Hope Home Care Inc.

“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…””