Triniti Home Health and Hospice

“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 documentation and interview, the facility failed to report all OASIS data collected in accordance with federal regulations. Total number of records submitted beyond the 30 days was nine, which equaled 0.31% of the submissions submitted. On the HHA Error Summary by Agency report period of 1/1/24 - 12/31/2024, the agency had an error code 0f -3330: record submitted late. The description included the submission was more than 30 days after completion on the new record. During an interview on 2/12/25 at 1:07 p.m., clinical manager (CM)-A confirmed the agency staff had problems completing and submitting four of the nine assessments on time. CM-A stated the clinicians completing the assessment did not always complete them in a timely manner or there was miscommunication regarding the readiness for transmission of those four completed assessments. CM-A also confirmed the other five of the nine late Oasis submissions were related to coding errors requiring corrections and resubmissions. The agency policy Encoding and reporting OASIS Data dated February 2010, identified the facility will electronically report all OASIS data collected in accordance with federal regulations including encoding individual client assessment within thirty days of completing the assessment and transmitted within thirty days of the Oasis completion.”

“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 observation, interview and record review the agency failed to ensure provider orders were followed or revised for 1 of 2 patients (P7) reviewed for wound care. Findings include: P7’s plan of care (POC) for certification period 1/23/25-3/23/25, indicated P7 was cognitively intact and had diagnoses of bladder dysfunction and post-polio syndrome. P7’s required skilled nursing (SN) to perform pressure ulcer care to bilateral heels, cleanse with wound cleanser, apply skin prep to area, apply xeroform dressing to wound bed, cover with ABD and secure with roll gauze twice weekly. P7’s SN visit note dated 1/28/25, indicated P7’s wounds on bilateral heels were healed, and no wound care was provided. The note lacked indication P7’s provider was notified, and wound care orders or interventions were updated. P7’s SN visit note dated 1/31/25, indicated P7’s wounds on bilateral heels were healed. P7’s note further indicated the skin was still very fragile and required close monitoring and protective dressings. P7’s heels were cleansed with wound cleanser, patted dry and skin prep was applied to full heel with ABD dressing and gauze. The note lacked indication P7’s provider was notified, and wound care orders or interventions were updated. P7’s SN visit note dated 2/7/25, indicated P7’s skin was intact and bilateral heel wounds had healed and lacked indication wound care was provided. P7’s note lacked indication P7’s provider was notified, and wound care orders or interventions were updated. P7’s electronic medical record lacked indication P7’s provider had been updated or new orders requested. An observation on 2/11/25 at 12:30 p.m., home health aide (HHA)-A assisted P7 with bathing. P7 was in bed with their head of bed elevate. P7’s had no socks on, heels were not wrapped and had no protective dressings in place. When HHA-A washed P7’s feet, P7 stated nursing had only been cleaning the heels. When interviewed on 2/11/25 at 1:10 p.m., HHA-A stated P7’s heels were much better, and it had been a “few weeks” since P7’s heels had dressings or wraps in place. When interviewed on 2/13/25 at 10:20 a.m., the Director of Home Health (DHH) verified P7 had no provider notifications to obtain new orders for P7’s heels. DHH expected staff to update the provider and obtain new orders when wounds have a change or had healed. A facility policy titled Physician Orders revised 8/2023, directed staff to ensure all treatments provided to patients must be ordered by a physician. The policy further directed the staff to review orders for appropriateness and obtain modification of orders when necessary.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on interview and record review the agency failed to ensure the provider was notified of a change in condition for 1 of 1 patients (P15) discharged patients reviewed who required hospitalization. Findings include: P15’s plan of care (POC) for certification period 11/13/24-1/11/25, indicated P15 was cognitively intact and had diagnoses of gastrointestinal bleed, cancer, heart failure and lung disease. Furthermore, P15’s POC indicated P15 required skilled nursing (SN) visits weekly to assess and evaluate P17’s diagnoses to identify changes and to intervene to minimize complications. P15’s SN visit note dated 12/16/24, indicated P15 had diminished lung sounds throughout the left and right lung and severe breathlessness. P15 had a cough with clear/yellow sputum and was short of breath while talking. P15 had reported weakness and fatigue and needed to lean forward to support breathing. P15 declined an ER visit. Furthermore, P15’s note lacked indication P15’s provider was notified. P15’s electronic medical record lacked indication staff had notified P15’s provider of the increased weakness, fatigue and severe breathlessness. When interviewed on 2/13/25 at 10:20 a.m., the Director of Home Health expected staff to notify providers when patient had a change in condition. The director further stated if a patient had a change from baseline, their provider should be notified, and a coordination of care note should be placed detailing the communication. The director verified P15’s, medical record had not indicated P15’s provider was notified of the increased SOB and weakness after the SN visit on 12/16/24. An agency policy titled Medical Supervision revised 8/2023, directed agency staff to promptly report to providers a change in client condition. An agency policy titled Coordination of Client Services revised 8/2023, directed staff to provide the attending provider with an ongoing assessment of the client and identify responses to the client’s services and any care coordination will be documented in the client’s medical record.”