Guarding Angels Home Health LLC

The agency failed to ensure that the Emergency Preparedness Plan had policies and procedures related to patient data management and information sharing for all patients and employees.

The agency failed to ensure its Emergency Preparedness communication plan included current employee contact information for all patients and employees.

The agency failed to ensure development, implementation, and maintenance of processes for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for all patients and employees.

The agency failed to ensure emergency preparedness disaster table-top exercises, drills, community drills or plan activation events were conducted for calendar year 2024 for all patients and employees.

The agency failed to ensure utilization and analysis of patient outcome data in its QAPI Program for all patients and employees.

The agency failed to ensure baseline and goal measurements of the PIP through their QAPI Program for all patients and employees.

The agency failed to ensure individualized POCs included: 1.Pain management reporting parameters for eight (Patients #1, 2, 3, 4, 5, 6, 7 and #8) of nine patients. 2.Vital sign assessment reporting parameters for blood pressure, pulse, temperature and respiratory rate for eight (Patients #1, 2, 3…

The agency failed to ensure physician orders were documented for wound care interventions for one (Patient #4) of nine patients.

The agency failed to ensure: 1.SN visit frequency was conducted as ordered for two (Patients #4 and #6) of nine patients. 2.Aide visit frequency was conducted as ordered for one (Patient #8) of nine patients.

The agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees.

The agency failed to ensure SN visit notes showed interventions and patient response to wound care for one (Patient #4) of nine patients.

The agency failed to ensure development of an episodic Plan of Care after a comprehensive OASIS assessment for two (Patients #4 and #5) of seven patients.

The agency failed to show utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees.

The agency failed to ensure its infection control program included surveillance, monitoring and reporting and was included in QAPI program activities for all patients and staff.

The agency failed to ensure a community-based risk assessment (All Hazards Risk Assessment) was developed and implemented for all patients and employees.

The agency failed to ensure development, implementation and maintenance of processes for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for all patients and employees.

The agency failed to ensure emergency preparedness disaster table-top exercises, drills, community drills or plan activation events were conducted and properly documented for calendar years 2021 and 2022 for all patients and employees.

The agency failed to ensure development of an episodic Plan of Care after a comprehensive OASIS assessment for two (Patients #4 and #5) of seven patients.

The agency failed to show utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees.

The agency failed to show conduction of patient centered QAPI Program activities for all patients and employees.

The agency failed to ensure the initiation and review of a PIP through their QAPI Program for calendar years 2020, 2021 and 2022 for all patients and employees.

The agency failed to ensure governing body oversite of the conduction of patient centered QAPI Program plan and activities for all patients and employees.

The agency failed to ensure its infection control program included surveillance, monitoring and reporting and was included in QAPI program activities for all patients and staff.

The agency failed to show infection control education was: 1) Included in QAPI activities and; 2) Was provided and/or maintained for all patients and employees.

The agency failed to ensure the patients’ right to participate in the establishment and revision of a plan of care and be informed of disciplines to provide services with expected frequencies of visits after comprehensive assessments for two (Patients #4 and #5) of seven patients.

The agency failed to ensure individualized patient POC included weight reporting parameters for two (Patients #1 and #6) of seven patients.

The agency failed to ensure SN visits were ordered by the physician for two (Patients #4 and #5) of seven patients.

The agency failed to ensure services were provided as ordered on the POC for: 1. SN to conduct assessment of patient weight every visit for two (Patients #1 and #7) of seven patients and; 2. SN to conduct visit frequencies as ordered by the physicians for three (Patients #2, 3 and #7) of eight…

The agency failed to ensure a completed transfer/discharge summary was provided to a receiving service provider for one (Patients #7) of seven patients.