Every finding on record at Deltacare Home Health Service, LLC

A recertification and complaint survey was initiated on 3/17/25 with the Administrator/Supervising Nurse. Agency Census: License and Certified Home Health – 155 Personal Assistance Services – 38 Total census: 193 Intake 470122 No violations cited.

A recertification and complaint survey was initiated on 3/17/25 with the Administrator/Supervising Nurse. Agency Census: License and Certified Home Health – 155 Personal Assistance Services – 38 Total census: 193 Intake 470122 Abbreviations: OASIS-Outcome and Assessment Information Set

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 record review and interview, the agency failed to ensure the plan of care included a description of the patient's risk for emergency department visits and hospital re-admission in 7 (Patient #’s 1, 2, 3, 4, 5, 6, and 7) of 7 active records reviewed These failures placed patients at risk of a decline in their health status and subsequent emergency room visits and hospital re-admissions. Findings include: Review of Patient #1’s chart revealed a plan of care with a certification period of 2/26/25 through 4/26/25. The plan of care included the primary diagnosis of unspecified dementia (loss of cognitive functioning-thinking, remembering, and reasoning) The plan of care was signed and dated by Supervising Nurse on 2/26/25. The plan of care did not include a description of the patient's risk for emergency department visits or hospital re-admission. Review of Patient #2’s chart revealed a plan of care with a certification period of 2/10/25 through 4/10/25. The plan of care included the primary diagnosis of type 2 diabetes mellitus with hyperglycemia (a condition where your body either doesn’t make enough insulin or can’t use the insulin it does make effectively, leading to high blood sugar levels). The plan of care was signed and dated by Supervising Nurse on 2/10/25. The plan of care did not include a description of the patient's risk for emergency department visits or hospital re-admission. Review of Patient #3’s chart revealed a plan of care with a certification period of 2/17/25 through 4/17/25. The plan of care included the primary diagnosis of acute on chronic diastolic heart failure (a sudden worsening of a pre-existing condition where the heart has trouble relaxing and filling with blood, leady to symptoms like shortness of breath and fatigue). The plan of care was signed and dated by Supervising Nurse on 2/17/25. The plan of care did not include a description of the patient's risk for emergency department visits or hospital re-admission. Review of Patient #4’s chart revealed a plan of care with a certification period of 12/30/24 through 2/27/25. The plan of care included the primary diagnosis of chronic obstructive pulmonary disease (a conditions caused by damage to the airways or other parts of the lung). The plan of care was signed and dated by Supervising Nurse on 2/26/25. The plan of care did not include a description of the patient's risk for emergency department visits or hospital re-admission. Review of Patient #5’s chart revealed a plan of care with a certification period of 1/18/25 through 3/18/25. The plan of care included the primary diagnosis of essential primary hypertension (high blood pressure (when blood flows through your arteries at higher-than-normal pressures) where the cause is unknown). The plan of care was signed and dated by Supervising Nurse on 1/16/25. The plan of care did not include a description of the patient's risk for emergency department visits or hospital re-admission. Review of Patient #6’s chart revealed a plan of care with a certification period of 1/8/25 through 3/8/25. The plan of care included the primary diagnosis of encounter for orthopedic aftercare following surgical amputation (care focused on wound care following the surgical removal of a limb) due to a right below the knee amputation (surgical removal of part of the body). The plan of care was signed and dated by Supervising Nurse on 1/8/25. The plan of care did not include a description of the patient's risk for emergency department visits or hospital re-admission. Review of Patient #7’s chart revealed a plan of care with a certification period of 1/28/25 through 3/28/25. The plan of care included the primary diagnosis of type 2 diabetes mellitus with hyperglycemia (a condition where your body either doesn’t make enough insulin or can’t use the insulin it does make effectively, leading to high blood sugar levels). The plan of care was signed and dated by Supervising Nurse on 1/28/25. The plan of care did not include a description of the patient's risk for emergency department visits or hospital re-admission. An interview was conducted on 3/18/25 at 1:35 pm with the Administrator/Supervising Nurse. The Surveyor asked Administrator/Supervising Nurse where on the plan of care would the patient risk factors for emergency department visits and/or re-hospitalizations be found. The Surveyor explained none of the plans of care included the patient’s risk factors. Administrator/Supervising Nurse reviewed a plan of care and read the section labeled “Patient Risk Profile.” Surveyor explained that the plan of care did not state that the risks listed in the patient risk profile were the patient’s risks for emergency department visits or re-hospitalizations. The Administrator stated, “I wasn’t aware of that.” The Surveyor asked the Administrator/Supervising Nurse does the agency software not roll the patient risks from the OASIS assessment into the plan of care. The Administrator/Supervising Nurse said, “I don’t use the software for the plan of care, I make sure the plan of care includes everything.” The Surveyor asked Administrator/Supervising Nurse how not listing a patient’s risk factors for emergency department visits or re-hospitalizations could affect patient care. Administrator/Supervising Nurse said, “We would not be teaching the right interventions to keep the patients out of the hospital.”