Every finding on record at Trinity Home Health, LLC

EMERGENCY PREPAREDNESS SURVEY At the time of the emergency preparedness survey completed on 01/24/23, Trinity Home Health, LLC is in compliance with the provisions of 42 CFR Part 484.102, Conditions of Participation for Home Health Agencies.

Partial Extended Survey An entrance conference was conducted with administrative staff on 01/23/23 and an exit conference was conducted with administrative staff on 01/24/23. Trinity Home Health, LLC, was found not to be in compliance with the requirements at 42 CFR Part 484, Subpart B,C for Home Health Agencies as a result of partial extended survey completed on 01/24/23.

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 medical record review and staff interview, the agency failed to patients received home health services as written in the physician ordered plan of care for one of seven medical records reviewed (Patient #5). The census was 17. Findings include: Review Patient #5's physician ordered plan of care for the certification period dated 11/17/22 through 01/15/23 revealed orders for skilled nursing services once daily. Review of the skilled nursing visit notes revealed skilled nursing services were only being provided five days per week. An interview was conducted with Staff A on 01/24/23 at 4:34 PM. Staff A stated the nursing services were being provided five days per week based on the comprehensive assessment completed on 11/15/22 and confirmed that was not consistent with the plan of care.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on medical record review, staff interview, and policy review, the agency failed to ensure a registered nurse made an onsite visit to the patient's home no less than every fourteen days for five patients who were receiving skilled services (Patient #1, #2, #3, #6, #7). The total sample was seven medical records. The census was 17. Findings include: Review of the policy titled, Home Health Aide Supervision, revised February 2022, revealed if home health aide services are provided to a patient who is receiving skilled nursing, physical, or occupational therapy, or speech- language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care and the written patient care instructions must make an onsite visit to the patient’s home no less frequently than every fourteen days. The home health aide does not have to be present during the visit. 1. Review of the medical record for Patient #1 for the certification period dated 12/13/22 through 02/10/23 revealed orders for skilled nursing services twice daily and home health aide services six hours daily. Review of the supervisory visits revealed supervision of the home health aide occurred on 11/02/22 and 12/31/22. Staff A stated in an interview on 01/24/23 at 1:46 PM that home health aide supervision occurred every sixty days for skilled patients. 2. Review of the medical record for Patient #2 for the certification period dated 11/03/22 through 01/01/23 revealed physician orders for skilled nursing services twice daily and home health aide services three hours daily, five days per week. Review of the supervisory visits revealed supervision of the home health aide occurred on 11/22/22 and 01/19/23. Staff A stated in an interview on 01/24/23 at 1:46 PM that home health aide supervision occurred every sixty days for skilled patients. 3. Review of the medical record for Patient #3 for the certification period dated 12/19/22 through 02/16/23 revealed physician orders for skilled nursing services once daily and home health aide services six hours weekly. Review of the supervisory visits revealed supervision of the home health aide occurred on 11/18/22 and 01/17/23. Staff A stated in an interview on 01/24/23 at 1:46 PM that home health aide supervision occurred every sixty days for skilled patients. 4. Review of the medical record for Patient #6 for the certification period dated 03/20/22 through 05/18/22 revealed physician orders for skilled nursing services twice daily and home health aide services thirty-five hours weekly. Review of the supervisory visits revealed supervision of the home health aide occurred on 01/30/22 and 03/29/22. Staff A stated in an interview on 01/24/23 at 1:46 PM that home health aide supervision occurred every sixty days for skilled patients. 5. Review of the medical record for Patient #7 for the certification period dated 07/17/22 through 09/14/22 revealed physician orders for skilled nursing services twelve times per week and home health aide services nine hours per day. Review of the supervisory visits revealed supervision of the home health aide occurred on 05/10/22 and 07/09/22. Staff A stated in an interview on 01/24/23 at 1:46 PM that home health aide supervision occurred every sixty days for skilled patients.