Hilltop Healthcare, LLC

The agency failed to ensure a clinical manager/RN was available during operating hours for one patient and all employees.

The agency failed to ensure an administrator or alternate administrator was available during all operating hours for one patient and all employees.

The agency failed to ensure evidence of a patient centered QAPI Program in calendar years 2023 and 2024 for all patients and employees.

The agency failed to ensure a governing body oversite of the agency: 1. Program evaluation and budget authorization for calendar year 2023.

The agency failed to ensure an Emergency Preparedness Communication Plan included current employee contact information for the agency for two patients and three employees.

The agency failed to ensure emergency preparedness disaster table-top exercises, drills, community drills or plan activation events were conducted from 05/15/23 to 12/31/23 and in calendar year 2024 for two patients and three employees.

The agency failed to ensure evidence of a patient centered QAPI Program in calendar years 2023 and 2024 for all patients and employees.

The agency failed to ensure utilization of QAPI quality indicator data in calendar years 2023 and 2024 for all patients and employees.

The agency failed to ensure conduction of patient centered QAPI program activities included self-monitoring efforts that identified and evaluated outcomes to improve care, services, and operations in calendar years 2023 and 2024 for all patients and employees.

The agency failed to ensure performance improvement projects for the agency in calendar years 2023 and 2024 included: 1. Goals 2. Collection, analysis and review of related data 3. Follow up monitoring and reporting for all patients and three employees.

The agency failed to ensure governing body oversite of conduction of a patient centered QAPI program in calendar years 2023 and 2024 for all patients and employees.

The agency failed to ensure infection control program surveillance data was included in QAPI program activities in calendar years 2023 and 2024 for all patients and employees.

The agency failed to ensure a governing body oversite of the agency and: 1. Program evaluation and budget authorization for calendar year 2023.

The agency failed to ensure governing body appointment of a supervising nurse for the agency for all patients and employees.

The agency failed to ensure the administrator’s name and contact information was included in the admission packet information for two (Patients #1 and #2) of seven patients.

The agency failed to ensure: 1. Notification to the physician the agency could no longer meet the patient’s needs prior to discharge for five (Patients #3, 4, 5, 6 and #7) of seven patients.

The agency failed to ensure an initial assessment was conducted within 48 hours of referral for one (Patients #2) of seven patients.

The agency failed to ensure individualized patient POC included pain reporting parameters for one (Patient #3) of seven patients.

The agency failed to ensure care was coordinated between the agency and physician for three (Patients #1, 2 and #7) of seven patients.

The agency failed to ensure: 1. PT conducted visits as ordered for one (Patient #3) of seven patients.

The agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees.

The agency failed to ensure certified home health aide supervisory visits were completed every 14 days in the patients home for two (Patients #6 and #7) of seven patients.

The agency failed to ensure a governing body appointment of the administrator for the agency from 02/11/24 to 04/12/25 for all patients and staff.

The governing body failed to ensure operational oversight of the agency by an administrator from 02/11/24 to 04/12/25 for all patients and all employees.