Every finding on record at Delta Health System

*EMERGENCY PREPAREDNESS* Survey conducted 07/21-07/23/2025 revealed the above HHA facility meets all applicable Federal, State and local emergency preparedness requirements. No deficiencies were cited.

*GREENVILLE * The Medicare Recertification survey conducted 07/21-07/23/2025 revealed the above facility has met all Medicare Conditions of Participation for Home Health Agencies (HHA). However, Standard-level deficiencies were cited. ___________________

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 staff interviews, policy and procedure review, and review of the facility report “HHA Error Summary by Agency”, the facility failed to encode and electronically transmit each completed Outcome and Assessment Information Set (OASIS) assessment within 30 days of completing the assessment of the beneficiary for 30 patients in the past 12 months: 07/18/2024-07/18/2025. Findings Include: During an interview on 07/24/2025 at 12:15 p.m., the Facility Director confirmed she was not aware of the 30 reports that were over 30 days late. She further confirmed two (2) of her staff members re- opened some of the oasis reports past the allowable time allowed. Review of the facility’s Internet Quality Improvement and Evaluation (iQIES) Report, “HHA Error Summary by Agency” for the report period of 07/18/2024-07/18/2025 revealed, Error # -3330 for 30 patient assessments were submitted late more than 30 days after completing the assessment of the beneficiary. Review of facility policy, “Completion and Transmission of Oasis” approval date 07/2025 confirmed, “…all Oasis assessments will be completed and signed by the assessing clinician within five (five) days…Oasis assessments will be transferred to Centers for Medicare K& Medicaid Services (CMS) via IQIES within 30 days…”. During the Exit Conference on 07/23/2025 at 2:30 p.m. with the Facility Director, Clinical Supervisors #1 and #2, survey findings were discussed, and no further documentation was submitted for review.