Trinity Home Health

The agency failed to electronically transmit monthly Outcome and Assessment Information Set (OASIS) data collected to the CMS system every 30. Failure to submit OASIS within 30 days has the potential to cause delay in care and affect quality of care for all patients with late OASIS submission.

The agency failed to include goals, and interventions with a diagnosis of end stage renal disease (a medical condition in which a person’s kidneys are no longer able to function adequately on their own and requires dialysis or kidney transplant to maintain life) for one patient (P) (P#16) of 17…

The skilled nurse (SN) failed to perform treatments as ordered by a physician for two patients (P) (P#1, P#2) of 17 sampled patients.

The agency failed to include orders to cover all pertinent diagnoses to ensure the patients' identified needs were addressed and failed to ensure disease specific treatments/interventions were included on plans of care for 5 of 17 (#6, #9, #10, #14, and #17) sampled patients.

The agency failed to ensure that appropriate care and services were provided in conformance with the patients' plans of care/treatment as ordered by physicians for 4 of 17 (#1, #6, #10, and #17) sampled patients.

The agency failed to ensure the clinical records contained clear, complete, and accurate documentation in the clinical record for 5 of 17 (#11, #12, #14, #16, and #17) sampled patients (P).