Trinity Home Health Care Inc

The home health agency failed to ensure their emergency preparedness plan (EPP) included a process to collaborate and cooperate with local, tribal, regional, state, and federal emergency preparedness entities to maintain an integrated response in case of an emergency (Tag E0009); failed to ensure…

The home health agency failed to ensure their emergency preparedness plan (EPP) included a process to collaborate and cooperate with local, tribal, regional, state, and federal emergency preparedness entities to maintain an integrated response in case of an emergency in 1 of 1 home health agency.

The home health agency failed to ensure their emergency preparedness plan (EPP) included procedures of how to inform State and local emergency preparedness officials about homebound home care patients in need of evacuation from their residences due to an emergency in 1 of 1 home health agency.

The home health agency failed to ensure the Emergency Preparedness Plan (EPP) included the physician’s name and contact information for each patient for 1 of 1 agency.

The home health agency failed to ensure the Emergency Preparedness Plan (EPP) included the contact information for Federal emergency preparedness staff in 1 of 1 agency.

The home health agency failed to ensure the Emergency Preparedness Plan (EPP) included a method for sharing agency patient information and the location of home health patients with other health providers to maintain continuity of care and for 1 of 1 agency.

The home health agency failed to ensure the Emergency Preparedness Plan (EPP) included a process for communicating the agency’s capacity, needs, and ability to provide assistance, to the designated community officials for 1 of 1 agency.

The home health agency failed to provide Emergency Preparedness policy and procedure training to all new and existing staff for 1 of 1 agency.

The agency failed to participate in a full-scale community-based or facility-based exercise every 2 years to test the emergency plan.

The agency failed to ensure the comprehensive assessment was updated to include the patient’s current condition for 1 of 3 active patients with only skilled nurse services (Patient #1).

The home health agency failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee had initiated and documented a performance improvement project (PIP) which was approved by the Governing Body which had the potential to affect all agency patients and staff.

The agency failed to ensure nurses followed appropriate hand hygiene during wound care for 1 of 1 registered nurse (RN) observation of wound care at a home visit (RN 1).

The agency failed to ensure there was a skills competency evaluation prior to providing patient care for 1 of 2 home health aide [HHA] personnel records reviewed (HHA #2).

The agency failed to ensure skilled nurse visit notes were completed within 7 days of the date of service for 3 of 5 active patient records reviewed (Patients #3, 4, and 5) and 2 of 2 discharge patient records (Patients #6 and 7).

The home health agency failed to ensure the revised plan of care (POC) was up-to-date and supported by the recertification comprehensive assessment for 1 of 2 active records reviewed of patients that resided in their home (Patient #4).

The agency failed to ensure the home health aide (HHA) reported changes in patient status to the registered nurse (RN) for 1 of 1 home visit for HHA observation.

The agency failed to ensure patient's clinical records would be made available to the patient, free of charge, upon request at the next home visit, or within 4 business days (whichever comes first).

The agency failed to ensure all patients received services as ordered on the plan of care for 1 of 3 records reviewed (#3).

The agency failed to ensure it provided all patients with the telephone number of the Quality Improvement Organization.

The agency failed to ensure the comprehensive assessment included the patient’s current health status in 2 of 3 records reviewed (Pt #2, 3).

The agency failed to ensure the HHA (Home Health Aide) and SN (Skilled Nurse) documentation notes were completed and entered into the clinical record for 1 of 3 records reviewed (Pt #3).

The agency failed to ensure all patients received the administrator's name in order to receive complaints (G414); failed to ensure all patients received an OASIS [Outcome and Assessment Information Set] privacy notice found on the CMS (Centers for Medicare and Medicaid Services) website to all…

The registered nurse failed to ensure a patient assessment was completed within 48 hours of referral (G514); failed to ensure all comprehensive assessments evidenced all patients' strengths, goals, and/or care preferences (G530); failed to ensure the comprehensive assessment/re-assessment evidenced…

The agency failed to ensure it assisted all discharged patients/caregivers in securing other formal assistance (such as another home health care provider) prior to discharge from the agency (G562); and failed to ensure all discharge and/or transfer summaries were completed, sent to the receiving…

The registered nurse failed to ensure all plans of care were individualized, established by the certifying physician, included patient-specific measurable outcomes and goals, and/or all patients received all services in the plan of care (G572); failed to ensure all patients’ plans of care were…

The registered nurse failed to ensure all patients/caregivers participated in the development and evaluation of the plan of care (G708); and failed to ensure all licensed practical nurses (LPNs) were assessed and demonstrated clinical skills competency prior to being assigned to a patient with…

The administrator failed to ensure all home health aides (HHAs) completed a home health training program that included classroom and supervised practical training which totaled at least 75 hours, and were currently listed in good standing on the Indiana Department of Health (IDOH) HHA registry…

The administrator failed to be responsible for the day-to-day operation of the agency (G948); failed to ensure the agency employed qualified personnel, and failed to ensure the agency developed personnel job descriptions and policies that met federal and state regulatory standards (G952); failed to…

The registered nurse failed perform a comprehensive re-assessment when the patient’s condition warranted for 1 of 1 record reviewed with a significant change in condition.

The agency failed to ensure all discharged patients/caregivers received assistance in finding another home care agency for 1 of 1 discharge records reviewed who required other formal assistance after discharge from the agency (#8).

The agency failed to ensure it sent a discharge and/or transfer summary to the receiving facility and/or physician, for 4 of 4 discharged and/or transferred records reviewed (#6, 7, 8, 9).

The registered nurse (RN) failed to ensure all plans of care were individualized, established by the certifying physician, included patient-specific measurable outcomes and goals, and/or all patients received all services in the plan of care, for 8 of 8 skilled records reviewed.

The clinical manager failed to ensure the agency’s home health aides (HHAs) were assigned to each patient by a registered nurse, with a written home health aide care plan prepared by a registered nurse.

The agency failed to ensure all patients received the administrator's name in order to receive complaints for 3 of 3 home visits observed.

The agency failed to ensure all patients received an OASIS [Outcome and Assessment Information Set] privacy notice found on the CMS (Centers for Medicare and Medicaid Services) website to all patients for whom the OASIS data was collected for 3 of 3 home visits observed.

The agency failed to ensure all patients received the agency's policies for transfer and discharge.

The agency failed to ensure patients/caregivers were treated with respect regarding preferences in his or her own home while agency staff was present.

The agency failed to ensure all patients participated in, were informed about, and/or consented to any changes in the home care services/treatment provided for 7 of 9 records reviewed (#1, 2, 4, 5, 6, 7, 9).

The agency failed to ensure all patients received all services as ordered on the plan of care and failed to have a policy to guide agency personnel for 3 of 9 records reviewed (#2, 3, 7).

The agency failed to provide all patients information on their right to be notified prior to the next home health visit, of any changes in the charges for services they received.

The agency failed to ensure it provided all patients with the names, addresses, and telephone numbers of the Agency on Aging/Aging and Disability Resource Center, Center for Independent Living, and Quality Improvement Organization.

The registered nurse failed to ensure a patient assessment was completed within 48 hours of referral for 1 of 1 records reviewed where the initial certification period was reviewed (#7), in a total sample of 9 records.

The registered nurse failed to ensure all comprehensive assessments evidenced all patients' strengths, goals, and/or care preferences for 13 of 13 comprehensive assessments reviewed for 7 of 9 records reviewed (#1, 2, 4, 5, 6, 7, 8).

The registered nurse failed to ensure the comprehensive assessment/re-assessment evidenced the patient's rehabilitative and/or discharge planning needs for 11 of 13 comprehensive assessment/re-assessments reviewed for 7 of 7 records reviewed which contained comprehensive assessments.

The registered nurse failed to review all medications the patient was currently taking (both prescription and non-prescription), failed to evidence indications for PRN (as needed) medications, failed to evidence a drug regimen review (DRR) was completed, and/or failed to evidence the physician was…

The registered nurse failed to ensure the comprehensive assessment/re-assessment included all required information regarding the patient’s primary caregiver 6 of 7 records reviewed which contained comprehensive assessments (#1, 4, 5, 6, 7, 8).

The registered nurse failed to ensure the comprehensive assessment/re-assessment evidenced the patient's representative (if any) for 5 of 7 records reviewed which contained comprehensive assessments (#1, 4, 5, 6, 7).

The registered nurse (RN) failed to ensure comprehensive re-assessments were completed during the last 5 days of every 60 days for 7 of 8 records reviewed with skilled services (#1, 2, 3, 4, 5, 6, 7).

The registered nurse (RN) failed to ensure a comprehensive reassessment was performed and completed at discharge, and/or failed to ensure it included a summary of the patient's progress in meeting the care plan goals for 2 of 2 discharged records reviewed when skilled care was provided (#6, 8).

The registered nurse failed to ensure all patients’ plans of care included a description of the patient’s risk for emergency department visits and hospital re-admission, all necessary interventions to address the underlying risk factors, patient-specific interventions and education, and information…

The registered nurse failed to ensure all patients and/or caregivers received ongoing training, monitored comprehension and response to training for 5 of 5 records reviewed with skilled nursing services.

The agency failed to ensure all patients received current medication schedules for 1 of 3 home visits observed.

The agency failed to provide all patients the written name and contact information of the agency’s clinical manager for 3 of 3 home visits observed.

The registered nurse failed to ensure all patients/caregivers participated in the development and evaluation of the plan of care for 4 of 9 records reviewed (#1, 4, 5, 7).

Based record review and interview, the registered nurse failed to ensure all licensed practical nurses (LPNs) were assessed and demonstrated clinical skills competency prior to being assigned to a patient with complex medical needs for 1 of 1 LPN employee record reviewed.

The administrator failed to ensure all home health aides (HHAs) completed a home health training program that included classroom and supervised practical training which totaled at least 75 hours, and were currently listed in good standing on the Indiana Department of Health (IDOH) HHA registry…

The agency failed to ensure its home health aide training program included classroom and supervised practical training which totaled at least 75 hours.

The clinical manager failed to ensure the home health aide (HHA) provided only services consistent with the HHA’s training/competency, and/or provided only services included on the plan of care for 6 of 6 records reviewed with services provided by an HHA (#1, 2, 4, 5, 6, 8).

The agency failed to ensure the duties performed by home health aides (HHAs) included only those evidenced in agency policies for 1 of 6 records reviewed with services provided by an HHA (#4).

The administrator failed to be responsible for the day-to-day operation of the agency.

The administrator failed to ensure the agency employed qualified personnel for 6 of 13 personnel records reviewed (G, J, L, M, N), and failed to ensure the agency developed personnel job descriptions and policies that met federal and state regulatory standards.

The clinical manager failed to ensure the agency’s home health aides (HHAs) were assigned to each patient by a registered nurse.

The agency failed to ensure the registered nurse (RN) provided a complete physical assessment to determine the patient’s needs for 3 of 3 (#1, 2, 3) home visits observed with an RN, and 2 additional patient interviews (#4, 5).

The agency failed to ensure wound care orders were provided as ordered by the physician in 1 of 2 clinical records reviewed of patients receiving wound care (#1).

The agency failed to ensure all staff followed infection control practices for 1 of 1 home visit observation.

The agency failed to ensure all staff followed infection control policies and procedures for 2 of 3 home visit observations.

The agency failed to ensure the administrator's employee file was current and contained appropriate documentation for 1 of 7 personnel records reviewed.

The agency failed to ensure home health aide (HHA) clinical background checks did not include a felony conviction within the past 10 years (employee H) for 1 of 4 HHA files reviewed; and failed to ensure criminal background checks were performed within 3 days of patient contact for 1 of 4 HHA files…

The agency failed to ensure the Registered Nurse performed a comprehensive assessment within 5 days of start of care to ensure no changes had occurred since the initial assessment for 1 of 7 clinical records reviewed.

The Registered Nurse failed to measure wounds weekly for 1 of 1 record reviewed of patients receiving wound care (# 1) in a sample of 9 records reviewed.

The agency failed to ensure the home health aides (HHA) were not instructed to apply medicated gel on patients for 1 of 6 records reviewed receiving HHA services.

The administrator failed to ensure she maintained the day to day operations of the agency for 1 of 1 agency.