Guardian Angel Home Health

“Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient’s discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner’s issuing orders for the HHA plan of care, and the patient’s 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). This Element is not met as evidenced by: Based on record review and interviews, the agency failed to notify the patient of an unplanned discharge for one out of the three discharged patients reviewed (Patient #3). Findings include: AGENCY POLICY: According to the agency policy titled “Patient Discharge Process” with no date, read in pertinent parts: “Agency makes effort to work with patient, representative if any to resolve the issue triggering possible discharge. Agency will assure documentation of communication with the patient, including trigger for potential for discharge, actions to avoid discharge and any behavioral agreements.” 1. Record review conducted on 7/21/26 at 3:17 P.M., revealed Patient #3 had a start of care date of 5/4/26. According to the plan of care dated for the certification period 5/4/26-7/2/26 revealed, Patient #3 was ordered to receive skilled nursing (SN), home health aid (HHA), occupational therapy (OT), and physical therapy (PT). a. The agency failed to notify the patient of the unplanned discharge. During an interview on 7/22/26 at 9:33 a.m., the Registered Nurse Case Manager (RNCM) stated she spoke with the agency’s Director of Nursing (DON) and the patient’s Primary Care Provider (PCP), but the RNCM admitted to not speaking with Patient #3 regarding the unplanned discharge. The RNCM also stated she notified the administrator and the DON. The RNCM was told by the administrator/DON that they would contact the patient regarding the discharge. During an interview on 7/22/26 at 10:33 A.M., the Physical Therapist (PT) who had the last in-person visit with the patient prior to the patient’s unplanned discharge. The PT explained he had gone to the patient’s home during a scheduled visit, where he allegedly found the patient intoxicated and the patient’s home “covered in feces.” Further interview found the PT made an Adult Protective Services (APS) report, notified the DON, and the patient’s PCP, who ordered a discharge effective immediately, but the PT did not communicate with the patient regarding discharge. Record review on 7/21/26 revealed no documentation of patient notification from the Administrator and DON regarding the unplanned discharge. During an interview on 7/22/26 at 12:28 P.M., the Administrator and DON confirmed there was no documentation of patient notification regarding the unplanned discharge.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment was completed in a timely manner. Specifically, the agency did not ensure the physician-ordered physical therapy evaluation was completed within 5 calendar days after the start of care for 1 of 1 sample patients receiving physical therapy services (Patient #1). Findings include: The clinical record for Patient #1 was reviewed on 2/3/26. Plan of care orders for the certification period dated 1/14/26 to 3/14/26 revealed a start of care date of 11/15/25; diagnoses included urinary tract infection, malignant neoplasm of prostate, and essential (primary) hypertension. Plan of care orders included skilled nursing once per week for medication management and sterile dressing changes, and physical therapy twice per week for gait and balance training to decrease the risk for injury. a) The agency failed to ensure the physician-ordered physical therapy evaluation was completed within 5 calendar days of the start of care. Review of the clinical record revealed a physician order, dated 11/15/25, for physical therapy to evaluate and treat Patient #1. Further review revealed the initial assessment for physical therapy occurred on 12/5/25. During an interview with the alternate administrator at 3:00 p.m. on 2/3/26, the alternate administrator stated the physical therapist had a difficult time getting in touch with Patient #1 to set a time for the initial physical therapy assessment. The alternate administrator stated the physical therapist did not document the attempts to schedule the assessment or notify the physician of the delay in performing the assessment. The alternate administrator acknowledged the assessment had not been completed within the required timeframe and stated the expectation for clinicians was for initial assessments for each discipline to be completed within 5 days of the start of care.”

“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 record review and interview, the agency failed to ensure staff followed the plan of care only as ordered by the physician for 1 of 2 patient receiving home health aid (HHA) services (Patient #3). 1. The clinical record for Patient #3 was reviewed on 2/3/26. The plan of care for the certification period dated 12/15/25 to 2/12/26 revealed a start of care date of 9/2/22; diagnoses included bed confinement, urinary catheter, chronic obstructive pulmonary disease, and oxygen dependence. Plan of care orders included skilled nurse (SN) visits two times weekly and HHA visits two times weekly. HHA services on the plan of care dated 12/13/25 include taking vital signs, giving bed baths, assisting with dressing, lotion, comb hair, clean/file nails, incontinence care, catheter care, empty drainage bag, and tidy area every visit and shampoo hair every week. a) Record review and interview showed the agency failed to ensure the HHA services was provided as ordered by the physician for Patient #3. Record review of nursing notes for certified nursing aid (CNA) #4 for Patient #3 dated 1/23/26 stated that the services provided were vitals taken, bed bath, shampoo hair, comb hair, skin care, record bowel movement, and turn and position. Incontinence care, catheter care, empty drainage bag, clean/file nails, and tidy areas were marked as not applicable. Same tasks were documented 1/26/26. During an interview with CNA #4 on 2/3/26 at 11 a.m., they stated that the consumer preferred that the skilled nurse to empty their catheter bag and provide incontinence care. They stated that they always turned and positioned the consumer and that she was unaware that the plan of care had clean/file nails as a task. During an interview on 2/3/26 at 3:06 p.m. with the director of nursing and alternate administrator, they stated that CNA #4 should have marked tasks that were refused by the consumer and given an explanation. They also stated that the plan of care should have included the task of turning and positioning.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 484.60, Care Planning, Coordination of Services, and Quality of Care was out of compliance. A total of 5 clinical records were reviewed for compliance with the Condition and Standards for Care planning, coordination of services and quality of care. Record review revealed a pattern of failures in regard to patient plan of care, administering services without physician orders, and integrating services to assure patient safety and treatment effectiveness. These failures had the potential to affect one patient with complex needs served by the home health agency. G574- Based on record review and interview, the agency failed to ensure the plan of care (POC) included all necessary interventions and services for 1 of 5 sample patients. (Patient # 2) G580- Based on record review and interview, the agency failed to ensure services and treatments were administered only as ordered by a physician or allowed practitioner for 1 of 5 sample patients. (Patient # 2) G606- Based on record review and interview, the agency failed to integrate services and treatments that could affect patient safety and treatment effectiveness for 1 of 5 sample patients. Specifically, the agency did not integrate physician referral information into a plan of care (POC) with complete and individualized orders signed by the physician. (Patient # 2)”

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 484.75 Condition of participation Skilled professional services was out of compliance. A total of 5 clinical records were reviewed for compliance with the Condition and Standards Skilled professional services. Record review revealed a pattern of failures in regard to patient plan of care, administering services without care plans, and integrating services to assure patient safety and treatment effectiveness. These failures had the potential to affect one patient with complex needs served by the home health agency. G708-Based on record review and interview, the agency failed to ensure the plan of care (POC) included all necessary interventions and services for 1 of 1 sample patients. (Patient #2)”

“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 care (POC), for 1 of 5 sample patients, included all necessary interventions and services. Specifically, the individualized plan of care did not contain information regarding tracheostomy size and care instructions, ventilator settings, gastrostomy tube parameters, contingency steps​ and home health aide tasks. (Patient # 2) Findings include: 1. The clinical record for Patient #2 was reviewed on 9/4/25. Patient # 2 was admitted to the agency on 3/1/18 with a principle diagnosis of spastic quadriplegic cerebral palsy. Record review revealed the individualized POC for the certification period from 8/9/25 to 10/07/25 did not contain information regarding gastrostomy tube flush/feed parameters, ventilator settings/management, tracheostomy size/care instructions and contingency steps (e.g., obstruction/dislodgement)​. Additionally, home health aide tasks were not listed on the POC. 2. During an interview at 10:46 a.m. on 9/4/25, the agency administrator stated no home health aide care plan had been created for Patient # 2 since February 2025. 3. During an interview at 2:21 p.m. on 9/4/25, the agency administrator stated no orders for tracheostomy, ventilator, or gastrostomy tube had been placed in Patient #2’s individualized plan of care. The administrator stated the agency clinicians providing care to Patient #2 relied on prior physician orders that had not been placed in the POC. 4. During an interview with a licensed practical nurse (Staff #4) at 2:40 p.m. on 9/4/25, Staff #4 stated that care details taken from the agency staff’s after-visit notes or summaries at the home were used as instructions because the orders from the hospital team were not in the POC.”

“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 record review and interview, the agency failed to ensure services and treatments were administered only as ordered by a physician or allowed practitioner for 1 of 5 sample patients. Specifically, agency staff provided care without complete and individualized orders for the patient’s tracheostomy, ventilator, and gastrostomy tube. (Patient # 2) Findings include: 1. The clinical record for Patient #2 was reviewed on 9/4/25. Patient #2 was admitted to the agency on 3/1/18 with a principle diagnosis of spastic quadriplegic cerebral palsy. Record review revealed daily ​skilled nursing ​visit notes documenting management of Patient # 2’s tracheostomy, ventilator, and gastrostomy tube​. Review further revealed the individualized POC​, for the certification period from 8/9/25 to 10/07/25​, did not contain information​ or orders regarding regarding gastrostomy tube flush/feed parameters, ventilator settings/management, tracheostomy size/care instructions and contingency steps (e.g., obstruction/dislodgement)​. 2. During an interview at 2:21 p.m. on 9/4/25, the agency administrator stated clinicians providing care ​for​ the management of ​Patient #2’s tracheostomy, ventilator, ​and gastrostomy tube​ relied on physician ​instructions​ that had not been placed ​as orders in the POC​. 3. During an interview with a licensed practical nurse (Staff #4) at 2:40 p.m. on 9/4/25, Staff #4 stated ​she used ​information from after-visit notes, or summaries​ of prior care provided at Patient #2’s home, as instructions ​for providing tracheostomy, ventilator, and gastrostomy tube​ care because ​specific orders f​o​r tracheostomy, ventilator, and gastrostomy tube​ management were not in the POC.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on record review and interview, the agency failed to integrate services and treatments that could affect patient safety and treatment effectiveness for 1 of 5 sample patients. Specifically, the agency did not integrate physician referral information into a plan of care (POC) with complete and individualized orders signed by the physician. (Patient #2) Findings include: 1. The clinical record for Patient #2 was reviewed on 9/4/25. Patient #2 was admitted to the agency on 3/1/18 with a principle diagnosis of spastic quadriplegic cerebral palsy. Record review revealed a pulmonology physician progress note, dated 4/24/25, with a referral for tracheostomy and ventilator management for Patient #2. The information from the referral was not found in the POC. 2. During an interview at 2:21 p.m. on 9/4/25, the agency administrator stated agency clinicians providing care ​for​ the management of ​Patient #2’s tracheostomy and ventilator relied on physician ​instructions​ from the pulmonary physician’s referral that had not been integrated​ into the POC​.”

“Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This Element is not met as evidenced by: Based on record review and interview, the agency failed to develop and evaluate a plan of care (POC), for 1 of 1 patients, including all necessary interventions and services. Specifically, the individualized plan of care did not contain tasks related to the patient (Patient #2). Findings include: 1. Patient #2’s record was reviewed on 9/3/25 at 10:37 a. m. Record review revealed a start of care date of 3/1/18 with a current certification period of 8/9/25 to 10/7/25. A recertification visit on 8/5/25 revealed Patient #2 was diagnosed with multiple chronic conditions which included Spastic quadriplegic cerebral palsy, gastrostomy tube, epilepsy, pulmonary disease and tracheostomy. a. The agency failed to develop and evaluate a POC with the patient, representative and caregiver. Review of Patient #2’s record revealed there was no POC developed with the patient, representative or caregiver. b. During an interview on 9/4/25 at 2:21 p.m. the alternate agency administrator stated no home health aide care plan had been created for Patient #2 due to the portal being down. Further interview revealed that the patient did not require an outcome and assessment information set (OASIS) due to the patient being under eighteen, so a POC was not created.”