Every finding on record at Trinity Home Health Services

Observed in Individual Tracer. In 1 of 6 Individual Tracers, it was noted that the organization did not ensure that the Hospice Election and Consent Form(s) were completed as required. The organization did not ensure the patient's right to choose an attending provider was implemented. For example, during a review of the consent in the medical record for HosRRHV#6, the Line titled “Physician’s Full Name” did not include the provider's complete name. This observation was reviewed with the Regional Director of Hospice Operations.

Observed in Record Review. In 1 of 18 patient records reviewed the organization did not ensure that updated assessments include all required information. For example, a review of the medical record for HosRRNHV#10, revealed that during week 3 of services, a clinician documented the following information: Stage 2 slow to heal with friction and shearing, ordered gel cushion to off load pressure, continue to use island foam dressing to area. Wound approximately 0.5cm, no drainage or signs and symptoms of infection. The wound assessment did not include the location of the wound, complete wound measurements, and the condition of the surrounding skin. This observation was reviewed with the Regional Director of Hospice Operations.

Observed in Record Review. In 1 of 18 patient records reviewed, it was noted that the organization did not ensure all requirements related to a comprehensive assessment were implemented. For example, during a review of the medical record for HosRRHV#6, it was noted that the comprehensive assessment did not include the initial bereavement risk assessment. This observation was reviewed with the Regional Director of Hospice Operations.

Observed in Record Review. In 3 of 18 patient records reviewed, it was noted that the organization did not ensure the plan of care goals included outcome measures for specific care activities. For example, a review of the medical record for HosRRHV#5, revealed that the patient’s terminal illness diagnosis was Dysphagia following Cerebral Infarction. The plan of care did not include a goal statement to evaluate the response to care, treatment, and services related to Dysphagia following Cerebral Infarction.Example #2: During a review of the medical record for HosRRNHV#5, an updated assessment documented that the patient was experiencing pain at his foot and receiving wound care for a stage two (2) pressure ulcer at the coccyx area. The plan of care did not include goal statements to evaluate the response to care, treatment and services related to pain management and wound care interventions. Example #2: A review of the medical record for HosRRNHV#10, revealed that during week 3 of services, a clinician documented the following information: Stage 2 slow to heal with friction and shearing, ordered gel cushion to off load pressure, continue to use island foam dressing to area. Wound approximately 0.5cm, no drainage or signs and symptoms of infection. The plan of care was not updated with a goal statement related to the care, treatment, and services of the patient's non-intact skin. This observation was reviewed with the Regional Director of Hospice Operations.

Observed in Record Review. In 1 of 18 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, during the assessment update completed during week 3 of the 1st benefit period, the clinician documented that the patient had experienced a fall with injury. The plan of care was not updated with interventions to maintain safety and strategies to prevent injury. Example #2: A review of the medical record for HosRRNHV#10, revealed that during week 3 of services, a clinician documented the following information: Stage 2 slow to heal with friction and shearing, ordered gel cushion to off load pressure, continue to use island foam dressing to area. Wound approximately 0.5cm, no drainage or signs and symptoms of infection. The plan of care was not updated with interventions to address the care, treatment, and services of the patient's non-intact skin. Example #3: In 2 of 18 patient records reviewed, it was noted that the organization did not ensure the plan of care goals included outcome measures for specific care activities. For example, a review of the medical record for HosRRHV#5, revealed that the patient’s terminal illness diagnosis was Dysphagia following Cerebral Infarction. The plan of care did not include a goal statement to evaluate the response to care, treatment, and services related to Dysphagia following Cerebral Infarction. Example #4: During a review of the medical record for HosRRNHV#5, an updated assessment documented that the patient was experiencing pain at his foot and receiving wound care for a stage two (2) pressure ulcer at the coccyx area. The plan of care did not include care, treatment, and service interventions related to pain management and wound care. This observation was reviewed with the Regional Director of Hospice Operations.

Observed in Tracer Activities. During a review of the volunteer hours presented, the hospice pharmacist surveyor noted that the organization had not accurately documented the estimated cost savings for 2024 as they had not met the required 5% of total patient care hours that were provided by volunteers. This issue was validated with the volunteer coordinator and the director at the time of the survey.

Observed in Tracer Activities. During a discussion with the volunteer coordinator and review of available records prepared in 2024, the pharmacy Hospice surveyor noted that current documentation of direct patient care and administrative hours to equal 5% of the total patient care hours of all paid employees was not achieved for 2024--only a 4% average for the year was achieved and reported. The validation of this information was reviewed with the volunteer coordinator and director. at the time of the survey.

Observed in Individual Tracer. In 1 of 6 individual tracers, it was noted that the organization did not ensure the medication list included accurate information. For example, individual tracer activities for HosRRHV#6, revealed that the medication list provided to the Hospice Surveyor, and the medication list in the patient’s home folder, did not include an accurate description of the medication’s the patient was currently taking. The following medication was not listed: Men’s Multivitamin & Omega – 3 gummies daily. Example #2: In 1 of 18 patient records reviewed, the organization did not ensure the medication list was updated when medication changes were noted. For example, a review of the medical record for HosRRNHV#5, revealed that during week 3 of the 1st benefit period the patient started taking Tylenol for foot pain. The medication list was not updated to include the addition of the this pain management medication. This observation was reviewed with the Regional Director of Hospice Operations.

Observed in Record Review. During review of a bereavement record, the Hospice pharmacy surveyor noted that an entry in this record by the bereavement coordinator was originally dated 12/16/2024. However there was also an entry listed as 1/6/2025 for this same information. Upon interview the bereavement coordinator indicated that she had entered a couple of misspelled words and when this change was made, it changed the note entry date to the new date in this case 1/6/25 which made the date now observed as inaccurate, This change in date made the current date of the original order in the patient's EMR to include a date which reflected an original inaccurate original note entry. date as well. This issue was validated wit the bereavement coordinator and the Hospice management team at the time of the survey.

Observed in Individual Tracer. In 1 of 2 Individual tracers, for patient’s receiving home oxygen therapy, it was noted that the organization did not ensure the comprehension of education related to general oxygen safety risks was assessed. For example, during the home visit activity for HosRRHV#6, it was noted that two oxygen tanks were stored in the patient’s closet. There was no documentation of the assessment of patient’s, family’s and/or caregiver’s level of comprehension of this identified risk and compliance with suggested interventions. This finding was observed during survey activity but corrected onsite prior to the surveyor’s departure. The corrective action taken needs to be included in the organization’s Evidence of Standards Compliance submission. Example #2: In 1 of 18 patient records reviewed, it was noted that the organization did not ensure the comprehension of education related to wound care was assessed. For example, during the record review activity for HosRRNHV#1, it was noted that the clinician documented the patient's caregiver was performing the wound care. There was no documentation of the assessment of patient’s, family’s and/or caregiver’s level of comprehension of the wound care regimen and skin integrity interventions. This observation was reviewed with the Regional Director of Hospice Operations.

Observed in Record Review. In 2 of 16 patient records reviewed, the hospice surveyor noted that the plan of care did not include all the services/interventions needed for management of the terminal illness and/or related conditions. Following record review of (HOS RR#6) of a patient that must self catheterize himself 4-5 times a day and who had a history of multiple urinary tract infections, the surveyor noted there was nothing related to this on the current plan of care/care paths. Following record review (HOS RR#3) of a patient that was ordered oxygen therapy, the surveyor noted on admission the oxygen order was for 2 liters via nasal cannula, when reviewing recent nursing visit documentation the oxygen is now at 3 liters via nasal cannula continuously. There was no order or changes in the plan of care noted. This was confirmed with the Director of Hospice.

Observed in Record Review. In 1 of 8 patient records reviewed, of patients that were ordered home health aide services, the hospice surveyor noted that the aide care plan did not include all the needed instructions based on the patients assessed needs. Following record review of (HOS HV#1) of a patient that was currently ordered oxygen continuously, the surveyor noted there are no instructions related to the oxygen/oxygen safety and if the oxygen could be removed during the bath. This was confirmed with the Director of Hospice.

Observed in Record Review. In 1 of 8 patient records reviewed, of patient's ordered home health aide services, the hospice surveyor noted that a hospice aide did not report changes related to the plan of care. Following record review of (HOS RR#2) of a patient in an assisted living facility, the surveyor noted when reviewing the home health aides visit notes for all of the recent visits that the patient was either refusing all the tasks or it stated that the facility completed care or care already done. This was confirmed with the Director of Hospice.

Observed in Individual Tracer. In 1 of 5 home visits conducted, the hospice surveyor noted that when conducting the medication reconciliation the medications listed on the agency's medication profile did not match what the patient was currently taking. When reviewing medications for (HOS HV#2), a patient who resides in a skilled nursing facility, the surveyor noted the following medications were not on the agency's medication profile: Acetaminophen 325 mg 2 tablets every hours as needed for temp, Ferrous Sulfate 325 mg 1 tablet daily, Guaifenesin 100mg/5mls 10 mls every 4 hours as needed for cough, loperamide 2 mg capsule 2 capsules give 2 caps after 1st loose stool then one cap after each loose stool not to exceed 4 capsules per day, Maalox 200mg/5 mls 15-30 mls every 4 hours as needed for nausea and heartburn, metoprolol 50 mg daily, milk of magnesia 400mg/5 mls 30 mls for no BM x 2 days, Norvasc 5 mg 1 tablet daily, Ventolin HFA 90 mcg/actuation aerosol inhaler 2 puffs every am, Ventolin HFA 90 mcg/actuation aerosol inhaler 2 puffs every 6 hours as needed. This was confirmed with the Director of Hospice.