Every finding on record at Guardian Home Health Services, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, 10/04/2024. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 10/04/24. Standard level deficiencies cited. Abbreviations: MSW = Medical Social Worker OASIS = Outcome and Assessment Information Set SN = Skilled Nurse Pt / Pts = Patient / Patients SOC = Start of Care POC / PsOC = Plan of Care / Plans of Care

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on a review of the Agency's OASIS submission report and staff interview it was determined that the Agency failed to submit OASIS assessment within the required time frame. Findings include: 1. The Agency's past 12 months OASIS submission report was reviewed on 10/01/24. The report contained information that out of the 375 Agency's OASIS assessment reports, 138 (27.03 %) were submitted beyond the required time frame of 30 days. 2. During an interview with the Administrator and the Alternate Administrator on 10/03/24 at 10:00 AM, the Alternate Administrator confirmed the Agency's late OASIS submission.

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 clinical records review and staff interviews, it was determined in 2 of 7 (Pts. # 3 and 2) clinical records reviewed, the patient care was not provided as ordered in the plan of care. 2. Pt # 2 was admitted to Home Health Services on 08/28/24 with diagnosis of Hypertension. The clinical record was reviewed on 10/02/24. The clinical records contained a Plan of Care for certification period of 08/28/24 to 10/26/24 that required SN to assess blood sugar levels and notify physician of fasting blood sugar greater than (>) 250 or less than () 300 less than (Findings include: 1.Pt. #3 was admitted to the Home Health Services on 08/02/24 with the diagnoses of: Spondylosis without myelopathy or radiculopathy, lumbar region and Chronic Atrial Fibrillation, Unspecified. The clinical record was reviewed on 10/02/24. The clinical record contained PsOC dated 08/02/24 and 10/01/24, that required the MSW to evaluate. As of 10/02/24 the MSW failed to evaluate the patient. The POC dated 10/01/24 required the SN to assess the patient 1 time a week for 9 weeks. The SN failed to assess/visit the week of 08/25/24 (week #5).

Recertification survey completed. Standard level deficiencies cited. Abbreviations POC = Plan of Care Pt / Pts. = Patient / Patients RN = Registered Nurse SOC = Start of Care # = Number ER = Extended Release

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: A. Based on clinical records review and staff interview, it was determined that the Agency failed to inform and obtain patient consent of the disciplines that will furnish care and the frequency of visits, after initial assessment. This was found in 7 of 7 clinical records reviewed. (Pts. # 1,2,3,4,5,6 and,7) Findings include: 1. The following clinical records were reviewed between 08/31/2021 and 09/01/2021 Pt. #1 SOC: 06/08/2021 Pt. #2 SOC: 06/04/2021 Pt. #3 SOC: 08/05/2021 Pt. #4 SOC: 05/21/2021 Pt. #5 SOC: 06/08/2021 Pt. #6 SOC: 01/22/2021 Pt. #7 SOC: 03/23/2021 The clinical records lacked documentation of patient being informed and consenting to the disciplines that will furnish care and frequency of visits. 2. During interviews with the Administrator and Agency Supervisor on 09/02/2021 between 10:00 AM and 11:00 AM it was confirmed that the signed consents lacked documentation of patients being informed of the services and frequency of visits to be provided after the initial assessment.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on a review of clinical records, staff interview and Agency policy review, it was determined the Agency failed to assess patients' Influenza and/or Pneumococcal vaccine status, as required by the Agency. This was found in 3 of 7 (Pts. #1, 2 and 4) clinical records reviewed. Findings include: 1.Pt. #1. SOC 06/08/2021. Principal Diagnosis: Essential Primary Hypertension. The clinical record was reviewed on 08/31/2021 at 11:30 AM. The record contained a form “Flu/Pneumonia Vaccine” dated 06/08/2021. The form included documentation “Current” but lacked entries regarding information on influenza and pneumonia status of Pt. #1. 2. Pt. #2. SOC 06/04/2021. Principal Diagnosis: Parkinson’s Disease. The clinical record was reviewed on 08/31/2021 at 12:20 PM. The record contained a form “Flu/Pneumonia Vaccine” dated 06/04/2021. The form included documentation “Current” but lacked entries regarding information on influenza and pneumonia status of Pt. #2. 3. Pt. #4. SOC 05/21/2021. Principal Diagnosis: Essential Hypertension. The clinical record was reviewed on 09/01/2021 at 11:00 AM. The record contained a form “Flu/Pneumonia Vaccine” dated 05/21/2021. The form included documentation “yes” and “no” to the questions but lacked entries regarding information on influenza and pneumonia status of Pt. #4. 4. The Agency policy on “Pneumonia Vaccination Policy” was reviewed on 09/02/2021 at 12:00 PM. The policy requires, “The staff…shall document through a note in the clinical record of each patient who is 65 years of age or older that the need for pneumonia vaccination was addressed and its outcome documented….When a referral or arrangement for pneumonia vaccine is made for a patient…staff will assist the patient in developing a plan for implementing the referral or arrangement…Staff shall also document the referral or arrangement made including: date of offer or referral, the patient’s response (acceptance of refusal), result (administration, contraindication…) and outcome. 5. The Agency policy on “Influenza Vaccination Policy” was reviewed on 09/01/2021 at 2:00 PM. The policy requires, “The staff…shall document through a note in the clinical record of each patient who is 65 years of age or older, and who also received service…from October 1st and March 31st of the preceding year, that the need for influenza vaccination was addressed and its outcome documented…. When a referral or arrangement for flu vaccine is made for a patient…staff will assist the patient in developing a plan for implementing the referral or arrangement…Staff shall also document the referral or arrangement made including: date of offer or referral, the patient’s response (acceptance of refusal), result (administration, contraindication…) and outcome. 6. During an interview with the Administrator, Assistant Administrator and Director of Nursing on 09/02/2021 at 11:00 AM, the Assistant Administrator stated the influenza and pneumonia screening is conducted when staff obtains the consent for treatment and the screening is documented on the paper form "Flu/Pneumonia Vaccine." During the same interview, the above findings were confirmed.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: A. Based on Agency's office observation and a review of the Agency's admission packet, business card, Administrator job description and staff interview it was determined that the Agency failed to ensure that the day to day operations were current and accurate. This was found in 4 of 4 informational items reviewed. Items (A, B, C and D). Findings include: 1. On 08/31/2021 at 1:00 PM it was observed that the Agency's entrance door sign (Item A) contain only the previous owner Agency name. During an interview with the Administrator on 08/31/2021 at 3:00 PM the Administrator stated that the Agency change of owner was in 2019. After 2019 the Agency continues to have previous owner name with an addition of dba (additional name). The Administrator confirmed and agreed that the entrance door sign does not display the Agency name with dba name. 2. The Agency's Admission packet (Item B)was reviewed on 08/31/2021 at 1:30 PM. The Admission Packet contain only the Agency name of the previous owner and does not include the dba additional name. 3. On 08/31/2021 at 1:30 PM, the Administrator business card (Item C) was reviewed and contain only the Agency name of the previous owner and does not include the dba additional name. 4. The patient admission consents (Item D) were reviewed between 08/30/2021 and 09/02/2021 and contain only the Agency name of the previous owner and does not include the dba additional name. 5. The Agency's job description titled "Administrator Job Description" was reviewed on 09/02/2021 at 2:30 PM and included..."Performance indicator of Essential Job Duties:...9...Ensures the accuracy of all public information materials, activities and continuing education program announcements." 6. During an interview with the Administrator and Agency Supervisor on 09/02/2021 at 10:00 AM findings of the Administrator not maintaining accurate and current public information materials and oversee the day to day operation of the Agency was confirmed.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: A. Based on clinical record reviews and staff interview, it was determined the Agency failed to ensure medical record documents were complete. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) records reviewed. Findings include: 1. The clinical records of the Patients listed below were reviewed on 08/31/2021 at 11:30 AM to 09/01/2021 at 2:00 PM. All the records contained a document titled "Beneficiary-Elected Transfer," signed by the Pt. The name and location of the Agency the Pt. was being transferred from was left blank. Pt. #1 SOC: 06/08/2021 Pt. #2 SOC: 06/04/2021 Pt. #3 SOC: 08/05/2021 Pt. #4 SOC: 05/21/2021 Pt. #5 SOC: 06/05/2021 Pt. #6 SOC: 01/22/2021 Pt. #7 SOC: 03/23/2021 2. The above findings were confirmed during an interview with the Administrator, Assistant Administrator and Director of Nursing on 09/02/2021 at 10:15 AM and 11:15 AM.