Every finding on record at Trinity North Home Health LLC

On 10/24/2022 at 12:30 PM, an entrance conference was conducted with Agency Staff. The Agency was informed the purpose of the visit was to conduct a Recertification Survey for compliance with the Conditions of Participation for Home Health. On 10/27/2022 at 11:20 AM, an exit conference was conducted with Agency Staff. Preliminary findings were discussed. On 11/02/2022, additional information was requested.

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: Based on Clinical Record Review and Staff interviews, it was determined the Skilled Nurse (SN) failed to include Oxygen (O2) during the review of the patients medications in 3 (#2, #3, #11) of 11 (#1-#11) clinical records reviewed. This failed practice by the SN posed a risk of potential harm for patients on census receiving O2 therapy by inhibiting the Nurse and Physician's ability to make informed decisions regarding the patients medication regimen related to potential adverse effects, drug interactions, significant side effects or significant drug interactions. Review of clinical record #2: A. Document titled "Home Health Certification And Plan of Care" dated 10/10/22-12/08/22 which listed a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) B. A goal of "patient/caregiver can demonstrate safe and effective use of home oxygen including: safe storage, compliance and precautions." C. The Medication Profile showed no evidence of the oxygen mentioned in the Plan of Care (POC). 2. Review of clinical record # 3: A. Document titled "Home Health Certification And Plan of Care" (POC) dated 10/12/22-12/10/22 listed a diagnosis of "Dependence on Supplemental Oxygen" B. A safety measure as "Oxygen Precautions" listed on POC. c. The medication Profile showed no evidence of the oxygen mentioned in the POC. 3. Review of clinical record #11: A. Document titled "Home Health Certification And Plan of Care (POC) dated 09/26/22-11/24/22. B. Supplies listed on POC "Oxygen" c. The medication profile showed no evidence of the oxygen listed in the POC. On 10/27/2022 at 11:20, Agency Staff were given an opportunity to provide additional information. With no additional information forthcoming, Agency Staff #1 stated, "We don't have it (oxygen) listed on the medication profiles."

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 clinical record review and Agency Staff interview, it was determined this element was not met in 7 (#2, #3, #4, #6, #7, #9, and #11) of 11 (#1-#11) clinical records reviewed. This failed practice by the Skilled Nurse (SN) had the potential to affect all patients on census with heart failure or diabetes, in that, the lack of a weight parameter or a blood glucose range could impede the SN, Physician and the patient from early interventions and treatments to prevent complications and rehospitalizations. 1. Review of Clinical Record #2 A. Plan of Care (POC) with certification dates 10/10/22-12/8/22 revealed a diagnosis of Chronic Obstructive Pulmonary Disease, Type 2 diabetes, and essential (primary) hypertension. B. Revealed an order, "Skilled nurse assess blood sugar monitoring and results" C. A document titled "Vital Signs" shows no blood glucose range/parameter or documentation of blood glucose readings reported either by the patient or obtained by the SN. D. A document titled "Vital Signs" shows no blood pressure range/parameter as a guideline of patients response to treatment and medications. E. On 10/27/22 at 11:20 AM, agency staff were given an opportunity to provide additional information. No additional information was received. 2. Review of Clinical Record #3 A. POC with certification dates 10/12/22-10/10/22 revealed a diagnosis of Acute on chronic diastolic (congestive) heart failure, essential (primary) hypertension, Type 2 diabetes. B. Revealed an order to "SN to teach regarding compliance with CHF treatment regimen." C. A document titled "Vital Signs" shows no evidence of a weight parameter, a blood glucose range/parameter or a blood pressure range/parameter for the Clinician to use during physical assessment of the patients condition. D. When interviewed on 10/27/2022 at 11:10 AM, Agency Staff stated, "We don't have CHF (Congestive Heart Failure) protocol." 3. Review of Clinical Record #4 A. POC with certification dates 7/6/22-11/2/22 revealed a diagnosis of Acute on chronic (congestive) heart failure. B. An order for the SN to "Assess for the presence of peripheral edema, monitor vital signs, monitor weight." C. The POC shows no evidence of a weight parameter or vital sign ranges/parameters to assist the Clinician in assessment of the patients condition. D. On 10/27/22 at 11:20 AM, agency staff were given an opportunity to provide additional information. No additional information was received. 4. Review of Clinical Record #6 A. POC with certification dates of 8/24/22-10/22/22 revealed a diagnosis of essential (primary) hypertension. B. Revealed orders for "Aide to monitor vital signs. Report abnormal vital signs to nurse." C. Revealed an order for SN "Monitor vital signs including blood pressure, and apical and radial pulse." D. A document titled 'Vital Signs" showed no evidence of an apical and a radial pulse assessment each visit. E. On 10/27/22 at 11:20 AM, agency staff were given an opportunity to provide additional information. No additional information was received. 5.Review of Clinical Record #7 A. POC with certification dates 8/24/22-10/22/22 reveled diagnosis of "Acute and chronic respiratory failure with hypoxia, Essential (primary) hypertension, Acute on chronic diastolic (congestive) heart failure, hypertensive heart disease with heart failure." B. Revealed an order for SN to monitor weight. C. A document titled "Vital Signs" showed no evidence of weight monitoring. D. POC showed no evidence of a weight range/parameter, blood pressure range parameters to assist the SN with assessing the patients condition and when to contact the physician. E. On 10/27/22 at 11:20 AM, agency staff were given an opportunity to provide additional information. No additional information was received. 6. Review of Clinical Record #9 A. POC with certification dates 10/8/22-12/6/22 revealed diagnosis of "Type 2 diabetes mellitus with other skin ulcer, unspecified diastolic (congestive) heart failure." B. An order for "SN to assess weight change" C. An order for SN "to monitor vital signs" D. No weight range/parameter, no vital sign parameters on the POC to assist the SN with assessment of patient condition. E. On 10/27/22 at 11:20 AM, agency staff were given an opportunity to provide additional information. No additional information was received. 7. Review of Clinical Record #11 A. POC with certification dates 9/26/22-11/24/22 revealed a diagnosis of "Heart failure, unspecified." B. An order for 'SN assess compliance with CHF regimen." C. No weight range/parameter on POC. D. When interviewed on 10/27/2022 at 11:10 AM, Agency Staff stated, "We don't have CHF (Congestive Heart Failure) protocol." E. POC SN goal: "Patient maintains vital signs within baseline range." F. No evidence in POC of vital sign ranges/parameters to assist SN with patient physical condition.

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 Skilled Nurse (SN) failed to follow the physicians orders in 11 (#1-#11) of 11 (#1-#11) clinical records reviewed by not monitoring vital signs, blood glucose levels or weights nor reporting out of range values to the physician. This failure to follow physicians orders had the potential to affect all patients on census, in that, it inhibited Agency Staff and the patient's attending physician to reassess, collaborate, or make changes to the Plan of Care (POC) and/or prevent complications and rehospitalization. This STANDARD is NOT MET as evidenced by: Clinical record #1 revealed a document titled "Home Health Certification and Plan of Care" dated 9/28/22-11/26/22. A. An order for "Skilled nursing observation/assess body systems related to diagnosis, vital signs, pain level, home medications and care provided." B. A Document titled "Vital Signs" showed 12 dated entries. Four of the entries are complete. Incomplete entries for the following dates 10/27/2022, 10/24/2022,10/20/2022, 10/18/2022, 10/13/2022, 10/11/2022, 10/06/2022, 10/03/2022, 9/29/2022 are missing temperatures, respirations, and blood pressure readings. 2. Clinical record #2 revealed a document titled "Home Health Certification and Plan of Care" dated 10/10/22-12/08/22. A. An order for "Skilled Nurse to assess blood sugar monitoring and results. Notify MD as indicated." B. There was no evidence of a blood sugar reading for the skilled nurse visit dated 10/24/2022. 3. Clinical record #3 revealed a document titled "Home Health Certification and Plan of Care" dated 10/12/22-12/10/22. A. A goal for "Patient maintains vital signs within baseline range." B. A document titled "Vital Signs" with 5 dated entries. Of the five entries, only three are completed set of vital signs.10/20/2022, 10/19/2022had missing temperature, respirations, and/or blood pressure readings. 4. Clinical record #4 revealed a document titled "Home Health Certification and Plan of Care." dated 7/06/22-9/4/22. A. An order for Skilled Nurse to "monitor weight." B. There was no evidence a weight was obtained on visit dated 7/20/2022. 5. Clinical record #5 revealed a document titled ""Home Health Certification and Plan of Care" dated 8/02/22-9/30/22 A. An order for "Skilled nurse to monitor vital signs" B. A document titled "Vital Signs" with two entries for 8/02/22. The other six visits listed in the clinical record have no vital signs recorded. 6. Clinical record #6 revealed a document titled ""Home Health Certification and Plan of Care" dated 8/24/2022-10/22/2022. A. An order for "Home Health Aide to monitor vital signs." B. An order for "Skilled Nurse to monitor vital signs." C. A document titled "Vital Signs" showed 25 dated entries. Visit entries for 8/30/22, 9/07/2022, 9/09/2022,9/15/2022, 9/16/2022, 9/19/2022, 10/01/2022, 10/04/2022 lacked of the vital sign readings. 7. Clinical record #7 revealed a document titled ""Home Health Certification and Plan of Care" dated 8/24/22-10/22/22. A. Goal of "Skilled Nurse: Patient maintains vital signs with in baseline range." B. A document titled "Vital Signs" revealed 17 time/dated entries. The following 9 visit dates had incomplete vital sign entries either missing one or all values of temperature, pulse, respirations, or blood pressure. 9/16/2022, 9/14/2022,9/12/2022,9/07/2022,9/06/2022, 9/05/2022, 9/02/2022,8/31/2022,8/30/2022. 8. Clinical record #8 revealed a document titled ""Home Health Certification and Plan of Care" dated 9/07/2022-11/05/202. A. An order for "Skilled Nurse to monitor vital signs." B. A document titled "Vital Signs" showed 13 dated vital sign entries. Of those 13, the following visit date vital sign entries were incomplete, missing either/all of temperature, pulse, respiratory rate or pulse. 9/09/2022, 9/13/2022,9/24/2022,9/30/2022, 10/07/2022,10/20/2022. 9. Clinical record #9 revealed a document titled ""Home Health Certification and Plan of Care" dated 10/08/22-12/06/22. A. Showed and order for "Skilled Nurse to monitor weight" B. There is no evidence of weight recorded in the medical record. 10. Clinical Record #10 revealed a document titled ""Home Health Certification and Plan of Care" dated 9/30/22-11/28/22. A. Showed an order for "Skilled Nurse to monitor vital signs." B. Showed a Home Health Aide order "to monitor vital signs." C. A document titled "Vital Signs." showed 11 entries dated and timed. Of those 11 entries, 2 of the vital signs entries for dates 11/01/2022 and 10/12/2022 were missing at least one of the following vital signs temperature, pulse, respirations, blood pressure. 11. Clinical record #11 revealed a document titled ""Home Health Certification and Plan of Care" dated 9/26/2022-11/24/2022. A. Showed a goal of "Patient to maintain vital signs with in normal limits." B. Showed a document titled "Vital Signs" with 17 entries. Of those 17, 12 vital sign entries for the following dates 9/30/2022,again on 9/30/2022, 10/03/2022, 10/06/2022, 10/07/2022, 10/09/2022,10/10/2022, 10/12/2022, 10/17/2022, and a second entry from 10/17/2022, 10/19/2022, 10/21/2022 were incomplete, either missing one or all of the values for temperature, pulse, respirations, blood pressure. On 10/27/2022 at 11:20 AM, Agency Staff were given an opportunity to provide additional information. None was provided.

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: Based on Clinical Record review and staff interview, the Agency failed to alert the Physician to changes in the patients condition which may have necessitated an alteration in the Plan of Care (POC) in 9 (#2, #3, #4, #6, #7, #8, #9, #10, #11) of 11 (#1-#11) Clinical Records reviewed. This failed practice resulted in Physician being unaware of changes in vital signs (#2 #3, #6,#7, #8, #9, #10, #11) changes in weight (#7), and a patient fall (#4) and resulted in missed opportunities for changes in the POC and this lack of notification could result in prolonged illness and precipitated poorly managed symptom control and/or rehospitalizations. Findings: During an interview with Agency Staff #1 on 10/27/2022 at 11:20 AM, it was revealed the Agency does not have a clinical guideline for abnormal vital sign values. Using the vital sign parameters from Http://medlineplus.gov/ency/article/002341.htm showing normal blood pressure to be from 90/60-120/80, respiration rate from 12-18 breaths per minute, pulse 60-100 beats per minute, temperature being 97.8-99.1 degrees. Review of Clinical Record #2 showed a document titled "Home Health Certification And Plan of Care" (POC) with dates of 10/10/22-12/08/22 with documented diagnosis of Essential (primary) hypertension with an exacerbation date of 10/05/22. A second document titled "Vital Signs" shows the following should have been reported to the physician as abnormal: A. 10/11/22 a blood pressure of 124/83 B. 10/26/22 a blood pressure of 166/73 C. 10/27/22 a blood pressure 151/76 2. Review of Clinical Record #3 POC shows a diagnosis of Essential (primary) Hypertension with an exacerbation date of 10/10/22. A second document titled "Vital Signs" shows the following should have been reported to the physician as abnormal: A. 10/20/22 a respiration rate of 20 breaths per minute. B. 10/27/22 showed a respiration rate of 20 breaths per minute and a blood pressure of 162/88. 3. Review of Clinical Record #4 revealed a document titled "Skilled Nursing Visit Note" dated 9/06/22 at 2:28 PM, with documentation of the patient falling. A. There was no evidence in the record to indicate the physician was notified about the fall. 4. Clinical record #6 POC revealed a diagnosis of Essential (primary) hypertension) with an exacerbation date of 8/23/22 and a document titled "vital Signs" shows the following should have been reported to the physician as abnormal: A. 8/29/22 blood pressure of 131/82 B. 8/30/22 blood pressure reading of 130/80 C. 9/8/22 respiratory rate of 20 breaths per minute D. 9/15/22 blood pressure of 148/57 E. 9/23/22 blood pressure of 114/82 F. 9/29/22 blood pressure of 94/48 G. 10/4/22 respiratory rate of 22 breaths per minute and blood pressure of 76/45 H. 10/6/22 blood pressure reading of 140/80 5. Clinical record #7 POC revealed a diagnosis of Essential (primary) hypertension) with an exacerbation date of 8/18/22 and a document titled "vital Signs" shows the following should have been reported to the physician as abnormal: A. 8/24/22 a pulse rate of 120 beats per minute, respiratory rate of 20 breaths per minute, and a blood pressure of 138/99 B. A second visit on 8/24/22 showed a pulse rate of 126 beats per minute, respiratory rate of 22 breaths per minute and a blood pressure of 172/102 C. 8/31/2 showed a weight increase of 7 pounds, a pulse rate of 114 beats per minute, respiratory rate of 20 breaths per minute and a blood pressure of 146/88 D. 9/06/22 respiration rate of 22 breaths per minute, blood pressure of 128/88 E. 9/27/22 showed a temperature of 99.4, a pulse of 110 beats per minutes, respiratory rate of 20 breaths per minute F. 10/18/22 showed a blood pressure reading of 148/76 6. Clinical record #8 revealed a document titled "vital Signs" shows the following should have been reported to the physician as abnormal: A. 9/07/22 blood pressure of 134/85 B. 9/09/22 a respiratory rate of 20 breaths per minute. 7.Clinical record #9 revealed a document titled "vital Signs" shows the following should have been reported to the physician as abnormal: A. 10/14/22 a blood pressure of 142/78 B. 10/18/22 a blood pressure of 154/71 C. 10/21/22 a blood pressure of 136/70 8.Clinical record #10 revealed a document titled "vital Signs" shows the following should have been reported to the physician as abnormal: A. 10/04/22 a blood pressure of 138/88 B. 10/11/22 a blood pressure of 152/92 C. 10/14/22 a blood pressure reading of 134/70 D. 10/18/22 a blood pressure reading of 150/89 E. 10/21/22 a blood pressure reading of 156/94 F. 10/25/22 a blood pressure reading of 126/50 G. 10/26/22 a blood pressure reading of 103/58 H. 10/28/22 a temperature reading of 99.7 and a blood pressure reading of 138/76 9.Clinical record #11 revealed a document titled "vital Signs" shows the following should have been reported to the physician as abnormal: A. 9/26/22 a blood pressure reading of 90/52 B. 9/28/22 a blood pressure of 110/48 C. 10/6/22 a blood pressure reading of 118/56 D. 10/12/22 a blood pressure reading of 92/58 E. 10/26/22 a blood pressure reading of 119/93

HHA maintains documentation of training CFR(s): 484.80(b)(4) The HHA must maintain documentation that demonstrates that the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on Clinical Record Review and Staff interview, it was determined the Agency failed to maintain documentation of clinical competencies for obtaining vital signs on patients in 2 of 2 Agency Staff interviewed.(staff member # 3 & #4). The inability of the Agency to maintain training records had the potential to affect all patients on census in that Staff members were not assessed for competencies which could lead to patients being hospitalized for exacerbation of symptoms. Findings: During an interview on 10/27/22 at 10:01 AM, staff #3 was asked if they had to demonstrate the ability to assess vital signs since being employed by Agency. Staff #3 said, "No. I don't think I did that." During an interview on 10/27/22 at 10:32 AM, staff #4 was asked if they had to demonstrate the ability to assess vital signs since being employed by Agency. Staff #4 said, "The last PT (Physical Therapist), who I took over for, I had to demonstrate how to check a blood pressure." Staff #4 denied having any documentation of the skills validation/assessment. Agency Staff were asked to provide documentation of skills validation for Staff #3 and #4. During an interview on 10/27/22 at 11:23 AM, Staff #1 stated, "I guess the previous PT purged the files. I don't have any record to show you."