Every finding on record at Trinity Health Group LLC

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees and Federal, state, tribal, regional, and local emergency management agencies. The communication plan did not include a primary and alternate means of communicating with tribal, regional and local emergency management agencies.

Upon patient record review, 1 of 14 (Patient # 3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient # 3: Patient's comprehensive assessment dated 7/31/25 noted patient to have a foley catheter in place, in addition the foley catheter was noted to be in place during home visit. There was no evidence in the patient's medical record that the patient had orders or a reference on the plan of care for the patient's foley catheter, the orders needed for frequency to change the foley, maintenance and/or education related to the foley catheter.

Upon patient record review, 14 of 14 (Patient # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient# 1 - 14: These patients' plan of care did not contain any supplies. After review of patient supply delivery log, all patient's had supplies delivered to their place of residence from the agency.

Upon patient record review, 13 of 14 (Patient's # 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient's # 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14: Aide care plans did not contain frequencies for any of the ordered tasks to be provided.

Upon patient record review 2 of 14 (Patient's # 1, 2) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient # 1: Patient record did not contain evidence of an RN aide supervisory visit being completed between the dates of 7/9/25 to 8/13/25, and 8/13/25 to 9/3/25. Patient # 2: Patient record did not contain evidence of an RN aide supervisory visit being completed between the dates of 7/16/25 to 9/3/25.

Upon personnel record review, 8 of 12 (Personnel # 1, 2, 3, 4, 9, 10, 11, 12 ) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel # 1, 2, 3, 4, 9, 10, 11, 12: Employee files did not contain evidence of orientation on the hospice philosophy.

Upon personnel record review, 2 of 12 (Personnel # 8, 11) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel # 8: The employee file did not contain evidence of a 2024 skills competency assessment. Personnel # 11: The employee file did not contain evidence of a 2023 or 2024 competency assessment for the roles of spiritual counselor, bereavement counselor or volunteer coordinator.

Upon observation, there was no evidence the organizational chart matches the hospice's information submitted to CMS and/or State licensing agencies for ownership and management personnel. New Administrator hired on 6/16/25. There was no evidence the agency updated CMS within thirty days of the change in management.

Upon patient record review, 2 of 5 (Patients #1, #5) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: As observed during the home visit, patient was taking Morphine for pain and symptom management. Morphine was not included on the medication profile. Corrected on site. Patient #5: There was documentation the patient was using Tylenol for pain management. Tylenol was not included on the medication profile.

Upon patient record review, 2 of 5 (Patients #1,#5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: As observed during the home visit patient was taking morphine for pain and symptom management. The record did not contain evidence of an order for morphine. Corrected on site. Patient #5: There was documentation the patient was using Tylenol for pain management. The record did not contain evidence of an order for Tylenol.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment. Patient #1: The agency plan of care does not include equipment. As observed during the home visit the patient was noted to have a specialty mattress and suction in the home. Corrected on site.

Upon patient record review, 1 of 5 (Patient #4) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #4: On 6/29/22 a revised plan of care is on record. The patient had an infection and the RN did not revise the plan of care to include problems, interventions, and goals related to infection.

Upon patient record review 1 of 3 applicable (Patient #1) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1: The order visit frequency for the aide on 7/11/22 was 2X/week. No evidence aide visits were completed or an order to discontinue aide services. Corrected on site.

Upon patient client record review, 1 of 5 (Patient #3) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #3: The record contained assessments for spiritual and bereavement on 6/10/22 that were not appropriately authenticated with the clinician's signature.