Triune Home Health Provider, Inc

The agency failed to implement an alternate office or command post site to ensure business operations will continue during an actual emergency, which was necessary for supporting the care continuation, in a universe of 18 patients, when staff members were unable to provide information regarding the…

The agency failed to ensure an updated patient records were readily available to support continuity of care during an emergency, when the agency’s emergency preparedness policy and procedure did not contain the most current patient roster.

The facility failed to ensure a review of all patients’ current medications was being conducted for three of seven sampled patients (Patients 1, 2, and 3).

The facility failed to ensure that the physicians orders were followed for one of seven sampled patients (Patients 5) when Patient 5's physical therapy evaluation was not performed timely, as ordered by the physician.

The agency failed to ensure that the office was open and available to provide care to patients during operational hours, when the agency office was found to be closed during operational hours on Monday, August 19, 2024, from 9:00 AM to 2:00 PM.

The agency failed to follow their policy and procedure to ensure a discharge summary was completed within two calendar days for one of seven sampled patients (Patients 7), when Patient 7’s discharge summary was not completed 51 days after it was ordered.

The agency failed to follow physician’s orders documented on the CMS 485 (a form provided by the Centers for Medicare and Medicaid Services-CMS-which documents a patient’s plan of care and physician’s orders) for one of three sampled patients (Patient 3) when three Skilled Nursing (SN) visits were…

The agency failed to ensure the comprehensive assessment was updated by a discharge assessment and summary for one of three sampled patients (Patient 2).

The agency failed to ensure verbal orders were signed, within 30 days of the interim order, for one of three sampled patients (Patient 2).

The agency failed to ensure that the Condition of Participation: E 001 484.22 Establishment of the Emergency Program (EP) was in compliance as follows: 1. Based on interview and record review, the agency failed to review and update its Emergency Plan annually, for 15 of 15 months reviewed, in a…

The agency failed to ensure the Condition of Participation: G 510 484.55 Comprehensive Assessment of Patients was in compliance when: 1. Based on interview and record review, the agency failed to ensure the comprehensive assessment, which included the patients' care plan, was completed in its…

The agency failed to ensure that the Condition of Participation: G 570 484.60: Care planning, coordination, quality of care was in compliance as follows: Based on interview and record review, the agency failed to individualize, follow, or provide physician oversight of the plan of care for five of…

The agency failed to ensure that the Condition of Participation: G 640 484.65 Quality assessment and performance improvement (QAPI) was in compliance as follows: 1. Based on interview and record review, the agency failed to track, measure and analyze quality indicators (a measurable element of the…

The agency failed to ensure that the Condition of Participation: G 680 484.70: Infection prevention and control was in compliance when: Based on interview and record review, the agency failed to maintain an infection control program that was integrated into the agency's Quality Assessment…

The agency failed to ensure that the Condition of Participation: G 940 484.105 Organization and administration of services was in compliance as follows: 1. Based on interview and record review the Governing Body (GB) failed to operate and manage the agency from November 25, 2019 to March 8, 2021…

The agency failed to review and update its Emergency Plan annually, for 15 of 15 months reviewed, in a universe of 33 patients.

The agency failed to develop individual patient emergency preparedness plans, based on, and included in, the patients' comprehensive assessments, for 15 of 15 months reviewed, in a universe of 33 patients.

The agency failed to provide training to all staff, as well as contracted staff, on the agency's Emergency Preparedness Program, for 15 of 15 months reviewed, in a universe of 33 patients.

The agency failed to conduct full-scale emergency preparedness exercises that were community based (a full-scale exercise is a multi-agency, multi-jurisdictional, multi-discipline exercise involving functional [for example, joint field office, emergency operation centers, etc.] and "boots on the…

The agency failed to ensure the comprehensive assessment, which included the patients' care plan, was completed in its entirety by one clinician for seven out of seven sampled patients (Patients 1, 2, 3, 4, 5, 6, and 7).

The agency failed to individualize, follow, or provide physician oversight of the plan of care for five of seven sampled patients (Patients 1, 3, 5, 6 and 7) when: 1. Patient 1's plan of care was not signed or reviewed by a physician.

The agency failed to track, measure and analyze quality indicators (a measurable element of the agency's practice that can be used to assess the quality of care provided) in order to assess the agency's processes of care, services, and operations, for 15 of 15 months reviewed, in a universe of 33…

The agency failed to use quality indicator (a measurable element of the agency's practice that can be used to assess the quality of care provided) data to improve the quality of the agency's services.

The agency failed to conduct and document performance improvement projects (PIP - a concentrated effort on a particular problem in one area of the agency or agency wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements) the agency had…

The agency's Governing Body (GB) failed to ensure a Quality Assessment and Performance Improvement (QAPI) Program was implemented, maintained and evaluated for effectiveness, for 15 of 15 months reviewed, in a universe of 33 patients.

The agency failed to maintain an infection control program that was integrated into the agency's Quality Assessment Performance Improvement (QAPI) program in order to: identify infection trends (analysis of a pattern), develop action plans and improve disease prevention, for 15 of 15 months…

The Governing Body (GB) failed to operate and manage the agency from November 25, 2019 to March 8, 2021, in a universe of 33 patients when: 1. A current California State License was not maintained.

The agency failed to ensure a Director of Patient Care Services (DPCS) or Director of Patient Care Services Designee (DPCSD) was available to provide clinical oversight of clinical care and services, 24 hours a day, seven days a week, in a universe of 33 patients.

The agency failed to ensure the comprehensive assessment, which included the patient's care plan, was completed no later than five days after the start of care for two of seven sampled patients (Patients 1 and 6).

The agency failed to ensure a review of all medications the patients were taking was conducted for three of seven sampled patients (Patients 1, 2, and 3) when: 1. For Patient 1, one medication on the medication profile (MP-a current list of all medications prescribed for a specific patient)…

The agency failed to ensure the care plan was developed within five working days of the recertification assessment for two of seven sampled patients (Patients 2 and 3).

The Home Health Agency (HHA) failed to ensure the hiring of qualified employees as evidenced by incomplete employment files.

The agency failed to ensure that the Condition of Participation: E 001 484.22 Establishment of the Emergency Program (EP) was in compliance as follows: 1. Based on interview and record review, the agency failed to conduct and document a community-based and/or facility-based risk assessment…

The agency failed to ensure the Condition of Participation: G 510 484.55 Comprehensive Assessment of Patients was in compliance when: 1. Based on interview and record review, the agency failed to ensure the patients' initial assessment was completed within 48 hours of the physician's referral date…

The agency failed to ensure that the Condition of Participation: G 570 484.60: Care planning, coordination, quality of care was in compliance as follows: 1. Based on interview and record review the agency failed to ensure the plan of care was reviewed and signed by a physician within 30 days of the…

The agency failed to ensure that the Condition of Participation: G 640 484.65 Quality assessment and performance improvement (QAPI) was in compliance as follows: 1. Based on interview and record review, the agency failed to analyze and utilize quality indicator (a measurable element of the agency's…

The agency failed to ensure that the Condition of Participation: G 700 484.75: Skilled professional services was in compliance when: 1. Based on interview and record review, the agency failed to ensure a Physical Therapy Assistant (PTA 1) practiced according to his scope of practice and the…

The Agency failed to ensure that the Condition of Participation: G 848 484.100: Compliance with Federal, State, and Local laws and regulations related to the health and safety of patients was in compliance when: 1) Based on interview and record review the facility failed to disclose a change in…

The Agency failed to ensure that the Condition of Participation: G 940 484.105: Organization and administration of services was in compliance when: 1) Based on interview, and record review, the Home Health Agency (HHA) failed to ensure the hiring of qualified employees as evidenced by incomplete…

The agency failed to conduct and document a community-based and/or facility-based risk assessment (community/facility-based includes, but is not limited to, hazards specific to a facility based on the geographic location; patient population; facility type and potential surrounding community assets…

The agency failed to provide for the continuity of operations during an emergency when a succession of authority plan (a plan indicating who will take control in the absence or inability of another) was not in place for seven of seven patients (Patients 1, 2, 3, 4, 5, 6 and 7).

The agency failed to collaborate with local, regional, State, and Federal emergency preparedness officials to cooperate in the planning efforts to maintain an integrated response during a disaster or emergency for seven of seven sampled patients (Patients 1, 2, 3, 4, 5, 6 and 7).

The agency failed to develop procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, for seven of seven sampled patients (Patients 1, 2, 3, 4, 5, 6 and 7).

The agency failed to develop a back-up communication plan with Federal, State, tribal, regional and local emergency management agencies in the event of communications (phone service, including cellular phone and internet) failure during a disaster or emergency, for seven of seven sampled patients…

The agency failed to provide training to all staff, as well as contracted staff, on the emergency preparedness policy and procedure titled, "Emergency Management Plan," dated March 2007, for seven of seven sampled patients (Patients 1, 2, 3, 4, 5, 6 and 7).

The agency failed to develop policy and procedures on conducting full-scale emergency preparedness exercises that were community based (a full-scale exercise is a multi-agency, multi-jurisdictional, multi-discipline exercise involving functional [for example, joint field office, emergency operation…

The agency failed to ensure the comprehensive assessment was updated for one of seven sampled patients (Patient 5) when a Physical Therapist (PT) did not conduct a 30-day reassessment.

The agency failed to ensure the plan of care was reviewed and signed by a physician within 30 days of the patient's start of care for six of seven sampled patients (Patients 1, 2, 4, 5, 6 and 7).

The agency failed to ensure home health agency services were provided in accordance with a physician's order for three of seven sampled patients (Patients 5, 6 and 7) when: 1. For Patient 5, there was no signed: referral order or admission order.

The agency failed to analyze and utilize quality indicator (a measurable element of the agency's practice that can be used to assess the quality of care provided) data in order to assess the agency's processes of care, services, and operations, for seven of seven sampled patients (Patients 1, 2, 3…

The agency's Governing Body (GB) did not approve the frequency and detail of the Quality Assessment and Performance Improvement (QAPI) program's data collection, for seven of seven sampled patients (Patients 1, 2 ,3 4, 5, 6 and7).

The agency failed to document performance improvement projects (PIP - a concentrated effort on a particular problem in one area of the agency or agency wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements) the agency had undertaken…

The agency's Governing Body (GB) failed to ensure a Quality Assessment and Performance Improvement (QAPI) Program was implemented, maintained and evaluated for effectiveness, for seven of seven sampled patients (Patients 1, 2, 3, 4, 5, 6 and 7).

The agency failed to ensure a Physical Therapy Assistant (PTA 1) practiced according to his scope of practice and the agency's policy and procedure when PTA 1 completed a discharge assessment and summary for one of seven sampled patients (Patient 4).

The facility failed to disclose a change in ownership to the state agency.

The Home Health Agency (HHA) failed to notify the state agency of a change in ownership and a change in location as required by the state and local laws under Title 22, section 74667 (a)(b)(2).

The facility failed to maintain a current Home Health Agency (HHA) license according to the state and local laws under title 22 section 74677. This had the potential to place 17 of 17 patients at risk for harm due to closure and loss of health care services.

The facility failed to maintain a current Clinical Laboratory Improvement Amendments (CLIA) Waiver.

The agency failed to ensure the Director of Patient Care Services (DPCS) provided clinical oversight for personnel and patient care services for 17 of 17 sampled patients.

The agency failed to ensure the patients' initial assessment was completed within 48 hours of the physician's referral date or on the physician-ordered start of care date for one of seven sampled patients (Patient 1).

The agency failed to ensure a review of all medications the patients were taking was conducted for two of seven sampled patients (Patients 2 and 3) when: 1. For Patient 2, two medications the patient was taking were not indicated on the medication profile and three medications on the medication…

The agency failed to ensure the comprehensive assessment was updated by a discharge assessment and summary when: 1. For Patient 5, a Physical Therapist (PT) and an Occupational Therapist (OT) did not conduct a discharge or complete a discharge summary.

The agency failed to obtain signed physician orders before providing home health services for three of seven sampled patients (Patients 1, 2 and 4).

The agency failed to follow physician's orders documented on the CMS 485 (a form provided by the Centers for Medicare and Medicaid Services-CMS-which documents a patient's plan of care and physician's orders) for two of seven sampled patients (Patient 1 and 4) when: 1. For Patient 1, four Skilled…

The agency failed to ensure a Registered Nurse (RN) provided supervision of care provided by a Licensed Vocational Nurse (LVN) for two of seven sampled patients (Patients 3 and 4).

The agency failed to ensure Physical Therapy Assistants (PTA) were supervised by a Physical Therapist (PT) for two of seven sampled patients (Patients 5 and 6).

The Home Health Agency (HHA) failed to notify the state agency of the change in the Administrator and the Director of Patient Care Services (DPCS).

The Home Health Agency (HHA) failed to ensure the hiring of qualified employees as evidenced by incomplete employment files.

The Home Health Agency failed to ensure there was an Administrator available during the hours of operation as evidenced by the lack of agency oversight.

The agency failed to obtain contracts with Physical Therapists (PT), Physical Therapy Assistants (PTA), Occupational Therapists (OT) and Occupational Therapy Assistants (OTA) before patient contact and care for six of seven sampled patients (Patients 1, 3, 4, 5, 6 and 7).