Hope Professional Services, Inc

The agency failed to electronically submit the completed Outcome and Assessment Information Set (OASIS - a standard set of data elements used by home health agencies to collect and report patient information, to tract and monitor quality of home health, used to develop individualized care plans…

The facility failed to ensure the approved visit frequencies in the patient’s Plan of Care (POC) were followed when the agency did not notify the physician of missed visits for three of 7 patients reviewed (Patients 4, 6 and 7).

The agency failed to ensure the OASIS (Outcome and Assessment Information Set - a standardized set of data that helps measure and improve the quality of care for home health patients) Assessments were accurate and complete that included patient's past medical history, and active health status…

The agency failed to ensure the patient's current Plan of Care (POC) and the current medication profiles were updated, accurate, and complete for two patients reviewed (Patients 1 and 2).

The physician's post operative orders related to embolization (a procedure that involves blocking a blood vessel with small particles or materials to control bleeding) and angioplasty (a procedure used to open narrowed or blocked arteries) were not entered and documented in patient's current Plan…

The agency failed to ensure the approved visit frequencies in the patient's Plan Of Care (POC) were followed when the agency failed to notify the attending physician of missed visits for three of seven sampled patients reviewed (Patients 1, 3 and 4).

The agency failed to ensure the medications listed in patient's Plan of Care (POC) and current medication home profile were updated, accurate, and complete for two of seven sampled patients reviewed (Patient 1 and 4) when: 1. For Patient 1, - a.

The agency failed to ensure the following were included in the patient's individualized Plan of Care (POC): - Wound care treatment frequency, medications and supplies; - Patient and Primary Caregiver (PCG) education regarding dressing changes using aseptic technique (free from contamination); and -…

The agency failed to ensure patient's individualized Plan of Care (POC) was revised to reflect current clinical condition, skilled nursing care and medical management for one of seven patients reviewed (Patient 1).

The agency failed to ensure the frequency of visits in Plan of Care (POC) was followed as ordered by the physician for one of seven sampled patients (Patient 4).

The agency failed to develop, and implement an effective, on -going, agency-wide data driven quality and performance improvement (QAPI) program when: 1. The agency failed to collect, measure, analyze, and tract quality indicator (QI- a measurable element of the agency's practice that can be used to…

The agency failed to operate and furnish services in compliance with applicable federal, state, and local laws when: 1. The agency failed to ensure it followed Title 22 (California Regulations) section 7467(d), when the agency was operating with an expired license (See G 860); 2. The agency failed…

The agency failed to ensure emergency preparedness training was provided to agency staff annually.

The agency failed to encode (convert in a coded form) and electronically transmit multiple Outcome and Assessment Information Set (OASIS- an assessment tool used to collect health information) assessments to the Centers for Medicare and Medicaid (CMS) within 30 days after the completion of…

The agency failed to ensure the plan of care (POC) was followed and the physician was notified when skilled nursing (SN) visits were missed for three of ten sampled patients (Patients 1, 2, and 9).

The agency failed to collect, measure, analyze, and tract quality indicator (QI- a measurable element of the agency's practice that can be used to assess the quality of care provided) data in order to assess the agency's processes of care, services, and operations.

2. Based on interview, the agency failed to tract adverse patient events, analyze their causes, and implement preventive actions.

The agency failed to conduct performance improvement projects which includes the scope and number of projects conducted annually that reflects the scope, complexity, and past performance of the agency's services and operations.

The agency's governing body failed to ensure a program for quality improvement and patient safety was defined, implemented and maintained.

The agency failed to ensure it followed Title 22 (California Regulations) section 7467(d), when the agency was operating with an expired license.

The agency failed to comply with waived testing criteria (standards the agency must follow in order to perform simple laboratory tests such as blood sugar monitoring) by failing to maintain a current Clinical Laboratory Improvement Amendments (CLIA) waiver.

The agency failed to ensure the Outcome and Assessment Information Set (OASIS- an assessment tool used to collect health information) privacy notice was provided the patients during the initial patient evaluation visit, to four of four patients (Patients 5, 6, 7, and 8) who were observed during…

The agency failed to ensure the patient's comprehensive assessment included all prescribed medications and the medication profile was reviewed and updated for one of ten sampled patients (Patient 7).

The agency failed to ensure the plan of care (POC) for five of ten sampled patients (Patients 3, 5, 6, 9, and 10) included the specific information related to the patient's risk for emergency department visits and hospital readmissions, including all the necessary interventions to address the…

The agency failed to ensure there was a physician order for the patient's need for an extra skilled nursing (SN) visit for one of ten sampled patients (Patient 10).

The agency failed to develop a policy and procedure to ensure the patients were assessed for their flu and pneumonia vaccines' status, and were offered the vaccines when needed for nine of ten sampled patients (Patients 1, 2, 4, 5, 6, 7, 8, 9, and 10).

The agency failed to ensure an Occupational Therapy (OT, therapy to enhance self-care skills) evaluation was conducted as ordered by the physician for one of ten sampled patients (Patient 9).

The agency failed to ensure clinical notes were prepared and accurate when: 1) The skilled nurse (SN) failed to prepare and submit visit notes timely for two of ten sampled patients (Patients 5 and 8) and 2) the SN documented diabetic teaching was conducted for one patient of ten sampled patients…

The agency failed to ensure the care and services provided by a Licensed Vocational Nurse (LVN) to four of ten sampled patients (Patients 7, 8, 9, and 10) were evaluated and supervised by a Registered Nurse (RN).

The agency failed to ensure the Clinical Manager (CM) provided oversight of all patient care services, including coordinating patient care when patients had missed visits (Cross reference G572); services were not provided as ordered by the physician (Cross reference G710); a nurse continued to…

The agency failed to ensure the patient was assessed upon discharge and a discharge summary was completed for one of ten sampled patients (Patient 4).