Trio Home Care

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on record review and interviews, the agency failed to enforce its written policy that included requirements to document infections patient’s acquired while receiving services from the agency in order to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases for one of two records reviewed with documented infections (Patient 1). The failure could affect the agency’s ability to protect patients from infections. Findings included: Agency policy titled, “Infection Control Program IC.10” with a last reviewed dated of 11/01/2025 read in part, “… Procedure… patient/client infection data will be collected by staff and management. The clinical manager, or designee, will be responsible for receiving, reviewing, and assessing the data… Every patient/client infection will be reported and documented as soon as any Agency staff member is aware of it… All reported infections will be documented on the appropriate Agency form…” Patient 1: Record review of the clinical record included a Plan of Care dated 03/28/2025 to 05/26/2025 with a start of care date of 03/28/2025. The Plan of Care included a primary diagnosis of noninfective gastroenteritis and colitis (swollen digestive tract that food/liquids travel through when they are swallowed, caused by things other than germs/infections). The Plan of Care included Patient 1 had a history of pneumonia (lung infection) but did not include an active diagnosis of pneumonia. The Plan of Care included orders for a Physical Therapist to visit the patient once a week for one week, then twice a week for four weeks, then once a week for four weeks. The record included an order from Nurse Practitioner dated 04/11/2025 that read in part, “… Patient admitted to [Hospital] on 4/8/25 with dx of pneumonia…” The record revealed a post-hospital order from Nurse Practitioner dated 04/14/2025 that included a diagnosis of pneumonia. The order included the medication Cefdinor 300 milligrams by mouth twice daily (antibiotic that fights infection) with a start date of 04/13/2025 and an end date of 04/15/2025 and Macrobid 100 milligrams by mouth twice daily (antibiotic that fights infection) with a start date of 04/13/2025 and an end date of 04/15/2025. The order included for a nurse to visit the patient once a week for five weeks; Physical Therapist to visit once a week for one week; and Occupational Therapist to visit once a week for one week. The record did not include the new diagnosis of pneumonia was documented on the appropriate Agency form. The record revealed an order from Nurse Practitioner dated 04/16/2025 that included a diagnosis of a urinary tract infection (an infection in any part of the urinary system) on 04/10/2025. The record did not include the new diagnosis of urinary tract infection was documented on the appropriate Agency form. In an email sent to the DON on 09/16/2026 at 1:32 pm, the surveyor asked if there were any infection reports for Patient 1 since the start of care date on 03/28/2025. On 09/16/2026 at 1:40 pm, the surveyor received an email from the DON that included an infection report for Patient 1 titled, “QI Event Report” with a date range of 03/28/2025-09/16/2026. The report read in part, “…No data has been returned for your selections.” During an interview with the DON on 09/16/2026 at 1:45 pm, the surveyor asked why infection reports for Patient 1 had not been completed in April 2025 for the new diagnosis of pneumonia and urinary tract infection. The DON stated she had received conflicting information from the agency’s corporate office on when infection reports were to be done and thought they were to be done after antibiotics were completed, not when they were ordered. The surveyor asked if any infection reports had been completed for Patient 1’s infections. The DON stated “No.” The surveyor asked why they were not done. The DON stated infection reports should have been completed for both infections and she was not sure why they were not done. During an interview with the Alt Adm on 09/17/2026 at 1:45 pm, the surveyor asked who was responsible for completing patient infection reports. The Alt Adm stated that ultimately, it was the DON or Administrator. The surveyor asked why infection reports were not completed for Patient 1 and why agency policy was not followed. The Alt Adm stated they were overlooked and if the agency did not supply the reports to the surveyor, then obviously they did not do them.”