Trinity Health and Home Care Services LLC

“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 record review and interview, the agency failed to transmit completed OASIS assessments to the CMS system within 30 days of completing the OASIS assessment of the beneficiary (patient) for 11% of the assessments transmitted during the period of 1/1/25 to 8/18/25. Failure of the agency to transmit OASIS data within the required time frame prevented the agency’s patient data from being made available to CMS for analysis to identify agency performance levels in the provision of patient care. Findings include: On 8/18/25 at approximately 11:00 am, the surveyor reviewed the agency OASIS HHA Error Summary by Agency report from 1/1/25 through 8/18/25. The error summary report read in part…”Error -3330, record submitted late: The submission date is more than 30 days after M0090 (date the assessment was completed). # (number) of assessments processed, 132.”… 11.36% submitted over 30 days after the M0090 date. An interview was conducted on 8/18/25 with the Administrator. The Surveyor asked the Administrator who was responsible for submitting the OASIS. The Administrator said, “I am.” Surveyor explained to The Administrator that in reviewing the OASIS reports, the agency was late over 11% this year to date. Surveyor asked the Administrator what was his process for submitting the OASIS. The Administrator said, “When the nurse completes the OASIS and locks it, the OASIS goes into a file in the software. Then I create a file with it and transmit it to CMS” The surveyor asked the Administrator how he knows to submit the OASIS. The Administrator said, “The biller looks every day and if there are any ready, I submit them that same day.” The Administrator said, “The nurses must be late because the biller checks every day.” The surveyor asked The Administrator how that could affect patient care. The Administrator said, “The OASIS has all the information that we use to make the plan of care, so the plan of care would be late.” Agency policy 8.10 TIMELINES revised 1/29/2020 read in part:… The Agency will ensure timely provision of services and services to meet the client’s needs in compliance with all federal and state laws and regulations. Agency will also establish timely parameters for all client record information… Encoding and locking OASIS data for the state will be completed within seven (7) days of the completion of the Comprehensive Assessment. Completed, encoded, and locked OASIS data will be transmitted within thirty (30) days of the M0090 date.”

“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 review and interview, the agency failed to ensure the patients’ plan of care was complete and included all the required elements including patient specific interventions in 2 (Patients’ # 1 and 2) of 4 records reviewed with a diagnosis of hypertensive heart disease with heart failure (complications of high blood pressure affecting the heart). These failures placed patients at risk of an exacerbation of heart failure with subsequent emergency room visits and/or hospital re-admissions. Findings include: Patient #1-review of Patient #1 revealed a plan of care dated 5/27/25 through 7/25/25 with a start of care of 5/27/25. The plan of care was electronically signed by the Alternate Supervising Nurse on 5/27/25 with primary diagnosis of hypertensive heart disease with heart failure. The plan of care did not include the interventions for monitoring for heart failure and parameters for reporting to the physician. Patient #2-review of Patient # revealed a plan of care dated 5/27/25 through 7/25/25 with a start of care of 5/27/25. The plan of care was electronically signed by the Alternate Supervising Nurse on 5/27/25 with primary diagnosis of hypertensive heart disease with heart failure (the heart muscle has become thick and stiff due to years of high blood pressure (the force of blood pushing against your artery walls is consistently too high, forcing your heart to work harder to pump blood throughout your body) and cannot pump blood well enough to meet your body’s needs). The plan of care did not include the interventions for monitoring for heart failure and parameters for reporting to the physician. An interview was conducted on 8/18/25 at 2:15 pm with the Alternate Supervising Nurse. The surveyor reviewed the plan of care Patient #1 and Patient #2 with a primary diagnosis hypertensive heart disease with heart failure. The surveyor explained the plan of care failed to include interventions to measure for fluid retention related to heart failure and parameters for reporting. The surveyor asked the Alternate Supervising Nurse how the patients were being monitored for fluid retention related to their heart failure. Alternate Supervising Nurse said, I usually weigh them. Surveyor explained no weights were documented. Alternate Supervising Nurse said, I would also monitor for SOB, edema, cough and do lots of teaching. Surveyor reviewed that no weights were documented indicating Patient #1 or Patient #2 were being monitored for fluid retention. Alternate Supervising Nurse said, “I thought I did but I guess not.” The surveyor asked how not monitoring for fluid retention affect the patient with heart failure. Alternate Supervising Nurse said, “They could have an exacerbation, too much edema, shortness of breath or need to go back to the hospital.” Agency policy 5.7 Care Planning Process revised 1/29/2020 read in part…”The Agency will utilize data/information gathered during patient assessments in the care planning process which involves the identification of patient goals, actions or interventions that will resolve or alleviate the patient’s problems and/or needs. To ensure that care provided is appropriately planned in a timely manner to meet the patient’s specific needs and problems…. The 485, which included the following plan of care elements, is developed in consultation with staff, client, physician, and other providers involved in the client’s care and will serve as the initial plan of care…specific procedures/treatments to be performed…patient specific interventions” …”