Guardian Angels Home Health Care, Inc.

“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 observation, record review, and interview the agency failed to have a signed POC or a verbal POC order from the primary physician before providing services and treatments to patients (See tag G572); failed to administer medication as ordered by the physician and failed to obtain orders for care provided (See tag G580) The cumulative effect of these systemic problems resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation at 42 CFR 484.60 Care Planning, Coordination of Care, Quality of Care, with the likelihood to affect all 101 current patients receiving Home Health services from this provider. Findings include: An immediate jeopardy was identified and announced on 01/13/2025 at 3:00 PM related to 42 CFR §484.60: Care planning, coordination of services, and quality of care. The immediate jeopardy was identified as beginning on 10/08/2024. The Immediate Jeopardy remained unremoved at the time of exit on 01/14/2025. The agency’s 2nd immediate jeopardy removal plan and actions were confirmed to have removed the immediacy jeopardy component on 01/21/2025.”

“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 record review and interviews, the agency failed to have a signed POC or a verbal POC order from the primary physician before providing services and treatments to patients for 1 of 3 closed record reviews (Patient #4); and for 3 of 8 active record reviews. (Patients #6, #7, #10) Findings Include: 3. A record review of Patient #4, certification period 10/08/2024 to 12/06/2024, revealed patient care was provided to Patient #4 without a detailed verbal order or physician-signed order received for visits 10/08/2024 and 10/09/2024. The agency failed to have orders before providing patient care. During an interview on 01/09/2025 at 9:55 AM, RN 2 referred to the Alternate Nurse Supervisor, who would have gotten an order from a physician before admission, and those specific orders would be on the referral form. RN 2 could not find a detailed physician’s order in the Patient #4 chart. RN 2 indicated she normally reports POC information to the physician. RN 2 reviewed Patient #4’s chart; she could not find documentation of physician communication. 5. A record review of Patient #7, certification period 12/05/2024 to 02/02/2024, revealed patient care was provided to Patient #7 without a detailed verbal order or physician-signed order received for visits: 12/08/2024, 12/05/2024, 12/06/2024, 12/09/2024, 12/11/2024, 12/13/2024, 12/16/2024, 12/18/2024, 12/20/2024, 12/23/2024, 12/27/2024, 12/30/2024 and 01/03/2025. The agency failed to have orders before providing patient care. During an interview with the Clinical Supervisor and the Alternate Clinical Supervisor on 1/10/2024 at 08:45 AM, the Clinical Supervisor reviewed patient #7’s chart; she indicated the physician did not date the POC in the chart; the fax information indicated the agency received POC from a physician on 01/09/2024. She did not locate a verbal order for services provided by the agency from 12/05/2024 to 01/09/2025; no wound care orders were in the referral packet. 6. A record review of Patient #10, certification period 12/24/2024 to 02/21/2025, revealed patient care was provided to Patient #10 without a detailed verbal order or physician-signed order received for visits: 12/24/2024, 12/26/2024, 12/31/2024, and 01/02/2025. The agency failed to have orders before providing patient care. During an interview with the Clinical Supervisor and the Alternate Clinical Supervisor on 1/10/2024 at 08:45 AM, the Clinical Supervisor reviewed Patient #10’s chart and confirmed there were no detailed orders for services provided from 12/24/2024 to 01/03/2025 7. During an interview on 01/09/2025 at 9:55 AM, RN 2 referred to an Alternate Nurse Supervisor who would obtain orders from a physician before admission. 1. An undated policy title “Plan of Care” indicated but not limited to, “All orders, including the plan Of Care and all verbal orders, will be signed by the physician in a timely manner … If the physician delays or fails to sign orders, care cannot be continued. Physician orders are tracked for timely signatures in the agency office. Efforts to obtain signature include frequent communication with the physician’s office staff, hand delivery and pick up of orders to the physician’s office, and senior management intervention, when necessary.” 2. An undated “Director of Nursing/Supervisor of Services” job description indicated but was not limited to “Responsibilities … Shall supervise the professional delivery of care.” 4. A review of Patient #6’s record, SOC date 11/26/2024, evidenced Patient #6 received HHA services without a physician-signed POC or a detailed verbal order. Patient #6 received 2 HHA visits on the following days: 12/02/2024 and 12/04/2024. The physician signed the POC on 12/11/2024. The agency failed to obtain a signed POC before providing HHA services to Patient #6. During an interview on 01/09/2025 at 12:38 PM, the Nursing Supervisor stated the physician has 30 days to sign the POC or verbal orders. She stated they do not put details in the verbal about the care they are providing. 410 AIC 17-13-1(a)”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review and interview the agency failed to provide patients with a completed written copy of the admission consent regarding non-covered services, disciplines to be furnished, and frequency of services for 2 of 4 home visits. (Patient #1, # 9) Findings include: 3. During a home visit on 01/09/2025 at 8:00 AM, Patient #9’s admission booklet revealed an incomplete admission consent form. The agency failed to provide the patient with a copy of the completed admission consent form. During an interview on 01/09/2025 at 8:15 AM, LPN 1 stated she was unsure why the admit packet did not contain a completed admission consent form. 4. During an interview on 01/09/2025 at 5:00 PM, the Alternate Administrator stated staff were to complete the admission consent form and provide the patient with a copy. 1. A document titled “Patient Rights and Responsibilities” failed to evidence charges for services that may be non-covered care, disciplines to be furnished, and frequency of services. 2. During a home visit with Patient #1 on 01/09/2025 at 1:34 PM, the admission booklet did not have a completed admission consent form. The agency failed to provide a copy of the completed admission consent form to the patient. 3. An interview with RN 4 on 01/09/2025 at 1:34 PM, indicated that the admitting nurse must have forgotten to finish filling out the admission consent.”

“HHA can no longer meet the patient’s needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient’s welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient’s needs, based on the patient’s acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA’s capabilities; This Element is not met as evidenced by: Based on record review and interview, the agency failed to make a safe and appropriate discharge for 1 of 3 closed record reviews. (Patient #3). Findings include: 1. An undated policy titled “Medical Chart Policy” indicated but not limited to, “All entries must be legible, clearly written, dated, and signed by the healthcare professional providing care. Staff should maintain all records in the EMR. Any pertinent paper documents will be scanned and attached to the chart.” 2. A review of Patient #3’s record, discharge date 06/06/2024 included a Care Coordination Note dated 06/06/2024 indicated the agency notified the physician’s office nurse that the agency was discharging Patient #3 from services due to safety concerns and non-compliance issues. The record failed to evidence that the physician agreed with the discharge and failed to evidence the agency attempted to resolve patient’s noncompliance, or provided a safe transfer and resource information upon discharge. During an interview on 01/08/2025 at 4:10 PM, the Nursing Supervisor reviewed the record and indicated the agency kept the information about the discharge in an “Inter-Office Communication Note” that was not part of the patient’s medical record. She stated the Case Manager was going to handle finding the Patient another agency because the Patient fired us.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the agency failed to complete an initial assessment within 48 hours of a referral and failed to document the reason for the delayed start of care for 3 of 8 active record reviews. (Patients #4, #6, # 8 ) Findings include: 2. A review of Patient #4’s record, SOC date 10/05/2024, included a referral form with a referral date of 09/27/2024 and a verbal order dated 10/07/2024; a General Order from Entity 2 that included an order description: Discharge home with home health care; start date 09/30/2024; the record failed to evidence a dated or signed physician order for verbal order. The agency failed to have a valid reason for the delayed SOC and failed to complete the initial assessment within 48 hours of the referral 1. An undated policy titled “Admission Criteria” indicated the agency would initiate services in a timely manner based on agency policy or physician order. The agency policy indicted, but was not limited to “When a referral is accepted, the patient will be contacted and service initiated within 48 hours of referral, discharge from inpatient facility or upon physician’s ordered start of care date. If care is not initiated within these time frames, the physician will be notified … patient doesn’t meet the admission criteria or Guardian Angel Home Health Care is unable to provide the service(s) due to the level Of intensity or skill level required or unavailable agency resources, the referring physician/referral source and, if indicated, the patient and/or caregiver will be informed.” 3. A review of Patient #6’s record, SOC date 11/26/2024, certification period 11/26/2024 to 01/24/2025, included a referral verbal order dated 11/20/2024. The record included an unsigned physician order dated 11/25/2024 indicating the RN to assess for home health care services on 11/26/2024. The agency failed to have a valid reason for the delayed SOC and failed to complete the initial assessment within 48 hours of the referral. During an interview on 01/09/2025 at 3:26 PM, the Nursing Supervisor reviewed Patient #6’s record and stated they had an order dated 11/25/2024 for an RN assessment for home health care services to start on 11/26/2024. The physician did not sign the order or have a reason for the delayed start. She stated the agency notified the physician there would be a delay in starting; we do not go into the home without an order. She stated the agency asked the physician if they would instead refer the Patient to another agency due to the delay or if they could wait until they got to it. 410 IAC 17-14-1(a)(1)(A)”

“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 provide treatments under the order of a physician on 2 of 11 patient records reviewed. ( Patient #4, #7) Findings include: 1. An undated policy titled “Plan of Care” indicates the agency staff must obtain an order from a physician before providing patient care; the staff will provide treatments as ordered by the physician. 2. A record review of Patient #4, certification period 10/08/2024 to 12/06/2024, included a coordination note that indicated RN 4 provided PleurX care to Patient #4 on 10/08/2024; the record failed to evidence a physical or verbal order from a physician for the agency to manage PleurX. During an interview on 01/09/2025 at 9:55 AM, RN 2 reviewed Patient #4’s chart; RN 2 could not find a physician’s order for PleurX in the Patient #4’s chart. During an interview with the Clinical Supervisor and the Alternate Clinical Supervisor on 1/10/2024 at 08:45 AM, the Alternate Clinical Supervisor indicated that a verbal order is needed to start service and for Specific treatment. She indicated no orders for Patient #4’s PleurX management on referral. 3. A record review of Patient #7, certification period 12/05/2024 to 02/02/2024, failed to evidence a valid verbal or physical order for wound care provided on 12/05/2024, 12/06/2024, 12/09/2024, 12/11/2024, and 12/13/2024. During an interview on 01/09/2025 at 9:55 AM, RN 2 indicated that the office staff received a description of the wound, and they would determine the appropriate wound care needed. There were no specific wound care orders from the Physician for Patient #7’s wounds. During the interview, RN 2 reviewed Patient #7’s chart and could not locate documentation of wound care orders for the admission visit 12/05/2024. She indicated that the first wound care order was from the wound center on 12/17/2024. 410 IAC 17-13-1(a) 1. An undated policy titled “Plan of Care” indicates that the agency staff will provide treatments as ordered by the physician. 2. During a home visit with Patient #9 on 01/09/2025 at 8:00 AM, SOC 03/03/2017, LPN 1 was observed giving Kate Farms formula 250mL and 200 mL of water. The agency failed to provide treatment under the physician’s order in the POC. 3. During an interview with LPN 1 on 01/09/2025 at 8:00 AM, they indicated that the formula given is 250mL and they also give 200mL of water for a total of 450mL for each feeding.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, the agency failed to notify the physician of the patient’s change in condition, affecting 1 of 1 patient discharged due to death record reviewed. (Patient #4) Findings include: 1. An undated policy titled “Plan of Care” indicates the agency staff must coordinate with the physician for any changes or additions to the original plan. The staff members are responsible for reporting any conditions or problems to the physician; the agency staff must notify the physician of changes in the patient’s condition or needs. 2. An undated policy titled “Reporting Client Condition” indicates the physician must be notified of any changes in patient conditions; changes should be documented and reported to the physician immediately; if a physician cannot be reached, the client/family will be instructed to call 9-1-1. The nurse should call or instruct the patient or family to call 9-1-1 if experiencing any adverse changes related to chest pain, shortness of breath, or other life-threatening conditions. 3. An undated document titled “ Registered Nurse Job Description” indicates that current nursing practice includes patient condition and assessment. The Registered Nurse will communicate condition and assessments to physicians involved in the patient’s care. 4. A record review of Patient #4, certification period 10/08/2024 to 12/06/2024, included an Oasis Nursing Service SOC/ROC dated 10/08/2024 that indicated the following findings during the admission visit for Patient #4: lung sounds: fine crackles heard in the posterior right lung base and left posterior lung base diminished; short of breath with minimal exertions and fatigues easily, 3+pitting edema Bilateral Lower Extremities (BLE), abdominal distention, blood sugar reading of 374. Patient #4 reports pain of a 2 in the lower abdomen. During this visit the nurse failed to assess when the patient’s Pleurex drain (a thin, flexible tube that drains fluid from the pleural space in the chest) had last been emptied, despite the referral indicating that the drain was to be emptied three times per week. RN 2 failed to report admission findings to the physician. A referral document indicated the patient was discharged from rehabilitation on September 27, 2024, but start of care did not begin until October 8, 2024, due to delays in obtaining necessary supplies. The agency failed to notify the physician of the delay in care. The record included a care coordination note by RN 4, dated 10/09/2024, that indicated RN 4 provided a courtesy visit to Patient #4 on 10/08/2024. Upon RN 4 arrival, Patient #4 had symptoms of wheezing and was slightly distressed. RN 4 failed to report Patient #4 condition during the courtesy visit to a physician. An untitled triage assessment document from the Emergency Room dated 10/09/2025 indicated that the patient had arrived via ambulance after being found unresponsive at home. CPR was initiated by the family. The patient arrived at the Emergency Room at 5:42 PM in cardiac arrest with CPR in progress. The triage document indicated the patient was in metabolic acidosis (a condition in which the body has a high concentration of acid) and that 400cc of blood was suctioned via a nasogastric tube (a flexible tube that is inserted through the nose and into the stomach), suggesting an active gastrointestinal (GI) bleed. The patient was pronounced dead at 7:52 PM. The cause of death was cardiac arrest, with contributing factors including a suspected STEMI (heart attack) and GI bleed. During an interview on 01/09/2025 at 9:55 AM, RN 2 reviewed Patient #4 chart; she located a coordination note in Patient #4 chart, which provided information about a courtesy visit made on 10/08/2024 after hours; no documentation of physician notified of Patient #4’s condition change was located. RN 2 indicated that the admission nurse should notify the physician of the patient’s condition and the POC updates. RN 2 indicated she usually speaks with a nurse, not directly to the physician, when reporting POC and patient condition to the physician. RN 2 could not find what was discussed with the physician’s office staff about Patient #4 POC in the chart. During an interview on 01/09/2025 at 10:10 AM, RN 4 indicated that the physician was not notified of Patient #4’s change in condition during courtesy visit. During an interview on 01/09/2024 at 1:00 PM, RN 1 indicated that staff should notify the physician if a patient’s condition changes.”

“Documentation of competency evaluation CFR(s): 484.80(c)(5) The HHA must maintain documentation which demonstrates that the requirements of this standard have been met. This Element is not met as evidenced by: Based on record review and interview the agency failed to maintain documentation demonstrating the competency requirements for 5 of 5 HHA records reviewed. (HHA 2, 3, 4, 5, 6) Finding include: 1. An undated policy titled “ Personnel Files” stated “ all staff members files will be retained according to state and federal guidelines.” 2. Personnel record for HHA 2, hire date 12/13/2024, included an ungraded document titled “Home Health-Hospice Aide Competency Assessment Exam Answer Sheet.” The agency failed to provide the required documents for a scored HHA competency test. 3. Personnel record for HHA 3, hire date 12/20/2018, included an ungraded document titled “Home Health-Hospice Aide Competency Assessment Exam Answer Sheet.” The agency failed to provide the required documents for a scored HHA competency test. 4. Personnel record for HHA 4, hire date 07/23/2024, included an ungraded document titled “Home Health-Hospice Aide Competency Assessment Exam Answer Sheet.” The agency failed to provide the required documents for a scored HHA competency test. 5. Personnel record for HHA 5, hire date 07/14/2023, included an ungraded document titled “Home Health-Hospice Aide Competency Assessment Exam Answer Sheet.” The agency failed to provide the required documents for a scored HHA competency test. 6. Personnel record for HHA 6, hire date 10/03/2022, included an ungraded document titled “Home Health-Hospice Aide Competency Assessment Exam Answer Sheet.” The agency failed to provide the required documents for a scored HHA competency test. 7. An interview with Human Resources on 01/13/2025 at 9:42 AM, indicated that the HHA test score was usually written at the top of the first page once graded. Human Resources indicated they did not know why the scores were not at the top of the page.”