Hope Home Health Services, Inc.

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on the review of the Agency’s Emergency Preparedness Plan, policy review, and staff interview, it was determined that the Agency failed to have a communication plan that included the required names and contact information. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 1/24/24. The plan lacked a communication plan that meets the following requirements: Updated names and contact information for all staff members, patients’ Physicians, and other allowed Practitioners. 2. The Emergency Preparedness Policy “Special Instruction” was reviewed on 1/24/24 and required, “4. A listing of all staff members and telephone numbers will be included in the Agency’s on-call book. If there were actual or impending disaster, the triage system would be initiated to ensure patient needs are met.” 3. During an interview with the Alternate Administrator, Alternate Director of Nursing, and Intake/Home Health Aide on 1/24/24 at 1:25 PM, the above finding was confirmed.”

“Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA’s policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This Standard is not met as evidenced by: Based on a review of the Agency’s patient admission folder, clinical record review, observation during home visits and staff interview, it was determined the Agency failed to provide Pts. information regarding the Agency’s transfer and discharge policies. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The Pt. admission folder was reviewed on 01/22/24 and lacked documentation of the Agency’s transfer and discharge policies. 2. The following clinical records were reviewed from 1/22/24 to 01/25/24: Pt. #1. SOC 12/2/23. Pt. #2. SOC 1/10/24. Pt. #3. SOC 12/13/23. Pt. #4. SOC 12/17/23. Pt. #5. SOC 12/29/23. Pt. #6. SOC 07/31/23. Pt. #7. SOC 9/9/23. The records lacked documentation the Agency provided Pts. information, regarding the Agency’s transfer and discharge policies. 3. The following home visits were conducted on 1/22/24 and 1/23/24: Pt. #1. SOC 12/2/23. Pt. #2. SOC 1/10/24. Pt. #3. SOC 12/13/23. During the home visits, the Pt. admission folder was observed, and lacked documentation the Agency had provided Pts. information regarding the Agency’s transfer and discharge policies. 4. During an interview with the Alternate Administrator and Alternate Director of Nursing on 1/24/24 at 1:35 PM, the Alternate Administrator confirmed the Agency failed to provide Pts. information pertaining to the Agency’s transfer and discharge policies.”

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on clinical record reviews, policy review and staff interviews, it was determined the Agency failed to ensure that Physician’s orders were followed for 5 of 7 (Pts. #1, 4, 3, 5 and 7) clinical records reviewed. 3. Pt. #3 was admitted to home health services on 12/13/23 with the primary diagnoses of Type 2 Diabetes Mellitus with Hyperglycemia, Right and Left Hand Contracture. The clinical record was reviewed on 1/24/24. The record contained the OT evaluation dated 12/15/23 and signed by the Physician requiring the OT to provide service “2 wk2, 1 wk2”. The record lacked a second OT visit during week 1 (12/15/23 to 12/16/23) and week 2 (12/17/23 to 12/23/23). 4. Pt. #5 was admitted to home health services on 12/29/23 with the primary diagnosis of Bronchiectasis with Acute Exacerbation. The clinical record was reviewed on 1/24/24 . The record contained the POC dated 12/29/23 that required: “SN may take patient oxygen saturation as needed to check for shortness of breath and report to MD if During an interview with the Alternate Administrator and the Alternate Director of Nursing on 1/24/24, the Alternate Administrator stated it was expected that the SN check this patient’s oxygen saturation, since the patient experienced dyspnea. 5. Pt. #7 was admitted to home health services on 9/9/23 with a primary diagnosis of Unspecified Polyneuropathy. The clinical record was reviewed on 1/23/24. The record contained the “Physician Telephone order Admitting Orders / Post-Hospitalization” requiring: “Skilled Nursing visits 1 wk 4”. The record lacked documentation the SN provided service during the week of 10/8/23 to 10/14/23. 6. The policy “Client Admission Process” was reviewed on 1/24/24 and required, “17. Upon acceptance and admission of a client, the admitting Registered Nurse/Therapist will assign the individual to the appropriately skilled professional...Services will be initiated within 48 hours after the assessment, unless documentation supports alternate plan based on client needs and wishes and physician orders.” 7. During interview with the Alternate Administrator, Alternate Director of Nursing and the Intake/Home Health Aide on 1/24/24 from 12:58 PM to 3:10 PM, they confirmed the above findings. Findings include: 1. Pt. #1 was admitted for skilled home health services on 12/2/23 with the primary diagnosis of Unspecified Dementia. The clinical record was reviewed on 1/23/24. The clinical record included a Plan of Care effective 12/2/23 requiring: “Orders for Discipline and Treatment: OT to evaluate and treat as needed with MD order. The clinical record also included the “Physician Order” dated 12/2/23 which required: “Admit patient for skilled Nursing, PT and OT services.” The clinical record lacked documentation of an OT evaluation or OT skilled visit. 2. Pt. #4 was admitted for skilled home health services on 12/17/23 with the primary diagnosis of Other Spondylosis. The clinical record was reviewed on 1/24/24. The clinical record included the “Physician Order” dated 12/17/23 which required: “Admit patient for skilled Nursing, PT and OT services.” The clinical record lacked documentation of an OT evaluation or OT skilled visit. 3. The policy “Client Admission Process” was reviewed on 1/24/24 and required, “17. Upon acceptance and admission of a client, the admitting Registered Nurse/Therapist will assign the individual to the appropriately skilled professional...Services will be initiated within 48 hours after the assessment, unless documentation supports alternate plan based on client needs and wishes and physician orders.””

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on a review of the Agency’s Pt. admission folder, observation during home visits, clinical record review and staff interview, it was determined the Agency failed to provide information regarding the Administrator and their contact information. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The Pt. admission folder was reviewed on 1/22/24. The folder lacked documentation identifying the Administrator’s name, address and phone number for the Pt. to contact. 2. The following home visits were conducted from 1/22/24 to 1/23/24: Pt. #1. SOC 12/2/23. Pt. #2. SOC 1/10/24. Pt. #3. SOC 12/13/23. During the home visits, the Pt. admission folders were observed and lacked the name of the Administrator, their address and phone number. 3. The clinical records of the following Pts. were reviewed from 1/22/24 to 1/24/24: Pt. #1. SOC 12/2/23. Pt. #2. SOC 1/10/24. Pt. #3. SOC 12/13/23. Pt. #4. SOC 12/17/23.. Pt. #5. SOC 12/29/23. Pt. #6. SOC 7/31/23. Pt. #7. SOC 9/9/23. The records lacked documentation the Agency had provided the name of the Administrator, their address and phone number. 4. During interviews with the Alternate Administrator and Alternate Director of Nursing on 1/24/24 at 1:35 PM, the Alternate Administrator confirmed this was the admission folder used for all Pts. admitted to this Agency, and that the Agency failed to provide information regarding the Administrator.”

“Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This Element is not met as evidenced by: Based on a review of the Agency’s patient admission folder, clinical record review, observation during home visits and staff interview, it was determined the Agency failed to provide information regarding Federal and state funded organizations that provide services in the patient’s community. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The Patient admission folder was reviewed on 1/22/24 and lacked documentation that the Agency provided the names and contact information of Federal and State funded organizations. 2. The following clinical records were reviewed from 1/22/24 to 1/24/24: Pt. #1. SOC 12/2/23. Pt. #2. SOC 1/10/24. Pt. #3. SOC 12/13/23. Pt. #4. SOC 12/17/23. Pt. #5. SOC 12/29/23. Pt. #6. SOC 7/31/23. Pt. #7. SOC 9/9/23. The records lacked documentation the Agency provided the names and contact information of Federal and State funded organizations. 3. The following home visits were conducted from 1/22/24 to 1/25/24: Pt. #1. SOC 12/2/23. Pt. #2. SOC 1/10/24. Pt. #3. SOC 12/13/23. During the home visits, the Patient’s admission folder was observed and lacked documentation that the Agency provided the names and contact information of Federal and state funded organizations. 4. During an interview with the Alternate Administrator, Alternate Director of Nursing on 1/24/24 at 1:35 PM, the Alternate Administrator confirmed the Agency failed to provide the names and contact information of Federal and State funded organizations.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on a review of closed clinical records and staff interview, it was determined the Agency failed to ensure the comprehensive assessment was updated at discharge. This was found in 1 of 2 (Pt. #7) closed clinical records reviewed. Findings include: 1. Pt. #7 was admitted to home health services on 9/9/23 with the primary diagnosis of Unspecified Polyneuropathy. The clinical record was reviewed on 1/23/24. The record contained documentation the SN, PT and OT provided services between 9/9/23 to 11/6/23. The record lacked documentation of an updated comprehensive assessment upon discharge. 2. During an interview with the Alternate Administrator and Alternate Director of Nursing on 1/24/24 at 1:35 PM, the Alternate Administrator confirmed the above findings. During the same interview, the Alternate Administrator stated the SN visit made on 11/6/23 was the last visit provided by the Agency, and that the SN should have completed a discharge comprehensive assessment.”

“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 clinical record review, observation during a home visit, policy review, and staff interviews, it was determined that the Agency failed to ensure the POC included all requirements. This was found in 1 of 7 (Pt. #2) clinical records reviewed. Findings include: 1. Pt. #2 was admitted for home health services on 1/10/24 with a primary diagnosis of Displaced Tri Malleolar Fracture Right Lower Leg Subsequent for Closed Fracture with Routine Healing. The clinical record was reviewed on 1/23/24. Pt. #2’s clinical record included an initial comprehensive assessment which indicated that Pt. #2 has a hemodialysis access and has other diagnosis of End Stage Renal Disease, and Dependence on Hemodialysis. During the home visit, Pt. #2 was observed to have a hemodialysis access on the right arm, and a peritoneal dialysis access on the left lower abdomen, which was covered with a dressing. The POC effective 1/10/24 lacked documentation of interventions and care for the hemodialysis access site and peritoneal dialysis access site. 2. The Agency Policy titled “Plan of Care” was reviewed on 1/24/24 and required, “Purpose: To provide guidelines for agency staff to develop a plan of care individualized to meet specific identified needs…The Plan of Care shall be completed to include: m. medical supplies and equipment required; o. instructions to client/caregiver, as applicable…” 3. During an interview with the Alternate Administrator, Alternate Director of Nursing, and Intake/Home Health Aide on 1/24/24 at 1:30 PM, it was confirmed that the above POC reviewed was the completed copy and was sent to the Physician for signature. During the same interview, the above finding was confirmed.”

“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 a clinical records review and staff interview, it was determined the Agency failed to ensure staff obtain Physician orders for all services. This was found in 2 of 7 (Pts. #3 and 7) clinical records reviewed. Findings include: 1. Pt. #3 was admitted to home health services on 12/13/23 with the primary diagnoses of Type 2 Diabetes Mellitus with Hyperglycemia, Right and Left Hand Contracture. The clinical record was reviewed on 1/24/24. The record contained the OT evaluation dated 12/15/23. As of 1/24/24, the record lacked a Physician order for the OT to evaluate Pt. #3. 2. Pt. #7 was admitted to home health services on 9/9/23 with a primary diagnosis of Unspecified Polyneuropathy. The clinical record was reviewed on 1/23/24. The record contained the LPN visit notes dated 9/28/23 and 10/4/23 which included documentation the LPN provided “Wound Care... wound in vaginal area cleansed with NSS and hydrogel applied.” The POC for the certification period of 9/9/23 to 11/7/23, and the “Physician Telephone Order...Post-Hospitalization” dated 10/2/23, lacked a Physician order for the LPN to provide wound care. 3. During an interview with the Alternate Administrator and Alternate Director of Nursing on 1/24/24 at 1:35 PM, both confirmed the Agency failed to ensure staff obtained Physician orders for all services.”

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on a review of the Agency’s Pt. admission folder, observation during home visits, clinical record review and staff interview, it was determined the Agency failed to provide information regarding the Director of Nursing. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 6 and 7) clinical records reviewed. Findings include: 1. The patient’s admission folder was reviewed on 1/22/24. The folder lacked the name and contact information of the Director of Nursing (Clinical Manager). 2. The following home visits were conducted from 1/22/24 to 1/23/24: Pt. #1. SOC 12/2/23. Pt. #2. SOC 1/10/24. Pt. #3. SOC 12/13/23. During the home visits, the patient’s admission folder was observed and lacked the name and contact information of the Director of Nursing. 3. The following clinical records were reviewed from 1/22/24 to 1/24/24 and lacked the name and contact information of the Agency Supervisor. Pt. #1. SOC 12/2/23. Pt. #2. SOC 1/10/24. Pt. #3. SOC 12/13/23. Pt. #4. SOC 12/17/23. Pt. #5. SOC 12/29/23. Pt. #6. SOC 7/31/23. Pt. #7. SOC 9/9/23. 4. During interviews with the Alternate Administrator on 1/24/24 at 1:35 PM, the Alternate Administrator confirmed the Agency failed to provide Pts. with the name and contact information of the Director of Nursing.”

“Contact information for the patient CFR(s): 484.110(a)(4) Contact information for the patient, the patient’s representative (if any), and the patient’s primary caregiver(s); This Element is not met as evidenced by: Based on clinical record reviews, policy review and staff interview, it was determined the Agency failed to ensure that Pt. contact information was obtained and documented in the clinical record. This was found in 2 of 7 (Pts. #2 and 4) clinical records reviewed. Findings include: 1. Pt. #2 was admitted for home health services on 1/10/24 with a primary diagnosis of Displaced Tri Malleolar Fracture Right Lower Leg Subsequent for Closed Fracture with Routine Healing. The clinical record was reviewed on 1/23/24. The clinical record lacked documentation of Pt. emergency contact, caregiver, or representative contact information. 2. Pt. #4 was admitted for skilled home health services on 12/17/23 with the primary diagnosis of Other Spondylosis. The clinical record was reviewed on 1/24/24. The record lacked documentation of Pt. emergency contact, caregiver, or representative contact information. 3. The policy “Clinical Records” was reviewed on 1/25/24, and required, “e. The Admission Assessment contains pertinent patient and family information...” 4. During an interview with the Alternate Administrator, Alternate Director of Nursing, and Intake/Home Health Aide on 1/24/24 at 12:58 PM, the above findings were confirmed.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on clinical record reviews, Agency policy and staff interview, it was determined the Agency failed to ensure staff completed a summary, after an inpatient transfer and at discharge. This was found in 2 of 2 (Pts. #6 and 7) closed records reviewed. Findings include: 1. Pt. #6 was admitted to home health services on 7/31/23 with the primary diagnosis of Chronic Respiratory Failure with Hypoxia. The clinical record was reviewed on 1/23/24. The record contained documentation that the SN and PT provided services from 7/31/23 to 8/16/23. The “Transfer to an Inpatient Facility” form, and “Telephone Orders” included documentation the Pt. was transferred to a hospital, both were written by the SN and dated 8/22/23. As of 1/23/24, the record lacked documentation the SN completed a transfer summary. 2. Pt. #7 was admitted to home health services on 9/9/23 with a primary diagnosis of Unspecified Polyneuropathy. The clinical record was reviewed on 1/23/24. The record contained documentation the SN, PT and OT provided services between 9/9/23 to 11/6/23. As of 1/23/24, the record lacked documentation the SN completed a discharge summary. During an interview with the Alternate Administrator and Alternate Director of Nursing on 1/24/24, the Alternate Administrator stated the SN visit made on 11/6/23 was the last visit provided by the Agency, and that the SN should have completed a discharge summary. 3. The Agency policy titled, “Clinical Records” was reviewed on 1/24/24 and contained: “...K. The transfer/discharge summary is completed upon discharge, or transfer if adequate time, and includes date of discharge or transfer, a summary of services from admission through discharge or transfer, and patient’s progress, current status, reasons for discharge, plans for meeting, post discharge needs for the patient, including the name of any organization to which the patient is being transferred or has been referred...” 4. During an interview with the Alternate Administrator and Alternate Director of Nursing on 1/24/24 at 1:35 PM, the Alternate Administrator confirmed staff failed to completed a transfer and discharge summary.”