Every finding on record at Hope Home Health Care LLC

Extended Substantial Allegation Survey Substantial Allegation 114679 At the time of the extended substantial allegation survey completed on 12/02/25, no deficiencies were issued in regard to allegations contained in substantial allegation number 114679; however, the facility was found not to be in compliance with all requirements for Home Health Agency participation and the following deficiencies are cited. Hope Home Health Care is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C, Home Health Agencies. Hope Home Health Care, LLC is precluded from providing its own home health aide training and competency testing or competency evaluation program for a period of two years from the date of the receipt of the deficiency report (2567) for this survey.

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, interview and policy review, the agency failed to ensure all physician orders were followed. This affected two (Patients #1 and #3) of three patients reviewed. The census was 22. Findings include: 1. Review of the medical record for Patient #1 and physician’s plan of care dated 12/30/24 to 02/27/25 revealed the medical social worker (MSW) was to assess psychosocial needs, environment and assist with community referrals and resources. The Speech Therapist (ST) was to evaluate Patient #1. The HHA was to provide 21 hours per week to assist with personal care and activities of daily living. The skilled nurse was to go three times a week for medication management and wound care. There was no documentation a MSW or ST had assessed the patient. 2. Review of the medical record for Patient #3 and physician’s plan of care dated 01/15/25 to 03/15/25 revealed the medical social worker (MSW) was to assess psychosocial needs, environment and assist with community referrals and resources. The Speech Therapist (ST) was to evaluate Patient #3. There was no documentation a MSW or ST had assessed the patient. During an interview on 12/02/25 at 9:10 AM the Office Manager (OM) stated skilled nursing and home health aides were the only services provided. During an interview on 12/02/25 at 11:42 AM the Administrator stated they never provided ST or MSW services. Review of the agency policy titled “Plan of Care – CMS #485 and physician’s Orders,” revised March 2018, revealed skilled nursing and other home health services will be in accordance with a Plan of Care signed and dated by the physician.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure the physician had been notified of all the missed visits. This affected one (Patient #1) of three patients reviewed. The census was 22. Findings include: Review of the medical record for Patient #1 and physician’s plan of care dated 12/30/24 to 02/27/25 revealed the home health aide (HHA) was to provide 21 hours per week to assist with personal care and activities of daily living. Review of the HHA time sheets revealed missed visits for 12/30/24, 01/01/25, 01/02/25, 01/05/25, 01/06/25, 01/07/25, 01/08/25, 01/13/25 and 01/14/25. The last HHA visit was 01/26/25. There was no documentation the physician was notified of the missed visits. During an interview on 12/02/25 at 12:36 PM, the Administrator confirmed there was no physician’s order to stop the HHA services. Review of the agency policy titled “C-680 Clinical Documentation,” revised 07/26/23, revealed services not provided and the reason for the missed visit will be documented and reported to the physician.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure staff were not hired when they had disqualifying offenses on a criminal records check. (G952) .

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure staff were not hired when they had disqualifying offenses on a criminal records check. This affected one (Staff C) of three personnel files reviewed. The census was 22. Findings include: Review of the personnel file for Staff C revealed a hire date of 07/23/24. Review of the fingerprint background check revealed an arrest on 06/04/23 for felonious assault resulting in a conviction. Review of the Tier 1 Disqualifying Offenses (Permanent Exclusion) listed 2903.11 Felonious Assault. During an interview on 12/02/25 at 3:00 PM the Administrator confirmed this Permanent Exclusion and verified Staff C was still currently employed. Review of the agency policy titled “Personnel Records,” revised 02/2021, revealed agencies in receipt of funds from Medicare, Medicaid and all other federal plans and programs verify that individuals hired are not on the Office of the Inspector General (OIG) List of Excluded Individuals and Entities (LEIE). OIG is required by law to exclude from participation in all federal health care programs individuals and entities convicted of the following types of criminal offenses (1) Medicare or Medicaid fraud, as well as any other offenses related to the delivery of items or services under Medicare, Medicaid, SCHIP or other State health care programs; (2) patient abuse or neglect; (3) felony convictions for other health care related fraud, theft or other financial misconduct; and (4) felony convictions relating to unlawful manufacture, distribution, prescription or dispensing of controlled substances.