Every finding on record at Deliverance Home Health Care, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 08/28/25. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 08/28/25. Standard level deficiencies cited. Abbreviations: = number Pt./Pts. = Patient/Patients % = percent SN = Skilled Nurse HHA = Home Health Aide PT = Physical Therapy/Physical Therapist SOC = Start of Care POC/PsOC = Plan of Care/Plans of Care FBS = Fasting Blood Sugar RBS = Random Blood Sugar > = more than < = less than

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on review of the Error Summary report and staff interview, the Agency failed to submit a timely report, resulting in a warning, for 13 of 373 reports submitted in the last 12 months. Findings include: 1. The Error Summary report for 07/01/24 to 07/24/25 (12 months), was reviewed on 08/28/25. The report included a warning for Error # -3330. The Error included 13 (3.49 %) of 373 assessments that were submitted late. 2. During an interview with the Administrator on 08/28/25 at 9:00 AM, the Administrator confirmed the above findings.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on review of Agency’s Pt. Admission folder, clinical record review, observation during home visits, and staff interviews, the Agency failed to ensure that the Pt. / representative was informed in writing of the services to be provided and the frequency of visits for 7 of 7 (Pts. # 1,2 ,3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 08/25/25 and included a form titled: "Proposed Home Health Services", indicating a space to write information on disciplines who will provide care and their proposed frequencies. 2. The following clinical records were reviewed from 08/26/25 to 08/27/25 and lacked documentation of the service(s) to be provided and visit frequencies. Pt. #1 SOC 05/15/25. Received SN and HHA services. Pt. #2 SOC 07/10/25. Received SN and PT services. Pt. #3 SOC 08/05/25. Received SN and PT services. Pt. # 4 SOC 05/14/25. Received SN services. Pt. #5 SOC 06/18/25. Received SN, HHA and PT services. Pt. #6 SOC 02/10/25. Received SN and PT services. Pt. #7 SOC 03/17/25. Received SN services. 3. The following home visits were conducted on 08/25/25: Pt. #1 SOC 05/15/25. Pt. #2 SOC 07/10/25. Pt. #3 SOC 08/05/25. During the home visits, the Pt. admission folders were observed, including the "Proposed Home Health Services" form and lacked documentation indicating the Pt. / representative was notified of the discipline (s) to provide service, and the frequency of visits in writing. 4. During interviews with the Administrator and Director of Nursing on 08/27/25 between 1:00 PM to 3:30 PM, the Administrative staff confirmed the above findings.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, it was determined the Agency failed to ensure an RN performed the initial assessment within 48 hours of the Physician referral for Home Health Care services in 2 of 7 (Pts. #2 and 3) clinical records reviewed. Findings include: 1. Pt. #2 was admitted to home health services on 07/10/25 with diagnosis of Bilateral Primary Osteoarthritis of the Knee. The clinical record was reviewed on 08/27/25. The Face-to Face was completed by Physician on 06/04/25 and received by Agency on 06/17/25 required: "Skilled Services" (Skilled Nursing Care). The record lacked a Physician ordered SOC date or documentation the Pt. was discharged from an inpatient facility. As of 08/28/25, the record lacked documentation the Agency initiated service within the required time frame. 2. Pt. #3 was admitted to home health services on 08/05/25 with the diagnosis of Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 08/27/25. The Face-to Face form signed by the Physician on 07/30/25 and received by Agency on 07/30/25 required: "Skilled Nursing Care and Home Health Aide.” The record lacked a Physician ordered SOC date or documentation the Pt. was discharged from an inpatient facility. As of 08/28/25, the record lacked documentation the Agency initiated service within the required time frame. 3. During an interview with the Administrator and Director of Nursing, on 08/27/25 at 2:15 PM, the administrative team confirmed the initial assessment visits were conducted, after 48 hours of the Face to Face or referral date.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical records review and staff interviews, the Agency failed to ensure that the staff provided service as ordered in the POC for 2 of 7 (Pts. # 4 and 5) clinical records reviewed. Findings include: 1. Pt. #4 was admitted to home health services on 05/14/25 with the diagnosis of Hypertensive Heart Disease without Heart Failure and Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 08/26/25. The clinical record included a POC effective 05/14/25 to 07/12/25, that required: “SN to perform fingerstick every SN visit, report to MD if FBS is > 250 or 400 The SN visit dated 07/09/25, lacked a blood sugar assessment, as ordered in the POC. 2. Pt. #5 was admitted to home health services on 06/18/25 with the diagnosis of Parkinson’s disease without dyskinesia, without mention of fluctuations and Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 08/27/25. The clinical recorded included PsOC effective 06/18/25 to 08/16/25 and 08/17/25 to 10/16/25, that required “SN to perform fingerstick every SN visit, report to MD if FBS is > 250 or 400 < 70. The SN visits dated 07/28/25, 08/14/25 and 08/19/25, lacked blood sugar assessments, as ordered in the PsOC. 3. During an interview with the Administrator and Director of Nursing on 08/27/25 at 2:15 PM, the Administrative staff confirmed the above findings.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interviews, the Agency failed to ensure the PsOC included Pt. specific interventions for 3 of 7 (Pts. #2, 6 and 7) clinical records reviewed. 1. Pt. #2 was admitted to home health services on 07/10/25 with diagnosis of Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 08/27/25. The clinical record included the POC effective 07/10/25 to 09/07/25, that required: “Notify Physician of vital sign parameters out of range: …Blood Sugar, Fasting: Greater Than (>)250 Less Than ()400 Less Than (The POC included a blood sugar assessment intervention that was not pertinent to Pt. #2’s diagnosis. Findings include: 2. Pt. #6 was admitted to home health services on 02/10/25 with the diagnosis of Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 08/26/25. The clinical record included the POC effective 04/11/25 to 06/09/25, that required: “Notify Physician of vital sign parameters out of range:….Blood Sugar, Fasting: Greater Than (>)250 Less Than ()400 Less Than ( The POC included a blood sugar assessment intervention that was not indicated for Pt.#6’s diagnosis. 3. Pt. #7 was admitted to home health services on 03/17/25 with the diagnosis of Other Chronic Pain. The clinical record was reviewed on 08/26/25. The clinical record included PsOC effective 05/16/25 to 07/14/25 and 07/15/25 to 09/12/25, that required: “Notify Physician of vital sign parameters out of range:….Blood Sugar, Fasting: Greater Than (>)250 Less Than ()400 Less Than ( The POC included a blood sugar assessment intervention that was not indicated for Pt. #7’s diagnosis. 4. During interviews with the Admnistrator and Director of Nursing on 08/27/25 between 1:00 PM to 3:30 PM, the Administrative staff confirmed the above findings.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on review of clinical records, policy review and staff interview, in 6 of 7 clinical records reviewed (Pts. #1, 2, 4, 5, 6 and 7) the Agency failed to conduct complete assessments for Pts. for influenza and pneumonia status. Findings include: 1. The following clinical records were reviewed on 08/26/25 and 08/27/25. The records lacked documentation of dates when the influenza and/or pneumonia vaccines were received by Pts. Pt. #1. SOC 05/15/25 Pt # 2. SOC 07/10/25 Pt. # 4. SOC 05/14/25 Pt. #5. SOC 06/18/25 Pt. #6. SOC 02/10/25 Pt. #7. SOC 03/17/25 2. The policy titled, “Vaccinations” was reviewed on 8/28/25 and required: “A. Influenza: B. Pneumococcal Pneumonia: The following shall be considered for documentation/be documented: a. Individual/client patient record entries identifying the assessment for the need of vaccination; date of offer or referral; client/patient response; administration, contraindication or refusal... b. Standardized check-off form recording client/patient specific information, including the assessment for the need of vaccination; date of offer or referral; client/patient response, administrations, contraindication or refusal; and any follow up activities.” 3. During an interview with the Administrator and the Director of Nursing on 08/27/25 at 2:00 PM and at 3:30 PM, the above findings were confirmed.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interview, the Agency failed to ensure a transfer/ discharge summary was sent to the receiving facility and/or Physician for 2 of 2 (Pts. #6 and 7) discharged records reviewed. Findings include: 1. Pt. #6 was admitted to home health services on 02/10/25 with the diagnosis of Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 08/26/25. The clinical record included a Discharge Summary with last visit date of 06/05/25. The record lacked documentation that the discharge summary was sent to the Physician. 2. Pt. #7 was admitted to home health services on 03/17/25 with the diagnosis of Other Chronic Pain. The clinical record was reviewed on 08/26/25. The clinical record included a Transfer summary, with date of transfer 07/11/25. The record lacked documentation that the transfer summary was sent to the receiving facility. 3. During an interview with the Administrator and Director of Nursing on 08/27/25 at 3:30 PM, the Administrative staff confirmed the above findings.