Trinity Inspired Home Health Care Agency

“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, observation and interviews, the agency failed to ensure the patient plan of care was complete and included all required elements for 1 (Patient #1) of 1 patient whose POC included the diagnosis of Congestive Heart Failure and 1 (Patient #5) of 1 patient who received weekly renal dialysis treatments. (Dialysis: process of removing excess water and toxins from the blood when kidneys can no longer perform the functions naturally.) This failure potentially placed the patients at risk of infection and complications when the SN did not have instructions to assess the patients for excessive fluid and signs/symptoms of a failing dialysis access site. FINDINGS INCLUDE: CHF assessing for signs and symptoms: referenced 05/26/2021 https://www.healio.com/news/cardiology/20210526/congestive-heart-failure-volume-fluid-status According to Healio Cardiology, assessment of CHF includes: weight increase, shortness of breath, pitting edema (swelling due to excessive fluid accumulation in body tissues), jugular vein distension and ascites (distended or tense abdomen). Lippincott Procedures- Hemodialysis access care, home care, revised 2020, the access site should be assessed for swelling, change in color or temperature, drainage, auscultated (listen with a stethoscope) for the presence of a bruit (a “whooshing” sound) and palpated (felt) for a thrill (vibration sensation). Never measure the patient’s blood pressure on the extremity with the AV access. Patient #1: Record review revealed a POC dated 10/21/2024-12/19/2024 with a SOC 10/21/2024. The POC included the following diagnoses: Atrial Fibrillation (an irregular or abnormal heartbeat); Congestive heart failure (a long-term condition that occurs when the heart can’t pump enough blood to meet the body’s needs) and Chronic obstructive pulmonary disease (a condition of the airways that causes difficulty or discomfort in breathing). Physician orders included SN frequency once a week for nine weeks. Review of the record did not reveal any additional physician order for SN to assess the patient’s edema. The POC did not include instructions for the SN to assess edema for Patient #1. During a home visit interview with Patient #1 on 01/03/2025 at 8:00 AM, the surveyor asked about the care and services received by the agency and staff nurse. Patient #1 stated he liked the nurse who visited and said she checked his blood pressure and weight. She also filled his medication pill box. In an interview with the Administrator/LVN A on 01/03/2025 at 3:10 PM, the surveyor reviewed the findings and the POC. The surveyor asked if there was an order from the physician for the SN to assess the patient’s weight and edema? The Administrator/LVN-A reviewed Patient #1’s POC and stated, “I do them, but I don’t see it on here (POC), to assess for edema or weights. She (AA) didn’t put it on this one. It should have been on there.” On 01/03/2025, AA was unable to be reached for interview. The Administrator stated AA worked in an Emergency Room on Fridays and was not easily accessible to talk on the phone. Patient #5: Record review revealed a POC dated 10/06/2024-12/04/2024 with a SOC 10/12/2023. The POC included the following diagnoses: Hypertension; Diabetes Mellitus type 1; End stage renal disease (kidney failure) and renal dialysis. Physician orders included SN frequency once a week for nine weeks. Review of the record did not reveal any additional physician order for SN to assess the patient’s AV shunt. The POC did not include instructions for the SN to assess the patient’s AV shunt. An undated recertification assessment was completed for the period 10/06/2024-12/04/2024. Included on page 4, under the Cardiovascular section, “Other, Arteriovenous Fistula/Shunt R&L Arm…” During a home visit interview with Patient #5 on 01/03/20254 at 9:15 AM, the surveyor asked Patient #5 about the care and services received from the agency. Patient #5 stated a nurse visited once weekly to, “check my feet, shunt and blood sugar, she just watches the (blood sugar) monitor I wear.” The Patient stated she received dialysis three times weekly and showed the surveyor her Right upper arm where the current A/V shunt was placed and used. In an interview with the Administrator on 01/03/2025 at 3:10 PM, the surveyor reviewed the findings and the POC. The surveyor asked if there was an order from the physician for the SN to assess the patient’s weight and edema? The Administrator/LVN-A reviewed Patient #5’s POC and stated, “It’s not in there, I have no idea why it’s not in there.” The surveyor asked how this failure could affect the patients. The administrator stated, “the patient is alert and she can tell a nurse to assess it (A/V shunt). If the patient could not tell the SN, it would be problem.” Agency policy, dated 05/02/2024, quoted in part, “Plan of Care, PC.35, Purpose: To ensure that care provided is appropriately planned in a timely manner to meet the patient’s/client’s specific needs and problems…. Procedure: … III. … The individualized Plan of Care must specify the care and services necessary to meet the patient/client-specific needs as identified in the comprehensive assessment, … A. The individualized Plan of Care must include the following: … 10. All medications and treatments; …””

“Documentation of competency evaluation CFR(s): 484.80(c)(5) The HHA must maintain documentation which demonstrates that the requirements of this standard have been met. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure documentation of the tasks listed at 484.80(b)(3)(i),(iii), (ix), (x) and (xi) were evaluated by direct observation of the hha performance of the tasks for 1 (hha D) of 1hha personnel records reviewed. No evidence of documentation was found for observed skills competencies completed. This failure potentially placed patients who received hha services at risk for receiving substandard or unsafe care from hha’s when competency could not be verified. FINDINGS INCLUDE: Hha, D: Review of the personnel record for hha D revealed job description for the position of hha dated 09/19/2022 and signed by hha D. A completed form titled, “Home Health Aide Competency Evaluation- Written Exam” was dated 09/19/2022. No hha observed skills competency verification was found in the record for hha D. In an interview with the Administrator on 01/03/2025 at 3:10 PM, the surveyor reviewed the findings and asked if hha D performed a skills competency. The Administrator stated, “she (Alternate Administrator/DON) does the hands-on stuff when she’s in the office, it’s (hha skills competency documentation) just not in the personnel record. Agency policy, dated 05/01/2024, quoted in part, “Home Health Aide Competency Evaluation, HR. 45, Purpose: To establish competency evaluation checklists for both written and skills demonstration. … Procedure: … III. Subjects Addressed in the Competency Evaluation, A. The following subject areas must be evaluated by observing a home health aide’s performance of the task with a patient/client or pseudo-patient/client: 1. Communication skills, including the ability to read, write, and verbally report clinical information to patients/clients, representatives, and caregivers, as well as to other agency staff 2. Reading and recording temperature, pulse, and respiration 3. Appropriate and safe techniques in performing personal hygiene and grooming tasks that include: a. Bed bath b. Sponge, tub, and shower bath c. Hair shampooing in sink, tub, and bed d. Nail and skin care e. Oral hygiene f. Toileting and elimination 4. Safe transfer techniques and ambulation 5. Normal range of motion and positioning. … V. The completed competency evaluations will be kept in the employee’s personnel file … “”