Every finding on record at Trinity Home Health Services

Observed in Record Review. In 2 of 14 patient records reviewed, it was noted that the organization did not ensure the patient and/or the patient's caregiver understanding of education and training was evaluated. For example, during a review of the medical record for RRHV#4, and RRHV#8, the clinician did not document an observation of wound care performed by the patient's caregiver. This observation was reviewed with the Hospice Clinical Manager.

Observed in Record Review. In 3 of 14 patient records reviewed, it was noted that the organization did not ensure that the plan of care goals included outcome measures for specific care activities. For example, during a review of the medical record for RRHV#1, the patient was receiving antibiotic therapy for the treatment of a urinary tract infection. The following goal statement was noted: Patient/Caregiver demonstrates appropriate measures to prevent infection. The goal statement did not include a method to measure the effectiveness of problem interventions. Example #2: A review of the medical record for RRHV#2, revealed that the patient was receiving treatment for a stage 2 pressure ulcer at the right buttocks. The following goal statement was noted: Patient/Caregiver demonstrates appropriate measures to prevent infection. The goal statement did not include a method to measure the effectiveness of problem interventions. Example #3: A review of the medical record for RRHV#3, revealed that the patient was receiving care, and treatment related to the presence of an indwelling supra-pubic catheter. The following goal statement was noted: Patient/Caregiver demonstrates appropriate measures to prevent infection. The goal statement did not include a method to measure the effectiveness of problem interventions. This observation was reviewed with the Hospice Clinical Manager.

Observed in Record Review. In 1 of 14 patient records reviewed, it was noted that the organization did not ensure it policy titled Hospice Care Planning Process was implemented. For example, during the review of the plan of care for RRHV#4, the following information was noted: Pressure Ulcer Care to Coccyx two times weekly …. Hospice Nurse or Family to Provide Care. The plan of care did not include an intervention to train and educate the patient's caregiver on the wound care procedure. The plan of care did not include an intervention to evaluate the patient's caregiver's performance of the wound care procedure. This observation was reviewed with the Hospice Clinical Manager.

Observed in Record Review. In 2 of 14 patient records reviewed, it was noted that the organization did not ensure the plan of care was revised when the patient's condition changed. For example, a review of the medical record for RRNHV#8, revealed that the patient experienced a fall during the first hospice benefit period, and two falls during the second hospice benefit period. The plan of care was not updated with interventions to maintain patient safety, and strategies to prevent injury. Example#2: A review of the medical record for RRNHV#9, revealed that the patient experienced a witnessed fall without injury during week 5 of the first hospice benefit period. During a review of the plan of care update completed during week 5, it was noted that a description of the fall, interventions to maintain patient safety, and strategies to prevent injury were not included in the interdisciplinary team documentation. This observation was reviewed with the Hospice Clinical Manager.

Observed in Data Session. During the QAPI session, it was noted that the organization did not ensure improvement was demonstrated in the indicators related to improved palliative outcomes and hospice services. For example, a review of the QAPI plan revealed the following indicator related to patient safety - Patient falls rate will be less than 0.64%. During the first quarter of fiscal year 2024 the falls rate was 16%. During the second quarter of fiscal year 2024 the falls rate was 20%. During the third quarter of fiscal year 2024 the falls rate was 23%. This observation was reviewed with the Quality Management Specialist Home Health/Hospice.

Observed in Infection Control System Tracer. During the Infection Control System Tracer, it was noted that the organization did not take action when it did not achieve planned improvements. For example, the infection control plan included the following indicator – UTI rate will be equal or less than 2%. During the second quarter of fiscal year 2024 the UTI rate was 2.25%. In addition, the infection control plan included the following indicator – Wound infection rate will be less than or equal to 5%. During the first quarter of fiscal year 2024 the rate was 5.76%. During the second quarter of fiscal year 2024 the rate was 5.06%. There was no documented evidence that the organization implemented actions to achieve improvement with these indicators. This observation was reviewed with the Quality Manager Specialist Home Health/Hospice.

Observed in Tracer Activities. During tracer activities for Emergency Management, the Hospice Nurse Surveyor observed the organization did not provide emergency preparedness training to volunteers initially or at least every two years. This was verified with the Clinical Manager.

Observed in Patient Home. In 1 of 4 home visits conducted, the Hospice Nurse Surveyor observed that the nurse failed to conduct an effective medication evaluation per organizational policy and Plan of Care. During HV#1, the nurse did a medication reconciliation based only on the medication bottles neglecting to use the agency medication orders for verification.This was verified with the Hospice Clinical Manager.

Observed in Record Review. In 9 of 10 patient records reviewed, the Plan of Care goals did not have measurable outcomes or time frames for achieving goals. For example: In HV#1, the goals listed for MSW, Chaplain and SN all state beginning of certification period with no measurable timeframes noted. In HV#4, the goals listed state throughout care. This was noted in HV#1, HV#2, HV#3, HV#4, RR#6, RR#7, RR#8, RR#9 and RR#10. This was verified with the Hospice Clinical Nurse Manager.

Observed in Tracer Activities. During the system tracer for Infection Control, the Hospice Nurse Surveyor observed the organization did not identify infection risks based on an analysis of its surveillance activities and other infection control data. This was verified with the Director of Hospice.