Every finding on record at Delta Home Health Care, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 11/15/24. 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 11/15/24. Standard level deficiencies cited. Abbreviations: SN = Skilled Nurse SOC = Start of care RN = Registered Nurse Pt./ Pts. = Patient/Patients PTA = Physical Therapy Assistant OASIS = Outcome and Assessment Information Set

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 the review of the Agency’s Error Summary report and Staff interview, it was determined in 249 of 361 reports submitted for the last 12 months, the Agency failed to submit all timely reports. Finding include: 1. The Agency’s Error Summary report for 11/01/23 thru 10/31/24, was reviewed on 11/12/24 at 9:30 AM. The report included error # -3330 for 249 of 361 submissions. 68.98% of the OASIS reports were not submitted timely, resulting in a warning. 2. The above findings were confirmed, during the interview with the Administrator and Director of Nursing, on 11/12/24 at 1:00 PM.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on the clinical record review, home visit observations and Staff interview, it was determined in 2 of 7 (Pts.# 1 and 3) Patient's admission folders, the Agency failed to provide the contact information for the current Clinical Manager. 2. Pt. #3 was admitted to the Home Health Services on 08/24/24 with the diagnoses of: Hypertensive Heart Disease without Heart Failure and Paroxysmal Atrial Fibrillation. The clinical record was reviewed on 11/12/24. A home visit was conducted on 11/13/24 with the SN. It was observed the patient’s home admission folder lacked the contact information for the Clinical Manager. 3.The above findings were confirmed, during the interview with the Administrator and Director of Nursing (Clinical Manager), on 11/13/24 at 2:30 PM and 11/14/24 at 1:00 PM. Findings include: 1. Pt. #1 was admitted to the Home Health Services on 11/01/24 with the diagnosis of: Type 2 Diabetes Mellitus with Diabetic Neuropathy. The clinical record was reviewed on 11/12/24. A home visit was conducted on 11/12/24 with the PTA. It was observed the patient’s home admission folder lacked the contact information for the Clinical Manager.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on clinical record review and Staff interview, it was determined that in 4 of 7 (Pts. #1, 2, 3 and 6) clinical records reviewed, the Agency failed to ensure the clinical records were complete and accurate. 3. Pt. #3 was admitted to the Home Health Services on 08/24/24 with the diagnoses of: Hypertensive Heart Disease without Heart Failure and Unspecified and Paroxysmal Atrial Fibrillation. The clinical record was reviewed on 11/12/24. The clinical record contained an incomplete document titled “Beneficiary Elected Transfer” that lacked the name of the agency and the date of the transfer. 4. Pt. #6 was admitted to the Home Health Services on 02/01/24 with the diagnoses of: Other Spondylosis with Myelopathy, Cervical Region and Pain Right Knee. The clinical record was reviewed on 11/12/24. The clinical record contained an incomplete document titled “Beneficiary Elected Transfer” that lacked the name of the agency and the date of the transfer. 5.The above findings were confirmed, during the interview with the Administrator and Director of Nursing, on 11/13/24 between 11:00 AM and 2:30 PM. Findings include: 1. Pt. #1 was admitted to the Home Health Services on 11/01/24 with the diagnosis of :Type 2 Diabetes Mellitus with Diabetic Neuropathy. The clinical record was reviewed on 11/12/24. The clinical record contained a "Medicare Secondary Payor" form completed by the SN on 11/01/24. The form was ineligible and lacked entries to the form, as required. 2. Pt. #2 was admitted to the Home Health Services on 08/27/24 with the diagnosis of: Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 11/13/24. The clinical record contained "Beneficiary Elected Transfer" form signed by Pt and RN and dated 08/27/24 at SOC. The form lacked the name of the agency where Pt. transferred from and effective date, as the form required.

Recertification survey completed. Standard level deficiencies cited. A Focused Infection Control Survey (FIC) was conducted on 09/30/21. Delta Health Care, Inc. was in compliance with the requirements for Infection Control for COVID-19. Abbreviations: Pt./Pts. = Patient/Patients SOC = Start of Care POC/PsOC = Plan of Care/Plans of Care PTA = Physical Therapy Assistant OT = Occupational Therapy/Therapist AM = Morning PM = Afternoon, Evening HHN = home health nurse Hh = Home Health HHS = Home Health Services Dr = Doctor eval = evaluation Rx = Medical Prescription + = plus cc = cubic centimeters cm = centimeters fr = french (>) = greater than (<) = less than mg/dl = milligrams per deciliter % = percent x = times w = week FIC = Focus Infection Control COVID-19 = Coronavirus 2019

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: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure the initial assessment visit was done within 48 hours of the referral date. This was found in 4 of 7 (Pts. #1, 5, 6 and 7) clinical records reviewed. Findings include: 1. Pt. #1. SOC 9/16/21. Diagnoses: Lumbar Region Other Spondylosis with Myelopathy, Other abnormalities of Gait and Mobility. The clinical record was reviewed on 9/27/21 at 2:00 PM. The record contained the form titled, “Encounter… Home Visit” conducted on 9/1/21 and signed by the Physician. The Physician required the Pt. to receive “Hh sn PT” services”. The Encounter form was faxed to the Agency on 9/1/21. The SOC was conducted on 9/16/21 which was 15 days after the referral date. The record lacked a Physician ordered SOC date or documentation the Pt. was discharged from an inpatient facility. As of 9/27/21, the record lacked documentation the Agency started service within the required time frame. 2. Pt. #5. SOC 4/21/21. Diagnoses: Atherosclerotic Heart Disease of native Coronary Artery without Angina Pectoris and History of Falling. The clinical record was reviewed on 9/28/21 at 10:00 AM. A request was made to view the referral for this Pt. The Director of Operations/ Alternate Director of Nursing presented the SOC comprehensive assessment dated 4/21/21 (10:15 AM) and a Physician order to start services dated 4/21/21 (3:50 PM). As of 9/28/21, the record lacked documentation of a referral and/or Physician order, indicating the Agency started service within the required time frame. During an interview with the Director of Operations/ Alternate DON on 9/29/21 at 11:33 AM, the Director of Operations stated: “I received a verbal order from the doctor the day before (4/20/21)… I was not able to put the verbal order in the computer on the 20th…” 3. Pt. #6. SOC 1/19/21. Diagnoses: Type 2 Diabetes Mellitus without Complications and Not Elsewhere Classified and Not Elsewhere Classified Difficulty in Walking. The closed clinical record was reviewed on 9/28/21 at 11:22 AM. The record contained the form titled, “Encounter… Home Visit” conducted on 1/8/21 and signed by the Physician on 1/7/21 requiring: “HHN, PT”. The Encounter form was faxed to the Agency on 1/8/21. The SOC was conducted on 1/19/21 (11 days after receipt of the referral). As of 9/28/21, the record lacked documentation the Agency started service within the required time frame. 4. Pt. #7. SOC 6/24/20. Diagnoses: Hypertensive Heart Disease without Heart Failure and History of Falling. The closed clinical record was reviewed on 9/28/21 at 3:00 PM. The record contained a form indicating Physician services were provided on 6/18/20, and included “HHS/ PT/OT eval + Rx.” The SOC was conducted on 6/24/21 which was 6 days after the referral date. As of 9/28/21, the record lacked documentation the Agency started service within the required time frame. 5. During an interview with the Administrator and the Director of Operations/ Alternate Director of Nursing (Administrative Staff) on 9/29/21 at 11:33 AM, the Administrative Staff confirmed the Agency failed to ensure service was initiated within 48 hours of the 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: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure staff provide service, as indicated in the POC. This was found in 1 of 2 (Pt. #6) closed clinical records reviewed. Findings include: 1. Pt. #6. SOC 1/19/21. Primary Diagnosis: Type 2 Diabetes Mellitus without Complications. The closed clinical record was reviewed on 9/28/21 at 11:22 AM. The record contained the POC for the certification period of 3/20/21 to 5/18/21 requiring: “Notify Physician of… Blood Sugar, Fasting: Greater Than (<) 150 Less Than (<) 60…” The SN visit note dated 3/23/21 included “Fasting Blood Sugar 185 mg/dl”. The SN visit note dated 4/13/21 included “Fasting Blood Sugar 193 mg/dl”. The SN visit note dated 5/4/21 included “Fasting Blood Sugar 185 mg/dl”. The record lacked documentation the SN notified the Physician the Fasting Blood Sugars were outside the stated parameters. The Recertification Comprehensive Assessment completed by the SN on dated 3/16/21 included “Patient is incontinent”. The POC effective 3/20/21 required: “SN to instruct on establishing bladder regimen”. The weekly SN visit notes from 3/23/21 to 5/4/21, and the Discharge Comprehensive Assessment form dated 5/11/21 lacked documentation the SN instructed on establishing a bladder regimen. 2. During an interview with the Administrator and the Director of Operations/ Alternate Director of Nursing on 9/29/21 at 11:33 AM, the Administrative Staff confirmed the Agency failed to ensure staff provided service as indicated in the POC.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: A. Based on clinical record review, Agency policy, and staff interview, it was determined the Agency failed to ensure Physician orders for PT were followed. This was found in 4 of 7 (Pts. #4, 5, 6, and 7) clinical records reviewed, wherein Physical Therapy services were ordered. Findings include: 1. Pt. #4. SOC 5/5/21. Primary Diagnosis: Chronic Combined Systolic and Diastolic Heart Failure. The clinical record was reviewed on 9/28/21 at 10:15 AM. The record contained a PT Care Plan dated 8/24/21, which included “Visit Frequency: 1w1, 2w3.” The record included two PTA “Missed Visit” notes, dated 9/8/21 and 9/10/21. The record lacked documentation the Physician was notified of these missed visits. 2. Pt. #5. SOC 4/21/21. Diagnoses: Atherosclerotic Heart Disease of native Coronary Artery without Angina Pectoris and History of Falling. The clinical record was reviewed on 9/28/21 at 10:00 AM. The record contained the form titled, “Encounter Home Visit” dated 7/22/21 signed by the Physician requiring: “PT to assist with gait training and strengthening.” As of 9/28/21, the Agency failed to provide PT services as ordered. 3. Pt. #6. SOC 1/19/21. Primary Diagnosis: Type 2 Diabetes Mellitus without Complications. The closed clinical record was reviewed on 9/28/21 at 11:22 AM. The record contained the form titled, “Encounter Home Visit” dated 1/6/21 signed by the Physician requiring: “Referral/ Evaluation…PT”. As of 9/28/21, the Agency failed to provide PT services as ordered. 4. Pt. #7. SOC Pt. #7. SOC 6/24/20. Diagnoses: Hypertensive Heart Disease without Heart Failure and History of Falling. The closed clinical record was reviewed on 9/28/21 at 3:00 PM. The record contained a form indicating Physician services were provided on 6/18/20, and included a Physician’s order for “…PT eval + Rx.” As of 9/28/21, the Agency failed to provide PT services as ordered. 5. The Agency’s policy titled “Clinical Records” was reviewed on 9/29/21 at 3:30 PM. The policy required: “The clinical record shall contain…13. Documentation of missed visits, including the reason and Physician notification…” 6. During an interview with the Administrator and the Director of Operations/ Alternate Director of Nursing on 9/29/21 at 11:33 AM and 1:40 PM, 9/30/21 at 9:15 AM and 9:45 AM, the Administrative Staff confirmed the Agency failed to provide services as ordered by the Physician.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure Physician orders were obtained, prior to indwelling catheter insertion and performing wound dressing changes. This was found in 2 of 2 (Pts. #4 and #7) clinical records reviewed for Pts. requiring an indwelling urinary catheter/wound care. Findings include: 1. Pt. #4. SOC 5/5/21. Primary Diagnosis: Chronic Combined Systolic and Diastolic Heart Failure. The clinical record was reviewed on 9/28/21 at 10:15 AM. The record contained the SOC comprehensive assessment dated 5/5/21, which included documentation the Pt. had an indwelling urinary catheter. The record also contained the POC effective 5/5/21 to 7/3/21, as well as the POC effective 7/4/21 to 9/1/21. These PsOC lacked orders for the SN to assess and provide treatment for the patient’s indwelling urinary catheter. The record lacked any further Physician’s orders pertaining to the patient’s urinary catheter during these two certification periods. The record contained an SN visit note, dated 7/30/21, which included: “…Pt. catheter was changed. 22 fr catheter was inserted, balloon inflated with 5 cc of water…” The record also included an SN recertification visit note, dated 8/30/21, which contained documentation “…22 fr catheter was inserted with 5 cc balloon inflated…” During an interview with the Administrator and Director of Operations/Alternate Director of Nursing on 9/29/21 at 11:40 AM, The Director of Operations/Alternate Director of Nursing stated the SN should obtain a Physician’s order prior to inserting an indwelling urinary catheter. The order should include the size of catheter and the frequency the catheter should be changed. 2. Pt. #7. SOC 6/24/20. Diagnoses: Hypertensive Heart Disease without Heart Failure and History of Falling. The closed clinical record was reviewed on 9/28/21 at 3:00 PM. The record contained the SN visit note dated 7/3/21 which included: “…Upon assessment assessed low back due to OT informing that patient had thermal burn due to placing hot water bottles to bare back to ease pain… Measuring 3.2 x 1 cm… …Contacted Dr... prescribed Silvadene 1% to apply to area. The weekly SN visit notes from 7/8/21 to 7/31/21 included documentation the SN provided wound care to the patient’s burn. The SN visit notes dated 7/24/21 and 7/31/21 included, “Treatment Performed: Cleanse the area with saline Apply Silvadene 1% to the affected area cover with gauze and secure with tape”. As of 9/28/21, the record lacked documentation the SN obtained a Physician order for instructions to care for the burn (such as: Solution to clean the wound, type of dressing to apply over the wound, frequency of the dressing changes, and instructings to teach the caregiver on the wound care). During an interview with the Administrator and the Director of Operations/ Alternate Director of Nursing on 9/29/21 at 11:33 AM, the Director of Operations stated the caregiver was performing the wound care on days the SN were not present. 3. During an interview with the Administrator and the Director of Operations/ Alternate Director of Nursing (Administrative Staff) on 9/29/21 at 11:33 AM and 1:40 PM, the Administrative Staff confirmed the Agency failed to ensure Physician orders were received, prior to provision of care and/or treatment.

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: A. Based on review of clinical records and staff interview, it was determined the Agency failed to ensure the Physician was sent a copy of the Discharge Summary. This was found in 2 of 2 (Pts. #6 and 7) closed/discharged clinical records reviewed. Findings include: 1. Pt. #6. SOC 1/19/21. Diagnoses: Type 2 Diabetes Mellitus without Complications and Not Elsewhere Classified and Not Elsewhere Classified Difficulty in Walking. The closed clinical record was reviewed on 9/28/21 at 11:22 AM. The record contained the Agency’s Discharge Summary form dated 5/11/21. As of 9/28/21, the record lacked documentation the Agency sent a copy of the Discharge Summary to the Physician. 2. Pt. #7. SOC 6/24/20. Diagnoses: Hypertensive Heart Disease without Heart Failure and History of Falling. The closed clinical record was reviewed on 9/28/21 at 3:00 PM. The record contained the Agency’s Discharge Summary dated 10/20/20. As of 9/28/21, the record lacked documentation the Agency sent a copy of the Discharge Summary to the Physician. 3. During an interview with the Administrator and the Director of Operations/ Alternate Director of Nursing on 9/29/21 at 11:33 AM, the Administrative Staff was unable to provide documentation, indicating a copy of the Discharge Summary was sent to the Physician.