Every finding on record at Trinity Hospitals-Home Health

A recertification survey, started on 01/27/25 and completed 01/28/25, found Trinity Hospital Home Health in compliance with the requirements of 42 CFR 484.102, Home Health Agency Emergency Preparedness.

For the standard and partial extended Medicare/Medicaid recertification survey, started on 01/27/25 and completed 01/28/25, the sample included six records reviewed with no home visits and four records reviewed with home visits.

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, policy review, and staff interview, the agency failed to provide services written in the plan of care for 1 of 3 closed records (Patient #9) reviewed. Failure to reschedule missed nurse visits and/or notify the patient's physician of alterations to the plan of care related to the nurse's inability to carry out visits limited the care the patient received and limited the physician's ability to determine whether the service or treatment may be skipped or whether further intervention was required by staff. Findings include: Based on review of the North Dakota Department of Health and Human Services, Health Facilities Unit provider files, this agency has not sustained correction of this issue. This requirement was found to be out of compliance during the survey completed in 2022. Review of the agency policy titled "Home Health Missed Visits" occurred on 01/28/25. This policy, dated December 2021, stated, "Purpose: To ensure that missed visits are documented and does not affect the quality of patient care. Policy: Missed visits will be communicated to the Director or designee and the patient's physician. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. . . . If a visit is missed and not rescheduled, the clinician will: 1. Notify the physician and Director or designee of the missed visit and reason for missed visit. . . ." Review of Patient #9's closed medical record occurred on 01/28/25. The Plan of Care for the certification period dated June 26 - August 24, 2024, identified Skilled Nurse visits three times a week. During the week of July 28 - August 3, 2024, the record showed the nurse documented a missed visit with physician notification on 07/29/24 but lacked evidence of two more visits that week. The record failed to show staff notified the physician of the other two missed visits that week or attempted to reschedule the three missed visits. During an interview on 01/28/25 at 2:38 p.m., a supervisory nurse (#1) confirmed Patient #9's record lacked documentation of the two missed visits.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (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) 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 paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review, policy review, and staff interview, the Home Health Agency (HHA) failed to ensure a registered nurse (RN) performed the supervisory visit no less frequently than every 14 days for 2 of 3 sampled patients (Patient #4 and #5) receiving home health aide services for more than two weeks. Failure to complete supervisory visits at least every 14 days limited the HHA's ability to assess the adequacy of aide services in relation to the needs of the patient/family and to ensure the aides furnished the appropriate care identified in the patient's plan of care. - Review of Patient #5's medical record occurred on January 27-28, 2025. The current plan of care, dated 12/10/25, identified home health visits one time per week for nine weeks. The record identified the most recent supervisory visit as 01/08/25 (20 days prior). The record failed to identify a skilled professional completed a supervisory visit since that time. During an interview on 01/28/25 at 2:52 p.m., a supervisory nurse (#1) confirmed Patient #5's most recent supervisory visit occurred on 01/08/25. Findings include: Review of the agency policy titled "Home Health Aide Plan of Care" occurred on 01/28/25. This policy, dated November 2021, stated, ". . . The Case Manager or other appropriate clinician will perform a supervisory visit for the home health aide at least every 14 days to ensure care is provided according to plan. . . ." - Review of Patient #4's medical record occurred on January 27-28, 2025. The record identified a physician’s order, dated 10/09/24, to add home health aide visits to the plan of care one time a week for one week then two times a week and included in the certification periods of 10/19/24 to 12/17/24 and 12/18/24 to 02/15/25. The record identified the aide made a visit on 10/11/24 and two times a week there after. The record identified the first aide supervisory visit occurred on 10/29/24, an 18-day interval. During an interview on 01/28/25 at 10:50 a.m., a supervisory nurse (#1) confirmed a clinician failed to complete a supervisory visit for Patient #4 as required.

A recertification survey conducted on May 09-11, 2022 found Trinity Hospitals Home Health in compliance with the requirements of 42 CFR §484.102, Home Health Agency (HHA) Emergency Preparedness.

For the standard Medicare/Medicaid recertification survey, started on 05/09/222 and completed 05/11/22, the sample included 4 records reviewed with home visits and 6 records reviewed with no home visits.

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, review of agency policy, and staff interview, the Home Health Agency failed to notify the patient’s physician of alterations to the plan of care for 10 of 10 sampled patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) Failure to notify the physician of missed visits limited the physician’s ability to determine whether the service or treatment may be skipped or whether further intervention is required by staff. Review of the Home Health Agency policy titled “Home Health Missed Visits” occurred on 05/11/22. This policy, dated December 2021, stated, “Purpose: To ensure that missed visits are documented and does not affect the quality of patient care. Policy: Missed visits will be communicated to the Director or designee and the patient’s physician. . . . If a visit is missed and not rescheduled, the clinician will: 1. Notify the physician and Director or designee of the missed visit and the reason for missed visit. . . .” - Review of Patient #1‘s active record occurred on 05/09/22. The Plan of Care for the certification period dated March 3 - May 1, 2022, identified Skilled Nurse (SN) visits three times a week. During the week of April 10th, only one SN visit occurred (04/11). The record failed to show staff notified Patient #1‘s physician of the missed visits. - Review of Patient #2‘s active record occurred on 05/09/22. The Plan of Care for the certification period dated February 24-April 24, 2022, identified Occupational Therapy (OT) visits one time a week and Physical Therapy (PT) visits two times a week during week 8 (the week of April 10th). During the week of April 10th, no OT visits occurred and only one PT visit occurred (04/11). The record failed to show staff notified Patient #2‘s physician of the missed visits. - Review of Patient #3‘s active record occurred on 05/09/22. The Plan of Care for the certification period dated March 5 - May 3, 2022, identified PT, OT, and Home Health Aide (HHA) visits two times a week. During the week of April 10th, only one PT visit (04/11), one OT visit (04/12) and one HHA visit (04/11) occurred. The record failed to show staff notified Patient #3‘s physician of the missed visits. - Review of Patient #4‘s active record occurred on 05/10/22. The Plan of Care for the certification period dated March 1 - April 29, 2022, identified HHA visits two times a week. During the week of April 10th, one HHA visit occurred (04/11). The record failed to show staff notified Patient #4‘s physician of the missed visit. - Review of Patient #5‘s active record occurred on 05/10/22. The Plan of Care for the certification period dated February 3 - April 3, 2022, identified PT visits two times a week. During the week of April 10th, one PT visit (04/12) occurred. The record failed to show staff notified Patient #5‘s physician of the missed visit. - Review of Patient #6‘s active record occurred on 05/10/22. The Plan of Care for the certification period dated January 15 – March 15, 2022, identified OT visits one time a week. During the week of February 6th, no OT visit occurred. The record failed to show staff notified Patient #6‘s physician of the missed visit. - Review of Patient #7‘s active record occurred on 05/11/22. The Plan of Care for the certification period dated February 13 - April 13, 2022, identified HHA visits two times a week. During the week of March 6th, one HHA visit occurred (03/07). The record failed to show staff notified Patient #7‘s physician of the missed visit. - Review of Patient #8‘s closed record occurred on 05/11/22. The Plan of Care for the certification period dated October 27, 2021 - December 25, 2021, identified HHA visits two times a week. During the week of November 28th, one HHA visit occurred. The record failed to show staff notified Patient #8‘s physician of the missed visit. - Review of Patient #9‘s closed record occurred on 05/11/22. The Plan of Care for the certification period dated December 4, 2021 - February 1, 2022, identified PT visits one time a week. During the week of January 16th, no PT visit occurred. The record failed to show staff notified Patient #9‘s physician of the missed visit. - Review of Patient #10‘s closed record occurred on 05/11/22. The Plan of Care for the certification period dated February 10 – April 7, 2022, identified PT visits two times a week. During the week of March 27th one PT visit occurred. The record failed to show staff notified Patient #10‘s physician of the missed visit. During an interview on 05/11/22 at 11:00 a.m., an administrative nurse (#2) confirmed the agency failed to implement a process to inform patient’s physicians of missed visits.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on review of the North Dakota Century Code, the Home Health Agency policies and job descriptions, record review, and staff interview, the Home Health Agency failed to ensure individuals providing therapeutic services provided those services within the scope of practice for their profession for 2 of 7 sampled patients (Patient #2 and #7) who received therapy services. This failure allowed therapists to perform duties (management of patient’s medical conditions and associated communication with the patient’s physician about these conditions, as well as accepting verbal orders for interventions and medications) outside their area of expertise, which has the potential to compromise patient safety. Review of the North Dakota Physical Therapy Practice Act in the North Dakota Century Code, Chapter 43-26.1 Physical Therapists, stated, “43-26.1-01. Definitions. . . . 10. ‘Physical therapist’ means an individual licensed under this chapter to practice physical therapy. . . . 14. ‘Practice of physical therapy’ means: a. Examining, evaluating, and testing individuals with mechanical, physiological, and developmental impairments, functional limitations in movement and mobility, and disabilities or other health and movement-related conditions . . . b. Alleviating impairments, functional limitations in movement and mobility, and disabilities . . . c. Engaging as a physical therapist in reducing the risk of injury, impairment, functional limitation and disability, . . . d. Engaging as a physical therapist in administration, consultation, education, and research. . . . 43-26.1-11. Patient care management. 1. A physical therapist shall manage all aspects of each patient’s physical therapy. . . . 2. If the diagnostic process reveals findings outside the scope of a physical therapist’s knowledge, experience, or expertise, a physical therapist shall inform the patient or client and refer the patient or client to an appropriate practitioner. . . .” Review of the North Dakota Occupational Therapy Practice Act in the North Dakota Century Code, Chapter 43-40. Occupational Therapists, stated, “43-40-01. Definitions. . . . 2. ‘Occupational therapist’ means a person licensed to practice occupational therapy under this chapter. . . . 5. ‘Occupational therapy practice’ means the use of occupation and purposeful activity or intervention designed to achieve functional outcomes . . . Occupational therapy practice includes evaluation by skilled observation, administration, and interpretation of standardized and nonstandardized tests and measurements. The occupational therapy practitioner designs and implements interventions directed toward developing, improving, sustaining, and restoring sensorimotor, neuromuscular, emotional, cognitive, or psychosocial performance components. . . .” Review of the Home Health Agency's Physical Therapist job description occurred on 05/11/22. The job description, last modified 03/08/18, stated, “Position Summary: Provides rehabilitative services to home health . . . patients. Carries out skills contributing to treatment, rehabilitation, and safety for home health patients . . . Plans for coordinated therapy service for individuals and families under his/her care. . . . This care will be delivered in accordance with established standards of performance. . . . Essential Duties And Responsibilities: 1. Rehabilitation Services. . . . h. Implements physician orders accurately; consults with appropriate resources for clarification of unfamiliar, illegible, or questionable orders. . . .” Review of the Home Health Agency's Occupational Therapist job description occurred on 05/11/22. The job description, last modified 03/08/18, stated, “Position Summary: Provides rehabilitative services to home health . . . patients. Carries out skills contributing to treatment, rehabilitation, and safety for home health patients . . . Plans for coordinated therapy service for individuals and families under his/her care. . . . The . . . occupational therapist works under the supervision of the manager/director . . . This care will be delivered in accordance with established standards of performance. . . . Essential Duties And Responsibilities: 1. . . . e. Accurately completes drug regimen review, notifies supervisor if new or changed medications. . . .” Review of the Home Health Agency policy “Provider Orders” occurred on 05/11/22. This policy, last revised November 2021, stated, “Purpose: Clarify scope of practice when dealing with provider’s orders including telephone/verbal orders . . . Policy: . . . Telephone or Verbal orders: A. May be taken from a physician or his/her designee . . . by only a registered nurse, licensed practical nurse, or paramedic. B. The following personnel may take verbal or telephone orders for treatment and/or procedures within their respective areas of practice: . . . Physical Therapist . . . Occupational Therapist . . . D. Orders for medication will be taken only by a nurse practitioner, registered nurse, licensed practical nurse, paramedic, COA [Certified Ophthalmic Assistant], COT [Certified Ophthalmic Technician] and COMT’s [Certified Ophthalmic Technologist’s], or registered pharmacist and only from the responsible practitioner . . .” - Review of Patient #7's active record occurred on 05/11/22. The patient started care on 12/15/21 after discharge from the hospital for Pulmonary Embolism, Respiratory Syncytial Virus Infection, Gastrointestinal Hemorrhage, and Critical Illness Myopathy. The record identified Patient #7 received Physical Therapy (PT), Occupational Therapy (OT), Skilled Nurse (SN), and Home Health Aide (HHA) services. Review of Patient #7's therapy notes showed the following: * An Occupational Therapy Assistant (OTA) Note, dated 03/15/22, stated, “Therapist called Pts [patient’s] doctor about increased blood pressure. Therapist took BP [blood pressure] after Pt ambulated to restroom and standing for extended amount of time. Therapist left a message. They would call back.” * An OT Note, dated 04/07/22, stated, “Patient stated increased depression in the last week due to functional decline following hospitalization two weeks ago for kidney stones. With permission from the patient, this therapist contacted the patient’s psychiatrist [name of doctor] at [name of clinic] regarding increased depression. Therapist is waiting on a return call at this time.” Patient #7 received SN services at the time of the above notes, but the therapists (OT and OTA) facilitated the management of the patient’s medical conditions of high blood pressure and depression. - Review of Patient #2's active record occurred on May 9-10, 2022. The started care occurred on 02/24/22 after discharge from the hospital for Pneumonia. The record identified Patient #2 received PT and OT services. A PT Visit Note on 03/07/22 indicated Patient #2 saw his doctor last week, gained 10 pounds, started the medication furosemide (used to reduce fluid in the body), stopped taking sodium chloride tabs (used to supply water and salt to the body), and has a cough/shortness of breath. The note showed the PT contacted the patient’s doctor’s office and obtained orders for nursing visits, medication changes, and to monitor fluids. Review of Patient #2’s medication orders showed the PT entered a verbal order for a medication change on 03/08/22 at 7:44 a.m. which reflected to add furosemide 20 milligram (mg) tablet (tab) daily and discontinue sodium chloride 1 gram (gm) tab three times a day. Review of Patient #2's therapy notes showed the following: * An OT Note, dated 03/09/22, stated, “Therapist contacted patient’s PCP [primary care practitioner] regarding patient confusion with current medication list due to recent med [medication] changes. Patient to keep amlodipine Besylate [used to treat high blood pressure] 2.5 mg tab on hold until the next doctor’s appointment on 3/17.” * A PT Visit Note on 03/30/22 indicated the patient saw Cardiology on Monday (03/28), is to continue Eliquis (used to thin the blood to prevent blood clots), change furosemide, and add cortisone 10 (used to relive itching/skin irritation). Review of Patient #2’s medication orders showed the PT entered a verbal order for a medication change on 03/30/22 at 3:21 p.m. which reflected to discontinue furosemide 20 mg tab daily, add Cortizone 10 1% topical cream as needed to affected area for itch/inflammation, add furosemide 20 mg tab as needed daily if weight increases five pounds in a week and if have increased lower extremity edema until weight returns to baseline. * On 04/07/22 at 6:43 p.m. a PT entered a verbal order for an added medication which reflected to add Vitamin D3 25 micrograms (mcg) daily and Vitamin B12 1000 mcg daily. * A Physical Therapy Assistant (PTA) Visit Note on 04/11/22 indicated patient reports went to walk in clinic last week, found low hemoglobin levels and a lung spot, referred to Pulmonology. * A PT Note, dated 04/21/22, stated, “. . . Patient reports having difficulty breathing, is weak and just not feeling well. I had talked to patient’s son yesterday regarding patient condition. He contacted patient’s providers and was advised to resume taking one 20 mg Furosemide until the symptoms improve per [name of provider] and to call with an update in a week. I also contacted him during the PT visit. We discussed the importance of weighing every day and to monitor the edema. . . .” * A PT Note, dated 05/09/22, stated, “. . . Patient reports not feeling well during weekend and had to go to ER [emergency room]. They recommended he stay in hospital due to pneumonia, but patient declined. He was treated with IV antibiotics that day 5/7/22 and started on cefdinir [an oral antibiotic] yesterday. He is feeling a little better but has SOB [shortness of breath] with walking and still doesn’t feel well in AM’s [mornings]. Med [medication] review was completed. Change noted. . . .” SN completed home visits on 03/15/22, 03/21/22, 03/24/22, and 03/29/22 after the PT prompted the visits, otherwise the patient received PT and OT services only. The PT and OT facilitated the management of Patient #2’s medical conditions, medication changes/additions, physician communication, follow-up from physician appointments and ER visit. During an interview on 05/09/22 at 3:15 p.m., an administrative nurse (#3) stated therapists reviewed patient medications at every visit and added new or changed medications per physician order to the medication list. The administrative nurse (#3) confirmed the therapists contacted the physician directly to obtain medication orders and entered them into the medical record. She stated she reviewed the medication orders after the fact to make sure they are electronically submitted to the physician for signature. During an interview on the morning of 05/11/22, a PT staff member (#4) stated she contacted the patient’s physician or clinic nurse directly to report concerns/changes in the patient’s condition and to obtain orders for medications or interventions, whether it pertained to therapy or medical issues. The staff member (#4) stated she would consult a nurse if the patient experienced a medical concern that became more serious or more difficult to manage. She admitted in the last two years, the therapists have taken on more medical responsibilities with the patients. During an interview on the afternoon of 05/11/22, three administrative staff members (#1, #2, and #5) stated they were unaware of the therapists reporting medical concerns and obtaining orders for interventions and medications to manage the concerns. The staff members (#1, #2, and #5) confirmed medical issues were out of their scope of practice.