Every finding on record at Hope Home Care Inc

A recertification survey and agency self-reported incidents investigation (Intake 1012349; 1021126; 535980; 543673; 1061009; 1061028; 1061020) was conducted on 01/13/2026. Census: Licensed and Certified Home Health Services: 3; Licensed Home Health Services: 0; Personal Assistance Services: 47 No deficiencies were cited.

A recertification survey and agency self-reported incidents investigation (Intake 1012349; 1021126; 535980; 543673; 1061009; 1061028; 1061020) was conducted on 01/13/2026. Census: Licensed and Certified Home Health Services: 3; Licensed Home Health Services: 0; Personal Assistance Services: 47 Abbreviations: Adm/DON/Sup Nurse – Administrator/Director of Nurses/Supervising Nurse PC – Provision of Care

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 cares included 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 and information related to any advanced directives in 7 of 7 records reviewed (Patient 4, 5, 6, 7, 8, 9 and 10). These failures placed patients in jeopardy of harm from agency staff who could not address the patient’s risk factors and types of services needed for appropriate care and placed them at risk of a declining health status and complications. Findings included: Patient 4: Record review of the electronic and paper medical record included a plan of care dated 08/26/2025 to 10/24/2025 signed by the Adm/DON/Sup Nurse on 08/21/2025 with a start of care date of 04/28/2025. The physician/ordering practitioner ordered the nurse to visit the patient once a week for nine weeks. The plan of care included a diagnosis of the loss of thinking, remembering, and reasoning and high blood pressure. The plan of care did not include 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 and information related to any advanced directives (legal documents signed by a competent person to provide guidance for medical and health care decisions). Patient 5: Record review of the electronic and paper medical record included a plan of care dated 12/10/2025 to 02/07/2026 signed by the Adm/DON/Sup Nurse on 12/10/2025 with a start of care date of 12/10/2025. The physician/ordering practitioner ordered the nurse to visit the patient once a week for nine weeks. The plan of care included a diagnosis of high levels of fat in the blood and pain. The plan of care did not include 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 and information related to any advanced directives. Patient 6: Record review of the electronic and paper medical record included a plan of care dated 10/20/2025 to 12/18/2025 signed by the Adm/DON/Sup Nurse on 10/15/2025 with a start of care date of 08/21/2025. The physician/ordering practitioner ordered the nurse to visit the patient once a week for nine weeks. The plan of care included a diagnosis of brittle and weak bones and heart disease. The plan of care did not include 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 and information related to any advanced directives. Patient 7: Record review of the electronic and paper medical record included a plan of care dated 04/01/2025 to 05/30/2025 signed by the Adm/DON/Sup Nurse on 04/03/2025 with a start of care date of 04/01/2025. The physician/ordering practitioner ordered the nurse to visit the patient once a week for nine weeks. The plan of care included a diagnosis of lung disease and heart failure. The plan of care did not include 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 and information related to any advanced directives. Patient 8: Record review of the electronic and paper medical record included a plan of care dated 08/25/2025 to 10/23/2025 signed by the Adm/DON/Sup Nurse on 08/20/2025 with a start of care date of 06/26/2025. The physician/ordering practitioner ordered the nurse to visit the patient once a week for nine weeks. The plan of care included a diagnosis of high blood sugar levels and high blood pressure. The plan of care did not include 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 and information related to any advanced directives. Patient 9: Record review of the electronic and paper medical record included a plan of care dated 05/08/2025 to 07/06/2025 signed by the Adm/DON/Sup Nurse on 09/25/2025 with a start of care date of 04/28/2025. The physician/ordering practitioner ordered the nurse to visit the patient once a week for nine weeks. The plan of care included a diagnosis of high blood pressure and high levels of fat in the blood. The plan of care did not include 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 and information related to any advanced directives. Patient 10: Record review of the electronic and paper medical record included a plan of care dated 09/25/2025 to 11/23/2025 signed by the Adm/DON/Sup Nurse on 05/03/2025 with a start of care date of 09/25/2025. The physician/ordering practitioner ordered the nurse to visit the patient once a week for nine weeks. The plan of care included a diagnosis of high blood sugar levels and high blood pressure. The plan of care did not include 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 and information related to any advanced directives. During an interview with the Adm/DON/Sup Nurse on 01/13/2026 at 2:30 PM, the Adm/DON/Sup Nurse stated she was responsible for ensuring the plan of cares included all required elements. During an interview with the Adm/DON/Sup Nurse on 01/13/2026 at 3:00 PM, the surveyor asked why the plan of care for Patients 4, 5, 6, 7, 8, 9 and 10 did not include the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors and information related to any advanced directives. The Adm/DON/Sup Nurse stated the information should have populated onto the plan of cares from the comprehensive assessments, but it did not. During an interview with the Adm/DON/Sup Nurse on 01/13/2026 at 3:30 PM, the surveyor asked why agency policy was not followed. The Adm/DON/Sup Nurse stated it was an oversight. Agency policy titled, “Plan of Care PC.35” with a last reviewed date of 01/01/2026 read in part, “… Procedure… The individualized Plan of Care must include the following… a description of the patient’s/client’s risk for emergency department visits and hospital re admission, and all necessary interventions to address the underlying risk factors… Information related to any advance directives…”

Purpose: Recertification and complaint survey Entrance Date: 1/5/2023 Census: Licensed and Certified patient - 8 Complaint 330858 The agency was in compliance with 42 CFR Part 484.102, Emergency Preparedness Requirements for Home Health Agencies.

Purpose: Recertification and complaint survey Entrance Date: 1/5/2023 Census: Licensed and Certified patient - 8 Complaint 330858

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to protect the patient's right to receive services all services as outlined in the Plan of Care for 1 (#7) of 2 discharged patient records reviewed where the patient had physical therapy ordered. The failure resulted in the delay of initiation of physical therapy services as ordered by the physician. Patient #7: Record review of Patient #7's record revealed a physician order dated 9/2/2021 and signed by the physician on 9/6/2021, for physical therapy to evaluate and treat Patient #7. Patient #7's clinical record revealed a Plan of Care that was dated 9/12/2021 to 11/10/2021. The Plan of Care indicated that Patient #7 started on the agency's services on 5/15/2021. The Plan of Care listed Hypertension as the diagnosis. The Plan of Care listed ambulation, endurance, and shortness of breath with minimal exertion as functional limitations. The Plan of Care contained an order for occupational therapy to evaluate and treat. The Plan of Care contained an order for "Physical Therapy to assess functional status, home environment to eliminate structural barriers and improve safety and functional independence. PT (physical therapy) to assess rehabilitation potential and determine need for gait training, safety precautions, pain management, strengthening/conditioning exercise, balance/coordination and transfers. PT to establish a home exercise program and plan of care as approved by physician. May obtained O2 (oxygen) saturation as needed for s/s (signs/symptoms) of possible respiratory distress." The Plan of Care did not include a frequency/duration order for physical therapy. Patient #7's record did not contain evidence that Patient #7 received physical therapy services from 9/12/2021 through 10/21/2021. Patient #7's record contained a physical therapy evaluation dated 10/22/2021 which was conducted by Physical Therapist E. Physical Therapist E documented that Patient #7 had been referred to skilled physical therapy by the physician due to inability of Patient #7 to safely transfer and ambulate. During an interview on 1/10/2022 at approximately 1:33 p.m. with the Administrator/Director of Nursing, the surveyor discussed the finding that there had been an order dated 9/2/2021 for physical therapy services and a physical therapist had not conducted an evaluation until 10/22/2021. The Administrator/Director of Nursing informed the surveyor that Patient #7's family had issues switching, wanted occupational therapy then physical therapy. The Administrator/Director of Nursing stated, "I don't know why that happened," regarding physical therapy ordered on 9/2/2021 and not started until 10/22/2021. The agency had a policy titled "Plan of Care" that was labeled PC.8 with a revision date of 11/1/2020. The policy read in part: "Purpose To ensure that care provided is appropriately planned in a timely manner to meet the patient's/client's specific needs and problems...Procedure...V. Each patient/client must receive the home health services that are written in an individualized plan of care..."

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: Based on record review and interview, the agency failed to provide all services that were written in the individualized Plan of Care for 1 (#7) of 2 discharged patient records reviewed where the patient had physical therapy ordered. The failure resulted in the delay of initiation of physical therapy services as ordered by the physician. Patient #7: Record review of Patient #7's record revealed a physician order dated 9/2/2021 and signed by the physician on 9/6/2021, for physical therapy to evaluate and treat Patient #7. Patient #7's clinical record revealed a Plan of Care that was dated 9/12/2021 to 11/10/2021. The Plan of Care indicated that Patient #7 started on the agency's services on 5/15/2021. The Plan of Care listed Hypertension as the diagnosis. The Plan of Care listed ambulation, endurance, and shortness of breath with minimal exertion as functional limitations. The Plan of Care contained an order for occupational therapy to evaluate and treat. The Plan of Care contained an order for "Physical Therapy to assess functional status, home environment to eliminate structural barriers and improve safety and functional independence. PT (physical therapy) to assess rehabilitation potential and determine need for gait training, safety precautions, pain management, strengthening/conditioning exercise, balance/coordination and transfers. PT to establish a home exercise program and plan of care as approved by physician. May obtained O2 (oxygen) saturation as needed for s/s (signs/symptoms) of possible respiratory distress." The Plan of Care did not include a frequency/duration order for physical therapy. Patient #7's record did not contain evidence that Patient #7 received physical therapy services from 9/12/2021 through 10/21/2021. Patient #7's record contained a physical therapy evaluation dated 10/22/2021 which was conducted by Physical Therapist E. Physical Therapist E documented that Patient #7 had been referred to skilled physical therapy by the physician due to inability of Patient #7 to safely transfer and ambulate. During an interview on 1/10/2022 at approximately 1:33 p.m. with the Administrator/Director of Nursing, the surveyor discussed the finding that there had been an order dated 9/2/2021 for physical therapy services and a physical therapist had not conducted an evaluation until 10/22/2021. The Administrator/Director of Nursing informed the surveyor that Patient #7's family had issues switching, wanted occupational therapy then physical therapy. The Administrator/Director of Nursing stated, "I don't know why that happened," regarding physical therapy ordered on 9/2/2021 and not started until 10/22/2021. The agency had a policy titled "Plan of Care" that was labeled PC.8 with a revision date of 11/1/2020. The policy read in part: "Purpose To ensure that care provided is appropriately planned in a timely manner to meet the patient's/client's specific needs and problems...Procedure...V. Each patient/client must receive the home health services that are written in an individualized plan of care..."

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the licensed vocational nurse failed to document receipt of a physician's verbal order in the patient's clinical record in accordance with the agency's internal policy in 1 (#5) of 1 patient record reviewed where a verbal order was received for laboratory testing. The failure placed the patients at risk for omission of care. The agency had a policy titled "Orders for Care" that was labeled PC.7 and revised on 11/1/2020. The policy read in part: "Purpose To ensure patient/client care is provided in accordance with a physician and/or non-physician practitioner order and federal and state laws and regulations...Definitions Verbal order means a physician and/or non-physician practitioner order that is spoken to appropriate personnel and later put into writing for the purposes of documenting as well as establishing or revising the patient's/client's plan of care. Procedures I. All orders are kept current and renewed or updated as appropriate when...C. Changes in diagnosis, treatment (including procedures and medications), and equipment occur...XII. Supplemental verbal orders may be obtained before care is provided and are written within twenty-four (24) hours of receiving the orders. The verbal orders may be accepted and put into writing by an LVN...with co-signature by the RN...responsible for furnishing or supervising the ordered services..." Client #5: Record review of Client #5's record revealed a Plan of Care dated 9/18/2022 to 11/16/2022. The Plan of Care indicated that Client #5 started on the agency's services on 5/21/2022. The Plan of Care listed Chronic Diastolic (congestive) heart failure, Hypertension, and Urinary tract infection Site not Specified as diagnoses. The Plan of Care contained an order for skilled nurse visits once a week. Licensed Vocational Nurse C conducted a skilled nursing visit on 10/8/2022. Licensed Vocational Nurse C documented receipt of a physician's order; "Urine sample test for culture and sensitivity ordered by primary care. Sample to be obtained by nurse." Licensed Vocational Nurse did not obtain a urine sample for laboratory testing on 10/8/2022. Licensed Vocational Nurse C conducted skilled nurse visits on 10/13/2022, 10/18/2022, 10/27/2022, and 11/5/2022. Licensed Vocational Nurse C did not obtain a urine sample for laboratory testing. Client #5's record contained results of laboratory testing of urine specimens that were collected on 7/12/2022 and 11/16/2022. Client #5's record did not contain evidence that a urine sample had been collected for laboratory testing between 10/8/2022 (when a verbal order was received) through 11/15/2022. During an interview on 1/10/2023 at approximately 1:33 p.m. with the Supervising Nurse, the surveyor discussed that Licensed Vocational Nurse C had received a verbal order to obtain a urine sample for laboratory testing on 10/8/2022 and that Licensed Vocational Nurse C did not write the order for the laboratory testing. The surveyor asked why the order for the laboratory testing was not written. The Supervising Nurse stated, "I am aware of this urine. I will look into it, will get with [Licensed Vocational Nurse C]." During an interview on 1/11/2023 at approximately 2:46 p.m. with the Supervising Nurse, the Supervising Nurse gave the surveyor a computerized document that was titled "Communication Note." Licensed Vocational Nurse C had signed the communication note on 1/11/2023. Licensed Vocational Nurse C documented the following: "For correction regarding lab (laboratory) UA (urinalysis) and culture order, we did not receive the physician signature in time to collect the specimen. The physician order was signed 10/28/2022, and specimen was collected then. The LVN (Licensed Vocational Nurse) was suppose (sic) to communicate with the DON (Director of Nursing), regarding new changes in labs..." Client #5's record contained an order for a clean catch urinalysis that was dated 10/18/2022 (10 days after Licensed Vocational Nurse C received the verbal order).

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to have a Quality Assessment Performance Improvement program that was able to show measurable improvement in health outcomes, patient safety, and quality of care for 3 (2020, 2021, 2022) of 3 years requested for review. Due to the failure, the agency was not able to measure, analyze, and track indicators that included adverse patient events, processes of care, agency services, and operations. The surveyor informed the agency staff on 1/10/2023 at approximately 3:30 p.m. that the surveyor would review the quality assessment performance improvement program for the years 2020, 2021, and 2022, on 1/11/2023 On 1/11/2023 the surveyor was given 3 binders that contained audits of patient records. The binders did not contain any other quality assessment performance improvement documentation. During an interview on 1/11/2023 at approximately 11:50 a.m. with Office Manager D, the surveyor asked whether the agency had any further documentation such as Quality Assessment and Performance Improvement Committee meetings. Office Manager D stated, " We did them (meetings) but we did not document them." During an interview on 1/11/2023 at 2:46 p.m. with the Administrator, the surveyor reviewed the findings of the survey to include the Quality Assessment Performance Improvement program. The Administrator did not dispute the finding that the agency was unable to provide documentation of the Quality Assessment Performance Improvement program. The agency did not present any further documentation regarding Quality Assessment Performance Improvement. The agency had a policy titled "Quality Assessment Performance Improvement Program" that was labeled QAPI.1 with a revision date of 1/13/18. The policy read in part:..."Purpose To develop, implement, evaluate, and maintain an effective, ongoing, Agency-wide, data-driven Quality Assessment Performance Improvement (QAPI) Program as defined by its QAPI Plan. Definition Quality Indicator is a specific, valid, and reliable measure of access, care outcomes, or satisfaction, or a measure of a process of care. Policy I...C. Focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions;...III. The Agency will maintain documentary evidence of its QAPI program and be able to demonstrate to CMS..."