Triunion Healthcare

Approach to service delivery (42 CFR 418.56(a)(1)(iv))

“Observed in Record Review. In 1 of 3 active patient records reviewed, the IDG is does not have all individuals present. On RRNHV #1, it was noted that the IDG did not have the chaplain and Social worker present for the IDG because they have not signed the note. Agency policy for signature of the IDG note is that it will be signed in 2 days and it has now been 4 days. This finding was reviewed with the administrator and CEO.”

Rule L0541. Standard-level.

Governing body and administrator (42 CFR 418.100(b))

Rule L0651. Condition-level.

Clinical records (42 CFR 418.104)

“Observed in Record Review. On review of patient records, it was noted that the organization did not have a technical safeguards in place to ensure accurate secure method for electronic signature. Notes entered into the medical record are pulling the date and time of the event and not the actual date and time the document was signed. This finding was reviewed and discussed in detail with the Administrator and CEO.”

Rule L0670. Condition-level.

EP Training Program (42 CFR 418.113(d)(1)(iii))

“Observed in HR File Review. In 6 of 7 employee files reviewed, there was no documentation to validate staff were provided emergency management training at least every 2 years. On review of HR #1, HR#2, HR #3, HR #5, HR #6, HR #7 it was noted that the last time the employees had training for emergency management was in 2022. This was reviewed in discussion with the Administrator.”

Rule E0037. Standard-level.

Exercise of rights/respect for proprty/person (42 CFR 418.52(b)(1)(i))

Rule L0505. Standard-level.

Content of comprehensive assessment (42 CFR 418.54(c)(7))

Rule L0531. Standard-level.

Approach to service delivery (42 CFR 418.56(a)(1)(iii))

“Observed in Record Review. On 9 of 10 active patient records review, all members of the Interdisciplinary Team did not participate in the IDG. On RRHV #1, RRHV #3, RRNHV #1, RRNHV #2, RRNHV #3, RRNHV #4, RRNHV #5, RRNHV #6 and RRNHV #7, it was noted that the Social worker and Spiritual Counselor was not regularly attending the IDG meetings as evidenced by no signature of attendance to the meeting since admission. This observation was reviewed and discussed with the Administrator.”

Rule L0541. Standard-level.

Content of plan of care (42 CFR 418.56(c)(2))

Rule L0547. Standard-level.

Program data (42 CFR 418.58(b)(2)(ii))

“Observed in Data Session. Upon review of the data management program and QAPI summaries it was noted that the organization was not comparing internal data over time to compare levels of performance, patterns, trends and variations. Each quarter the QAPI summary contained data solely for the quarter reporting and did not compare data over time and there was no summary for the end of year to analyze a trend. This observation was reviewed with the Administrator.”

Rule L0564. Standard-level.

Control (42 CFR 418.60(b)(2)(ii))

“Observed in Data Session. During review of the organization’s infection control plan and data it was noted the organization had not collected data on hand hygiene guideline compliance. It was noted in their QAPI plan they would collect and report the hand data yearly but there is nothing in the minutes to report on this data. This was discussed with the Administrator.”

Rule L0581. Standard-level.

In-service training (42 CFR 418.76(d))

“Observed in HR File Review. On 1 of 1 CHHA HR files reviewed, the organization had not documented that the aide had completed 12 hours of Inservice education. On HR #3, their was no documented monthly education for the aide in her file. This finding was reviewed with the administrator.”

Rule L0620. Standard-level.

Content (42 CFR 418.104(a)(5))

“Observed in Record Review. In 1 of 10 active patient records reviewed, it was noted that the physician CTI was not signed. Agency policy for documentation (5-006.2) states that documentation will be done on day of work and turned in by end of the day which includes signature of note. On RRNHV #4 it was noted that the recert CTI that began over one month ago has not been authenticated by the medical director in the EMR. This was discussed with the Administrator.”

Rule L0676. Standard-level.

Authentication (42 CFR 418.104(b))

“Observed in Record Review. On 1 of 14 patient records reviewed, the organization did not authenticate there notes. Agency policy is that notes will be signed by the end of the day of the visit. On RRBR #2, it was noted that a visit note on day patient passed away 7 months ago was not signed and appropriately authenticated. This finding was reviewed and validated with the administrator who reviewed the note with me.”

Rule L0679. Standard-level.

Criminal background checks (42 CFR 418.114(d)(1))

“Observed in Tracer Activities. On review of the DME and Pharmacy contracts, the contract failed to require criminal background checks for both the DME and pharmacy. This finding was reviewed with agency leadership.”

Rule L0795. Standard-level.