Every finding on record at Trinity Health and Home Care Services LLC

A recertification survey was completed on 8/22/25. Agency census: Licensed Home Health – 0 Licensed and Certified Home Health – 16 Personal Assistance Services – 6 No violations cited.

A recertification survey was completed on 8/22/25. Agency census: Licensed Home Health – 0 Licensed and Certified Home Health – 16 Personal Assistance Services – 6 Abbreviations: OASIS – Outcome and Assessment Information Set CMS – Centers for Medicare and Medicaid Services SOB – shortness of breath HHA – Home Health Agency

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to transmit completed OASIS assessments to the CMS system within 30 days of completing the OASIS assessment of the beneficiary (patient) for 11% of the assessments transmitted during the period of 1/1/25 to 8/18/25. Failure of the agency to transmit OASIS data within the required time frame prevented the agency's patient data from being made available to CMS for analysis to identify agency performance levels in the provision of patient care. Findings include: On 8/18/25 at approximately 11:00 am, the surveyor reviewed the agency OASIS HHA Error Summary by Agency report from 1/1/25 through 8/18/25. The error summary report read in part…”Error -3330, record submitted late: The submission date is more than 30 days after M0090 (date the assessment was completed). # (number) of assessments processed, 132.”… 11.36% submitted over 30 days after the M0090 date. An interview was conducted on 8/18/25 with the Administrator. The Surveyor asked the Administrator who was responsible for submitting the OASIS. The Administrator said, “I am.” Surveyor explained to The Administrator that in reviewing the OASIS reports, the agency was late over 11% this year to date. Surveyor asked the Administrator what was his process for submitting the OASIS. The Administrator said, “When the nurse completes the OASIS and locks it, the OASIS goes into a file in the software. Then I create a file with it and transmit it to CMS” The surveyor asked the Administrator how he knows to submit the OASIS. The Administrator said, “The biller looks every day and if there are any ready, I submit them that same day.” The Administrator said, “The nurses must be late because the biller checks every day.” The surveyor asked The Administrator how that could affect patient care. The Administrator said, “The OASIS has all the information that we use to make the plan of care, so the plan of care would be late.” Agency policy 8.10 TIMELINES revised 1/29/2020 read in part:… The Agency will ensure timely provision of services and services to meet the client’s needs in compliance with all federal and state laws and regulations. Agency will also establish timely parameters for all client record information… Encoding and locking OASIS data for the state will be completed within seven (7) days of the completion of the Comprehensive Assessment. Completed, encoded, and locked OASIS data will be transmitted within thirty (30) days of the M0090 date.

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 review and interview, the agency failed to ensure the patients' plan of care was complete and included all the required elements including patient specific interventions in 2 (Patients’ # 1 and 2) of 4 records reviewed with a diagnosis of hypertensive heart disease with heart failure (complications of high blood pressure affecting the heart). These failures placed patients at risk of an exacerbation of heart failure with subsequent emergency room visits and/or hospital re-admissions. Findings include: Patient #1-review of Patient #1 revealed a plan of care dated 5/27/25 through 7/25/25 with a start of care of 5/27/25. The plan of care was electronically signed by the Alternate Supervising Nurse on 5/27/25 with primary diagnosis of hypertensive heart disease with heart failure. The plan of care did not include the interventions for monitoring for heart failure and parameters for reporting to the physician. Patient #2-review of Patient # revealed a plan of care dated 5/27/25 through 7/25/25 with a start of care of 5/27/25. The plan of care was electronically signed by the Alternate Supervising Nurse on 5/27/25 with primary diagnosis of hypertensive heart disease with heart failure (the heart muscle has become thick and stiff due to years of high blood pressure (the force of blood pushing against your artery walls is consistently too high, forcing your heart to work harder to pump blood throughout your body) and cannot pump blood well enough to meet your body’s needs). The plan of care did not include the interventions for monitoring for heart failure and parameters for reporting to the physician. An interview was conducted on 8/18/25 at 2:15 pm with the Alternate Supervising Nurse. The surveyor reviewed the plan of care Patient #1 and Patient #2 with a primary diagnosis hypertensive heart disease with heart failure. The surveyor explained the plan of care failed to include interventions to measure for fluid retention related to heart failure and parameters for reporting. The surveyor asked the Alternate Supervising Nurse how the patients were being monitored for fluid retention related to their heart failure. Alternate Supervising Nurse said, I usually weigh them. Surveyor explained no weights were documented. Alternate Supervising Nurse said, I would also monitor for SOB, edema, cough and do lots of teaching. Surveyor reviewed that no weights were documented indicating Patient #1 or Patient #2 were being monitored for fluid retention. Alternate Supervising Nurse said, “I thought I did but I guess not.” The surveyor asked how not monitoring for fluid retention affect the patient with heart failure. Alternate Supervising Nurse said, “They could have an exacerbation, too much edema, shortness of breath or need to go back to the hospital.” Agency policy 5.7 Care Planning Process revised 1/29/2020 read in part…”The Agency will utilize data/information gathered during patient assessments in the care planning process which involves the identification of patient goals, actions or interventions that will resolve or alleviate the patient’s problems and/or needs. To ensure that care provided is appropriately planned in a timely manner to meet the patient’s specific needs and problems…. The 485, which included the following plan of care elements, is developed in consultation with staff, client, physician, and other providers involved in the client’s care and will serve as the initial plan of care…specific procedures/treatments to be performed…patient specific interventions” …

A recertification survey was initiated on 8/23/2022. The census was: LCHH-7 LHH-0 PAS-15 Total agency census: 22

A recertification survey was initiated on 8/23/2022. The census was: LCHH-7 LHH-0 PAS-15 Total agency census: 22 Abbreviations PAS-personal assistance services LHH-Licensed Home Health LCHH-Licensed and Certified Home Health POC-Plan of Care SN-Skilled Nursing Services EMR-electronic medical record RN – Registered Nurse mm Hg - millimeters of mercury MD – Medical Doctor (Physician)

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: Based on record review and interview the agency failed to ensure the physician orders per the plan of care were executed as written in 4 (Patient #2, #4, #6, & #7) of 7 Medicare patients charts reviewed. The failure placed the Patients at risk of hospitalization and/or exacerbation of hypertension. Findings include: Patient #2 Record review of Patient #2’s chart revealed a start of care of 4/11/2022 with a plan of care for an episode from 5/31/2022 through 7/21/2022. The primary diagnosis was listed as Low vision right eye/Low vision left eye and essential hypertension. The plan of care ordered skilled nursing visits 1 time a week for 9 weeks. Skilled nurse to notify physician for parameters for blood pressure as follows: : systolic blood pressure greater than 160 or less than 90 and diastolic blood pressure greater than 90 or less than 50. RN #1 provided skilled nursing visits on 6/2/2022, 6/9/2022, 6/16/2022, 6/24/2022, 6/30/2022, 7/5/2022, 7/14/2022, 7/21/2022 and 7/27/2022. Patient #2’s blood pressure was out of parameters on: 6/9/2022 at 180/118 mm Hg, 6/30/2022 at 152/96 mm Hg,, 7/5/2022 at 150/93 mm Hg, , and 7/14/2022 at 160/97 mm Hg,. The skilled nurse’s notes included a section “MD notified” with “NO” indicated on each one. Further review of the record failed to reveal documentation RN #1 followed orders in the plan of care to report out of parameters blood pressure readings to Patient #2’s physician. An interview was conducted on 8/26/2022 at 3:50 pm with RN #1. The surveyor asked RN #1 why the blood pressure out of ordered parameters on Patient #2 were not reported to the physician. RN #1 said, “I will have to go back and take a look at that. (nurses notes). Patient #4 Record review of Patient #4’s chart revealed a start of care of 11/7/2020 with a plan of care for an episode from 5/1/2022 through 6/29/2022. The primary diagnosis was listed as atherosclerotic of the native coronary artery without angina pectoris and hypertension. The plan of care ordered skilled nursing visits 1 time a week for 9 weeks. Skilled nurse to notify physician for parameters for blood pressure as follows: systolic blood pressure greater than 160 or less than 90 and diastolic blood pressure greater than 90 or less than 50 and pulse less than 60 or greater than 110. RN #1 provided skilled nursing visits on 5/4/2022, 5/13/2022, 5/20/2022, 5/27/2022, 6/3/2022, 6/10/2022, 6/17/2022, 6/24/2022 and 6/29/2022. Patient #4’s vitals were out of parameters on: 5/13/2022 blood pressure was 88/75 mm Hg, and pulse was 55, 6/3/2022 blood pressure was 84/64 mm Hg,, and 6/17/2022 blood pressure was 102/55 mm Hg, . The skilled nurse’s notes included an MD notified with “NO” indicated on each one. Further review of the record failed to reveal documentation RN #1 followed orders in the plan of care to report out of parameters blood pressure readings to Patient #4’s physician. An interview was conducted on 8/26/2022 at 3:50 pm with RN #1. The surveyor asked RN #1 why the blood pressures out of parameters on Patient #4 were not reported to the physician. . RN #1 said the doctor is aware because the nurse practitioner also sees the patient as well. Patient #6 Record review of Patient #6’s chart revealed a start of care of 10/5/2021 with a plan of care for an episode from 6/2/2022 through 7/31/2022. The primary diagnosis was listed as hypertension. The plan of care ordered skilled nursing visits 1 time a week for 8 weeks. Skilled nurse to notify physician for parameters for blood pressure as follows: systolic blood pressure greater than 160 or less than 90 and diastolic blood pressure greater than 90 or less than 50. RN #1 provided skilled nursing visits on 6/8/2022, 6/15/2022, 6/22/2022, 6/29/2022, 7/6/2022, 7/14/2022, 7/21/2022 and 7/29/2022. Patient #6’s blood pressure was out of parameters on 6/8/2022 at 134/101 mm Hg,. The skilled nurse’s notes included an MD notified with “NO” indicated on each one. Further review of the record failed to reveal documentation RN #1 followed orders in the plan of care to report out of parameters blood pressure readings to Patient #6’s physician. An interview was conducted on 8/26/2022 at 3:50 pm with RN #1. The surveyor asked RN #1 why the blood pressures out of ordered parameters were not reported to the physician. RN #1 said she may have overlooked documenting what she did. Patient #7 Record review of Patient #7’s chart revealed a start of care of 11/7/2020 with a plan of care for an episode from 3/2/2022 through 4/30/2022. The primary diagnosis was listed as osteoarthritis of bilateral hips with hypertension as well. The plan of care included orders for skilled nursing 1 time a week for 9 weeks and skilled nurse to notify physician of blood pressure out of the parameters: systolic blood pressure greater than 160 or less than 90 and diastolic blood pressure greater than 90 or less than 50. RN #1 provided skilled nursing visits on 3/10/2022, 3/17/2022, 3/25/2022, 3/31/2022, 4/7/2022, 4/14/2022 and 4/23/2022. Patient #7’s blood pressure was out of parameters on 3/25/2022 at 120/95 mm Hg, and 4/23/2022 at 114/93 mm Hg, . The skilled nurse’s note included an MD notified with “NO” indicated on 3/25/2022. Further review of the record failed to reveal documentation RN #1 followed orders in the plan of care to report out of parameters blood pressure readings to Patient #7’s physician. An interview was conducted on 8/26/2022 at 3:50 pm with RN #1. The surveyor asked RN #1 why the blood pressures out of ordered parameters were not reported to the physician.. RN #1 said she misread the parameters or forgot to make a note of that. The surveyor asked RN #1 what are the possible impacts to Patient #2, #4, #6, and #7 if vitals are not reported per the plan of care. RN #1 said the doctor can’t make the right decision if medications need to be changed or not. An interview was conducted on 8/29/2022 at 2:00 pm with the Supervising Nurse. The surveyor asked the Supervising Nurse the agency process was for reporting vitals signs out of parameters to the physician as ordered. The Supervising Nurse stated, “We are to call the physician office and make them aware.” The surveyor asked where would that be documented in the patient charts. The Supervising Nurse said, “In the nurses note or a communication note. The surveyor asked the Supervising Nurse how not reporting vital signs out of ordered parameters per the plan of care could impact the patients. The Supervising Nurse said that it could be detrimental to clients’ health. Agency Policy: Agency policy 5.6 Orders for Care read in part…”The Agency will obtain orders and provide care in accordance with physician orders…”

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interviews, the agency failed to provide the patient and/or caregiver with written information outlining a visit schedule including frequency of visits by home health staff in 3 (Patients #1, #3 and #7) of 3 patients' home folders reviewed during home visits. This failure placed the patients at risk of missed visits by staff when visits were not scheduled and conflicted with other appointments and the availability of the patients. Findings included: Patient #1: Record review contained a plan of care for the period of 5/25/2022 through 7/23/2022 with a start of care of 3/26/2022. The frequency for the skilled nurse was ordered 1 time a week for 9 weeks. During a home visit with Patient #1 on 8/29/2022 at 11:40 am, no documentation was found in the agency home folder provided to Patient #1 of written information outlining a visit schedule including frequency of visits to be made by the skilled nurse. The surveyor asked if anything had been removed from the folder. Patient #1 said “No.” The surveyor asked if Patient #1 had been provided with a written schedule of visits. Patient #1 said, "No." Patient #3: Record review contained a plan of care for the period of 5/17/2022 through 7/15/2022 with a start of care of 5/17/2022. The frequency for the skilled nurse was ordered 2 times a week for 1 week, 1 time a week for 8 weeks. During a home visit with Patient #3 on 8/29/2022 at 10:00 am, no documentation was found in the agency home folder provided to Patient #3 of written information outlining a visit schedule including frequency of visits to be made by the skilled nurse. The surveyor asked if anything had been removed from the folder. Patient #3’s sister said “No.” The surveyor asked if Patient #3 had been provided with a written schedule of visits. Patient #3’s sister said, "No." Patient #7: Record review contained a plan of care for the period of 3/2/2022 through 4/30/2022 with a start of care of 11/7/2020. The frequency for the skilled nurse was ordered 1 time a week for 9 weeks. During a home visit with Patient #7 on 8/29/2022 at 12:40 pm, no documentation was found in the agency home folder provided to Patient #7 of written information outlining a visit schedule including frequency of visits to be made by the skilled nurse. The surveyor asked if anything had been removed from the folder. Patient #7 said ”No.” The surveyor asked if Patient #7 had been provided with a written schedule of visits. Patient #7 said, "No." An interview was conducted on 8/29/2022 at 2:00 pm with the Supervising Nurse. The surveyor asked the Supervising Nurse how the agency patients knew when the nurse or therapists would be making home visits. The Supervising Nurse said, “We call them.” The surveyor asked the Supervising Nurse if the patients are provided with a written schedule of the visits. The Supervising Nurse said, ‘No.” The surveyor asked the Supervising Nurse what the possible impacts to the patients could be when not provided with a written schedule of visits including therapy. The Supervising Nurse said, “the patient won’t know when we are coming.”