Every finding on record at Guardian Home Care of Northeast Georgia, LLC

An Abbreviated/Partial Extended Survey investigating complaint #2636735 was conducted at Accentcare Home Health of Northeast Ga on January 20, 2026, and concluded on January 21, 2026. At the time of the survey, the agency was not in compliance with Chapter 42 CFR Part 418, Rules and Requirements for Home Health and Hospice Agencies. The census was 738. Based on record reviews and interviews, the agency was found not to be in compliance with complaint #2636735. The following citations were cited:

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 review of policy titled “Care Planning and Coordination,” review of records, and staff interview, it was determined the agency failed to follow accepted standards of practice ensuring patient incoming calls were received and returned by staff in a timely manner for two patients (P) (P#4, P#5) of three sampled patients. Findings include: Cross reference to G0608 relating to Coordinate care delivery.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on review of policy titled “Care Planning and Coordination,” review of records, and staff interview, it was determined the agency failed to effectively follow accepted standards of practice for ensuring patient’s needs are met through staff coordination of care. Specifically, the agency failed to ensure that patient incoming phone calls were received and returned in a timely manner for two patients (P) ( P#4, P#5) of three sampled patients. Findings include: Review of policy titled “Care Planning and Coordination” revised 6/10/2025 revealed the following: 17. Agency personnel involved in patient care will communicate changes and care coordination activities to the case manager or designated Patient Care Manager in a timely manner via telephone, one-on-one meetings, case conferences, and home visits. Review of agency complaint log dated 1/15/2026 revealed P#4 filed a complaint with the agency stating the family of P#4 “has left multiple messages with the office and on the managers voicemail for her to return call over the past 2 weeks and still has not received return call”. Review of agency’s complaint log dated 12/23/2025 revealed P#5 filed a complaint with the agency stating, "called office several times and left a message with no return call”. On 1/20/2026 the surveyor attempted to call the agency office phone, on two different occasions, at 12:06 p.m., and again at 12:12 p.m., and was unable to reach or talk to staff in the office. Surveyor brought the previous phone attempts to the Administrator’s attention and then Administrator attempted to call the office phone, from her cell phone, and was unable to reach or talk to staff in the home health office. On 1/21/2026 at 11:30 a.m., during an office interview, the Administrator admitted the agency has a problem with the current phone system. The Administrator explained all phone calls into the agency office were directed to the secretary’s desk as well as other staff members. The Administrator explained the office secretary would answer the phone call, unless the secretary was unavailable, at that point the agency had designated other members of the office staff to answer the phone. The Administrator admitted on 1/20/206, when the surveyor called the office, four members of the office staff, not including the office secretary, were receiving the phone call to their office phone. The Administrator added that the agency secretary would return all missed calls at the end of the workday.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on review of policy titled “Care Planning and Coordination,” review of records, and staff interview it was determined the agency’s governing body failed to effectively manage daily operations for ensuring effective patient coordination of care manner for two patients (P) ( P#4, P#5) of three sampled patients. Findings include: Cross refer to G0608 for findings related to coordination of care.

An abbreviated/partial extended survey investigating complaint #95629 was initiated on 4/25/2023 and concluded on 4/27/2023. Complaint #95629 was substantiated. At the time of the survey, the agency was not in compliance with compliance with Chapter 42 CFR Part 418, Rules and Requirements for Home Health and Hospice Agencies. Census at the time of the survey was 666. The following deficiencies were cited:

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health 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) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on clinical record review, staff and family interview and policy review titled, “Patient Transfer and Discharge/ NONMC”, the home health agency failed to advise the patient, representative and the patient’s primary care physician that a discharge was being considered for one of one patient (P) (P#1). Findings include: Policy review on 4/27/2023 at 10:00 a.m. of policy titled, “Patient Transfer and Discharge/ NONMC” revised 2/15/2023, reads, “a completed discharge summary is sent to the physician, podiatrist, allowed practitioner or other healthcare professional responsible for providing care and services to the patient after discharge from the Agency, if any, within five (5) business days of the patient’s discharge.” “The agency staff shall notify the patient, the patient’s representative, attending physician, podiatrist, or allowed practitioner of the patient’s discharge and reason for discharge.” “Unless there are stricter state or payor notification requirements, the patient shall be notified of planned discharge at least 48 hours before a planned discharge.” “The patient, family, physician, podiatrist, or allowed practitioner are included in the discharge planning process consistent with state and federal regulations and participation or notification is documented in the medical records.” P#1 was admitted on 3-31-2022 for management of urinary catheter. Patient discharged effective 1/20/2023 and re-admitted on 2-6-2023. The family of P#1 telephone interview on 4/26/2023 at 2:50 p.m. revealed that family was not aware patient was discharged until called by agency to coordinate re-admission. Clinical record review for P#1 on 4/26/2023 at 2:00 p.m. revealed no evidence of discharge planning with patient, representative or primary care physician (PCP). Review of Discharge-Transfer Summary Report, with discharge date of 1/20/2023 indicates discharge summary faxed to patient’s PCP on 2/2/2023, 13 days after discharge. Interview with Administrator on 4/27/2023 at 10:00 a.m. revealed patient discharged 1/20/2023 due to a change in insurance and confirms that all of P#1’s clinical records were provided.

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: This ELEMENT is not met as evidenced by: Based on record review, family and staff interviews, and policy titled, “ Concern, Complaint or Grievance reporting Internal and External”, it was revealed the agency failed to document complaint resolution given by the referenced patient (P) (P#1) in complaint #95629. Findings include: A record review, on 4/25/2023 at 12:00 pm, of agency’s policy titled: Concern, Complaint or Grievance reporting Internal and External" with effective date of 01/2000 and a revision date of 01/19/2023: “Any staff member receiving a concern/complaint shall complete the Concern/Complaint Report form (c 2.8) or, if available, electronically in the medical record including any action taken and shall report the concern to the supervisor who ensures the notification of appropriate management personnel.” “The supervisor shall investigate the grievance and shall make every effort to resolve the grievance to the patient’s satisfaction.” “Any corrective action shall be specific and related to the concern/complaint.” “Resolution information shall be communicated orally or in writing to the patient or their representative and the results of this communication shall be documented on the statement of concern.” Review of records on 4/25/2023 at 10:00 a.m., revealed documentation of RN CC speaking with P#1’s caregiver via telephone on 1/20/2023. During the telephone conversation the caregiver requested a nurse visit to change the patient's urinary catheter and during the conversation the caregiver complained to RN CC of a lack of communication received from RN AA. Caregiver then requested a call back from RN AA to discuss a time to come to the patient’s home for the urinary catheter change and to discuss patient care concerning a possible urinary tract infection (UTI). In reviewing the agency’s Complaint and Grievance log on 1/20/2023 at 10:30 am it was revealed the agency failed to document, as stated in policy on a Concern/Complaint Report with form (c 2.8), the complaint nor the resolution to the previous complaint. The agency failed to notify the patient’s representative orally or in writing the resolution information. During an interview, with the family member of P#1 on 4/26/2023 at 1:00 pm, revealed the family member called the agency five or six times during the week of 1/15/2023 through 1/21/2023 to request a nurse visit without a return call and P#1 blood sugar was elevated and was showing signs of a urinary tract infection (UTI). Family member additionally revealed urinary catheter had not been changed in 6 weeks and needed a nurse to come for a home visit to address concerns. After finally talking to a nurse at the agency on 1/20/2023 via telephone and complained about the delay in the nurse visit and RN AA not following up with his concerns about P#1 urinary catheter, blood sugar, and possible UTI, a nurse did finally come to home on 1/20/2023 and changed urinary catheter and discussed with the medical doctor, via phone, about a possible UTI but did not receive any medication for the UTI. Family member reveled calls to the agency many times, after the nurse visit on 1/20/2023 to request medications for P#1 symptoms of a UTI, again complained about the lack of communication with RN AA, and no one from the agency ever discussed complaints in writing or verbally.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review, staff and family interview, and review of policy titled, “Physician Plan of Care”, it was revealed the agency’s staff nurse, RN AA, failed to accept and document verbal orders received by the agency’s medical director (MD), in P#1’s clinical documents. Furthermore, verbal order was not signed, dated, or timed by the agency medical director. Findings include: During record review on 4/46/2023 at 2:30 p.m., of policy titled, “Physician Plan of Care”, dated 12/1997 with a revised date of 12/22/2022, revealed the following: “Verbal orders must be accepted only by personnel authorized by applicable state laws and regulations. The nurse or other qualified clinician responsible for furnishing or supervising the ordered service must record, sign, date, and time the orders in the clinical records.” “The plan of care or supplemental orders will be approved, signed, and dated by the certifying physician or allowed practitioner within 60 days of receiving a verbal or written order and filed in the medical record.” During an interview with family member of P#1 on 4/26/2023 at 1:00 p.m., revealed during RN AA’s visit on 1/20/2023 witnessed the phone communication between RN AA and the MD when orders were given by the agency’s MD to RN AA about patient’s symptoms and family member stated “I heard the MD give the orders for the UA to the nurse and watched nurse write the order down. I thought I would get a phone call from the agency nurse about the UA results and to tell me the MD ordered P#1 antibiotics for UTI, but no one called me about either. I called the agency several times over the next couple of days requesting the UA results and medications for UTI, but I never got a return call from the agency”. During record review, on 4/46/2023 at 12:00 p.m., this surveyor observed a nurses note dated 1/20/2023 and signed by RN AA which revealed RN AA had received a verbal order from P#1’s MD for a urinalysis (UA) to be completed on 1/20/2023 to determine if the P#1 had a UTI. In the nurses note dated 1/20/2023 RN AA noted P#1’s urine was milky in color and his blood sugars were elevated. Surveyor observed UA results from P#1’s medical records dated 1/20/2023 with a time of 1:51 pm. During the record review surveyor noted there was not a written order for a UA or medications dated on or after 1/20/2023 for certification period 11/26/2022 through 1/24/2023. In an interview on 4/26/23 at 12:30 p.m., RN AA confirmed taking the previously stated verbal orders from the agency’s MD. RN AA stated “I remember going to P#1’s home on Friday 1/20/2023 and noticing P#1 urine was milky in color. I changed the catheter and called the doctor for an order for a UA to confirm a possible UTI, but I did not write an order. I only put a nurse’s note in the patient’s chart. I took a sample of his urine for the UA and sent it to the lab for analysis”.