Delta Health Home Health

The Condition of Participation 484.65, QUALITY ASSESSMENT/PERFORMANCE IMPROVEMENT, was out of compliance: G642 Program Scope - The agency failed to implement a quality assessment and performance improvement (QAPI) program which evaluated all agency services and showed measurable improvement in…

A pattern of failure by the agency to ensure skilled professionals participated in the oversight of patient care and services to ensure delivery of safe care in accordance with the plan of care; failed to ensure professional nurses appropriately performed ongoing assessment and monitoring of…

Based on the manner and degree of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 484.105 ORGANIZATION AND ADMINISTRATION OF SERVICES, was out of compliance.

The agency failed to develop and maintain an emergency preparedness plan which addressed the following criteria in the event of an emergency: - Identification of potential at-risk residents; - Types of services the agency could provide; - Plan for homebound patients for evacuation in the event of…

The agency failed to develop a plan for contacting emergency officials regarding homebound patients and their evacuation status.

The agency failed to develop and maintain an emergency preparedness communication plan that complied with federal, state and local laws.

The agency failed to implement a quality assessment and performance improvement (QAPI) program which evaluated all agency services, showed measurable improvement in indicators for which there was evidence the improvements would show positive health outcomes and quality of care and complied with the…

The agency failed to utilize quality indicator data in the design of its program and to monitor the effectiveness and safety of services, quality of care, and opportunities for improvement.

The agency failed to ensure home health aides (HHAs)/certified nurse aide (CNAs) received the required observed competency evaluation in accordance with regulation prior to assignment of CNA services for 2 of 3 CNA personnel records reviewed who were hired after 1/1/18 (CNAs #12 and #13).

The agency failed to ensure the registered nurse (RN) or other appropriate skilled professionals prepared and updated patient-specific written care instructions for the home health aide (HHA)/certified nurse aide (CNA) for 1 of 5 patient records reviewed where the patient was receiving CNA services…

The supervising nurse (who is also the Director of Nursing (DON/Administrator) failed to provide clinical oversight, supervision and coordination of all patient care services and personnel in accordance with requirements set forth in regulation.

The agency failed to ensure all complaints made by the patient or the patient's caregivers related to care and services were investigated and resolved.

The agency failed to ensure the plan of care contained orders for needed therapy services based on the updated comprehensive assessment of the patient for 1 of 2 pediatric patient records reviewed (Patient #18).

The agency failed to have their QAPI focus on high risk, high volume or problem prone areas. in order to improve the safety of services and quality of care.

The agency failed to ensure ongoing interdisciplinary assessment occurred by the Registered Nurse (RN) who failed to re-evaluate the nursing needs for 4 of 16 patients reviewed, who received skilled nursing services (Patients #4, #6, #7 and #13).

The agency failed to ensure therapy services were provided in conformance with the physician orders as indicated in the plan of care for 4 of 7 patients reviewed, who were receiving skilled therapy services (Patients #1, #3, #8 and #13).

The agency failed to ensure nursing professional services communicated with all physicians involved in the plan of care for 2 of 16 patients reviewed, who received skilled nursing services.

The agency failed to ensure a registered nurse (RN) or other appropriate skilled professional familiar with the patient, the patient's plan of care and the written patient care instructions made an onsite visit to the patient's home no less frequently than every 14 days to conduct certified nurse…

The agency failed to supervise the CNAs competency with tasks and adherence to the care plan to ensure care was furnished in a safe and effective manner for 1 of 5 patients receiving CNA services (Patient #17).

The Administrator/DON (director of nursing) failed to adequately and effectively organize and direct the agency's day-to-day operations.