Every finding on record at Kings Home Healthcare, Inc.

Based on the findings of an onsite unannounced home health agency Medicare recertification and complaint investigation survey conducted January 24, 2023 and January 26, 2023 and continued off-site through February 15, 2023, Golden Home Healthcare, was found not to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on review of the Agency's emergency preparedness plan, the agency failed to ensure that the emergency preparedness plan was updated with change of ownership and location of agency for one (1) of one (1) plan reviewed. EP #1. Review of the agency’s emergency preparedness plan on January 24, 2023 at 12:40 PM revealed: 1. Emergency preparedness plan not updated for new location of agency. An interview with the Agency Administrator on January 26, 2023 at 4:30 PM confirmed the above findings.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on review of emergency plan and interview with agency Administrator the agency failed ensure the emergency plan was specific for the current location for one (1) of one (1) plan reviewed. EP #1. Review of the agency’s emergency preparedness plan on January 24, 2023 at 12:40 PM revealed: 1. Emergency preparedness plan did not contain an emergency preparedness plan based on an all-hazards risk assessment. An interview with the Agency Administrator on January 26, 2023 at 4:30 PM confirmed the above findings.

Based on the findings of an onsite unannounced home health agency Medicare recertification and complaint investigation survey conducted January 24, 2023 and January 26, 2023 and continued off-site through February 15, 2023, Golden Home Healthcare, was found not to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies The cumulative effect of these systemic problems resulted in the Home Health Agency’s inability to ensure the provision of care planning, coordination and quality of care, the provision of services by Skilled Professionals and the inability to organize, manage and administer its resources to attain and maintain the highest practicable functional capacity and provide optimal care. As a result of the survey, four (4) condition level deficiencies and thirteen (13) standard level deficiencies were cited. No immediate jeopardy situation was identified.

Treatment or care CFR(s): 484.50(e)(1)(i)(A) (i)(A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; and This ELEMENT is not met as evidenced by: Based on reviews of medical records and interviews with agency administrator the agency failed to ensure that treatment or care was furnished appropriately for six (6) of nine (9) records reviewed. MR #1-3, #6, #8-9. Review of medical records completed January 24, 2023, between approximately 1:30 PM to 2:00 PM and January 26, 2023, between approximately 2:30 PM to 3:30PM revealed: MR #1, 12 yr. old female, start of care date (SOC) 5/1/22., certification period: 12/27/22-2/24/23; Primary diagnosis: Todd's paralysis (paralysis of the extremities that occurs following epileptic seizures), cerebral palsy. Physician's orders: SN 66 hours weekly, No physician order for a home health aide on care plan. MR #2, 6 yr. male, SOC: 4/20/21, certification period: 12/11/22-2/8/23; Primary diagnosis: Autism, Autistic disorder, Physician's orders: SN 1 time every nine weeks, home health aide 40 hours per week. " SN to perform a neurological assessment each visit", " SN to instruct client to wear proper footwear when ambulating", "SN to instruct caregiver to remove clutter form client's path, such as clothes, books, shoes, other items that may cause client to trip". Nursing interventions do not match diagnosis. MR #6, 6 yr. male, SOC: 8/4/22, certification period: 1/31/23-3/31/23; Primary Diagnosis: Autistic Disorder, Speech and language development delay d/t hearing loss, Physician orders: "SN 1 every 2 months, home health aide 32 hours per week". "SN to assess skin for breakdown every visit. SN to perform neurological assessment each visit. SN to instruct client to wear proper footwear when ambulating. SN to instruct client to change positions slowly". Nursing interventions not appropriate for diagnosis. MR #8, 3 yr. male, SOC: 11/15/22; certification period:11/15/22-1/13/23; Primary Diagnosis: full incontinence of feces, delayed milestone in childhood, reduced mobility; Physician's orders: "SN 1 every 2 months, SN assess skin for breakdown every visit. SN to instruct on establishing bowel regime. SN to instruct on bladder regime. SN to instruct on seizure disorder signs and symptoms and appropriate actions during seizure activity. SN to instruct caregiver on seizure precautions. SN to assess for client adherence to appropriate activity levels". Goals listed as: " client will be independent in ostomy management by.... Client will verbalize understanding not eat 4 hours before bedtime to reduce acid reflux and indigestion by...". No diagnosis of seizure disorders, acid reflux or indigestion on the care plan. Nursing goals and interventions inappropriate. MR #9, 6 yr. old male, SOC: 11/15/22; certification period:11/15/22-1/13/23; Primary Diagnosis: full incontinence of feces, delayed milestone in childhood, reduced mobility; Physician's orders: "SN 1 every 2 months. home health aide 293 hours per month 2:1 case. SN assess skin for breakdown every visit. SN to instruct on establishing bowel regime. SN to instruct on bladder regime. Physical Therapy to evaluate. Goals listed: "Client will be free of respiratory distress during the care period. Client will be independent in ostomy management by.... Client will verbalize understanding not eat 4 hours before bedtime to reduce acid reflux and indigestion by... Client will maintain mechanical diet compliance during the care period". No diagnosis of respiratory illness or ostomy on the care plan, agency does not offer physical therapy services, No diagnosis of acid reflux or indigestion on the care plan. No indication of a mechanical diet on the care plan. Nursing goals and interventions inappropriate. Interview with agency administrator completed on January 26, 2023, at approximately 4;30 PM confirmed the above findings. 1. MR #3, 5 yr. male, SOC: 8/17/21, certification period: 12/10/22-2/7/23; Primary diagnosis: Autistic disorder, Physician's orders: SN 1 time every nine weeks, home health aide sixty-four (64) hours per week. Home health aide hours: Monday through Friday eight (8) hours times five (5) days, Saturday and Sunday. Twelve (12) hours times two (2) days. “SN to instruct on adequate hydration, proper handling and maintenance of drainage bag.” No documentation noted that client has a drainage bag of any type.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on reviews of medical records, and interview with agency Administrator the agency failed to ensure an update of the comprehensive assessment was completed within the last five (5) days of every sixty (60) days for one (1) of one (1) skilled record reviewed. MR #1. Review of medical records completed January 24, 2023, between approximately 1:30 PM to 2:00 PM and January 26, 2023, between approximately 2:30 PM to 3:30PM revealed: MR #1, 12 yr. old female, start of care date (SOC) 5/1/22, Primary diagnosis: Todd's paralysis (post epileptic) (paralysis of the extremities that occurs following epileptic seizures), cerebral palsy. contained an initial comprehensive assessment dated 5/3/22. No other comprehensive assessments/updates to the comprehensive assessment were noted in the record. Interview with agency administrator completed on January 26, 2023, at approximately 4;30 PM confirmed the above findings.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on review of policy/procedures, medical records (MR) and interview with the staff (EMP), the agency failed to ensure that discharge summaries and/or transfer summaries were maintained in the medical record for five (5) of fourteen (14) records reviewed. (MR # 10-# 14) Findings include: Review of Golden Home Healthcare policy: DISCHARGE FROM AGENCY conducted on 2/15/23 at approximately 5:00PM revealed, DISCHARGE PROCESS; "7. A discharge summary will be completed and maintained in the clinical record. 9. Documentation of the provision of discharge instruction and patient/physician notification of discharge will be maintained in the clinical record…” 1. MR # 10; SOC: 3/8/22; Discharged: 9/1/22; admitting diagnosis: autistic disorder/developmental delay; non OASIS discharge: transfer/discharge/death: marked as unknown, no documentation of discharge orders or discharge summary sent to physician. 2. MR # 11; SOC: 1/4/22; Discharged: 9/1/22; admitting diagnosis: developmental disorder of speech and language/autistic disorder; non OASIS discharge: transfer/discharge/death: marked as patient remained in the community; no documentation if patient transferred to another agency. No documentation of discharge orders or discharge summary sent to physician. 3. MR # 12; SOC: 4/4/22; Discharged: 9/2/22; admitting diagnosis: autistic disorder/developmental delay; OASIS D1 Discharge: assessment reason: discharge from agency; OASIS M2420: Discharge disposition: marked as patient moved to a geographic location not served by this agency. No documentation of discharge orders or discharge summary sent to physician. 4. MR # 13; SOC: 1/31/22; Discharged: 9/1/22; admitting diagnosis: autistic disorder; OASIS D1 Discharge: Visit date: 9/1/22; care period information: date assessment completed: 8/1/22; assessment reason: discharge from agency; OASIS M0906: Discharge/transfer/death date: enter the date the date of discharge, transfer, or death (at home) of the patient: 8/1/22; OASIS M2420: Discharge disposition: marked as patient moved to a geographic location not served by this agency. Discharge reasons: transferred to another home health agency (HHA); No documentation of discharge orders or discharge summary. OASIS D1 discharge electronically signed by PF # 1 Date: 8/1/22. Unclear of exact date of discharge from agency due to conflicting dates in OASIS D1 discharge. 5. MR # 14; SOC: 11/12/21; Discharged: 9/5/22; admitting diagnosis: autistic disorder; non OASIS discharge: transfer/discharge/death: no reason marked; in narrative section of discharge, discharge reason noted as: “The client transferred to another HHA service providing facility as per the parent.” No documentation of discharge orders or discharge summary. Interview with Agency Administrator on February 15, 2023 at 4:47 PM confirmed the above findings.

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 policies /procedures, medical records (MR), and an interview with the Agency Administrator , it was determined that the agency failed to ensure staff provided quality care through the establishment of a written plans of care, conformance with physicians orders and adherence to written policies. Cross references: 484.60(a)(1) Plan of Care Tag: 0572- failed to ensure that the clients had individualized plans of care in nine (9) of nine (9) medical records reviewed. (MR #1-9). 484.60(b) Conformance with Physicians Orders Tag: 0578- failed to ensure conformance with physician's orders in six (6) of nine (9) medical records reviewed. (MR # 1-3, # 6, and #8-9) The cumulative effect of these systemic problems resulted in the Home Health Agency's inability to ensure the provision of care planning, coordination and quality of care.

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 review of policy/procedures, medical records (MR) and interview with the Agency Administrator, the agency failed to ensure that the clients had individualized plans of care in nine (9) of nine (9) medical records reviewed. (MR #1-9). Review of medical records completed January 24, 2023, between approximately 1:30 PM to 2:00 PM and January 26, 2023, between approximately 2:30 PM to 3:30PM revealed: Clients didn’t have individualized plans of care as evidenced by medical records reviewed for nine (9) out of nine (9) medical records (MR #1-#9) containing the following statements in orders and goals regardless of admitting diagnosis, age or ambulatory status and for all certification periods reviewed for nine (9) out of nine (9) medical records: a. “The caregiver educated to call 911 or visit emergency room (ER) with chest pain, difficulty breathing, chest tightness, continuous nausea/vomiting.” b. “Skilled nurse (SN) to instruct on establishing bowel/bladder regimen.” c. “Client skin integrity will remain intact during care period.” d. “Client will be without signs/symptoms of urinary tract infection (UTI)- (pain, foul odor, cloudy or blood-tinged urine and fever) during this care period.” e. “SN to instruct the caregiver to remove clutter from client’s path such as clothes, books, shoes, electrical cords, or other items that may cause client to trip.” f. “Client will exhibit stable neuro status evidenced by increased alertness, mobility and self-care by the end of the care period.” g. “SN to instruct client to wear proper footwear when ambulating.” h. “SN to assess skin for breakdown every visit.” i. “SN to perform a neurological assessment each visit.” j. “Client’s strength, endurance and mobility will be improved.” Interview with agency administrator completed on January 26, 2023, at approximately 4:30 PM confirmed the above findings.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on review of policy/procedures, medical records (MR) and interview with the Agency Administrator, the agency failed to ensure conformance with physician orders for six (6) out of nine (9) medical records (MR # 1-3, # 6, and #8-9) Review of medical records completed January 24, 2023, between approximately 1:30 PM to 2:00 PM and January 26, 2023, between approximately 2:30 PM to 3:30PM revealed: MR #1, 12 yr. old female, start of care date (SOC) 5/1/22., certification period: 12/27/22-2/24/23; Primary diagnosis: Todd's paralysis (paralysis of the extremities that occurs following epileptic seizures), cerebral palsy. Goal: “They will be independent in ostomy management by: Client will verbalize understanding not to eat four (4) hours before bedtime to reduce acid reflux/indigestion.” No documentation of client having an ostomy or physician order for ostomy management. MR #2, 6 yr. male, SOC: 4/20/21, certification period: 12/11/22-2/8/23; Primary diagnosis: Autism, Autistic disorder. Goal: “They will be independent in ostomy management by: Client will verbalize understanding not to eat four (4) hours before bedtime to reduce acid reflux/indigestion.” No documentation of client having an ostomy or physician order for ostomy management. MR #3, 5 yr. male, SOC: 8/17/21, certification period: 12/10/22-2/7/23; Primary diagnosis: Autistic disorder. Physician order: “SN to instruct on adequate hydration, proper handling and maintenance of drainage bag.” No documentation noted that client has a drainage bag. MR #6, 6 yr. male, SOC: 8/4/22, certification period: 1/31/23-3/31/23; Primary Diagnosis: Autistic Disorder, Speech and language development delay d/t hearing loss. Goal: “They will be independent in ostomy management by: Client will verbalize understanding not to eat four (4) hours before bedtime to reduce acid reflux/indigestion.” No documentation of client having an ostomy or physician order for ostomy management. MR #8, 3 yr. male, SOC: 11/15/22; certification period:11/15/22-1/13/23; Primary Diagnosis: full incontinence of feces, delayed milestone in childhood, reduced mobility. Goal: “They will be independent in ostomy management by: Client will verbalize understanding not to eat four (4) hours before bedtime to reduce acid reflux/indigestion.” No documentation of client having an ostomy or physician order for ostomy management. MR #9, 6 yr. old male, SOC: 11/15/22; certification period:11/15/22-1/13/23; Primary Diagnosis: full incontinence of feces, delayed milestone in childhood, reduced mobility. Goal: “They will be independent in ostomy management by: Client will verbalize understanding not to eat four (4) hours before bedtime to reduce acid reflux/indigestion.” No documentation of client having an ostomy or physician order for ostomy management. Interview with agency administrator completed on January 26, 2023, at approximately 4:30 PM confirmed the above findings.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on reviews of medical records and interviews with agency administrator the agency failed to ensure that home health aide care plans contained visit frequency for eight (8) out of eight (8) files (MR # 2-9). Findings include: MR #2, 6 yr. male, SOC: 4/20/21, certification period: 12/11/22-2/8/23; Primary diagnosis: Autism, Autistic disorder, Physician's orders: SN 1 time every nine weeks, home health aide 40 hours per week. Home health aide care plan contains no frequency. MR #3, 5 yr. male, SOC: 8/17/21, certification period: 12/10/22-2/7/23; Primary diagnosis: Autistic disorder, Physician's orders: SN 1 time every nine weeks, home health aide sixty-four (64) hours per week. Home health aide hours: Monday through Friday eight (8) hours times five (5) days, Saturday and Sunday twelve (12) hours times two (2) days. Home health aide care plan states regular frequency. MR #4, 15 yr. male, SOC: 4/21/22, certification period: 12/17/22-2/14/23; Primary diagnosis: Autistic disorder, Physician's orders: SN 1 time every two (2) months, home health aide seventy (70) hours per week two (2) to one (1) case. Home health aide care plan states regular frequency. MR #5, 10yr. male, SOC: 4/20/22, certification period: 12/17/22-2/14/23; Primary diagnosis: Autistic disorder, Physician's orders: SN 1 time every nine weeks, home health aide seventy (70) hours per week two (2) to one (1) case. Home health aide care plan contains no frequency. MR #6, 6 yr. male, SOC: 8/4/22, certification period: 1/31/23-3/31/23; Primary Diagnosis: Autistic Disorder, Speech and language development delay d/t hearing loss, Physician orders: "SN 1 every 2 months, home health aide thirty-two (32) hours per week". Home health aide care plan states regular frequency. MR #7, 4 yr. male, SOC: 8/4/22, certification period: 1/31/23-3/31/23; Primary diagnosis: Autistic disorder, Speech and language development delay, Physician's orders: SN 1 time every nine weeks, home health aide thirty-two (32) hours per week". Home health aide care plan states regular frequency. MR #8, 3 yr. male, SOC: 11/15/22; certification period:11/15/22-1/13/23; Primary Diagnosis: full incontinence of feces, delayed milestone in childhood, reduced mobility; Physician's orders: "SN 1 every 2 months.” No physician order for home health aide frequency. Home health aide care plan contains no frequency. MR #9, 6 yr. old male, SOC: 11/15/22; certification period:11/15/22-1/13/23; Primary Diagnosis: full incontinence of feces, delayed milestone in childhood, reduced mobility; Physician's orders: "SN 1 every 2 months. home health aide 293 hours per month 2:1 case.” Home health aide care plan contains no frequency. Interview with agency administrator completed on January 26, 2023, at approximately 4:30 PM confirmed the above findings.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on review of personnel files (PF) and interview with the agency administrator, the agency failed to ensure staff had health screenings for Mycobacterium tuberculosis upon hire for nine (9) out of nine (9) files (PF # 1- # 9) and on an annual basis for five (5) out of nine (9) files (PF #1-2, # 6-7 and PF # 9) Findings include: The CDC guidelines state that all Health Care Workers (HCW) should receive baseline tuberculosis screening upon hire... HCWs should receive TB screen annually. CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings, 2005. In May 2019, the CDC updated its recommendations for TB testing of health care personnel. The updated recommendations include for health care personnel to be screened for TB upon hire and involves three (3) steps as follows: TB risk assessment, a TB symptom screen and a TB test using either a two-step tuberculin skin test (TST) or a single blood assay for TB. The 2019 recommendations included that healthcare workers should receive TB screen and TB education annually. Review of Personnel files (PF) on 1/24/2023 and 1/26/2023 revealed: 1. PF # 1; DOH: 11/3/21; contained no documentation of TB symptom screening or risk assessment upon hire and year 2022. 2. PF # 2; DOH: 11/8/21; contained no documentation of TB screening or risk assessment upon hire and year 2022. 3. PF # 3; DOH: 6/6/22; contained no documentation of TB symptom screening or risk assessment upon hire. 4. PF # 4; Date of hire (DOH): 5/1/22; contained no documentation of TB symptom screening or risk assessment upon hire. 5. PF # 5; DOH: 2/1/22; contained no documentation of TB symptom screening or risk assessment upon hire. 6. PF # 6; DOH: 12/6/21; contained no documentation of TB symptom screening or risk assessment upon hire and year 2022. 7. PF # 7; DOH: 4/16/21; contained no documentation of TB symptom screening or risk assessment upon hire and year 2022. 8. PF # 8; DOH: 12/11/22; contained no documentation of TB symptom screening or risk assessment upon hire. 9. PF # 9; DOH: 8/25/21; contained no documentation of TB symptom screening or risk assessment upon hire and year 2022 Interview with agency administrator completed on January 26, 2023, at approximately 4:30 PM confirmed the above findings.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on review of policies/procedures, job descriptions and an interview with the Agency Administrator, it was determined that the agency failed to ensure competency of skilled nursing staff through documentation of competency skill assessments. Cross references: 484.75(a) Services by Skilled Professionals: Tag 0702- failed to ensure that skilled nursing staff had pediatric competencies completed upon hire for four (4) out of four (4) files (PF # 1- # 4) The cumulative effect of these systemic problems resulted in the Home Health Agency's inability to ensure the provision of services by Skilled Professionals and quality of care.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on reviews of job descriptions, personnel files (PF) and interview with the agency administrator, the agency failed to ensure that skilled nursing staff had pediatric competencies completed upon hire for four (4) out of four (4) files (PF # 1- # 4) Findings include: Review of Golden Home Healthcare Registered Nurse (RN) job description on February 14, 2023 at 12:25 PM revealed: “Organizational overview: “We serve children, aging populations and special needs populations….Our nurses mindfully assess your needs and help develop your individual care plan…” “The Registered Nurse…promoting overall compliance with state and federal guidelines and professional standards of practice..”. Position Qualifications/Requirements: “Cardiopulmonary resuscitation (CPR) certified”; “preferences: “One (1) to two (2) years pediatric/neonatal experience, one (1) year of home health experience with special focus on pediatrics…” Review of Golden Home Healthcare Licensed Practical Nurse (LPN) job description on February 14, 2023 at 12:25 PM revealed: “Organizational overview: “We serve children, aging populations and special needs populations… Our nurses mindfully assess your needs and help develop your individual care plan…” “Licensed Practical Nurse Position Overview: “Provides nursing services in the patient’s home in accordance with agency standards and applicable laws and regulations…” Essential Job Functions: “Promotes and maintains an agency environment that is in compliance with federal, state, and local regulatory agencies…Qualifications/Requirements: “Cardiopulmonary resuscitation (CPR) certified” Review of Personnel files (PF) on 1/24/2023 and 1/26/2023 revealed: PF # 1; Date of hire (DOH): 11/3/21; contained no documentation of pediatric competencies upon hire and for year 2022 2. PF # 2; DOH: 11/8/21; contained no documentation of pediatric competencies upon hire and for year 2022. 3. PF # 3; DOH: 6/6/22; contained no documentation of pediatric competencies upon hire. 4. PF # 4; DOH: 5/1/22; contained no documentation of pediatric competencies upon hire. Interview with agency administrator completed on January 26, 2023, at approximately 4:30 PM confirmed the above findings.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on review of policies /procedures, job descriptions, personnel files (PF), medical records (MR), and an interview with the Agency Administrator, it was determined that the agency failed to ensure organization, management, and administration of its resources to attain and maintain the highest practicable functional capacity including providing optimal care to achieve the goals and outcomes identified in the patients’ plans of care. Cross Reference: 484.105(a) Governing Body: Tag 0942- the governing body failed to ensure the overall operation of the agency to ensure the agency provided services in a compliant manner through appropriate plans of care and adherence to written policies and procedures. 484.105(b)(1) Administrator must: Tag 0944- the Agency administrator failed to ensure the agency adhered to written policies and procedures, was compliant in adhering to all federal, state, and local regulations and provided services in a compliant manner through appropriate plans of care. 484.105(b)(1)(iv) Ensure that HHA employs Qualified Personnel: Tag 0952- failed to ensure that the agency employed qualified personnel in four (4) out of four (4) files. (PF #1-4) 484.105(c) Clinical Manager: Tag 0958- the agency director of nursing (DON) failed to ensure that staff had pediatric competencies completed upon hire for nine (9) out of nine (9) files (PF # 1- # 9); failed to ensure that staff had pediatric competencies and performance evaluations completed on an annual basis for five (5) out of nine (9) files (PF # 1-2, # 6-7, and PF # 9) The cumulative effect of these systemic problems resulted in the Home Health Agency’s inability to organize, manage and administer its resources to attain and maintain the highest practicable functional capacity and provide optimal care.

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 policies/procedures, job descriptions, personnel files, medical records, and an interview with the Agency administrator, it was determined that the governing body failed to ensure the overall operation of the agency to ensure the agency provided services in a compliant manner through appropriate plans of care and adherence to written policies and procedures. The agency failed to ensure that treatment or care was furnished appropriately for five (5) of nine (9) records reviewed. MR #1-2, #6, #8-9.; The agency failed to ensure that home health aide care plans contained visit frequency for eight (8) out of eight (8) files (MR # 2-9); the agency failed to ensure that skilled nursing staff had pediatric competencies completed upon hire for four (4) out of four (4) files (PF # 1- # 4); the agency failed to ensure that discharge summaries and/or transfer summaries were maintained in the medical record for five (5) of fourteen (14) records reviewed. (MR # 10-# 14); the agency director of nursing (DON) failed to ensure that staff had pediatric competencies completed upon hire for nine (9) out of nine (9) files (PF # 1- # 9); failed to ensure that staff had pediatric competencies and performance evaluations completed on an annual basis for five (5) out of nine (9) files (PF # 1-2, # 6-7, and PF # 9); Failed to ensure that the agency employed qualified personnel in four (4) out of four (4) files. (PF #1-4); failed to ensure staff had health screenings for Mycobacterium tuberculosis upon hire for nine (9) out of nine (9) files (PF # 1- # 9) and on an annual basis for five (5) out of nine (9) files (PF #1-2, # 6-7 and PF # 9). Findings include: Review of Golden Home Healthcare PAHH8.1 - AGENCY ADMINISTRATIVE MANAGEMENT policy on February 14, 2023 at 12:45 PM revealed: Policy: “Administrator’s Duties: The Governing Body shall approve an Administrator who is authorized to organize and direct the Agency's ongoing functions. The Administrator's duties include: “1. Directing the Agency’s ongoing operations to assure the availability and provision of care and services. 2. Implementing governing body directives and organizational policies and procedures. 3. Complying with applicable laws and regulations 5. Monitoring recruiting, employing, and retaining efforts of qualified personnel to maintain appropriate staffing levels.” Review of Golden Home Healthcare Director of Nurses (DON) job description on February 14, 2023 at 12:25 PM revealed: “The Director of Nursing (DON) is responsible and accountable for planning, organizing, directing and evaluating nursing services. The DON is responsible for the management of all operational services for their responsibility. Working within the federal, state and regional regulations covering home health…the DON who oversees hiring, discipline, training, and all nursing related activities… Review of Golden Home Healthcare Registered Nurse (RN) job description on February 14, 2023 at 12:25 PM revealed: “Organizational overview: “We serve children, aging populations and special needs populations….Our nurses mindfully assess your needs and help develop your individual care plan…” “The Registered Nurse…promoting overall compliance with state and federal guidelines and professional standards of practice..”. Position Qualifications/Requirements: “Cardiopulmonary resuscitation (CPR) certified”; “preferences: “One (1) to two (2) years pediatric/neonatal experience, one (1) year of home health experience with special focus on pediatrics…” Review of Golden Home Healthcare Licensed Practical Nurse (LPN) job description on February 14, 2023 at 12:25 PM revealed: “Organizational overview: “We serve children, aging populations and special needs populations… Our nurses mindfully assess your needs and help develop your individual care plan…” “Licensed Practical Nurse Position Overview: “Provides nursing services in the patient’s home in accordance with agency standards and applicable laws and regulations…” Essential Job Functions: “Promotes and maintains an agency environment that is in compliance with federal, state, and local regulatory agencies…Qualifications/Requirements: “Cardiopulmonary resuscitation (CPR) certified” Review of Golden Home Healthcare Home Health Aide Job description on 2/14/2023 at 10:40 AM revealed: “POSITION SUMMARY: Works under the supervision of the Director of Nurses or designated registered nurse. Provides direct patient care as assigned by the registered nurse. Provides quality and delivery of home health care services. Assist in the home health care services that reflect the home health care agency philosophy and standards of home health nursing care of assigned clients. Duties:” Implements current Home Health Aide practices. Feeding, assistance with elimination (including enemas unless skills of licensed nurse are required to the patient's condition, routine catheter care and routine colostomy care)…Home Health Aide services are those services ordered in the plan of care that the aide is permitted to perform under state law. Review of medical records completed January 24, 2023, between approximately 1:30 PM to 2:00 PM and January 26, 2023, between approximately 2:30 PM to 3:30PM revealed: MR #1, 12 yr. old female, start of care date (SOC) 5/1/22., certification period: 12/27/22-2/24/23; Primary diagnosis: Todd's paralysis (paralysis of the extremities that occurs following epileptic seizures), cerebral palsy. Physician's orders: SN 66 hours weekly, No physician order for a home health aide on care plan. MR #2, 6 yr. male, SOC: 4/20/21, certification period: 12/11/22-2/8/23; Primary diagnosis: Autism, Autistic disorder, Physician's orders: SN 1 time every nine weeks, home health aide 40 hours per week. " SN to perform a neurological assessment each visit", " SN to instruct client to wear proper footwear when ambulating", "SN to instruct caregiver to remove clutter form client's path, such as clothes, books, shoes, other items that may cause client to trip". Nursing interventions do not match diagnosis. MR #6, 6 yr. male, SOC: 8/4/22, certification period: 1/31/23-3/31/23; Primary Diagnosis: Autistic Disorder, Speech and language development delay d/t hearing loss, Physician orders: "SN 1 every 2 months, home health aide 32 hours per week". "SN to assess skin for breakdown every visit. SN to perform neurological assessment each visit. SN to instruct client to wear proper footwear when ambulating. SN to instruct client to change positions slowly". Nursing interventions not appropriate for diagnosis. MR #8, 3 yr. male, SOC: 11/15/22; certification period:11/15/22-1/13/23; Primary Diagnosis: full incontinence of feces, delayed milestone in childhood, reduced mobility; Physician's orders: "SN 1 every 2 months, SN assess skin for breakdown every visit. SN to instruct on establishing bowel regime. SN to instruct on bladder regime. SN to instruct on seizure disorder signs and symptoms and appropriate actions during seizure activity. SN to instruct caregiver on seizure precautions. SN to assess for client adherence to appropriate activity levels". Goals listed as: " client will be independent in ostomy management by.... Client will verbalize understanding not eat 4 hours before bedtime to reduce acid reflux and indigestion by...". No diagnosis of seizure disorders, acid reflux or indigestion on the care plan. Nursing goals and interventions inappropriate. MR #9, 6 yr. old male, SOC: 11/15/22; certification period:11/15/22-1/13/23; Primary Diagnosis: full incontinence of feces, delayed milestone in childhood, reduced mobility; Physician's orders: "SN 1 every 2 months. home health aide 293 hours per month 2:1 case. SN assess skin for breakdown every visit. SN to instruct on establishing bowel regime. SN to instruct on bladder regime. Physical Therapy to evaluate. Goals listed: "Client will be free of respiratory distress during the care period. Client will be independent in ostomy management by.... Client will verbalize understanding not eat 4 hours before bedtime to reduce acid reflux and indigestion by... Client will maintain mechanical diet compliance during the care period". No diagnosis of respiratory illness or ostomy on the care plan, agency does not offer physical therapy services, No diagnosis of acid reflux or indigestion on the care plan. No indication of a mechanical diet on the care plan. Nursing goals and interventions inappropriate. MR #2, 6 yr. male, SOC: 4/20/21, certification period: 12/11/22-2/8/23; Primary diagnosis: Autism, Autistic disorder, Physician's orders: SN 1 time every nine weeks, home health aide 40 hours per week. Home health aide care plan contains no frequency. MR #3, 5 yr. male, SOC: 8/17/21, certification period: 12/10/22-2/7/23; Primary diagnosis: Autistic disorder, Physician's orders: SN 1 time every nine weeks, home health aide sixty-four (64) hours per week. Home health aide hours: Monday through Friday eight (8) hours times five (5) days, Saturday, and Sunday. Twelve (12) hours times two (2) days. “SN to instruct on adequate hydration, proper handling and maintenance of drainage bag.” No documentation noted that client has a drainage bag of any type. MR #4, 15 yr. male, SOC: 4/21/22, certification period: 12/17/22-2/14/23; Primary diagnosis: Autistic disorder, Physician's orders: SN 1 time every two (2) months, home health aide seventy (70) hours per week two (2) to one (1) case. Home health aide care plan states regular frequency. MR #5, 10yr. male, SOC: 4/20/22, certification period: 12/17/22-2/14/23; Primary diagnosis: Autistic disorder, Physician's orders: SN 1 time every nine weeks, home health aide seventy (70) hours per week two (2) to one (1) case. Home health aide care plan contains no frequency. MR #6, 6 yr. male, SOC: 8/4/22, certification period: 1/31/23-3/31/23; Primary Diagnosis: Autistic Disorder, Speech and language development delay d/t hearing loss, Physician orders: "SN 1 every 2 months, home health aide thirty-two (32) hours per week". Home health aide care plan states regular frequency. MR #7, 4 yr. male, SOC: 8/4/22, certification period: 1/31/23-3/31/23; Primary diagnosis: Autistic disorder, Speech and language development delay, Physician's orders: SN 1 time every nine weeks, home health aide thirty-two (32) hours per week". Home health aide care plan states regular frequency. MR #8, 3 yr. male, SOC: 11/15/22; certification period:11/15/22-1/13/23; Primary Diagnosis: full incontinence of feces, delayed milestone in childhood, reduced mobility; Physician's orders: "SN 1 every 2 months.” No physician order for home health aide frequency. Home health aide care plan contains no frequency. MR #9, 6 yr. old male, SOC: 11/15/22; certification period:11/15/22-1/13/23; Primary Diagnosis: full incontinence of feces, delayed milestone in childhood, reduced mobility; Physician's orders: "SN 1 every 2 months. home health aide 293 hours per month 2:1 case.” Home health aide care plan contains no frequency. Review of Personnel files (PF) on 1/24/2023 and 1/26/2023 revealed: 1. PF # 1; DOH: 11/3/21; contained no documentation of pediatric competencies upon hire and for year 2022 2. PF # 2; DOH: 11/8/21; contained no documentation of pediatric competencies upon hire and for year 2022. 3. PF # 3; DOH: 6/6/22; contained no documentation of pediatric competencies upon hire. 4. PF # 4; Date of hire (DOH): 5/1/22; contained no documentation of pediatric competencies upon hire. Review of Golden Home Healthcare policy: DISCHARGE FROM AGENCY conducted on 2/15/23 at approximately 5:00PM revealed, DISCHARGE PROCESS; "7. A discharge summary will be completed and maintained in the clinical record. 9. Documentation of the provision of discharge instruction and patient/physician notification of discharge will be maintained in the clinical record…” 1. MR # 10; SOC: 3/8/22; Discharged: 9/1/22; admitting diagnosis: autistic disorder/developmental delay; non OASIS discharge: transfer/discharge/death: marked as unknown, no documentation of discharge orders or discharge summary sent to physician. 2. MR # 11; SOC: 1/4/22; Discharged: 9/1/22; admitting diagnosis: developmental disorder of speech and language/autistic disorder; non OASIS discharge: transfer/discharge/death: marked as patient remained in the community; no documentation if patient transferred to another agency. No documentation of discharge orders or discharge summary sent to physician. 3. MR # 12; SOC: 4/4/22; Discharged: 9/2/22; admitting diagnosis: autistic disorder/developmental delay; OASIS D1 Discharge: assessment reason: discharge from agency; OASIS M2420: Discharge disposition: marked as patient moved to a geographic location not served by this agency. No documentation of discharge orders or discharge summary sent to physician. 4. MR # 13; SOC: 1/31/22; Discharged: 9/1/22; admitting diagnosis: autistic disorder; OASIS D1 Discharge: Visit date: 9/1/22; care period information: date assessment completed: 8/1/22; assessment reason: discharge from agency; OASIS M0906: Discharge/transfer/death date: enter the date the date of discharge, transfer, or death (at home) of the patient: 8/1/22; OASIS M2420: Discharge disposition: marked as patient moved to a geographic location not served by this agency. Discharge reasons: transferred to another home health agency (HHA); No documentation of discharge orders or discharge summary. OASIS D1 discharge electronically signed by PF # 1 Date: 8/1/22. Unclear of exact date of discharge from agency due to conflicting dates in OASIS D1 discharge. 5. MR # 14; SOC: 11/12/21; Discharged: 9/5/22; admitting diagnosis: autistic disorder; non OASIS discharge: transfer/discharge/death: no reason marked; in narrative section of discharge, discharge reason noted as: “The client transferred to another HHA service providing facility as per the parent.” No documentation of discharge orders or discharge summary. Review of Personnel files (PF) on 1/24/2023 and 1/26/2023 revealed: 1. PF # 1; Date of hire (DOH): 11/3/21; contained no documentation of pediatric competencies upon hire and year 2022 and no documentation of a performance evaluation in year 2022. 2. PF # 2; DOH: 11/8/21; contained no documentation of pediatric competencies upon hire and year 2022 and no documentation of a performance evaluation in year 2022. 3. PF # 3; DOH: 6/6/22; contained no documentation of pediatric competencies upon hire. 4. PF # 4; DOH: 5/1/22; contained no documentation of pediatric competencies upon hire. 5. PF # 5; DOH: 2/1/22; contained no documentation of pediatric competencies upon hire. 6. PF # 6; DOH: 12/6/21; contained no documentation of pediatric competencies upon hire and year 2022 and no documentation of a performance evaluation in year 2022. 7. PF # 7; DOH: 4/16/21; contained no documentation of pediatric competencies upon hire and year 2022 and no documentation of a performance evaluation in year 2022. 8. PF # 8; DOH: 12/11/22; contained no documentation of pediatric competencies upon hire. 9. PF # 9; DOH: 8/25/21; contained no documentation of pediatric competencies upon hire and year 2022 and no documentation of a performance evaluation in year 2022. Review of the skilled nursing resumes on February 14, 2023 at 12:50 PM revealed: 1. PF #1: Date of hire (DOH): 11/3/21; this position is the Director of Nursing (DON) and Registered Nurse (RN). No documentation of previous neonatal or pediatric work experience. 2. PF #2: DOH: 11/8/21; RN. No documentation of previous neonatal or pediatric work experience. 3. PF #3: DOH: 6/6/22; RN. No documentation of previous neonatal or pediatric work experience. 4. PF #4: DOH: 5/1/22. Licensed Practical Nurse (LPN). No documentation of previous neonatal or pediatric work experience; contained no documentation of CPR certification Review of Personnel files (PF) on 1/24/2023 and 1/26/2023 revealed: 1. PF # 1; DOH: 11/3/21; contained no documentation of TB symptom screening or risk assessment upon hire and year 2022. 2. PF # 2; DOH: 11/8/21; contained no documentation of TB screening or risk assessment upon hire and year 2022. 3. PF # 3; DOH: 6/6/22; contained no documentation of TB symptom screening or risk assessment upon hire. 4. PF # 4; Date of hire (DOH): 5/1/22; contained no documentation of TB symptom screening or risk assessment upon hire. 5. PF # 5; DOH: 2/1/22; contained no documentation of TB symptom screening or risk assessment upon hire. 6. PF # 6; DOH: 12/6/21; contained no documentation of TB symptom screening or risk assessment upon hire and year 2022. 7. PF # 7; DOH: 4/16/21; contained no documentation of TB symptom screening or risk assessment upon hire and year 2022. 8. PF # 8; DOH: 12/11/22; contained no documentation of TB symptom screening or risk assessment upon hire. 9. PF # 9; DOH: 8/25/21; contained no documentation of TB symptom screening or risk assessment upon hire and year 2022. Interview with agency administrator completed on January 26, 2023, at approximately 4:30 PM confirmed the above findings.

Administrator must: CFR(s): 484.105(b)(1) Standard: Administrator. The administrator must: This STANDARD is not met as evidenced by: Based on review of policies/procedures, job descriptions, personnel files, medical records and an interview with the Agency administrator, the Agency administrator failed to ensure the agency adhered to written policies and procedures, was compliant in adhering to all federal, state, and local regulations and provided services in a compliant manner through appropriate plans of care. The agency failed to ensure that treatment or care was furnished appropriately for five (5) of nine (9) records reviewed. MR #1-2, #6, #8-9.; The agency failed to ensure that home health aide care plans contained visit frequency for eight (8) out of eight (8) files (MR # 2-9); the agency failed to ensure that skilled nursing staff had pediatric competencies completed upon hire for four (4) out of four (4) files (PF # 1- # 4); the agency failed to ensure that discharge summaries and/or transfer summaries were maintained in the medical record for five (5) of fourteen (14) records reviewed. (MR # 10-# 14); the agency director of nursing (DON) failed to ensure that staff had pediatric competencies completed upon hire for nine (9) out of nine (9) files (PF # 1- # 9); failed to ensure that staff had pediatric competencies and performance evaluations completed on an annual basis for five (5) out of nine (9) files (PF # 1-2, # 6-7, and PF # 9); Failed to ensure that the agency employed qualified personnel in four (4) out of four (4) files. (PF #1-4); failed to ensure staff had health screenings for Mycobacterium tuberculosis upon hire for nine (9) out of nine (9) files (PF # 1- # 9) and on an annual basis for five (5) out of nine (9) files (PF #1-2, # 6-7 and PF # 9). Findings include: Review of Golden Home Healthcare PAHH8.1 - AGENCY ADMINISTRATIVE MANAGEMENT policy on February 14, 2023 at 12:45 PM revealed: Policy: “Administrator’s Duties: The Governing Body shall approve an Administrator who is authorized to organize and direct the Agency's ongoing functions. The Administrator's duties include: “1. Directing the Agency’s ongoing operations to assure the availability and provision of care and services. 2. Implementing governing body directives and organizational policies and procedures. 3. Complying with applicable laws and regulations 5. Monitoring recruiting, employing, and retaining efforts of qualified personnel to maintain appropriate staffing levels.” Review of Golden Home Healthcare Director of Nurses (DON) job description on February 14, 2023 at 12:25 PM revealed: “The Director of Nursing (DON) is responsible and accountable for planning, organizing, directing and evaluating nursing services. The DON is responsible for the management of all operational services for their responsibility. Working within the federal, state and regional regulations covering home health…the DON who oversees hiring, discipline, training, and all nursing related activities… Review of Golden Home Healthcare Registered Nurse (RN) job description on February 14, 2023 at 12:25 PM revealed: “Organizational overview: “We serve children, aging populations and special needs populations….Our nurses mindfully assess your needs and help develop your individual care plan…” “The Registered Nurse…promoting overall compliance with state and federal guidelines and professional standards of practice..”. Position Qualifications/Requirements: “Cardiopulmonary resuscitation (CPR) certified”; “preferences: “One (1) to two (2) years pediatric/neonatal experience, one (1) year of home health experience with special focus on pediatrics…” Review of Golden Home Healthcare Licensed Practical Nurse (LPN) job description on February 14, 2023 at 12:25 PM revealed: “Organizational overview: “We serve children, aging populations and special needs populations… Our nurses mindfully assess your needs and help develop your individual care plan…” “Licensed Practical Nurse Position Overview: “Provides nursing services in the patient’s home in accordance with agency standards and applicable laws and regulations…” Essential Job Functions: “Promotes and maintains an agency environment that is in compliance with federal, state, and local regulatory agencies…Qualifications/Requirements: “Cardiopulmonary resuscitation (CPR) certified” Review of Golden Home Healthcare Home Health Aide Job description on 2/14/2023 at 10:40 AM revealed: “POSITION SUMMARY: Works under the supervision of the Director of Nurses or designated registered nurse. Provides direct patient care as assigned by the registered nurse. Provides quality and delivery of home health care services. Assist in the home health care services that reflect the home health care agency philosophy and standards of home health nursing care of assigned clients. Duties:” Implements current Home Health Aide practices. Feeding, assistance with elimination (including enemas unless skills of licensed nurse are required to the patient's condition, routine catheter care and routine colostomy care)…Home Health Aide services are those services ordered in the plan of care that the aide is permitted to perform under state law. Review of medical records completed January 24, 2023, between approximately 1:30 PM to 2:00 PM and January 26, 2023, between approximately 2:30 PM to 3:30PM revealed: MR #1, 12 yr. old female, start of care date (SOC) 5/1/22., certification period: 12/27/22-2/24/23; Primary diagnosis: Todd's paralysis (paralysis of the extremities that occurs following epileptic seizures), cerebral palsy. Physician's orders: SN 66 hours weekly, No physician order for a home health aide on care plan. MR #2, 6 yr. male, SOC: 4/20/21, certification period: 12/11/22-2/8/23; Primary diagnosis: Autism, Autistic disorder, Physician's orders: SN 1 time every nine weeks, home health aide 40 hours per week. " SN to perform a neurological assessment each visit", " SN to instruct client to wear proper footwear when ambulating", "SN to instruct caregiver to remove clutter form client's path, such as clothes, books, shoes, other items that may cause client to trip". Nursing interventions do not match diagnosis. MR #6, 6 yr. male, SOC: 8/4/22, certification period: 1/31/23-3/31/23; Primary Diagnosis: Autistic Disorder, Speech and language development delay d/t hearing loss, Physician orders: "SN 1 every 2 months, home health aide 32 hours per week". "SN to assess skin for breakdown every visit. SN to perform neurological assessment each visit. SN to instruct client to wear proper footwear when ambulating. SN to instruct client to change positions slowly". Nursing interventions not appropriate for diagnosis. MR #8, 3 yr. male, SOC: 11/15/22; certification period:11/15/22-1/13/23; Primary Diagnosis: full incontinence of feces, delayed milestone in childhood, reduced mobility; Physician's orders: "SN 1 every 2 months, SN assess skin for breakdown every visit. SN to instruct on establishing bowel regime. SN to instruct on bladder regime. SN to instruct on seizure disorder signs and symptoms and appropriate actions during seizure activity. SN to instruct caregiver on seizure precautions. SN to assess for client adherence to appropriate activity levels". Goals listed as: " client will be independent in ostomy management by.... Client will verbalize understanding not eat 4 hours before bedtime to reduce acid reflux and indigestion by...". No diagnosis of seizure disorders, acid reflux or indigestion on the care plan. Nursing goals and interventions inappropriate. MR #9, 6 yr. old male, SOC: 11/15/22; certification period:11/15/22-1/13/23; Primary Diagnosis: full incontinence of feces, delayed milestone in childhood, reduced mobility; Physician's orders: "SN 1 every 2 months. home health aide 293 hours per month 2:1 case. SN assess skin for breakdown every visit. SN to instruct on establishing bowel regime. SN to instruct on bladder regime. Physical Therapy to evaluate. Goals listed: "Client will be free of respiratory distress during the care period. Client will be independent in ostomy management by.... Client will verbalize understanding not eat 4 hours before bedtime to reduce acid reflux and indigestion by... Client will maintain mechanical diet compliance during the care period". No diagnosis of respiratory illness or ostomy on the care plan, agency does not offer physical therapy services, No diagnosis of acid reflux or indigestion on the care plan. No indication of a mechanical diet on the care plan. Nursing goals and interventions inappropriate. MR #2, 6 yr. male, SOC: 4/20/21, certification period: 12/11/22-2/8/23; Primary diagnosis: Autism, Autistic disorder, Physician's orders: SN 1 time every nine weeks, home health aide 40 hours per week. Home health aide care plan contains no frequency. MR #3, 5 yr. male, SOC: 8/17/21, certification period: 12/10/22-2/7/23; Primary diagnosis: Autistic disorder, Physician's orders: SN 1 time every nine weeks, home health aide sixty-four (64) hours per week. Home health aide hours: Monday through Friday eight (8) hours times five (5) days, Saturday, and Sunday. Twelve (12) hours times two (2) days. “SN to instruct on adequate hydration, proper handling and maintenance of drainage bag.” No documentation noted that client has a drainage bag of any type. MR #4, 15 yr. male, SOC: 4/21/22, certification period: 12/17/22-2/14/23; Primary diagnosis: Autistic disorder, Physician's orders: SN 1 time every two (2) months, home health aide seventy (70) hours per week two (2) to one (1) case. Home health aide care plan states regular frequency. MR #5, 10yr. male, SOC: 4/20/22, certification period: 12/17/22-2/14/23; Primary diagnosis: Autistic disorder, Physician's orders: SN 1 time every nine weeks, home health aide seventy (70) hours per week two (2) to one (1) case. Home health aide care plan contains no frequency. MR #6, 6 yr. male, SOC: 8/4/22, certification period: 1/31/23-3/31/23; Primary Diagnosis: Autistic Disorder, Speech and language development delay d/t hearing loss, Physician orders: "SN 1 every 2 months, home health aide thirty-two (32) hours per week". Home health aide care plan states regular frequency. MR #7, 4 yr. male, SOC: 8/4/22, certification period: 1/31/23-3/31/23; Primary diagnosis: Autistic disorder, Speech and language development delay, Physician's orders: SN 1 time every nine weeks, home health aide thirty-two (32) hours per week". Home health aide care plan states regular frequency. MR #8, 3 yr. male, SOC: 11/15/22; certification period:11/15/22-1/13/23; Primary Diagnosis: full incontinence of feces, delayed milestone in childhood, reduced mobility; Physician's orders: "SN 1 every 2 months.” No physician order for home health aide frequency. Home health aide care plan contains no frequency. MR #9, 6 yr. old male, SOC: 11/15/22; certification period:11/15/22-1/13/23; Primary Diagnosis: full incontinence of feces, delayed milestone in childhood, reduced mobility; Physician's orders: "SN 1 every 2 months. home health aide 293 hours per month 2:1 case.” Home health aide care plan contains no frequency. Review of Personnel files (PF) on 1/24/2023 and 1/26/2023 revealed: 1. PF # 1; DOH: 11/3/21; contained no documentation of pediatric competencies upon hire and for year 2022 2. PF # 2; DOH: 11/8/21; contained no documentation of pediatric competencies upon hire and for year 2022. 3. PF # 3; DOH: 6/6/22; contained no documentation of pediatric competencies upon hire. 4. PF # 4; Date of hire (DOH): 5/1/22; contained no documentation of pediatric competencies upon hire. Review of Golden Home Healthcare policy: DISCHARGE FROM AGENCY conducted on 2/15/23 at approximately 5:00PM revealed, DISCHARGE PROCESS; "7. A discharge summary will be completed and maintained in the clinical record. 9. Documentation of the provision of discharge instruction and patient/physician notification of discharge will be maintained in the clinical record…” 1. MR # 10; SOC: 3/8/22; Discharged: 9/1/22; admitting diagnosis: autistic disorder/developmental delay; non OASIS discharge: transfer/discharge/death: marked as unknown, no documentation of discharge orders or discharge summary sent to physician. 2. MR # 11; SOC: 1/4/22; Discharged: 9/1/22; admitting diagnosis: developmental disorder of speech and language/autistic disorder; non OASIS discharge: transfer/discharge/death: marked as patient remained in the community; no documentation if patient transferred to another agency. No documentation of discharge orders or discharge summary sent to physician. 3. MR # 12; SOC: 4/4/22; Discharged: 9/2/22; admitting diagnosis: autistic disorder/developmental delay; OASIS D1 Discharge: assessment reason: discharge from agency; OASIS M2420: Discharge disposition: marked as patient moved to a geographic location not served by this agency. No documentation of discharge orders or discharge summary sent to physician. 4. MR # 13; SOC: 1/31/22; Discharged: 9/1/22; admitting diagnosis: autistic disorder; OASIS D1 Discharge: Visit date: 9/1/22; care period information: date assessment completed: 8/1/22; assessment reason: discharge from agency; OASIS M0906: Discharge/transfer/death date: enter the date the date of discharge, transfer, or death (at home) of the patient: 8/1/22; OASIS M2420: Discharge disposition: marked as patient moved to a geographic location not served by this agency. Discharge reasons: transferred to another home health agency (HHA); No documentation of discharge orders or discharge summary. OASIS D1 discharge electronically signed by PF # 1 Date: 8/1/22. Unclear of exact date of discharge from agency due to conflicting dates in OASIS D1 discharge. 5. MR # 14; SOC: 11/12/21; Discharged: 9/5/22; admitting diagnosis: autistic disorder; non OASIS discharge: transfer/discharge/death: no reason marked; in narrative section of discharge, discharge reason noted as: “The client transferred to another HHA service providing facility as per the parent.” No documentation of discharge orders or discharge summary. Review of Personnel files (PF) on 1/24/2023 and 1/26/2023 revealed: 1. PF # 1; Date of hire (DOH): 11/3/21; contained no documentation of pediatric competencies upon hire and year 2022 and no documentation of a performance evaluation in year 2022. 2. PF # 2; DOH: 11/8/21; contained no documentation of pediatric competencies upon hire and year 2022 and no documentation of a performance evaluation in year 2022. 3. PF # 3; DOH: 6/6/22; contained no documentation of pediatric competencies upon hire. 4. PF # 4; DOH: 5/1/22; contained no documentation of pediatric competencies upon hire. 5. PF # 5; DOH: 2/1/22; contained no documentation of pediatric competencies upon hire. 6. PF # 6; DOH: 12/6/21; contained no documentation of pediatric competencies upon hire and year 2022 and no documentation of a performance evaluation in year 2022. 7. PF # 7; DOH: 4/16/21; contained no documentation of pediatric competencies upon hire and year 2022 and no documentation of a performance evaluation in year 2022. 8. PF # 8; DOH: 12/11/22; contained no documentation of pediatric competencies upon hire. 9. PF # 9; DOH: 8/25/21; contained no documentation of pediatric competencies upon hire and year 2022 and no documentation of a performance evaluation in year 2022. Review of the skilled nursing resumes on February 14, 2023 at 12:50 PM revealed: 1. PF #1: Date of hire (DOH): 11/3/21; this position is the Director of Nursing (DON) and Registered Nurse (RN). No documentation of previous neonatal or pediatric work experience. 2. PF #2: DOH: 11/8/21; RN. No documentation of previous neonatal or pediatric work experience. 3. PF #3: DOH: 6/6/22; RN. No documentation of previous neonatal or pediatric work experience. 4. PF #4: DOH: 5/1/22. Licensed Practical Nurse (LPN). No documentation of previous neonatal or pediatric work experience; contained no documentation of CPR certification Review of Personnel files (PF) on 1/24/2023 and 1/26/2023 revealed: 1. PF # 1; DOH: 11/3/21; contained no documentation of TB symptom screening or risk assessment upon hire and year 2022. 2. PF # 2; DOH: 11/8/21; contained no documentation of TB screening or risk assessment upon hire and year 2022. 3. PF # 3; DOH: 6/6/22; contained no documentation of TB symptom screening or risk assessment upon hire. 4. PF # 4; Date of hire (DOH): 5/1/22; contained no documentation of TB symptom screening or risk assessment upon hire. 5. PF # 5; DOH: 2/1/22; contained no documentation of TB symptom screening or risk assessment upon hire. 6. PF # 6; DOH: 12/6/21; contained no documentation of TB symptom screening or risk assessment upon hire and year 2022. 7. PF # 7; DOH: 4/16/21; contained no documentation of TB symptom screening or risk assessment upon hire and year 2022. 8. PF # 8; DOH: 12/11/22; contained no documentation of TB symptom screening or risk assessment upon hire. 9. PF # 9; DOH: 8/25/21; contained no documentation of TB symptom screening or risk assessment upon hire and year 2022. Interview with agency administrator completed on January 26, 2023, at approximately 4:30 PM confirmed the above findings.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based upon review of policies/procedures, job descriptions, personnel files (PF) and an interview with the Agency Administrator, the agency administrator failed to ensure that the agency employed qualified personnel in four (4) out of four (4) files. (PF #1-4) Findings include: Review of Golden Home Healthcare PAHH8.1 - AGENCY ADMINISTRATIVE MANAGEMENT policy on February 14, 2023 at 12:45 PM revealed: Policy: “The Governing Body shall be the operating authority for the Agency and shall approve a qualified Administrator to supervise the Agency's performance in providing home care services… “Administrator’s Duties: The Governing Body shall approve an Administrator who is authorized to organize and direct the Agency's ongoing functions. The Administrator's duties include: 5. Monitoring recruiting, employing, and retaining efforts of qualified personnel to maintain appropriate staffing levels.” Review of Golden Home Healthcare Registered Nurse (RN) job description on February 14, 2023 at 12:25 PM revealed: “Organizational overview: “We serve children, aging populations and special needs populations….Our nurses mindfully assess your needs and help develop your individual care plan…” “The Registered Nurse…promoting overall compliance with state and federal guidelines and professional standards of practice..”. Position Qualifications/Requirements: “Cardiopulmonary resuscitation (CPR) certified”; “preferences: “One (1) to two (2) years pediatric/neonatal experience, one (1) year of home health experience with special focus on pediatrics…” Review of Golden Home Healthcare Licensed Practical Nurse (LPN) job description on February 14, 2023 at 12:25 PM revealed: “Organizational overview: “We serve children, aging populations and special needs populations… Our nurses mindfully assess your needs and help develop your individual care plan…” “Licensed Practical Nurse Position Overview: “Provides nursing services in the patient’s home in accordance with agency standards and applicable laws and regulations…” Essential Job Functions: “Promotes and maintains an agency environment that is in compliance with federal, state, and local regulatory agencies…Qualifications/Requirements: “Cardiopulmonary resuscitation (CPR) certified” Review of the skilled nursing resumes on February 14, 2023 at 12:50 PM revealed: 1. PF #1: Date of hire (DOH): 11/3/21; this position is the Director of Nursing (DON) and Registered Nurse (RN). No documentation of previous neonatal or pediatric work experience. 2. PF #2: DOH: 11/8/21; RN. No documentation of previous neonatal or pediatric work experience. 3. PF #3: DOH: 6/6/22; RN. No documentation of previous neonatal or pediatric work experience. 4. PF #4: DOH: 5/1/22. Licensed Practical Nurse (LPN). No documentation of previous neonatal or pediatric work experience. Interview with Agency Administrator on February 15, 2023 at 4:47 PM confirmed the above findings.

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: Based on review of policies/procedures, job descriptions, personnel files (PF) and an interview with the agency administrator, the agency director of nursing (DON) failed to ensure that staff had pediatric competencies completed upon hire for nine (9) out of nine (9) files (PF # 1- # 9); failed to ensure that staff had pediatric competencies and performance evaluations completed on an annual basis for five (5) out of nine (9) files (PF # 1-2, # 6-7, and PF # 9) Findings include: Review of Golden Home Healthcare Director of Nurses (DON) job description on February 14, 2023 at 12:25 PM revealed: “The Director of Nursing (DON) is responsible and accountable for planning, organizing, directing and evaluating nursing services. The DON is responsible for the management of all operational services for their responsibility. Working within the federal, state and regional regulations covering home health…the DON who oversees hiring, discipline, training, and all nursing related activities… Review of Golden Home Healthcare Registered Nurse (RN) job description on February 14, 2023 at 12:25 PM revealed: “Organizational overview: “We serve children, aging populations and special needs populations….Our nurses mindfully assess your needs and help develop your individual care plan…” “The Registered Nurse…promoting overall compliance with state and federal guidelines and professional standards of practice..”. Position Qualifications/Requirements: “preferences: “One (1) to two (2) years pediatric/neonatal experience, one (1) year of home health experience with special focus on pediatrics…” Review of Golden Home Healthcare Licensed Practical Nurse (LPN) job description on February 14, 2023 at 12:25 PM revealed: “Organizational overview: “We serve children, aging populations and special needs populations… Our nurses mindfully assess your needs and help develop your individual care plan…” “Licensed Practical Nurse Position Overview: “Provides nursing services in the patient’s home in accordance with agency standards and applicable laws and regulations…” Essential Job Functions: “Promotes and maintains an agency environment that is in compliance with federal, state, and local regulatory agencies…Qualifications/Requirements: “Cardiopulmonary resuscitation (CPR) certified” Review of Golden Home Healthcare Home Health Aide Job description on 2/14/2023 at 10:40 AM revealed: “POSITION SUMMARY: Works under the supervision of the Director of Nurses or designated registered nurse. Provides direct patient care as assigned by the registered nurse. Provides quality and delivery of home health care services. Assist in the home health care services that reflect the home health care agency philosophy and standards of home health nursing care of assigned clients. Duties:” Implements current Home Health Aide practices. Feeding, assistance with elimination (including enemas unless skills of licensed nurse are required to the patient's condition, routine catheter care and routine colostomy care)…Home Health Aide services are those services ordered in the plan of care that the aide is permitted to perform under state law. Review of Personnel files (PF) on 1/24/2023 and 1/26/2023 revealed: 1. PF # 1; Date of hire (DOH): 11/3/21; contained no documentation of pediatric competencies upon hire and year 2022 and no documentation of a performance evaluation in year 2022. 2. PF # 2; DOH: 11/8/21; contained no documentation of pediatric competencies upon hire and year 2022 and no documentation of a performance evaluation in year 2022. 3. PF # 3; DOH: 6/6/22; contained no documentation of pediatric competencies upon hire. 4. PF # 4; DOH: 5/1/22; contained no documentation of pediatric competencies upon hire. 5. PF # 5; DOH: 2/1/22; contained no documentation of pediatric competencies upon hire. 6. PF # 6; DOH: 12/6/21; contained no documentation of pediatric competencies upon hire and year 2022 and no documentation of a performance evaluation in year 2022. 7. PF # 7; DOH: 4/16/21; contained no documentation of pediatric competencies upon hire and year 2022 and no documentation of a performance evaluation in year 2022. 8. PF # 8; DOH: 12/11/22; contained no documentation of pediatric competencies upon hire. 9. PF # 9; DOH: 8/25/21; contained no documentation of pediatric competencies upon hire and year 2022 and no documentation of a performance evaluation in year 2022. Interview with agency administrator completed on January 26, 2023, at approximately 4:30 PM confirmed the above findings.

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on review of policies /procedures, job descriptions, personnel files (PF), medical records (MR), and an interview with the Agency Administrator, it was determined that the agency failed to ensure medical records that are accurate, complete, and adherent to current clinical record documentation standards of practice. Cross Reference: 484.110(a) Content of clinical record: Tag 1010- the agency failed to ensure medical records contained adequate and complete documentation. The agency failed to ensure that treatment or care was furnished appropriately for six (6) of nine (9) records reviewed. MR #1-3, #6, #8-9) failed to ensure that the clients had individualized plans of care in nine (9) of nine (9) medical records reviewed. (MR #1-9); the agency failed to ensure that discharge summaries and/or transfer summaries were maintained in the medical record for five (5) of fourteen (14) records reviewed. (MR # 10-# 14). 484.110(a)(6)(i-iii) Discharge and transfer summaries: Tag 1022- the agency failed to ensure that discharge summaries and/or transfer summaries were maintained in the medical record for five (5) of fourteen (14) records reviewed. (MR # 10-# 14).

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on review of policy/procedures, medical records (MR) and interview with the Agency Administrator, the agency failed to ensure medical records contained adequate and complete documentation. The agency failed to ensure that treatment or care was furnished appropriately for six (6) of nine (9) records reviewed. MR #1-3, #6, #8-9) failed to ensure that the clients had individualized plans of care in nine (9) of nine (9) medical records reviewed. (MR #1-9); the agency failed to ensure that discharge summaries and/or transfer summaries were maintained in the medical record for five (5) of fourteen (14) records reviewed. (MR # 10-# 14). Findings include: Review of Golden Home Healthcare policy: DISCHARGE FROM AGENCY conducted on 2/15/23 at approximately 5:00PM revealed, DISCHARGE PROCESS; “7. A discharge summary will be completed and maintained in the clinical record. 9. Documentation of the provision of discharge instruction and patient/physician notification of discharge will be maintained in the clinical record…” Review of medical records completed January 24, 2023, between approximately 1:30 PM to 2:00 PM and January 26, 2023, between approximately 2:30 PM to 3:30PM revealed: MR #1, 12 yr. old female, start of care date (SOC) 5/1/22., certification period: 12/27/22-2/24/23; Primary diagnosis: Todd's paralysis (paralysis of the extremities that occurs following epileptic seizures), cerebral palsy. Physician's orders: SN 66 hours weekly, No physician order for a home health aide on care plan. MR #2, 6 yr. male, SOC: 4/20/21, certification period: 12/11/22-2/8/23; Primary diagnosis: Autism, Autistic disorder, Physician's orders: SN 1 time every nine weeks, home health aide 40 hours per week. " SN to perform a neurological assessment each visit", " SN to instruct client to wear proper footwear when ambulating", "SN to instruct caregiver to remove clutter form client's path, such as clothes, books, shoes, other items that may cause client to trip". Nursing interventions do not match diagnosis. MR #6, 6 yr. male, SOC: 8/4/22, certification period: 1/31/23-3/31/23; Primary Diagnosis: Autistic Disorder, Speech and language development delay d/t hearing loss, Physician orders: "SN 1 every 2 months, home health aide 32 hours per week". "SN to assess skin for breakdown every visit. SN to perform neurological assessment each visit. SN to instruct client to wear proper footwear when ambulating. SN to instruct client to change positions slowly". Nursing interventions not appropriate for diagnosis. MR #8, 3 yr. male, SOC: 11/15/22; certification period:11/15/22-1/13/23; Primary Diagnosis: full incontinence of feces, delayed milestone in childhood, reduced mobility; Physician's orders: "SN 1 every 2 months, SN assess skin for breakdown every visit. SN to instruct on establishing bowel regime. SN to instruct on bladder regime. SN to instruct on seizure disorder signs and symptoms and appropriate actions during seizure activity. SN to instruct caregiver on seizure precautions. SN to assess for client adherence to appropriate activity levels". Goals listed as: " client will be independent in ostomy management by.... Client will verbalize understanding not eat 4 hours before bedtime to reduce acid reflux and indigestion by...". No diagnosis of seizure disorders, acid reflux or indigestion on the care plan. Nursing goals and interventions inappropriate. MR #9, 6 yr. old male, SOC: 11/15/22; certification period:11/15/22-1/13/23; Primary Diagnosis: full incontinence of feces, delayed milestone in childhood, reduced mobility; Physician's orders: "SN 1 every 2 months. home health aide 293 hours per month 2:1 case. SN assess skin for breakdown every visit. SN to instruct on establishing bowel regime. SN to instruct on bladder regime. Physical Therapy to evaluate. Goals listed: "Client will be free of respiratory distress during the care period. Client will be independent in ostomy management by.... Client will verbalize understanding not eat 4 hours before bedtime to reduce acid reflux and indigestion by... Client will maintain mechanical diet compliance during the care period". No diagnosis of respiratory illness or ostomy on the care plan, agency does not offer physical therapy services, No diagnosis of acid reflux or indigestion on the care plan. No indication of a mechanical diet on the care plan. Nursing goals and interventions inappropriate. MR # 10; SOC: 3/8/22; Discharged: 9/1/22; admitting diagnosis: autistic disorder/developmental delay; non OASIS discharge: transfer/discharge/death: marked as unknown, no documentation of discharge orders or discharge summary sent to physician. MR # 11; SOC: 1/4/22; Discharged: 9/1/22; admitting diagnosis: developmental disorder of speech and language/autistic disorder; non OASIS discharge: transfer/discharge/death: marked as patient remained in the community; no documentation if patient transferred to another agency. No documentation of discharge orders or discharge summary sent to physician. MR # 12; SOC: 4/4/22; Discharged: 9/2/22; admitting diagnosis: autistic disorder/developmental delay; OASIS D1 Discharge: assessment reason: discharge from agency; OASIS M2420: Discharge disposition: marked as patient moved to a geographic location not served by this agency. No documentation of discharge orders or discharge summary sent to physician. MR # 13; SOC: 1/31/22; Discharged: 9/1/22; admitting diagnosis: autistic disorder; OASIS D1 Discharge: Visit date: 9/1/22; care period information: date assessment completed: 8/1/22; assessment reason: discharge from agency; OASIS M0906: Discharge/transfer/death date: enter the date the date of discharge, transfer, or death (at home) of the patient: 8/1/22; OASIS M2420: Discharge disposition: marked as patient moved to a geographic location not served by this agency. Discharge reasons: transferred to another home health agency (HHA); No documentation of discharge orders or discharge summary. OASIS D1 discharge electronically signed by PF # 1 Date: 8/1/22. Unclear of exact date of discharge from agency due to conflicting dates in OASIS D1 discharge. MR # 14; SOC: 11/12/21; Discharged: 9/5/22; admitting diagnosis: autistic disorder; non OASIS discharge: transfer/discharge/death: no reason marked; in narrative section of discharge, discharge reason noted as: “The client transferred to another HHA service providing facility as per the parent.” No documentation of discharge orders or discharge summary. Clients didn’t have individualized plans of care as evidenced by medical records reviewed for nine (9) out of nine (9) medical records (MR #1-#9) containing the following statements in orders and goals regardless of admitting diagnosis, age or ambulatory status and for all certification periods reviewed for nine (9) out of nine (9) medical records: a. “The caregiver educated to call 911 or visit emergency room (ER) with chest pain, difficulty breathing, chest tightness, continuous nausea/vomiting.” b. “Skilled nurse (SN) to instruct on establishing bowel/bladder regimen.” c. “Client skin integrity will remain intact during care period” d. “Client will be without signs/symptoms of urinary tract infection (UTI)- (pain, foul odor, cloudy or blood-tinged urine and fever) during this care period.” e. “SN to instruct the caregiver to remove clutter from client’s path such as clothes, books, shoes, electrical cords, or other items that may cause client to trip.” f. “Client will exhibit stable neuro status evidenced by increased alertness, mobility and self-care by the end of the care period.” g. “SN to instruct client to wear proper footwear when ambulating.” h. “SN to assess skin for breakdown every visit.” i. “SN to perform a neurological assessment each visit.” j. “Client’s strength, endurance and mobility will be improved.” Interview with agency administrator completed on January 26, 2023, at approximately 4:30 PM confirmed the above findings.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the 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) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on review of policy/procedures, medical records (MR) and interview with the Agency Administrator, the agency failed to ensure that discharge summaries and/or transfer summaries were maintained in the medical record for five (5) of fourteen (14) records reviewed. (MR # 10-# 14). Findings include: Review of Golden Home Healthcare policy: DISCHARGE FROM AGENCY conducted on 2/15/23 at approximately 5:00PM revealed, DISCHARGE PROCESS; "7. A discharge summary will be completed and maintained in the clinical record. 9. Documentation of the provision of discharge instruction and patient/physician notification of discharge will be maintained in the clinical record…” MR # 10; SOC: 3/8/22; Discharged: 9/1/22; admitting diagnosis: autistic disorder/developmental delay; non OASIS discharge: transfer/discharge/death: marked as unknown, no documentation of discharge orders or discharge summary sent to physician. MR # 11; SOC: 1/4/22; Discharged: 9/1/22; admitting diagnosis: developmental disorder of speech and language/autistic disorder; non OASIS discharge: transfer/discharge/death: marked as patient remained in the community; no documentation if patient transferred to another agency. No documentation of discharge orders or discharge summary sent to physician. MR # 12; SOC: 4/4/22; Discharged: 9/2/22; admitting diagnosis: autistic disorder/developmental delay; OASIS D1 Discharge: assessment reason: discharge from agency; OASIS M2420: Discharge disposition: marked as patient moved to a geographic location not served by this agency. No documentation of discharge orders or discharge summary sent to physician. MR # 13; SOC: 1/31/22; Discharged: 9/1/22; admitting diagnosis: autistic disorder; OASIS D1 Discharge: Visit date: 9/1/22; care period information: date assessment completed: 8/1/22; assessment reason: discharge from agency; OASIS M0906: Discharge/transfer/death date: enter the date the date of discharge, transfer, or death (at home) of the patient: 8/1/22; OASIS M2420: Discharge disposition: marked as patient moved to a geographic location not served by this agency. Discharge reasons: transferred to another home health agency (HHA); No documentation of discharge orders or discharge summary. OASIS D1 discharge electronically signed by PF # 1 Date: 8/1/22. Unclear of exact date of discharge from agency due to conflicting dates in OASIS D1 discharge. MR # 14; SOC: 11/12/21; Discharged: 9/5/22; admitting diagnosis: autistic disorder; non OASIS discharge: transfer/discharge/death: no reason marked; in narrative section of discharge, discharge reason noted as: “The client transferred to another HHA service providing facility as per the parent.” No documentation of discharge orders or discharge summary. Interview with agency administrator completed on January 26, 2023, at approximately 4:30 PM confirmed the above findings.