD on 2/25/2025 at 2:15 p.m., RN DD confirmed that the agency failed to address intervention on diagnosis of end stage renal disease on P#16, POC, because she was not aware that she had to obtain order to assess and monitor for bleeding and infection at fistula site. During an interview on phone with RN EE on 2/25/2025 at 2:58 p.m., RN EE confirmed that the agency failed to address intervention on diagnosis of end stage renal disease on P#16, POC, because she was not aware that she had to include it (intervention). On 2/4/2025 at 3:38 p.m., an interview conducted with the Administrator, who acknowledged that she failed to correct or include intervention for the diagnosis of end stage renal disease for P#16.”

“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 record reviews, and staff interviews, it was determined that the skilled nurse (SN) failed to perform treatments as ordered by a physician for two patients (P) (P#1, P#2) of 17 sampled patients. The Findings include: 1. Review of plan of care (POC) for P#1 (certification period of 1/25/2025 to 3/25/2025) revealed P#1 was admitted to the Home Health agency on 1/25/2025. Review of records for P#1 reveals a stage one wound on sacral area (bottom of the spine). The POC revealed that the skilled nurse would perform wound care as follows: Skilled nurse to perform and instruct patient and caregiver procedure of wound care to sacral area daily and as needed; irrigate and cleanse with soap and water; apply barrier cream (a cream use to protect irritants and prevent skin breakdown). Review of the POC and nursing visit notes failed to reveal the skilled nurse performed wound care to sacral area. Licensed Practical Nurse (LPN) AA failed to perform stage 1 sacral wound area as ordered by physician. During an interview on phone with LPN AA on 2/25/2025 at 12:20 p.m., LPN AA confirmed that she failed to perform stage 1 sacral wound because she was not aware of the wound care order written in P#1 POC; she just performed the right upper arm wound care. On 2/25/2024 at 1:09 p.m., an interview was conducted with the Administrator who acknowledged that LPN AA failed to follow physician’s order. 2. Review of the plan of care (POC) for P#2 (certification period of 1/21/2025 to 3/21/2025) revealed P#2 was admitted to the Home Health agency on 1/21/2025, with a diagnosis of type 2 diabetes mellitus (inability to produce enough insulin results in high blood sugar). Review of records for P#2 revealed P#2 was taking two insulins (HUMULIN 70/30 inject 10 units subcutaneous twice daily, and Novolin 15units subcutaneous daily), (insulin is used to lower high blood glucose). The plan of care (POC) failed to reveal order to monitor blood sugar for P#2. During an interview on phone with Registered Nurse (RN) BB on 2/25/2025 at 1:30 p.m., RN BB confirmed that she just missed it, (that is, she failed to obtain order to check P#2 blood sugar). On 2/25/2025 at 2:46 p.m., an interview conducted with the Administrator who acknowledged that RN BB failed to obtain order to check P#2’s blood sugar.”