Hope Home Health, Inc.

“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 the clinical records reviewed and Staff interview, it was determined in 2 of 7 (Pts. #4 and 7) clinical records reviewed, the Pt. care was not provided as ordered in the POC. Findings include: 1. Pt. #4 was admitted to the Home Health Services on 04/17/24 with the diagnosis of Chronic Atrial Fibrillation, Unspecified. The clinical record was reviewed on 04/29/25. The clinical record contained a POC dated 03/11/25, that required the PT services 3 time a week for 9 weeks. The PT provided services 2 times a week instead of 3 times, and the POC was not modified. 2. Pt. #7 was admitted to the Home Health Services on 10/04/24 with the diagnosis of Cerebral Infarction, Unspecified. The clinical record was reviewed on 04/29/25. The clinical record contained a POC dated 10/04/24, that required the SN to assess the patient 3 time a week for 9 weeks and assess the patient’s blood glucose every visit. The SN assessed the blood glucose on 11/04/24. The SN failed to assess the blood glucose weeks #1, 2 and 3 and the POC was not modified. 3. The findings were confirmed during the interview with the Clinical Manager on 04/29/25 between 2:45 PM and 3:30 PM.”

“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 the clinical records reviewed and Staff interview, it was determined in 2 of 7 (Pts. #6 and 7) clinical records reviewed, the PsOC lacked Pt. specific information. Findings include: 1. Pt. #6 was admitted to the Home Health Services on 02/27/25 with the diagnosis of Type 2 Diabetes Mellitus with Other Specified Complications. The clinical record was reviewed on 04/29/25. The clinical record contained a POC dated 02/27/25, and PT notes dated 03/15/25, 03/29/25 and 03/31/25. The POC lacked the PT orders and frequency for the PT visits dated 03/15/25 (week #3), 03/29/25 (week #5) and 03/31/25 (week #6). 2. Pt. #7 was admitted to the Home Health Services on 10/04/24 with the diagnosis of Cerebral Infarction, Unspecified. The clinical record was reviewed on 04/29/25. The clinical record contained a POC dated 10/04/24, that required the SN to assess the patient’s blood glucose 3 time a week for 9 weeks. The POC lacked the diagnosis for the blood glucose monitoring. 3. The findings were confirmed during the interview with the Clinical Manager on 04/29/25 between 2:45 PM and 3:30 PM.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on the clinical records reviewed and Staff interview, it was determined in 2 of 7 (Pts. #3 and 7) clinical records reviewed, the record lacked the physician’s orders. Findings include: 1. Pt. #3 was admitted to the Home Health Services on 03/11/25 with the diagnosis of Unspecified Fall , Subsequent Encounter. The clinical record was reviewed on 04/29/25. The clinical record lacked the physician’s order dated 03/15/25 for PT services, that was presented on 04/30/25 for the survey review. 2. Pt. #7 was admitted to the Home Health Services on 10/04/24 with the diagnosis of Cerebral Infarction, Unspecified. The clinical record was reviewed on 04/29/25. The clinical record lacked the physician’s order dated 11/04/24, that was presented on 04/30/25 for the survey review. 3. The findings were confirmed during the interview with the Clinical Manager, on 04/29/25 between 2:45 PM and 3:30 PM and on 04/30/25 at 10:30 AM, with the Operations Manager, that the physician orders should have been in the records.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on observation and interview during home visits, clinical record reviews, Agency policy review, and Staff interviews, it was determined in 2 of 7 (Pts. #1 and 2) clinical records reviewed, the Agency failed to ensure the medications listed in the clinical record were accurate. Findings include: 1. Pt. #1 was admitted for Home Health Services on 06/26/24 with the diagnoses of, but not limited to, Essential (Primary) Hypertension, and Phantom Limb Syndrome with Pain. A home visit was conducted on 04/28/25 with Employee #1. During the home visit, the patient’s medications were observed, and interviews were conducted with the Pt. and Employee #1. Observed the prescription bottle dated “01/31/25” and labeled, “Oxycodone/ Acetaminophen 7.5-325 MG TB Take 1 Tablet By Mouth Three Times Daily in Morning, At Noon and At Bedtime”. During an interview with Pt. #1, the Pt. stated, “the Percocet was too strong… the doctor replaced the Percocet with Oxycodone.” During the same interview, Pt. #1 stated the Hydrochlorothiazide was discontinued, Employee #1 stated the Physician discontinued the Hydrochlorothiazide on 04/04/25. The clinical record was reviewed on 04/29/25. The clinical record contained the Patient Medication Record/Medication Profile forms for the certification period of 02/21/25 to 04/21/25 and effective 04/22/25. The forms lacked Oxycodone/ Acetaminophen; and contained Percocet and Hydrochlorothiazide as current medications. The Patient Medication Record and/or Medication Profile forms were not updated to reflect new or changed medications, as required by the Agency’s policy. 2. Pt. #2 was admitted for Home Health Services on 03/06/24 with the diagnosis of, but not limited to, Vascular Dementia, Severe, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. A home visit was conducted on 04/28/25 with Employee #2. During the home visit, an interview was conducted with the patient’s representative that stated, “I give him all his medications… he only take Trazadone once a day now…” The patient’s representative stated, the Pt. is given Trazadone HCI 100 MG tablets 1 ½ (one and one-half) tablets at bedtime since March” (2025). The clinical record was reviewed on 04/29/25. The clinical record included the Medication Profile form for the certification period of 03/01/25 to 04/29/25. The form included “Trazodone HCI Oral 50 MG 45 Tab(s) Take one-half tablet by mouth three times a day as needed for agitation… Trazodone HCI Oral 100 MG 90 Tab(s) Take one tablet by mouth at 1pm and two tablets at bedtime”. The Medication Profile form was not updated to reflect dosage changes for the Trazodone. 3. The Agency’s policy titled; “Medication Reconciliation” was reviewed on 04/30/25. The policy required, “The Agency will reconcile patient’s medications… on an ongoing basis in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy…2… The medication list/profile will be updated with each new or changed medication. The patient’s medication list in the home will also be updated.” 4. During an interview with the Clinical Manager on 04/30/25 at 10:32 AM, the Clinical Manager confirmed the medications listed in the clinical record were inaccurate.”