Every finding on record at Trinity Angels Healthcare Services Inc

An Emergency Preparedness Recertification Survey was initiated with the Administrator 09/13/2023 at 10:00 AM. Census: Licensed and Certified- 2 Licensed Home Health- 0 Personal Assistance Services- 41 An exit conference was conducted with the Administrator on 09/20/2023 at 1:30 PM. The preliminary findings were discussed. The agency was given an opportunity to provide additional information. The agency was found to be in substantial compliance with the Medicare Conditions of Participation for Emergency Preparedness, no deficiencies were cited.

A Recertification Survey was initiated with the Administrator 09/13/2023 at 10:00 AM. Census: Licensed and Certified- 2 Licensed Home Health- 0 Personal Assistance Services- 41 An exit conference was conducted with the Administrator on 09/20/2023 at 1:30 PM. The preliminary findings were discussed. The agency was given an opportunity to provide additional information. Acronyms/Definitions: Congestive heart failure, or heart failure, is a condition in which the heart can't pump enough blood to the body's other organs. POC- Plan of Care SOC- Start of Care RN- Registered Nurse SN- Skilled Nurse LVN- Licensed Vocational Nurse Pt- patient PRN- as needed CHF- Congestive Heart Failure Wt- weight Bil LE- bilateral lower extremities

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 and interviews, the agency failed to ensure the patients’ plan of care was complete and included all the required elements for 2 (Patient # 2 and 7) of 7 patient records reviewed who received skilled nursing care. These failures potentially placed patients at risk of medication errors, fluid overload and a deterioration in their health status. FINDINGS: Resources: https://www.healio.com/news/cardiology/20210526/congestive-heart-failure-volume-fluid-status According to Healio Cardiology, “an assessment of heart failure includes weight increase …” Patient #2: Record review revealed a POC dated 07/12/2023-09/09/2023 with a SOC 03/14/2023. On page 3, the POC listed 10 medications and physician’s orders for the “… SN to assess patient’s response to new/changed medications, instruct pt/cg in medication regimen, including schedule, purpose, and possible side effects or adverse reactions….” On page 4, the POC included in the Goals section, “… Medication management, Education and skill training…” The POC did not include instructions for the SN to fill the patients’ medication box. The following SN notes signed by the RN, Identifier B, included documentation the RN filled the patients’ medication box: 07/19/23; 08/02/23; 08/09/23; 08/16/23; 08/23/23; and 08/30/23. On 09/19/2023 at 10:30 AM, the surveyor conducted a home visit with Patient #2. During the visit, the surveyor asked the patient about care and services from the agency. The patient stated, “usually the nurse (Identifier B) visits every week and fills my medication box.” In an interview with the Administrator on 09/20/2023 at 12:00 PM, the surveyor reviewed the findings and asked why the POC did not include instructions for the skilled nurse to fill the patient’s medication box. The Administrator stated, “the patient’s family requested for the nurse to fill the patient’s medication box. Yes, I understand why it should be there (on the POC).” Patient #7: Discharge record review revealed a POC dated 06/23/2023-08/21/2023 with a SOC 06/23/2023. On page 1, the POC listed the diagnosis heart disease with heart failure congestive heart failure. On page 3, the POC listed physician orders for the “SN to weigh pt PRN/weekly (check one) …” On page 4, the Goals included, “… Pt. will maintain nutritional status for 60 days as evidenced by no wt gain….” The POC had auto-generated SN instructions but, was not check marked to include instructions for the SN to weigh the patient. A comprehensive assessment dated 06/23/2023 included on page 4, “Height 68 inches and Weight 138 pounds…” Page 10 included, “… (Pt.) Has 2 plus swelling to bil LE. Patient with CHF….” The following SN notes signed by the LVN, Identifier C, did not include an assessment of the patients’ weight: 06/30/23; 07/09/23 and 07/14/23. In an interview with the Administrator on 09/20/2023 at 12:00 PM, the surveyor reviewed the findings and asked why the POC was not check marked to include instructions for the skilled nurse to weigh the patient. The Administrator stated, “nurse mistake.” Agency policy, dated 03/17/2023, 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…. Policy: I. The Agency will use data/information gathered during patient/client assessments in the care planning process… Procedure: … III. Each patient/client must receive an individualized written plan of care … 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; 11. Safety measures to protect against injury; … 14. Patient/client-specific interventions….”