Every finding on record at Golden Star Home Health Agency Inc

An Emergency Preparedness recertification survey was initiated on 03/30/2026. Census: Licensed and Certified: 0 Licensed Home Health: 0 Personal Assistance Services: 9 The agency was in compliance with the Medicare Conditions of Participation for Emergency Preparedness and no deficiencies were cited.

A Recertification survey was initiated on 03/30/2026. Census: Licensed and Certified: 0 Licensed Home Health: 0 Personal Assistance Services: 9 Acroynym: DON- Director of Nurses QAPI- Quality Assessment Performance Improvement AA- Alternate Administrator PAS- Personal assistance services

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to document the quality improvement projects undertaken, the reasons for conducting these projects and the measurable progress achieved on these projects for 3 of 3 (2023, 2024 and 2025) years of QAPI records reviewed. This failure potentially placed patients at risk of poor health outcomes when the agency failed to identify and address areas of the home health's program for which performance could be improved. Review of the documentation regarding the agency's QAPI Program included no documentation to indicate the home health agency had developed, implemented and described the reasons for conducting the projects, or evaluated the measurable progress achieved for the years of 2023 2024 and 2025. During an interview on 04/01/2026 at 1:00 PM, with the Administrator/DON, the surveyor reviewed the findings and asked if the agency had completed and documented any performance improvement projects. The Administrator/DON stated, "No, we haven’t done those, we haven’t had any Medicare patients since 2018.” Agency policy dated 05/01/2024, quoted in part, “Quality Assessment Performance Improvement Program, … Policy: … II. The Agency will strive to improve operational and client health outcomes by implementing a performance improvement plan … VII. Agency leaders and the QAPI Committee will choose an approach to performance improvement that is planned, systematic, Agency-wide in scope, collaborative in effort and includes all departments/disciplines. … Procedure: … VI. The performance improvement plan will be implemented. …”