Every finding on record at Trinity Health Care Services LLC

During the Health Recertification survey commenced on 09/13/2023 and concluded on 09/15/2023 at Trinity Health Care Services, Inc., a Home Health Agency, Emergency Preparedness was reviewed. Trinity Health Care Services, Inc. is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.102, Condition of Participation for Home Health Agencies.

An unannounced Recertification survey was commenced on 09/13/2023 and concluded on 09/15/2023 at Trinity Health Care Services, Inc., Home Health Agency provider. The provider was not in compliance with Code of Federal Regulations (CFR) 42, Part 484, Subpart A-C, Conditions of Participation for Home Health Agencies.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to ensure the patient’s Plan of Care for medications was followed, as the physician ordered, for 2 of 3 sampled home visit patients (Patient #2 and #3). The findings included: 1) Review of Patient #3’s clinical record revealed a “Home Health Certification and Plan of Care (POC)” certification period from 08/19/23 to 10/17/23. The POC documents physician orders for Fluticasone 1 (one) spray nasal twice a day in each nostril for congestion, Jardiance 10 milligrams (mg) once a day by mouth at lunch time, increase water intake for Diabetes and Promethazine -DM 6.25-15 mg per 5 millimeters (ml) as needed every four (4) hours for cough. The physician orders included a “skilled nurse 18 hours daily seven (7) days a week for medication management, blood glucose monitoring, safety/supervision…skilled nurse supervisory visit to be performed every 14 days…”. The patient’s diagnoses included Diabetes Mellitus Type 2 and Congenital Malformation Syndrome. On 09/14/23 at 12:55 PM, a home visit was conducted with the Home Health Agency's Director of Nursing (DON) and Staff B, a Licensed Practical Nurse for Patient #3. An interview was conducted with Staff B who stated that today (09/14/23) she held the patient’s medication Jardiance for Diabetes because his blood sugar result was 87. Staff B was asked if she had a physician order to hold the medication due to a blood sugar of 87 and replied that she did not. Staff B was asked if she call Patient #3’s physician to notify her interventions and stated that in the home care settings, the physician does not get back to her when she calls, or the physician’s office does not answer the phone. Staff B was asked if she called the HHA DON and stated she did not. During the review, the DON stated she had to call the patient’s physician if she was holding the medication. The DON added she was not aware that Staff B was holding the patient’s medication. On 09/14/23 at 1:55 PM, a side by side review of Patient #3’s Home- Medication Administration Record (MAR) for September 2023 was conducted with Staff B and the DON. The MAR record documents Fluticasone 1 spray twice a day. Further review revealed the MARs schedule times was marked to be administered as needed (prn). During the review, Staff B stated that the Fluticasone was to be given as needed. Staff B was apprised that the physician order was to be administered twice a day and not as needed. The DON confirmed the physician order for Fluticasone was to be administered daily not as needed. Continue side by side review of Patient #3 September MAR documents Promethazine 6.25-15 mg/5 ml as needed every four hours for cough. The review revealed the medication was not available in the patient’s medication basket at home. Staff B stated she did not know why the medication was not in the patient’s medication basket. Staff B stated she had not called the physician to notify regarding holding the patient’s Jardiance due to lower than 100 blood sugar results. Review of Patient #3’s September 2023 MAR documents that on 09/05/23 the patient’s medication Jardiance was marked as held at the scheduled time and marked as given at 5:00 PM. Staff B stated that Jardiance was not delivered until 5:00 PM and that she administered at that time. Staff B was asked if she contacted the patients physician regarding the delay of the administration of the medication for Diabetes Jardiance and replied she did not. Staff B s Further review revealed Patient 3’s Jardiance was marked as held on 09/08/23 at the scheduled time. Review of Staff B nursing notes documents that Jardiance was held on 09/08/23 due to decrease blood sugar. Staff B documentation lack written evidence of contacting the patient’s physician related to holding the medication Jardiance. Staff B was apprised that she must call the patient’s physician when she is not administering his medications as ordered. On 09/15/23 at 11:50 AM, an interview via telephone was conducted with Staff A, RN who stated she was responsible to do revisions (new/change of physicians orders) to the patient’s plan of care. Staff A stated she had not received a revision to change Patient #3’s Fluticasone spray to as needed nor received an order to discontinue it. Staff A confirmed that the patient’s Fluticasone inhaler was not to be administered in as needed basis. Staff A stated she did not have a revision to hold Patient #’3s Jardiance medication if his blood sugar were low. 2) Review of Patient #2 record revealed a “Home Health Certification and Plan of Care (POC)” with a certification period from 08/17/23 to 10/15/23. The POC documents the patient’s diagnoses as Diabetes Mellitus Type 1, Convulsions and Intellectual Disabilities. The physician orders included a skilled nurse visits three (3) times daily for management of blood glucose level monitoring and safe/accurate administration of insulin. The POC physician orders included Humalog Insulin sliding scale three times a day before breakfast, lunch and dinner. The physician order documents administration of insulin as follow: For blood sugar less than 120 = 0 units of insulin. For blood sugar 121-150 = 4 units of insulin. For blood sugar 151-200 = 8 units of insulin. For blood sugar 201- 250 = 10 units of insulin. For blood sugar 251- 300 = 12 units of insulin. For blood sugar more than 300 = 14 units of insulin. On 09/14/23 at 3:55 PM, a home visit was conducted with the Home Health Agency's Director of Nursing and Staff C, a Licensed Practical Nurse for Patient #2. An interview was conducted with Staff C who stated that the patient was on the same Novolog Insulin sliding scale for a long time, since 2012. Review of Patient #2’s diabetic flow sheet dated week of 08/20/23 to 08/26/23 documents as follow: -08/21/23, untimed (AM) blood sugar result of 134 and administration of ??(unable to read) units of Novolog insulin. The physician order documents that for a blood sugar result between 121-150 the patient should have received 4 units of insulin. Unable to read how many were administered. -08/22/23, untimed (AM) blood sugar result of 118 and administration of 2 units of Novolog insulin. The physician order documents that for a blood sugar result less than 120 the patient should have received no insulin. -08/22/23, untimed (PM) blood sugar result of 219 and administration of insulin of NovoLog 12 units. The physician order documents that for a blood sugar result between 201-250 the patient should have received 10 units of insulin and not 12 units as documented. -08/23/23, untimed (AM) blood sugar result of 153 and administration of 4 units of Novolog insulin. The physician order documents that for blood sugar result between 151-200, the patient should have received 8 units of insulin and not 4 units as documented. -08/24/23, untimed (AM) blood sugar result of 282 and administration of 8 units of Novolog insulin. The physician order documents that for a blood sugar result between 251-300 the patient should have received 12 units of insulin and not 8 units as documented. -08/25/23, untimed (AM) blood sugar result of 310 and administration of 10 units of Novolog insulin. The physician order documents that for a blood sugar result of more than 300 the patient should have received 14 units of insulin and not 10 units as documented. -08/26/23, untimed (AM) blood sugar result of 213 and administration of 4 units of Novolog insulin. The physician order documents that for a blood sugar result between 201-250 the patient should have received 10 units of insulin and not 4 units as documented. -08/27/23, untimed (AM) blood sugar result of 220 and administration of 6 units of Novolog insulin. The physician order documents that for a blood sugar result between 201-250 the patient should have received 10 units of insulin and not 6 units as documented. -08/28/23, untimed (AM) blood sugar result of 224 and administration of 6 units of Novolog insulin. The physician order documents that for a blood sugar result between 201-250 the patient should have received 10 units of insulin and not 6 units as documented. On 09/15/23 at 3:20 PM, a side-by- side review of Patient #2’s blood sugar results and insulin administration record as above-mentioned was conducted with the DON. The DON confirmed the findings and stated, “ I have to bring those nurses to the office”. The DON was unable to read the nurse documented amount of insulin administered on 08/21/23 and the blood sugar result for 08/22/23.