Trek Healthcare

“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 interview and record review, the agency failed to ensure the ordering provider was notified of patient declination of prescribed treatment orders for occupational therapy (OT) services from the original referral for 1 (#4) of 7 sampled patients. Findings include: Patient #4 had a certification period from 1/22/25 to 3/22/25, with a primary diagnosis of acute duodenal ulcer with perforation. Review of patient #4’s referral, dated 1/15/25, showed, “Home Health for PT [Physical Therapy], OT [Occupational Therapy] and BA [Bath Aide].” Review of patient #4’s Start of Care OASIS, dated 1/22/25, showed, “Clinical Statement of Assessment Findings and Recommendations: The patient performed very well during the initial physical therapy evaluation and did not report any adverse s/s [signs and symptoms]. The patient has denied the need for SW [Social Work] but would like a HHA [Home Health Aide] 1x/week at this time to ‘watch and make sure she is safe’.” … The start of care OASIS did not reflect the patient’s declination of OT services. Review of patient #4’s Physician Order, dated 2/4/25, showed, “PT [sic] attempted to contact PCP [Primary Care Physician] regarding referral and SOC [Start of Care] for [Patient #4]. Phone stated, ‘user busy’. The patient will be seen for Physical Therapy at a frequency of 2x/week for the next 8 weeks…” The physician order failed to establish the declination of OT Services. Review of patient #4’s Plan of Care, with a certification period from 1/22/25 to 3/22/25, did not show OT services were provided as prescribed on the ordered start of care. Review of patient #4’s ordered and provided services, from 1/22/25 to 2/13/25, did not show OT services were provided as ordered on the referral for start of care. During an interview on 2/12/25, staff member A stated staff member B completed the start of care. She stated he believed he had made a note the start of care summary about the patient declining the need for OT services. She stated staff member B did not send an updated order to discontinue the OT services. Staff member A stated it was the expectation that any discontinued or refused services were to be communicated to the ordering provider for an updated order. A review of the agency’s policy and procedure, titled, Plan of Care Revision Policy, with no revision date, showed, “Reasons for Plan of Care Revisions: The Plan of Care must be revised when: … There is a change in the prescribed treatment (e.g., medication adjustments, new therapies). New services are required (e.g., additional therapy, home health aide services) …””

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, interview, and record review, the agency failed to adhere to infection control practices regarding hand sanitizing and glove changes, and failed to use an effective product for cleansing equipment for 1 (#5) of 7 sample patients. Findings include: During an observation on 2/12/25 at 12:00 p.m., staff member E changed the dressing and wound vac canister on patient #5’s left ischial tuberosity. Staff member E established a clean barrier for her bag and for the supplies. Staff member E set up supplies and donned clean gloves and removed the gloves, then sanitized her hands and donned clean gloves. Staff member E removed the dressing off the patient’s left ischial tuberosity. Staff member E did not change gloves after removing the dressing. Staff member E opened the dressing packages and placed them on the clean barrier, removed gloves, sanitized her hands and donned clean gloves. Staff member E then put the clean dressing on the patient’s wound and removed gloves. Staff member E did not sanitize her hands before she donned clean gloves. Staff member E then continued to finish the dressing on patient #5’s wound. Staff member E concluded the visit following an assessment including vital signs. When staff member E was finished with the use of her equipment, she cleaned them with alcohol pads. During an interview on 2/13/25 at 12:38 p.m., staff member E stated she cleaned all of her equipment with alcohol pads. During an interview on 2/13/25 at 2:00 p.m., staff member B stated equipment was to be cleaned with Cavi wipes. During an observation of the supply room on 2/13/25 at 2:20 p.m., there were containers of Cavi wipes with a black lid. The directions showed equipment was to be wet for one minute to sanitize. Review of the facility Policy, titled Standard Precautions showed...1. Gloves A. Gloves should be worn when performing wound care...C Gloves are to be changed...1. Between tasks and procedures on the same patient...3. After removing an old dressing... Review of the facility Policy, titled Hand Hygiene...3. Hand decontamination...should be performed...G. After removing gloves...”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure a patient was assessed within 48 hours of the referral; failed to ensure the comprehensive assessment was completed; and failed to initiate the comprehensive plan of care within 5 days of the referral for 1 (#7) of 7 sampled patients. Findings include: Patient #7 had a SOC date of 1/7/25, with a principle diagnosis of Cerebral Infarction. Review of the SOC OASIS showed a referral date of 12/31/24, and a SOC date of 1/7/25. There were seven days between the referral and SOC. Review of the Plan of Care, with a certification date from 1/7/25 to 3/7/25, showed a SOC date of 1/7/25. Review of a physician order, dated 2/4/25, showed patient #7’s SOC may be delayed due to scheduling conflicts. During an interview on 2/13/25 at 2:00 p.m., staff member B stated patient #7 had a late SOC because of staff scheduling.”

“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 interview and record review, the agency failed to complete a medication regimen review to identify any potential adverse medication side effects, including significant medication interactions, and duplicate therapy for 1 (# 4) of 7 sampled patients. Findings include: Patient #4 had a certification period from 1/22/25 to 3/22/25, with a primary diagnosis of acute duodenal ulcer with perforation. Review of patient #4 SOC OASIS, with a (M0090) Date Assessment Completed, of 7/24/24, showed (M2001) Drug Regimen Review: no issues found during review. Review of patient #4’s EMR, did not show a medication interaction profile was completed for the patient at the start of care. Review of the medication interaction completed during the survey on 2/15/25, showed: duplicate therapy identified for Propranolol HCl ER Oral Capsule Extended Release 24 Hour 60 MG and Losartan Potassium Oral Tablet 50 MG. Review of patient #4’s EMR failed to show the responsible provider was notified of any medication interactions at the patient’s start of care. During an interview on 2/13/25 at 11:14 a.m., staff member A stated staff member B completed the start of care. She stated staff member B was under the impression that the RN would review medications and determine any medication interactions. He was not aware of the agency’s policy change which would indicate that the skilled professional completing the start of care would complete the medication interaction. Review of the agency’s policy and procedure titled, Reporting Concerns Regarding Medication Interactions, Provider Notification of Potential Drug Interactions, and Drug Medication Review for Changes at Each Visit, with an effective date of, 12/4/24, showed: “This policy outlines the procedures for reporting medication concerns, specifically regarding drug interactions, provider notification, OASIS M2003 reporting, and drug medication reviews during each visit to ensure patient safety, compliance with CMS regulations, and the provision of quality care. This includes the obligation of home health agency staff to identify, report, and communicate any potential medication-related issues, including drug interactions, to the appropriate healthcare provider… 1. Identification of Medication Concerns: … Duplicate prescriptions or conflicting therapy regimens. 2. Ongoing Medication Review (OASIS M2003): During each home health visit, the medication regimen must be reviewed as part of the OASIS assessment, specifically OASIS M2003 (Current Medication List). This includes a review of all medications the patient is currently taking… - Home health staff must verify that the medication list in the patient’s record is accurate and up-to-date, and they must document any new medications or changes to existing medications. - OASIS M2003 must be updated with any new or changed medications, and any concerns about medication interactions should be documented as part of the clinical visit. 3. Provider Notification of Potential Drug Interactions: If any potential drug interactions are identified during the medication review, the clinician must: • Document the concern in the patient’s medical record, detailing the suspected drug interaction, affected medications, and potential risks. • Notify the physician or prescribing provider as soon as possible, providing relevant details about the interaction and recommended alternatives or modifications. • Follow up with the provider to ensure the issue is resolved and updated orders are received. • If immediate action is required, contact the pharmacy or the prescribing physician for guidance. • Clinicians must escalate concerns to the supervising RN or manager if the issue involves severe reactions, acute risks, or emergency-level concerns. 4. Provider Notification of Potential Drug Interactions: Any time a drug interaction or medication concern is identified, the home health clinician must notify the prescribing provider immediately. Notification should include: • The specific medication(s) involved. • The potential interaction and its risks to the patient. • The patient’s current condition, including any signs or symptoms that may indicate a problem. • A recommended course of action (e.g., adjusting medications, alternative medications, or closer monitoring). - Documentation of all notifications to the provider must be completed in the patient’s record, including the date, time, and manner of communication (e.g., phone call, fax, or email) …””

“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 interview and record review, the agency failed to ensure the individualized plan of care included the frequency and duration of visits to be made by the prescribed services, for 3 (#s 3, 4, and 7); and failed to ensure the ordered skilled nursing services included patient-specific interventions, education, measurable outcomes and goals identified by the agency and the patient, for 1 (#3) of 7 sampled patients. Findings include: 2. Patient #7 had a certification period of 1/7/25 to 3/7/25 with a primary diagnosis of cerebral infarction. Review of patient #7’s Plan of care with a certification period of 1/7/25 to 3/7/25, under orders and treatment, showed an order for aide services: tbd. There was not a frequency or duration of aide visits within the Plan of Care. Review of patient #7’s Aide Care Plan, with a date of 1/7/25 showed the frequency of aide visits was one time per week. During an interview on 2/13/25 at 2:00 p.m., staff member B stated the frequency of aide visits was on the aide care plan, but not on the comprehensive plan of care. Staff member B stated the agency was trying to figure out the frequency of visits. 1. Frequency and Duration of Visits Review of the agency’s policy and procedures titled, Home Health Plan of Care Policy, with an effective date of 10/31/24, showed, “… Plan of Care Requirements: … The Plan of Care must outline all home health services provided, including but not limited to nursing services…” The Plan of Care must include: … Interventions: Specific services to be provided, including frequency and duration…” a. Patient #3 had a start of care of 1/4/24, with a primary diagnosis of Disruption of external operation (surgical) wound. Review of patient #3’s Plan of Care, with a certification period from 12/29/24 to 2/26/25, showed: “… [Skilled Nursing]: [To be determined] …” The patient’s plan of care did not reflect the ordered frequency and duration for the skilled nursing services. b. Patient #4 had a start of care of 1/22/25, with a primary diagnosis of duodenal ulcer with perforation. During an interview on 2/12/25 at 5:00 p.m., staff member A stated it was the expectation that the patient’s plan of care showed the ordered frequency and duration for ordered services. Review of patient #4’s Plan of Care with a certification period from 1/22/25 to 3/22/25, showed, “… Patient’s [Activities of Daily Living/Instrumental Activities of Daily Living] needs will be met with assistance of [Home Health Aide] …” The patient’s plan of care did not reflect the ordered frequency and duration for the ordered home health aide services. 2. Patient-Specific Interventions, Goals, and Outcomes Review of the agency’s policy and procedures titled, Home Health Plan of Care Policy, with an effective date of 10/31/24, showed, “…This policy ensures that all patients receiving home health services at [Agency Name] have an individualized Plan of Care (POC) developed, implemented, and regularly reviewed in accordance with CMS and state regulations. The Plan of Care ensures that the services provided are medically necessary, tailored to meet the patient’s needs, and include specific goals, interventions, and outcomes. It is a living document that is updated regularly to reflect the patient’s progress, needs, and changing conditions...” a. Patient #3 had a start of care of 1/4/24, with a primary diagnosis of Disruption of external operation (surgical) wound. Review of patient #3’s Plan of Care, with a certification period from 12/29/24 to 2/26/25, did not include the patient-specific interventions, education, measurable outcomes and goals identified for the ordered skilled nursing services to provide. During an interview on 2/12/25 at 5:00 p.m., staff member A stated it was the agency’s expectation to follow the agency’s policy and procedure for developing the plan of care for every patient.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on interview and record review, the agency failed to revise the patient’s Plan of Care with treatment orders for ordered wound care for 1 (#3) of 7 sampled patients. Findings include: Review of the agency’s policy and procedure titled, Plan of Care Revision Policy, with no revision date, showed, “1. Reason for Plan of Care Revisions: The Plan of Care must be revised when: … There is a change in the prescribed treatment (e.g., medication adjustments, new therapies.) … “ Patient #3 had a certification period from 12/29/24 to 2/26/25, with a primary diagnosis of Disruption of external operation (surgical) wound Review of patient #3’s Physician Orders showed wound care orders, from the wound clinic, dated 1/10/25, 1/17/25, and 1/28/25. Review of patient #3’s Plan of Care, with a certification period from 12/29/24 to 2/26/25, did not reflect the revised wound care orders from 1/10/25, 1/17/25, and/or 1/28/25. During an interview on 2/12/25 at 5:00 p.m., staff member A stated it was the expectation that the Plan of Care reflect any new or current treatment orders.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the supervisory visit of the Home Health Aide (HHA) was completed and documented in the patient medical record every 14-days for 1 (#3) of 7 sampled patients. Findings include: Review of patient #3’s Plan of Care, with a certification period from 12/29/24 to 2/26/25, showed an order for HHA visits for one time a week for eight weeks. Review of patient #3’s HHA Visits showed the HHA visited the patient on the following dates: - 12/29/24 - 12/31/24 - 1/8/25 - 1/10/25 - 1/15/25 - 1/17/25 - 1/22/25 - 1/24/25 - 1/29/25 - 1/31/25 - 2/5/25 - 2/7/25. Review of patient #3’s Skilled Nursing Visits from 12/30/24 to 2/10/25, did not show supervisory visits of the HHA were completed and documented. During an interview on 2/13/25 at 11:14 a.m., staff member A stated staff member E stated she did complete the supervisory visits of the HHA, but did not document the supervisory visits in the patient’s chart. A request was submitted on 2/12/25 at 5:00 p.m., for the agency’s policy and procedure for supervisory visits of the HHA. This documentation was not provided by the end of the survey on 2/13/25 at 2:30 p.m.”