Every finding on record at Trinity Central Home Health LLC

On 03/03/2025 at 12:15 PM, an entrance conference was conducted with Agency Representatives. The Agency was informed the purpose of the visit was to conduct a Medicare recertification Survey for compliance with 42 CFR Part 484 Conditions of Participation for Home Health Agencies. On 03/07/2025 at 10:20 AM, an exit conference was conducted with Agency Representatives. Preliminary findings of the survey were discussed.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: The HHA must follow accepted standards of assessment and formulate individualized Plan of Care with the Physician or Practitioner to fulfill the needs of each patient and assure each patient gets the care they need in each individuals situation or ability to communicate. Findings Follows: Based on clinical record review, it was determined the HHA (Home Health Agency) failed to create an individualized POC (Plan of Care) in 1 (#2) of 18 (#1-#18) charts reviewed. If not corrected, this has the ability to impact all patients on census who cannot communicate verbally by creating a barrier to, and thus leaving out, the patient's ability to be an integral part of creating their plan of care with their healthcare team. 1.A Plan of Care with certification dates from 01/07/2025-03/07/2025. Per the Psychosocial section ..."the patient is nonverbal." This same POC had SN (Skilled Nurse) Intervention to ..."report to physician unrelieved pain of >7 on 0-10 scale." 2. Skilled Nurse Visit note dated 01/08/2025 had documentation that, "...Patient is nonverbal and doesn't respond to skilled nurse by movements or eye contact." 3. Skilled Nurse Visit note dated 01/26/25 showed the nurse instructed "patient/cg (caregiver)...to report pain levels of 7/10 or higher to SN."

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observations during home visits, staff interview, review of the Agency’s Infection Control Plan, Agency Policy for providing PICC care, Center for Disease Control (CDC) guidelines, the Skilled Nurse (SN) failed to follow accepted professional standards for infection control in 1 (#1) of 7 home visits observed (#1-#7). This failed practice had the potential to place the patient at risk for a PICC (Peripheral Inserted Central Catheter) or systemic infection. The deficient practice identified, if continued, potentially placed all patients with PICC's at risk of adverse outcomes and hospitalization. During a home visit on 03/05/2025 at 11:10 AM, this surveyor observed the SN (Skilled Nurse) attempt to perform a sterile PICC Dressing Change for Patient #1. Patient #1 was seated in a dining room chair with his head turned to the right. SN opened the PICC dressing kit set in a sterile fashion. She handed Patient #1 a mask and assured he had placed it over his mouth and nose correctly, then SN donned a mask as well. SN donned clean gloves and began swabbing the edges of the transparent dressing covering the PICC to loosen the old dressing. SN then removed the old transparent dressing and the soiled Bio-patch (an antimicrobial foam disc that fits around the PICC tube where it enters the patient's arm). SN then changed into sterile gloves and began scrubbing the area where the transparent dressing was, as well as around the PICC tube itself. SN then returned back to the sterile field to retrieve tape to secure the PICC as the Stat-Loc (an adhesive device meant to stick to the skin while also holding the PICC catheter tube secure so it won't be pulled out accidentally) was removed during the cleaning. SN secured the PICC tube to the patient's skin. SN went back to the sterile field to retrieve a paper measuring tape (used to assure the PICC hasn't accidentally been pulled out partially and to measure the circumference on the patient's arm (this is part of a standard practice to assure there is no swelling to the arm where the PICC is). SN turned back towards the patient to measure the arm, but SN dropped the paper measuring tape. SN retrieved the tape with the sterile gloves. SN then changed into clean gloves, opened an alcohol wipe and began cleaning the PICC area, thus contaminating the area by wearing clean gloves. SN continued to place a new stat-loc and Bio-patch, then a sterile transparent dressing. This surveyor alerted Agency Administration about the lack of sterility of the dressing and a different SN was sent to change the dressing. During an interview with agency staff #1, Infection Control Policy and the Agency written PICC procedure were obtained. Agency Staff #1 concurred that PICC care is a sterile procedure.

On 07/19/2022 at 8:50 AM an entrance conference was conducted with Agency Representatives. The Agency was informed the purpose of the visit was to conduct a Medicare Recertification survey for compliance with the Conditions of Participation for Home Health. On 7/21/2022 at 11:50 AM an exit conference was conducted with Agency Representatives. Preliminary findings of the survey were discussed.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: This was a repeat deficiency from the previous Recertification survey 1/17/2019. Based on clinical record review and staff interviews, it was determined the Skilled Nurse (SN) failed to update and check for interactions for one (#1) of 10 (#1-#10) clinical records reviewed. This failed practice by the SN posed a risk to all patients on census receiving chemotherapy (medication used to treat cancer) medications by inhibiting the Nurse and Physician's ability to make informed decisions regarding the patient's medication regimen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. 1. Review of clinical record #1 revealed the following: A. Document titled "Skilled Nurse Note" dated 06/27/2022, SN documented the patient report of beginning IV (intravenous) chemotherapy (medication to treat cancer) treatment on 6/22/22. B. There is no evidence in the record showing an updated medication list or any communication attempts made by SN or Agency Staff to obtain the medication information from Oncologist's (a Physician specializing in cancer treatments) clinic. C. Agency Staff #2 confirmed there was no chemotherapy medications added to the patient's medication list.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on Clinical Record Review and staff interviews, it was determined the Occupational Therapist (OT) failed to follow physician's orders by not alerting him/her for an SPO2 (pulse oximetry) below 90% in 1 (#1) of 10 (#1-#10) records reviewed. This failure to follow physician's orders had the potential to affect all patients on census in that it is a missed opportunity to reassess, make changes to the POC and/or prevent rehospitalization. Review of Clinical Record #1 revealed the following: 1. A document titled "Plan of Care" dated 06/15/22 through 08/13/2022 lists a physician order to "Report to MD if SPO2 (pulse oximetry OR a measurement of oxygen saturation in the body) is less than 90%. 2. A document titled "MED-PASS Therapy NOTE dated 06/27/2022, Occupational Therapist documented SPO2 as 85%. 3. A document titled "MED-PASS Therapy NOTE dated 06/28/2022, Occupational Therapist documented SPO2 as 78%. 4. There is no evidence in the record to indicate the physician was notified. 5. Interview with Agency Staff #2 confirmed the physician was not contacted. 6. The record indicated patient #1 was transferred to the hospital secondary to respiratory distress/respiratory failure.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: This is a repeat deficiency from Recertification survey 1/17/2019 Based on Clinical Record Review and staff interview, the agency failed to alert the Physician to changes in patient's condition which may have necessitated a change to the patients Plan of Care (POC) or treatment in one (#1) of 10 (#1-#10) records reviewed. This failed practice resulted in the physician being unaware of worsening respiratory symptoms and resulted in missed opportunities for changes in the POC which may have prevented hospitalization. Review of Clinical Record #1 revealed the following: 1. Plan of Care (POC)with certification dates 06/15/2022 through 08/13/2022 lists a physician's order to notify him/her if the patient's pulse oximetry (a reading taken to check oxygen saturation) falls below 90%. 2. A document titled "MED-PASS Therapy Visit Note" dated 06/27/2022 shows the Occupational Therapist (OT) recorded a pulse oximetry of 85%. 3. A document titled "MED-PASS Therapy Visit Note" dated 06/28/2022 shows the OT recorded a pulse oximetry of 78%. 4. There was no evidence in the patient's record to indicate the physician or the Registered Nurse had been notified. 5. Patient was transferred to hospital on 06/28/2022 with Respiratory Failure/Distress. 6.During interview, Agency Staff #2 denied there was any contact made to the physician or the Registered Nurse.