Every finding on record at Golden Haven Care, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 11/07/24. 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 11/07/24. Standard level deficiencies cited. Abbreviations: # = number % = percent AM = morning SN = Skilled Nurse SOC = Start of care PM = afternoon/evening Pt./ Pts. = Patient/Patients OASIS = Outcome and Assessment Information Set

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 review of the Error Summary report and Staff interview, it was determined that in 186 of 281 reports submitted for the last 12 months, the Agency failed to submit a timely report, resulting in a warning. Findings include: 1. The Error Summary report for 10/2023 to 09/2024 (12 months), was reviewed on 11/06/24. The report included a warning for Error # -3330. The Error included 186 of 281 (66.19 %) assessments that were submitted late. 2. During an interview with the Administrator and Director of Nursing on 11/06/24 at 3:00 PM, the Administrator stated that the timeframe for submission of OASIS is within 30 days after completion. During the same interview, the Administrator confirmed the above findings.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on a review of closed clinical records and staff interview, it was determined that in 1 of 2 (Pt. #6) closed clinical records reviewed, the Agency failed to ensure the comprehensive assessment was updated at discharge. Findings include: 1. Pt. #6 was admitted to Home Health Services on 03/05/23 with the Diagnosis of Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 11/06/24. The clinical record documented that the last visit by the SN was on 06/16/23. The clinical record contained a transfer assessment completed by the SN on 06/17/23, indicating that Pt. #6 was transferred to an inpatient facility (patient not discharged from agency). The clinical record included a discharge order from Home Health Services and a discharge summary dated 06/23/23. As of 11/07/24, the record lacked documentation that the comprehensive assessment was updated at discharge. 2. During an interview with the Administrator and Director of Nursing on 11/06/24 at 3:00 PM, the Administrator and Director of Nursing confirmed the above findings.

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 clinical record review and Staff interview, it was determined that in 4 of 7 (Pts. #2, 3, 5 and 7) clinical records reviewed, the Agency failed to ensure Pts. were assessed for the Influenza and / or Pneumonia vaccination status. Findings include: 1.The following clinical records were reviewed on 11/06/24 from 9:00 AM to 2:00 PM: Pt. #2 SOC 10/22/24 Pt. #3 SOC 07/27/24 Pt. #5 SOC 08/28/24 Pt. #7 SOC 02/28/24 The records lacked documentation that the Pts. were assessed for Influenza and / or Pneumonia vaccine. 2. The Agency’s policy for Influenza and Pneumonia vaccination assessment was requested. The Agency's policy titled: “Vaccination Policy”. was reviewed on 11/07/24 and indicated:…6. Clients may receive the influenza vaccine and / or pneumococcal vaccine in their homes from agency staff if the following procedures are in place….a. The agency has a specific policy for how the program will be administered….” The policy did not include a procedure for Influenza and pneumonia vaccination assessment for patients. 3. During interviews with the Administrator and Director of Nursing on 11/06/24 between 2:15 PM to 3:40 PM, both stated that the Influenza and Pneumococcal vaccination status is done during admission and documented on the Agency’s Flu / Pneumonia Vaccine Questionnaire form. During an interview with the Administrator on 11/07/24 at 9:00 AM, the above findings were confirmed.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: # = number AM = morning SN = Skilled Nurse SOC = Start of Care PM = afternoon/evening Pt./ Pts. = Patient/Patients PT = Physical Therapy/Therapist

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: A. Based on review of clinical records, Agency’s policy and Staff interview, it was determined that the Agency failed to ensure the staff documented all interventions/ services and responses to those intervention/ services. This was found in 4 of 7 (Pts. #1, 2, 5 and 4) clinical records reviewed. Findings include: 1. Pt. #1. SOC 08/04/21. Diagnoses: Hypertensive Heart Disease with Heart Failure and Personal History of COVID-19. The clinical record was reviewed on 09/21/21 at 1:00 PM. The record contained SN visit notes dated 08/08/21 and 09/15/21. The notes lacked documentation that the SN screened the Pt./family and the responses for COVID-19 symptoms, before providing care/service as required by the Agency. 2. Pt. #2. SOC 06/23/21. Diagnoses: Type 2 Diabetes Mellitus with Hyperglycemia and Chronic obstructive Pulmonary Disease, Unspecified. The clinical record was reviewed on 09/21/21 at 2:00 PM. The record contained the SN visit notes dated 09/01/21, 09/08/21 and 09/15/21. The notes lacked documentation that the SN screened the Pt./family and the responses for COVID-19 symptoms, before providing care/service as required by the Agency. 3. Pt. #5. SOC 05/28/21 Diagnoses: Alzheimer’s Disease Unspecified and Personal History of COVID-19. The clinical record was reviewed on 09/21/21 at 3:00 PM. The record contained SN visit notes dated 09/01/21, 09/08/21 and 09/15/21. The notes lacked documentation that the SN screened the Pt./family and the responses for COVID-19 symptoms, before providing care/service as required by the Agency. 4. Pt. #4. SOC 08/18/21. Diagnosis: Venous Insufficiency. The clinical record was reviewed on 09/22/21 at 11:00 AM. The record contained SN visit notes dated 09/03/21 and 09/10/21 but lacked documentation that staff screened Pt/family and the responses for COVID-19 symptoms prior to visits. The same record contained PT visit notes dated 09/01/21, 09/03/21, 09/08/21, 09/10/21, 09/15/21 and 09/17/21 but lacked documentation that staff screened of Pt/family and responses for COVID-19 symptoms as required by the Agency. 5. The Agency’s Policy “Coronavirus Protocol” Updated 01/05/21 was reviewed on 09/23/21 at 9:00 AM and documented: “Pre-visit Screening….Effective immediately, all clinicians must conduct a screening call immediately before each visit:….once these questions have been answered, include the response in your visit note to document that you conducted the pre-visit screening…” 6. During interview with Administrator on 09/22/21 at 10:00 AM, the Administrator stated that staff screen patients and family before the home visit but do not document responses to pre-screening questions performed. The Administrator confirmed the above findings during interviews on 09/23/21 at 10:00 AM and 11:45 AM.