Delta Home Health Care, LLC

The agency failed to review and update the Emergency Preparedness plan at least every two years, resulting in the potential to negatively affect the health and safety of all patients served by this agency in the event of an actual agency or community-based emergency.

The agency failed to develop written emergency preparedness policies and procedures that were based on an emergency preparedness plan, risk assessment, and communication plan.

The agency failed to ensure goals written in the plan of care were patient-specific and measurable in 7 (P-1, 2, 3, 4, 5, 6, 7) of 7 records reviewed, resulting in the inability to determine the patient’s progress towards achieving goals and the potential for poor patient outcomes.

The agency failed to ensure the registered nurse prepared an aide care plan that contained safety precautions for 1 (P-4) of 1 record reviewed in which aide services were provided, resulting in the potential for unsafe, substandard care and unmet care needs.

The agency failed to ensure the comprehensive assessment was completed within 5 calendar days after the start of care in 1 (P-6) of 7 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes.

The agency failed to ensure the comprehensive assessment accurately reflected the patient’s current health, psychosocial, functional, and cognitive status in 5 (P-1, 4, 5, 6, 7) of 7 records reviewed, resulting in incomplete clinical information to aide in determining the needs of the patient and…

The agency failed to ensure the comprehensive assessment contained sufficient information to demonstrate the continuing in need for homecare services in 1 (P-6) of 7 records reviewed, resulting in the potential for delivery of unnecessary services.

The agency failed to ensure skilled professionals provided services as ordered by the physician in the plan of care for 3 (P-2, 4, 6) of 7 records reviewed, resulting in the potential for poor patient outcomes for these patients.

The agency failed to ensure the aide provided care as instructed for 1 (P-4) of 1 record reviewed in which aide services were provided, resulting in the potential for poor patient outcomes.

The agency failed to ensure the clinical record contained completed assessments and physician orders for 4 (P-2, 3, 4, 7) of 7 records reviewed, resulting in the potential for poor patient outcomes and a lack of information for all agency staff caring for the patient.

The agency failed to ensure the clinical records contained an accurate representation of all treatments and interventions provided in 2 (P-5, 7) of 7 records reviewed, resulting in the potential for an unclear picture of the patient’s treatment and an incomplete medical record.

The agency failed to ensure a completed discharge summary was sent to the primary care physician or other health care professional who will be responsible for providing care to the patient after discharge in 2 (P-5, 7) of 6 discharged records reviewed, resulting in a lack of information…

The agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status for 2 of 7 (MR# 4 and 6) records reviewed, resulting in incomplete clinical information to aid in determining the needs of these patients and for measuring the patient's progress toward…

The agency failed to ensure the plan of care included measurable outcomes and goals for skilled nursing for 7 of 7 (MR# 1, 2, 3, 4, 5, 6, 7) records reviewed and failed to ensure the plan of care included safety measures and interventions for 2 of 2 (MR# 4 and 6) records reviewed in which the…

The agency failed to ensure that skilled nursing services were provided at the frequency ordered by the physician for 1 of 7 (MR#4) records reviewed in which nursing services were ordered, resulting in the potential for poor patient outcomes for this patient.

The agency failed to ensure the clinical record contained physical therapy clinical notes for 1 of 5 (MR#6) records reviewed in which physical therapy services were provided, resulting in a lack of information regarding the health status of this patient.

The agency failed to ensure a discharge summary was sent to the physician within 5 business days of the patient's discharge for 2 of 2 (MR# 6, 7) records reviewed in which the patient was discharged from the agency, resulting in the physician not having knowledge of the patient's health status at…

The Agency failed to implement in the Emergency Preparedness policy/Plan, the use of volunteers, as appropriate, and other emergency staffing strategies to address surge needs during the COVID-19 crisis, resulting in the potential for the interruption in needed care and services for all 29 patients…

The agency failed to maintain a coordinated agency-wide program for the surveillance, identification, and prevention of COVID-19, resulting in the potential spread of a contagious viral infection between agency staff and the agency's 29 current patients.

The agency failed to maintain compliance with this condition of participation.

The agency failed to maintain compliance with this condition of participation.

The Agency (HHA) failed to measure, track and analyze it's quality indicators in order to assess processes of care and services, resulting in the inability to determine the scope of services provided (G642); and failed to develop Performance Improvement activities, as part of the Agency's QAPI…

The Agency (HHA) failed to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of the HHA's Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for…

The agency failed to maintain compliance with this condition of participation.

The Agency (HHA) failed to ensure the Administrator was appointment by the Governing Body (G946); failed to ensure a qualified alternate, was authorized in writing by the Administrator and the governing body, to function in the Administrator's absence, resulting in the potential for uncoordinated…

The agency failed to develop a comprehensive emergency preparedness program, resulting in no directions for agency actions in the event of an actual disaster.

The agency failed to develop and maintain a communication plan for emergency preparedness, resulting in no directions for agency methods of communication with staff and officials in the event of an actual disaster.

The agency failed to develop and maintain an emergency preparedness training and testing program for staff based on the agency's emergency plan, resulting in agency personnel not being educated in actions to take in the event of an actual disaster.

The agency failed to provide documentation for the required annual tabletop and community based full-scale exercises nor documentation of an actual event that would qualify as a test of the emergency plan, resulting in no testing of the agency's emergency preparedness plan.

The Agency (HHA) failed to measure, track and analyze its quality indicators in order to assess processes of care and services, resulting in the inability to determine the scope of services provided.

The Agency (HHA) failed to develop Performance Improvement activities, as part of the Agency's QAPI (Quality Assessment Performance Improvement) program, in order to track and trend adverse patient events, analyze the cause and implement preventive interventions, resulting in the potential for the…

The Agency (HHA) failed to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of the HHA's Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for…

The Agency (HHA) failed to provide documented evidence that infection control education was provided to all staff employed by the agency and who were granted clinical privileges, resulting in the potential for the development and spread of infection.

The agency failed to ensure the RN (registered nurse) prepared written patient care instructions alerting the home health aide (HHa) to the safety precautions and special conditions that were applicable to each patient, for 3 of 3 records reviewed (MR#'s 2, 3, 6) in which HHa services were ordered…

The Agency (HHA) failed to ensure that all entries in the medical record were legible in 2 of 7 records in which Skilled Nursing (SN) services were provided, from a total sample of 7 sampled records reviewed (MR #6, 2), resulting in the potential for negative patient outcomes, uncoordinated patient…

The agency failed to ensure the patient received written notice regarding the agency's transfer and discharge policies in advance of furnishing care, resulting in a lack of patient rights information for the 10 current patients.

The agency failed to include the administrator's name in the contact information, resulting in the potential for unaddressed patient concerns or complaints for the 10 current patients.

The agency failed to inform the patient in writing of their right to..."Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property," resulting in a lack of knowledge of their rights for the 10 current patients.

The agency failed to inform the patient/caregiver before care was initiated of the extent to which payment for home health agency services may be expected from Medicare or other insurance sources and the extent to which payment may be required from the patient in 3 of 7 records reviewed (MR#'s 1…

The agency failed to ensure patients had the right at any time to register a complaint on the state toll free hotline, resulting in the potential for unresolved complaints for the agency's 10 current patients.

The agency failed to ensure the registered nurse (RN) documented a patient-specific comprehensive assessment that accurately reflected the patient's current health status leading to current home care needs in 1 of 7 records reviewed (MR# 1), from a total sample of 7 records reviewed, resulting in…

The agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects; failed to document the findings of the drug regimen review as required and failed to ensure the physician was notified of potential drug interactions in 6 of 7 records…

The agency failed to ensure the plan of care (POC) covered all pertinent services, supplies, treatments, interventions with reportable parameters, measurable goals, patient /caregiver education and training for 3 of 7 records reviewed (MR#2, 4 and 6), from a total sample of 7 records reviewed…

The Agency (HHA) failed to ensure that care and services were provided only in accordance with Physician's orders for 1 of 2 records where the patient resumed services after hospitalization, from a total of 7 sampled records reviewed (MR #6), resulting in the potential for overlooked patient needs…

The agency failed to ensure that skilled nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services were administered in accordance with the physician's orders and the plan of care (POC) in 4 of 7 records reviewed (MR#'s 1, 2, 3, 6), from a total sample of 7 records reviewed…

The Agency (HHA) failed to ensure the clinical record was complete and included Skilled Nursing (SN), Home Health Aide (HHa), and Occupational Therapy (OT) notes for 2 of 7 patients with the specified ordered services, from a total of 7 records reviewed (MR's #7, 6), resulting in the Physician not…

The agency failed to ensure the home health aide (HHa) provided services only as ordered in the plan of care for 1 of 3 patients (MR#3) in which HHa services were ordered, from a total sample of 7 records reviewed, resulting in the patient receiving services that were not ordered.

The agency failed to ensure the registered nurse completed an on-site supervisory visit to the patient's home at least every 14 days to supervise the services that were provided by the home health aide (HHa) for 1 of 2 records reviewed (MR#3) in which aide services had been documented for a period…

The Agency failed to ensure the Administrator was appointment by the Governing Body.

The Agency (HHA) failed to ensure a qualified alternate, was authorized in writing by the Administrator and the governing body, to function in the Administrator's absence, resulting in the potential for uncoordinated Agency functions.

The agency failed to ensure the clinical manager coordinated patient care for 2 of 6 records reviewed (MR#1, 2) in which patients received services from more than one discipline, from a total sample of 7 records reviewed, resulting in the potential decline in physical functioning, unidentified…

The Agency (HHA) failed to ensure the discharge summary was complete, provided the patient's current health status at the time of discharge, progress toward goals, and forwarded to the physician in 1 of 2 closed/discharged records, from a total of 7 records reviewed (MR #5), resulting in the…