Interim Healthcare of Delaware LLC

“HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This Standard is not met as evidenced by: Based on observation, policy review, interview, and review of the facility’s Emergency Preparedness Plan (EPP), the agency failed to ensure two Patients, (P)1 and P3, out of a total of 10 patients in the sample had individualized emergency/disaster plans in place to direct care and services in the event of a natural or man-made disaster. This failure had the potential to affect all 236 patients currently receiving care from the agency. Findings include: Review of the Agency policy “Contents of the Patient/Client Record” dated 04/02/21 revealed, “The following standardized paper forms or their equivalent are found in the in-home presentation pocket folder…i) Patient Emergency Plan.” 1. A review of P1’s medical record revealed that P1 was admitted to receive Agency services on 10/8/21 and was certified to receive ongoing services, most recently on 5/20/25. The record indicated that P1 had diagnoses including cerebral palsy (CP) with spastic quadriplegia. A comprehensive review of P1’s record revealed nothing to indicate an individualized emergency/disaster plan had been developed. Observation during P1’s home care visit performed by EMP4 on 06/19/25 at 8:30 AM revealed that P1 did not have an individualized emergency/disaster plan accessible to his/her caregivers in the home. During an interview on 06/19/25 at 9:00 AM, EMP4 confirmed he/she was unable to locate an individualized emergency/disaster plan for P1 in his/her home. He/she stated he/she was unaware of what the patient’s individualized emergency/disaster plan would entail. Review of the Agency’s 2025 Emergency Preparedness Plan/Binder revealed no documentation of P1’s individualized emergency/disaster plan. 2. Review of P3’s medical record revealed that P3 was admitted to receive Agency services on 06/26/24 and was certified to receive ongoing services, most recently on 04/22/25. The record indicated P3 had multiple diagnoses, including spastic CP. A comprehensive review of P3’s record revealed nothing to indicate that an individualized emergency/disaster plan had been developed. Observation during P3’s home care visit performed by EMP6 on 06/19/25 at 10:30 AM revealed no documentation of P3’s individualized emergency/disaster plan accessible to his/her caregivers in the home. During an interview on 06/19/25 at 10:45 AM, EMP6 confirmed that they were unable to locate an individualized emergency/disaster plan for P3 in his/her home. He/she stated he/she was unaware of what the patient’s individualized emergency/disaster plan would entail. Review of the Agency’s 2025 Emergency Preparedness Plan/Binder revealed no documentation of P3’s individualized emergency/disaster plan. During an interview on 06/20/25 at 10:30 AM, the EMP1 confirmed P1 and P3 did not have individualized emergency/disaster plans in place. He/she stated the expectation was that every patient receiving services by the Agency would have an individualized emergency/disaster plan in place, and the plan was expected to be accessible in each patient’s home as well as in the Agency’s 2025 Emergency Preparedness Plan/Binder.”

“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 document review, policy review, and staff interview, the Home Health Agency (HHA) failed to ensure the timely submission of Outcome and Assessment Information Set (OASIS) to the Internet Quality and Improvement and Evaluation System (IQIES). The failure had the potential to affect all patients receiving services from the HHA who require evaluation and care. Findings include: Review of the Agency’s “Management of OASIS data for Offices that Must Meet the Medicare Home Health Conditions of Participation Policy” dated 01/13/18 indicated, “OASIS data is collected, reviewed for accuracy and completeness, outstanding data issues resolved, and the data transmitted within 30 days of the date that the OASIS assessment is completed.” Review of the Agency’s “OASIS submission data” for 06/16/24 through 06/17/25 revealed that 176 out of a total of 1,780 assessments were coded as being transmitted to IQIES more than 30 days late during that time period. This resulted in an error code of -3330 (late submission) for 9.89% of all assessments submitted between 06/16/24 through 06/17/25. During an interview on 06/20/25 at 1:33 PM, EMP1 stated someone at the corporate office submitted the Agency’s OASIS data, although he/she did not know for sure who that person was currently, due to recent employee transitions within the company. He/She stated he/she was not sure why OASIS data was being transmitted to IQIES late.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on policy review, observations, record review, and staff (EMP) interviews, the Home Health Agency (HHA) failed to ensure that infection control procedures were appropriately followed for one Patient (P2) out of a total of 10 patients reviewed in the sample. This failure had the potential to affect all 236 patients receiving services in their homes Findings include: Review of the Agency policy “Equipment/Supply Bag Techniques” dated 11/2022 revealed, “All items in the Equipment/Supply bag are considered clean; therefore, the principles of infection control must remain uppermost on the employee’s mind. When items are taken out and used with one patient/client, they should be thrown away, if disposable, or cleaned before placing back in the bag to be used on another patient/client.” A review of P2’s medical record revealed P2 was admitted to the Agency for services on 06/18/24, and was most recently certified for the continuation of services on 06/13/25. The record indicated that P2 had diagnoses including hypertension and bipolar disorder. The medical record indicated that the patient had a gastrostomy tube (G-tube) in place in his stomach for the administration of food, fluids, and medication. A review of P2’s CMS 485 (Home Health Certification and Plan of Care), dated 06/20/25, revealed an order for the patient to be seen by a skilled nurse four times daily for physical assessment and administration of fluid and medication through his/her G-tube. Observation during P2’s homecare visit on 06/19/25 at 1:00 PM revealed that EMP2 removed his/her laptop computer and a bottle of hand sanitizer from his/her equipment/supply bag and then placed both items on the patient’s kitchen table without first placing a clean barrier on the table. EMP2 utilized both the laptop computer (for charting in P2’s record) and the hand sanitizer while in P2’s home, and then placed both items back into her equipment/supply bag without cleaning or sanitizing the equipment. During an interview on 06/19/25 at 1:45 PM, EMP2 confirmed that he/she had additional visits to conduct on that date and confirmed that he/she planned to use the laptop and bottle of hand sanitizer in other patients’ homes during their visits. He/she stated he/she should have used a clean barrier while in P2’s home and should have cleaned/sanitized the equipment after use and before placing the equipment back in his/her equipment/supply bag to prevent potential cross-contamination between patient visits. During an interview on 6/20/25, at 10:46 AM, EMP1 stated that the expectation was that any equipment removed from a staff member’s equipment/supply bag for use during a home visit was to be cleaned and sanitized prior to placing the equipment back into the bag and between each patient visit to prevent cross-contamination.”

“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: Based on observation, policy review, record review, and staff (EMP) interview, the Home Health Agency (HHA) EMP2 failed to ensure physician’s orders were followed for one Patient (P2) out of a total of 10 patients reviewed in the sample. This failure had the potential to affect all 236 patients receiving services from the HHA. Findings include: Review of the Agency’s policy “Developing a Plan to Meet Patient/Client Needs” dated 04/02/21 revealed, “The provision of care/service is in accordance with a physician or allowed practitioner (e.g., NP [Nurse Practitioner], PA [Physician’s Assistant], CNS [Clinical Nurse Specialist] orders that are... a) Current as defined in law and regulations; and b) Complete including at least discipline, frequency, duration, and detailed intervention.” Review of P2’s medical record revealed P2 was admitted to the Agency for services on 06/18/24 and most recently certified for the continuation of services on 06/13/25. The record indicated that P2 had diagnoses including hypertension and bipolar disorder. The medical record indicated that P2 had a gastrostomy tube (G-Tube) in place in his stomach for the administration of food, fluid, and medication. Review of P2’s CMS 485 (Home Health Certification and Plan of Care), dated 06/20/25, revealed an order with an original order date of 06/13/25 for “Free Water bolus 500 mL via G-Tube every six hours/four times daily.” Observation during P2’s homecare visit on 06/19/25 at 1:00 PM revealed that EMP2 utilized a standard kitchen measuring cup to prepare and administer 2 cups, totaling 473.18 mL, rather than the ordered 500 mL of water through P2’s G-tube. During an interview on 06/19/25 at 1:45 PM, EMP2 believed the amount of water administered to P2 during the observation was correct. During an interview on 06/20/25 at 10:46 AM, EMP1 stated that the expectation is that all physician’s orders were to be followed and P2 should have received the ordered 500 ML of water through his/her G-tube during the home visit, rather than the 473.18 ML that RN1 administered.”